is wanted, I have tried to secure a lamp that would answer the purpose fairly well. The following may be recommended: a petroleum lamp with a round burner, 30 mm. in diameter; on one side of the flame should be a concave mirror, and on the other a glass ball containing water or glycerin. The lamps used for laryngoscopy may be changed so as to answer the purpose. As the direction of the light has to be changed frequently, it is best to use a movable stand. As it is desirable to use both hands, I prefer to attach the mirror to the forehead. The tubes through which the light is thrown in are supplied with a "bouton," and their interior surface is blackened. The length of the tubes I use is 10, 13, and 16 cm., and the caliber varies-I have used tubes the thickness of which corresponds to No. 16, 18, and 20 Charriere. The tube is introduced after having been dipped in oil, and then the obturator or “bouton" is removed; the light is now thrown in and local applications made. I have used pencilings with copper sulphate as well as with liquids. These instruments were used in the following cases:

1. S., thirty years old; strong, well nourished; works in an office. In June, 1868, he acquired gonorrhea for the first time. The attack yielded to the usual treatment after six to seven weeks. In the spring of 1869 symptoms of gleet became apparent, which subsided after a few months of vigorous treatment, to reappear in acute form on intercourse. Epididymitis developed on the right side. Eventually the discharge ceased again, but in March, 1870, it reappeared. In June of this year endoscopy and local treatment. There were no strictures or tender points in the urethra; the mucosa of the pars membranacea was deep red in color for 6 to 7 cm.; no granulations. Penciled with copper sulphate once, later twice, a week after about eight weeks' definitive cure.

2. V., thirty years old; well and strong; had several attacks of gonorrhea in the four years preceding September, 1870, resulting in a chronic discharge. There was a red area, about 5 cm. long, in the posterior part of the urethra, covered with a whitish discharge containing pus and epithelial cells. After about seven weeks of local treatment with copper sulphate complete cure.

3. Dr. Krenchel permits me to mention a case which he has treated in the same way. Here there was redness near the pars membranacea, as well as over an area anterior to it. The discharge appeared to cease after penciling with solid copper sulphate.

In the cases described copper sulphate was the only local application used. Desormeaux, who uses nitrate of silver solution, 1 : 1, or 1: 2, gives the length of the treatment as two to three months. In my two cases the treatment lasted about two months. Fürstenheim assigns no time limit, but advises the continuation of the treatment even after the mucosa has regained its normal smoothness, so long as there is redness where before were granulations. I found no granulations in my cases. As the "bouton" is removed the patient often complains of a sting at the end of the tube. The copper sulphate does not cause any pain, outside of an insignificant smarting, which passes away after a few minutes. Only once was there smarting on subsequent urination. The patient may go about his work immediately after being treated, and he soon feels that the treatment is beneficial, especially as the discharge soon diminishes. The view obtained of the urethra is sufficient to recognize

redness and small amounts of mucus, though at first the efforts to recognize the conditions of the urethra may not give very satisfactory results. Through the courtesy of Dr. Plum I have been able to compare my instruments with those of Desormeaux. To my surprise I find that one does not obtain so good a view through the endoscope as with the tubes. and mirror. On the other hand, it is easier for the beginner to see the urethra with Desormeaux's endoscope, because the relative positions of the lamp, the mirror, and the tubes are fixed. It is easier to carry in the applicator though my tubes than through the slit in the side of Desormeaux's tube, and also easier to remove mucus for microscopic examination.

The form of the cells in the mucus gives a good indication of the cause, and I believe that treatment may be suspended when the urethral orifice is dry and when the mucus contains fully developed, flat, epithelial cells, with only an occasional smaller cell here and there. I assume that the urethra then is covered with normal epithelium. The sign is better than the disappearance of the redness, because it is difficult to judge accurately of the varying degrees, and as some redness persists for some time after the epithelium is reformed.

ENDOSCOPY OF GUNSHOT WOUNDS*

DURING the Franco-Prussian war just ended it was not possible, as I had hoped it would be, to make observations on endoscopy of gunshot wounds. On the journey out I found that in the larger hospitals, as in Berlin, Frankfort, and Strassburg, there were no patients with wounds suitable for exploration; and when sent by the International Committee in Basle to the battlefield at Bourtaki-Werden, I reached it about three weeks after the battle. In connection with the ambulance which was stationed at Lure, a little town in Haute-Saône, between Belfort and Vesoul, I assumed charge of a division which was established after my arrival, and here I had the opportunity to examine a few older wounds. While I have no results of practical value to present in regard to endoscopy, I wish to report two observations, because they illustrate the use of the method:

1. Louis Gagnol, infantry, twenty-three years old; wounded January 17, 1871, in soft parts on anterior surface of left thigh. He was dressed once a day by the persons in a private lodging-place, and came to the ambulance every third or fourth day. As the suppuration continued freely, as there was no tendency of the openings to close, an endoscopic examination was made March 1st. The entrance was situated 3 inches above the patella, on the inner side of the anterior surface; the canal passed 21⁄2 inches upward and outward, so that the exit was about 5 inches above the patella. Tubes 10 mm. in diameter were easily introduced. Everywhere the canal was covered with large, pale-red granulations, and there was no foreign substance or dead tissue. The examination caused no bleeding, only little pain, and no increase in the suppuration.

2. Louis Guillemot, infantry, twenty-nine years old; wounded January 17, 1871, in the external and posterior part of right thigh. As suppuration continued without any tendency to healing, the wound was examined with the endoscope March 2d. The entrance was in the middle of the posterior surface of the thigh, and the canal passed 21⁄2 inches upward and outward, to a rather large exit surrounded by flabby granulations. The endoscope introduced through the wound of exit showed pus and blood; after removing this the walls were found to be covered with large, pale, flabby granulations. No foreign body. There was but little complaint of pain. No increase in suppuration.

In the fourth and fifth week after the lesions I found the canals of the wounds so narrowed that the tubes could not be introduced, and it seems to me that endoscopy is best suited for fresh wounds.

The observations I have made on older wounds have not given any positive results; that is to say, they have not revealed any foreign bodies, but they do throw light on the practicability of endoscopy, and remove * Hospitals-Tidende, 1871, vol. xiv, p. 77.

some of the objections that might be made against it. The following conclusions may be made:

(1) Endoscopic examination does not present any serious practical difficulties. My colleagues in the ambulance, Dr. Burckhardt and Dr.

Baader, from Switzerland, used the instruments offhand without any previous practice, and they as well as I found (2) that the walls of the wound can be inspected closely and, if desired, treated locally; (3) that the method is not especially painful; that it did not cause bleeding or

subsequent irritation to such extent as to hinder endoscopy of older granulating canals after gunshot wounds.

There is, however, one positive result to be emphasized, namely, the demonstration of the absence of a foreign body where the symptoms pointed to its presence. Consequently the cause of the continued suppuration had to be sought in other directions, such as absence of quiet, general and local conditions, etc., and in this way were secured more definite indications for treatment. It would not be safe to place a com

Fig. 5.

B

Fig. 6.

pressive bandage over a gunshot wound containing a foreign body, but in the absence of any such body, the approximation of the walls of the canal often promotes healing.

While the experiments and observations do not permit of any final judgment of the value of endoscopy in military surgery, I feel at liberty to recommend the method and the instruments to military surgeons for use in suitable cases, in the hope that endoscopy may prove to be of value in the examination and treatment of gunshot wounds.