ANILIN (TRIPHENYLMETHANE) DYES IN THE

TREATMENT OF HUNNER ULCER

PRELIMINARY REPORT 1
EDWIN DAVIS
From the University of Nebraska College of Medicine, Omaha

The condition variously known as Runner ulcer, submucous ulcer,

interstitial cystitis, and by the peculiarly appropriate title, "elusive"
ulcer, requires no definition or description before this audience, If there
is any non-fatal lesion to which the human body is heir, more damnably
persistent, distressing, and exasperating, and more utterly diabolical than
submucous ulcer, this has not come to my attention, Nor do I know of
any lesion more baffling as to etiology, more puzzling as to clinical be-
havior, and with symptoms so excruciatingly severe, as contrasted with
its relatively innocent and almost insignificant appearance, Questions
pertaining to the etiology and the consistently strange behavior of this
elusive lesion have been answered concisely, eloquently, and only too ac-
curately, by Hinman in 2 words, "Nobody knows," \Ve do know, how-
ever, that there is no recognized dependable cure, that dilatation tends to
be helpful, that cystoscopic fulguration usually gives surprising and in-
explicably prompt, though transient, symptomatic relief, and that
relapse is the rule rather than the exception, The intractable nature of
the symptoms of this lesion has been such as to justify as radical a pro-
cedure as resection of the bladder wall, as originally recommended by
Hunner, and subtotal cystectomy, as recently advocated by Folsom et aL
There is no occasion for a detailed description of the well-recognized
symptomatology and cystoscopic characteristics of submucous ulcer,
Antiseptic values of the triphenylnietlzane dyes, A previously reported
investigation (Davis), relative to the antiseptic properties and the renal
excretion of a large number of aniline dyes, indicated antiseptic values in
exceedingly high dilution in urine (in vitro), possessed by certain methyl-
ated dyes of the triamino-triphenylmethane group, including dyes known
to the trade as gentian violet, methyl violet and crystal violet; also the
ethyl derivative, ethyl violet, This investigation, confirmed by recent
repetition, showed that certain dyes of this group have the power to in-
hibit the development of the colon bacillus in alkaline urine (pH 7 ,5)
1 Read before annual meeting, American Urological Association, Colorado Springs, Colo.,
May 19 to 22, 194L
899
900 EDWIN DAVIS

in dilutions as high as 1: 100,000, and the staphylococcus in extreme dilu-

tions exceeding 1: 1,000,000. Not only was development inhibited, but
it was shown that heavy seedings of viable organisms died during a 24
hour incubation period in urine dilutions, as contrasted with profuse
growth in the control urine. These dyes were also shown to be potent in
acid (pH 6.5) urine, although not in such extreme dilution.
Bacteriological technique. Normal urine, free from gross infection and
voided into sterile flasks, was employed for antiseptic tests in vitro. The
reaction was adjusted to pH 5.5 and pH 7.5 in divided samples, after
which 2 series of 10 cc. dilutions in test t ubes were made from urine of
each reaction. Each tube was then inoculated with a standard loop
TABLE !.-Antiseptic values in acid and alkaline urine
COLON BACILLUS STAPHYLOCOCCUS AUREUS

Acid urine Alkaline urine Acid urine Alkaline urine

(pH5.5) (pH 7.5) (pH 5.5) (pH 7.5)
DYE
I n-
hibits Permits Inhibits Permits Inhibits Permits Inhibits
de- <level- develop- develop- P ermits
velop- growth opment growth ment growth ment growth
ment
-- - - - - - --- ---
1 to 1 to 1 to 1 to 1 to 1 to 1 to 1 to
Methyl violet B ·· ·· ··· ···· 10,000 100,000 100,000 1,000,000 10, 000 100,000 100, 000 1,000,000
Gentian violet . . .. ... . .. 10,000 100, 000 10,000 100,000 10,000 100,000 1,000,000 10,000,000
Cry stal violet .... . ... . .. . 10,000 100,000 10,000 100, 000 1, 000, 000 10,000,000 1,000, 000 10,000,000
Crystal violet purified . . . .. 5,000 10, 000 10,000 100,000 100,000 1,000,000 100, 000 1,000,000
Ethyl viole t ... . ... .. . ... 10,000 100,000 100,000 1, 000, 000 1,000,000 10,000,000 1,000,000 10,000,000
Ethyl violet purified ...... 10,000 100,000 10,000 100,000 100,000 1,000,000 100,000 1,000, 000
Brilliant green ........... 10,000 100,000 10,000 100,000 10,000 100,000 100,000 1, 000,000
Mercurochrome .. _.... . . . 5,000 10,000 5,000 10,000 5,000 10,000 5,000 100, 000
Hg bichloride. . . . . . . . . . . . . 10,000 100,000 10,000 100,000 10,000 100,000 10,000 100,000
Phenol ... ···· · ·· · · ·· · · · · · · 1,000 1,000 1,000 1, 000

