[Reprinted from the Journal of Cutaneous and Genito-Ubinary Diseases for April, 1895.] 
REMARKS ON THE TREATMENT OF CYSTITIS. 
By GARDNER W. ALLEN, M. D., 
Boston. 
THE following observations are based on the records of a num- 
ber of cases which have come to my notice within the last 
eight years. I have little to say of rare or severe forms of 
vesical disease and shall consider chiefly the treatment of the ordinary 
run of urinary symptoms met with in out-patient and office practice; 
but the commonplace in medicine is not always the least important. 
Most of the cases were of gonorrhoeal origin and in nearly all the 
inflammation was confined to the neck of the bladder. Extension 
backward of gonorrhoea into the neck of the bladder, accompanied by 
a sharp onset of urinary symptoms, is of course common enough. In 
n on-gonorrhoeal cases the cause of the cystitis is not always clear, but 
in a certain number is apparently traceable to a posterior urethral 
catarrh resulting from congestion of the prostatic portion, with or 
without inflammation of the seminal vesicles, and brought about by 
prolonged and repeated sexual excitement. It begins insidiously, has 
little or no tendency to recover, and is apt to be difficult to manage. 
As regards the treatment of cystitis, of the various internal reme- 
dies I prefer the saline diuretics, especially benzoate of sodium. Few 
surgeons nowadays, however, would long defer local treatment of the 
disease. For the simple purpose of washing out the bladder, perhaps 
a saturated solution of boric acid gives on the whole the best results. 
For the purpose of producing a decided impression upon the mucous 
membrane of the vesical neck I have had very gratifying experience 
with nitrate of silver and permanganate of potassium. I have tried 
various other substances, but not to a sufficient extent to furnish data 
of any value. 
Nitrate of silver is of course familiar to all, and I suppose is more 
used than anything else in the deep urethra, and deservedly so, for it 
Copyright 1895, by D. Appleton and Company. 2 
Original Communications. 
is probably the most valuable remedy we have. It is, therefore, so 
well known and has been so much written about that little need be 
said of it here. I will merely remark that I use a milder solution than 
formerly, rarely going above one per cent, but usually inject rather 
more, that is to say, ten or fifteen minims instead of four or five. I 
think also that these injections are much more effectual if immediately 
preceded by the passage of a large sound, except in the more acute 
cases. 
Permanganate of potassium, so far as I know, has not been very 
extensively used in the bladder; at least, I do not remember having 
seen the reports of its use. I have employed it a good deal in the last 
six years with great satisfaction in cystitis and chronic prostatitis, and 
reported some cases four years ago. Where it fails, nitrate of silver 
often succeeds, and vice versa. 
The bladder should be thoroughly irrigated with the permanganate 
solution, and this is conveniently done by means of a large Ultzmann 
syringe (which has a capacity of about five ounces) connected with an 
elastic or soft rubber catheter. One syringeful at a time is injected 
and allowed to flow out again, and so on until the solution comes away 
with as bright a color as it went in ; then two or three ounces are in- 
jected and left in the bladder, which the patient should hold as long 
as he comfortably can. It does not seem to me necessary to have the 
eye of the catheter just in the deep urethra during the injection, as 
advised by Ultzmann and others; if it projects a little beyond, it seems 
to serve the purpose as well. The fluid apparently settles down into 
the neck of the bladder as the patient walks about, and exerts a stimu- 
lating and astringent action on the mucous membrane ; this is checked, 
however, before it has time to become irritating, by the decomposition 
of the solution, which takes place as soon as a small quantity of fresh 
urine is secreted. It is well to begin with a solution of about 1 to 
4,000 or 5,000 ; weaker than this is useless on account of its rapid de- 
composition. It may be increased at the next sitting, generally after 
an interval of four to six days, to a strength of 1 to 3,000. For the 
third and subsequent injections a l-to-2,000 solution may be used, if 
well borne. The treatment is a mild and safe one, but is more trouble- 
some to carry out than the instillations of silver nitrate. If good is to 
result, it is soon apparent, and if there is no improvement after a few 
injections it might as well be abandoned. 
In order to show the practical results of treatment I will briefly 
report a few illustrative cases : 
Case I.-W. M., twenty-eight years old, on August 11, 1888, was 
afflicted with his second attack of gonorrhoea, which had already lasted Remarks on the Treatment of Cystitis. 
3 
nine months; for three months micturition had been painful and ab- 
normally frequent. The bladder was washed out with a solution of 
permanganate of potassium (1 to 4,000), three ounces being left in. 
This was repeated ten days later, and on the 30th he reported that he 
could hold his water four or five hours without trouble. He was now 
irrigated with a l-to-3,000 solution, and on September 6th micturition 
was normal. He remained well until the following May, when he con- 
tracted a fresh gonorrhoea, and on June 6th complained of being 
obliged to urinate every half hour day and night, the act being very 
painful, and followed by severe tenesmus. He was given an instilla- 
tion of silver nitrate, one per cent, which was followed by partial 
retention, and two days later the bladder was irrigated with a per- 
manganate solution (1 to 2,000). June 11th he reported great relief, 
but continued partial retention. He was catheterized, fourteen ounces 
of turbid urine evacuated, and the bladder again washed out with a 
1-to 2,000 solution, and on the 13th with a l-to-1,500 solution. After 
this there was entire relief from urinary symptoms, although the 
urethral discharge continued. No further local treatment was re- 
quired. The patient was seen a month later, and at that time was 
perfectly well. 