transferred from a broth tube, to which had been added 1 loop from a 24
hour broth culture of B. coli and S. aureus. T he inoculated urine dilu-
tions were then incubated for 24 hours and 0.1 cc amounts from each tube
plated. Dilutions inhibiting development and permitting growth of
B. coli and S. aureus in acid and alkaline urine are indicated in table 1.
Chemical terminology. In attempting specific designation of dyes of
the methyl violet group, one is immediat ely led into almost insurmount-
able difficulties by reason of loose terminology, multiplicity of synonyms
and variations in t he products marketed by different manufacturers.
This confusion is due primarily to the fact that the many and varied dyes
included under these names are mixtures rather than pure chemical com-
pounds. For instance, among others, there are various shades of methyl
 ANILIN DYES IN TREATMENT OF RUNNER ULCER 901

violet designated by the trade as methyl violet 2R, R, B, 2B, 3B, BBN,
BO, and V3, these being various mixtures of tetra-, penta-, and hexa-
methyl substitution products of triamino-triphenylmethane. The term
gentian violet has no definite chemical meaning. According to Conn,
this vague designation "apparently applied originally to a mixture con-
taining about half dextrin and half methyl violet," the latter being a mix-
ture of crystal violet (the hexamethyl or completely methylated com-
pound) and less completely methylated compounds of the same series.
In designating a specific preparation of the methyl violet group, the best
one is able to do is to quote precisely the label and the manufacturer.
However, the most completely methylated compound of this series, the
hexamethyl product, crystal violet, known also as violet C, G, or 7B,
hexamethyl violet, methyl violet 10B, and also (unfortunately) as gen-
tian violet, may be obtained in pure form. The mixture methyl violet B
employed in this investigation, was obtained originally from the American
Aniline Products Company, and the crystal violet, furnished through the
courtesy of DL H. A. Lubs of the DuPont Company, was further puri-
fied in the chemical laboratories of the University of Nebraska2 • Al-
though this report is limited largely to results obtained with these two
compounds, it is important to note that tentative tests carried out with
various dyes or mixtures of the methyl violet group, indicate the pos-
session of antiseptic values and clinical properties, (as outlined below) in
common.
Clinical application. By reason of the antiseptic values exhibited by
these dyes in extreme dilutions in urine, as well as the known penetrating
and staining properties possessed by many anilin dyes, and because of
the recognized inadequacy of available methods for the treatment of sub-
mucous ulcer, a clinical trial of these dyes was considered to be justified.
This involved the employment of different dyes, in varying concentra-
tions, as instillations and as irrigations, with and without bladder dis-
tension.
In order to avoid confusing the reader with a maze of complicated in-
dividual symptomatology and clinical findings, detailed case histories
have been omitted, and merely the essential facts presented. Of 16
patients, 1 was treated independently by my colleague, Dr. CA. Owens,
who also contacted and interviewed most of the others, and who is pre-
pared to corroborate results outlined below. All were female but 1, and
2 For willing and helpful cooperation in the purification of these dyes, I am indebted to Dr.
C. S. Hamilton, chairman, Department of Chemistry, University of Nebraska.
902 EDWIN DAVIS

all were middle-aged, excepting 1 girl, aged 20. In each instance, the
diagnosis of submucous ulcer was based upon the recognized criteria;
namely, chronicity, urinary frequency, pain on bladder distension,
severity of symptoms, relatively clear urine, and visible bleeding lesions
involving the bladder mucosa. In most of these cases, additional con-
firmation of the diagnosis was afforded by the history of transient response
to fulguration.
Clinical results. The dyes of this group have an irritating effect on the
bladder mucosa to an amazing degree, even in extreme dilution. Al-
though individual variation is to be recognized, and although the oc-
casional patient is able to tolerate instillations or irrigations in relatively
concentrated solution, as a general rule, irrigations stronger than 1: 10-
000, and even as dilute as 1: 20,000 tend to cause varying degrees of blad-
der distress, persistent for a day or two. In a few instances, strong
instillations (½ ounce of 1 per cent solution, retained for 5 minutes) were
employed. Such treatments caused immediate severe reaction char-
acterized by hematuria, and extreme urinary frequency, pain and suffer-
ing, persistent for a week to 10 days, then followed by a period of seem-
ingly miraculous symptomatic relief. It was possible to visualize the
immediate development of marked reddening and congestion of the
bladder mucosa by means of cystoscopic examinations, carried out fol-
lowing instillations of solutions even as dilute as 1: 10,000. In that such
reactions followed the employment of the commercial methyl violet mix-
ture, and the highly purified compound crystal violet as well, it may be
concluded that this irritating effect is inherent in the chemical structure of
the dye itself, rather than due to impurities. In this connection, mention
should be made of the report of Mason and Allen describing the "severely
irritative and destructive properties of anilin dyes" of the triphenyl-
methane group, as demonstrated by penetrating indelible pencil injuries
to the hands. Similar injurious effects resulting from indelible pencil
wounds of the eye have been noted by Bride and others.
As shown by table 2, and as confirmed by the statements of patients, a
summary of clinical results brings out certain rather surprising and in-
teresting facts. Whether a gentian violet or methyl violet mixture was
employed, or crystal violet, in the most purified form obtainable, whether
as an instillation or a dilating irrigation, whether in concentrated 1 per
cent solution or in dilution as extreme as 1: 20,000, treatment was im-
mediately followed by painful reaction, almost without exception, as
related above. This reaction, or period of increased bladder distress, was
 ANILIN DYES IN TREATMENT OF RUNNER ULCER 903

m turn followed by a period of unmistakable and extraordinary im-

provement, best brought to the attention of the reader, and proved, by
the following paragraph of direct, literal quotations from written state-
TABLE 2

.z:,i
0"'
elp""
"z RESULTS
H
z ~~
~§ TREATMENT "'0
H

~ ""'.,,
.,,:,i ~""
0-<
>o 1'0 i
P<
~i;;
A
[;'Jco
"'
Immediate
I
Secondary
I
Late ,~
0

Instillation
years
9297 53 7 0 Methyl violet 1: 100 Reaction Relief 8mo. Relapse A
8954 47 4 1 Methyl violet 1: 100 Reaction Relief 15 mo. "Well" B
9497 57 10 0 Methyl violet 1: 100 Reaction Relief 5 mo. "Well" B
9186 48 5 1 Methyl violet 1: 100 Reaction None Worse
8848 40 8 R Gentian violet 1: 100 Reaction Relief 6mo. Relapse C
8987 47 4 1 Gentian violet 1 : 100 Reaction Relief 2 mo. Relapse D
9241 20 7 1 Methyl violet 1:2,000 Reaction Relief 12 mo. "Well" B
6461 55 12 R Methyl violet 1: 2,000 Reaction Relief 6mo. Relapse
8890 50 9 R Methyl violet 1 :20, 000 Relief Relief 10 mo. "Well" B

Irrigation and dilatation

9565 60 8 0 Methyl violet 1: 10,000 Relief Relief 3 mo. Relapse

6320 54 10 1 Methyl violet 1: 20,000 Reaction Relief 5 mo. Relapse E
9523 44 7 0 Methyl violet 1: 15,000 Reaction Relief 3 mo. Relapse
9504 67 10 0 Methyl violet 1: 15,000 Relief Relief 3 mo. ? F
8708 54 9 1 Crystal violet 1: 10,000 Reaction Relief 5 mo. "Well" B
9598 55 3 0 Crystal violet 1:10,000 Reaction Relief 4mo. ? G
9225 47 4
- 0 Crystal violet 1: 10,000 Reaction Relief ! mo. Relapse
Av. 50 7 5

A Patient pronounced herself "well."