Case II.-J. C., age twenty-one, on May 24, 1890, had a gonor- 
rhoea of six weeks' duration, and for five days had been urinating with 
pain and difficulty every hour day and night. He was irrigated with 
permanganate solution four times with entire relief. On June 3d 
micturition was normal, and continued so. 
Case III.-A woman, twenty-eight years old, on May 6, 1892, had 
urinary symptoms of two weeks' duration accompanying gonorrhoea. 
Micturition was increased in frequency by day, although there was 
little trouble at night. There was severe burning during the act, and 
painful contraction at the end, followed by severe tenesmus. There 
was considerable urethral discharge. The urethra was irrigated with 
a solution of corrosive sublimate, after which the catheter was passed 
into the bladder, and urine containing a large amount of pus drawn 
off. The bladder was then washed out with a permanganate solution 
(1 to 3,000), and three ounces left in ; it was followed by considerable 
tenesmus. The irrigation was repeated three days later, as a result of 
which the cystitis was wholly relieved and did not return. 
CaseIV.-D. M., age twenty-eight, on July 23, 1892, had had 
gonorrhoea several times, the present attack having lasted five months, 
with vesical symptoms of five weeks' duration. Micturition was scald- 
ing and very difficult, sometimes stopping suddenly, and increased in 
frequency; there was pain at the end of the penis. The urine was 4 
Original Communications. 
high-colored, with offensive odor and a thick muco-purulent sediment. 
Examination for stone was negative. A catheter was passed, and five 
ounces of very foul residual urine drawn. The bladder was then 
washed out with a permanganate solution (1 to 3,000). Relief was 
prompt and improvement progressive. The irrigation was repeated 
six times within the next two weeks, and then the patient continued it 
daily at home for two or three weeks longer. On September 20th the 
urine was normal, and all symptoms had vanished. 
The following case was of interest to me as presenting more than 
average difficulty in treatment: 
Case K-J. C., age thirty-four, was first seen March 25, 1892. 
He was suffering with his second attack of gonorrhoea, which had 
lasted three months. Cystitis had set in during the first week of the 
disease. He had had internal treatment only, and had been confined 
to his room for the last month. Local treatment was begun with deep 
injections of silver nitrate. No relief being experienced, permanga- 
nate irrigations were tried, but were not well borne, and daily irriga- 
tions with boric acid were substituted. The patient was allowed to go 
about at first, but got worse and was then kept in his room nearly a 
month, the boric-acid irrigations being continued, and later increased 
to two a day. Improvement was marked for a while, but finally came 
to a standstill. I became convinced that the prostatic urethra needed 
stretching, and that he would not get well without it; so, on May 
16th, dilatation was cautiously begun. Sounds, followed by deep in- 
jections of silver nitrate, were passed three times a week, gradually 
increasing in size from No. 25, the meatus being freely divided. When 
No. 32 was first passed it seemed tight and caused a good deal of pain. 
Suddenly something was felt to give way, and the patient experienced 
a sharp pain ; the withdrawal of the sound was followed by consider- 
able bleeding. No. 33 was immediately passed and slipped in with 
ease. From this time improvement was more rapid. The dilatation 
was continued until No. 36 passed easily. June 29th, when treat- 
ment was suspended, there was still at times a slight sense of irrita- 
tion at the neck of the bladder and a few shreds in the urine; these 
symptoms subsequently entirely disappeared. The expulsive force of 
the bladder, which was impaired throughout the disease, has not been 
wholly recovered. 
I will conclude this paper with the report of a case of vesical 
catarrh : 
Case VI.-A. S., fifty-seven years old, has been under my treat- 
ment for chronic cystitis and stricture at intervals for about four years. 
Micturition has been abnormally frequent and more or less difficult Remarks on the Treatment of Cystitis. 
5 
for many years, requiring occasionally the use of a catheter. In 
March, 1893, he broke a catheter in his urethra; the encl slipped into 
the bladder and formed the nucleus for a stone. In July I found him 
in great distress and removed the stone, which gave marked relief ; 
but the cystitis remained in an aggravated form. During the next 
three months the strictures were cut and the bladder was pumped out 
twice and washed out frequently with various solutions; but, with the 
exception of a few periods of temporary improvement, he grew worse 
until it seemed as if some radical operation must be done to relieve 
his great suffering. As a last resort an emulsion of iodoform was in- 
jected into the bladder. The effect was almost immediate, and very 
striking, entire relief from the more distressing symptoms being af- 
forded. The injections were given three times a week, later twice a 
week, and continued several weeks. They enabled him to live in 
comparative comfort, although abnormal frequency of micturition and 
an ammoniacal condition of the urine persisted.