B No relapse to date.
C Patient now kept symptom-free with methyl violet irrigations, 1:20,000, given every
two weeks.
D Patient has had a subsequent fulguration, and is now symptom-free, with methyl violet
irrigations, 1 :20, 000, given every two weeks.
E Male. Pronounced himself "well." Situation complicated by prostatic obstructive
symptoms.
F Situation complicated by extreme neurosis.
G Patient continues "distinctly better, but not well."
R Repeated fulgurations.

ments made by the patients themselves. Of the 16 treated patients, one

was made distinctly worse, as evidenced by a prolonged period of in-
creased bladder distress, followed by a return to the status quo without an
intervening period of improvement. The remaining 15 (without further
904 EDWIN DAVIS

exception) experienced periods of relief varying from 2 to 15 months,

(average 5½ months), this in turn followed by a relapse and recurrence of
symptoms in all but 5. Of these 5 remaining symptom-free, 2 have ex-
perienced relief for periods slightly exceeding 1 year, and the other 3 for
periods of 10, 5, and 5 months respectively. It is to be particularly noted
that these 5 have been classified in the table as "well" with due recog-
nition of the possibility, if not the probability, of relapse in the near or
distant future. As a matter of fact, with reservations, I am inclined to
agree with the personal communication received from Hinman, stating
"This benefit would have to persist ... at least 10 years before convincing
most of us." One of these patients (8848) writes that she is being kept
comfortable by means of irrigations (1: 20,000) given at bi-weekly inter-
vals by her local physician. It is to be noted that 4 of these patients
volunteered the information that they had been able to attend the theatre
or church for the first time in a period of years. As indicated in the last
column of table 2, 1 of the 16 was classified as worse, 5 as temporarily
"well," and 8 as improved with relapse, while 2 were classified as doubt-
ful by reason of neurotic temperament and indefinite statements. Those
patients receiving concentrated 1 per cent instillations were given 1
treatment only, the others a brief course varying from 3 to 6 treatments.
Since the ultimate goal in any medical or surgical field is symptomatic
relief, and since, in the last analysis, this is best gauged by the statements
of patients, the following direct quotations come to be of particular sig-
nificance. In fact, these few terse comments tell the whole story, and
leave not the slightest doubt in the mind of the reader that these patients
suffered reactions (some of them very severe) following treatment, that
(almost without exception) a period of very gratifying relief was then
experienced, this, in turn, followed by relapse in the majority of instances.
During period of relief: After 2 weeks following treatment, with "pain
almost constantly and urination 15 to 20 times every night, I now feel
quite well and am able to sit through a theatre performance for the first
time in years." (9297) . After severe suffering following treatment "I
feel just fine. I can hold the urine for 4 hours and longer, and get up once
at night," and (after 15 months) "I feel just fine, and do not notice any
trouble with my bladder."(8954) . "I have no more misery in the blad-
der. I feel much better than before the treatments." (9497). "I feel
better than I have in years. I cannot remember when I have had a better
night's sleep. I take the treatments every 2 weeks." (8848). "I am
distinctly benefited and quite normal." Condition "best in years."
(8987). "I made a new record by sitting through a 3½ hour show."
 ANILIN DYES IN TREATMENT OF RUNNER ULCER 905

(9241), "After severe suffering, I feel a whole lot better. The last treat-
ment helped a great deal more than anything else I have ever had done."
(8890). "Since taking the treatment I have been without the severe
pain I had endured for more than 10 years. The straining and severe
sharp pain is a thing of the past. Words but feebly express my grati-
tude." (6461). "I feel almost good enough. I can now work without
pain and feel better than in several years. I am indeed thankfuL"
(9565). "I think that I am cured." (6320). "I went to the theatre for
the first time in years ... have got a great deal of benefit from the irri-
gation treatments." (9523). Condition "quite satisfactory. I feel so
much better that I do not believe further treatments necessary." (9504).
"I can truthfully say I am feeling fine ... not an ache or pain." (8708).
"I am a lot better. I shall never forget the pleasure of the past few weeks
of relief from bladder pain and suffering after 3 years of constant dis-
tress." (9598).
Following relapse: "My bladder feels just as if it was full of sand burrs.
I guess that the only thing I can do is pray I won't live forever." (9297).
"I felt right good for about 2 months, then the ulcers seemed to get worse
again." (8890). "I cannot stay away from the toilet. I got wonderful
help for about 2 months, but have been getting bad again ever since.
Now I cannot leave the house without a pad." (9225). "The pain
gradually came back." (9523).
Comment. This is a preliminary report only. No claims whatever are
made as to the value or the efficacy of dyes of the triphenylmethane group
in the treatment of submucous ulcer. Pending further investigation, I
consider the indiscriminate intravesical use of unidentified methyl violet
mixtures, particularly in concentrated solution, to be decidedly contra-
indicated. However, with better knowledge as to the identity of the dye
best suited, and as to the desirable concentration and technique, there is
the possibility that this method might serve a useful purpose, in spite of
the tendency toward reaction, and the recognized probability of relapse.
A course of irrigations or instillations, repeated at several-month inter-
vals, might well be considered less objectionable, and less in the nature of
an ordeal than fulguration, which often comes to be rather a formidable
procedure, requiring hospitalization and anesthesia. Moreover, there is
the possibility that by suitable technique relief might be achieved with-
out intervening reaction, although, contrary-wise, it must be recognized
that reaction is perhaps an essential preliminary, and that improvement
may be primarily dependent upon chemical irritation, congestion, and
perhaps even destructive processes, involving the vesical mucosa. Three
906 EDWIN DAVIS

of these patients, however, experienced relief without symptoms of inter-

vening reaction.
CONCLUSIONS

Certain methylated triamino-triphenylmethane dyes have been shown

to inhibit the development of the colon bacillus and the staphylococcus in
urine (in vitro), in exceedingly high dilution.
The chemical identity of these dyes is established with difficulty, and
the obtaining of pure samples a problem.
The local treatment of submucous ulcer, with dyes of this group, in a
series of 16 patients, was consistently followed by reaction, relief, and re-
lapse, in surprisingly regular sequence.
Reaction, due to the irritating properties of the dyes, characterized by
increased urinary frequency and painful tenesmus, (occasionally very
severe and associated with hematuria) persisting from 1 to 10 days, oc-
curred in 13 out of 16 cases.
Relief, observed in 15 out of 16 cases, unmistakable, and exceedingly
gratifying, lasted an average period of S½ months, this (I believe) being
not less than the average period of relief following fulguration.
Relapse, the rule rather than the exception, occurred in 9 out of 16
cases, 2 remaining doubtful.
Of the 5 classified as temporarily well, three have remained so for ap-
proximately 1 year, and 2 for 5 months only.
Instillation or irrigation treatment, even though providing only tem-
porary relief, is a less formidable procedure than fulguration.
With better knowledge as to the identity and concentration of the dye
best suited, and as to proper technique, there is the possibility that this
method might serve a useful purpose.
Pending further investigation, the indiscriminate intravesical use of
triphenylmethane dyes is distinctly contra-indicated. Caution is ad-
vised.
Medical Arts Bldg., Omaha, Nebr.
REFERENCES
BRIDE, T. M.: Perforation of the orbit with an indelible pencil. Brit. Med. J., 2: 57, 1932.
CONN, H. J.: Biological Stains. 3rd. Ed. Committee on Standardization of Biological
Stains. Geneva, N. Y., 1936.
DAVIS, EDWIN: Urinary antisepsis. A study of the antiseptic properties and the renal excre-
tion of 204 anilin dyes. Am. J. Med. Sci., 161: 251, 1921.
FOLSOM, A. I., O'BRIEN, H. A., AND CALDWELL, G. T. : Subtotal cystectomy in the treatment
of Hunner ulcer. J. Urol., 44: 650, 1940.
HINMAN, F.: What causes Hunner ulcer? Surgery, 5: 950, 1939.
HuNNER, G. L.: A rare type of bladder ulcer occurring in women. Tr. South. Surg. & Gynec.
Ass'n., 27: 247, 1914.
MASON, MICHAEL L., AND ALLEN, HARVEYS.: Indelible pencil injuries to the hands. Ann.
Surg., 113: 131, 1941.