Dr. R. R. Kime of Atlanta: The Association is exceedingly fortunate in having this subject presented to it in such an able manner. It has been presented in a way to simplify matters rather than to mystify them. A great deal of the work in this line has been such as to mystify the general practitioner in regard to the numberofinstruments that are used in treating diseases of the rectum. Dr. Tuttle has presented the matter in such a simple way that we can all comprehend it, and after hearing this paper and the methods of examination, many of us will be able to do effective and efficient work in the examination and treatment of discases of the rectum. I was glad to hear the essayist make the statement that many rectal diseases can be treated successfully with a few instruments. We know that the gencral practitioner is not able to supply himself with all of the delicate apparatus and instruments necessary for rectal examinations, as has been portrayed by some surgeons. About six years ago I devised an instrument for examinations in the knee-chest position on the principle of ballooning the vagina, and I used it with marked success in the knee-chest position. Of course, a man who is accustomed to making these examinations and treating these cases naturally becomes expert, and if a patient is properly placed in the Sims position the surgeon can balloon the rectum the same as the vagina. When you place a patient in the kneechest position and use a speculum you simply stretch the sphincter muscle, allow air to enter the rectum as it enters the vagina and you will have a plain view of the rectum. A circular instrument will let air enter and give you a good view with a reflected light. With the instrument devised by me the operator can see the posterior and anterior parts of the rectum without reflected light. The tubes described by Dr. Tuttle are admirably adapted to this kind of work, in that the surgeon can detect any pathological condition that may exist higher up in the rectum. I was very glad to hear him mention the usefulness of the ordinary Sims speculum, which nearly all practitioners have, and with variable sizes they can treat a great many patients with satisfaction to themselves and with benefit to their patients.

Dr. J. W. Duncan of Atlanta: I was delighted with the presentation of Dr. Tuttle's paper, and I do not rise to discuss it, but to ask a question with reference to rectal pockets, so often referred to in some of our medical journals, whether he considers them physiological or abnormal, and whether he operates to remove them. These pockets are just within the sphincter muscle.

Dr. Tuttle (closing the discussion): I have very little to say, because I fear I have already taxed your patience in my address. I would like to spend two or three hours in talking to you on the subject of rectal examinations, but I am afraid if I got started I would not know where to stop.

As to Dr. Montgomery's case of perirectal abscess, it would be difficult to say where the abscess originated. If it began in the broad ligament, there ought to be some relation between it and the uterus. I have followed perirectal abscesses up very carefully from time to time, but I cannot say that I ever found one originating from the neck of the uterus; I have found them beginning about the fundus of uterus connecting with and about the rectum. I have found them originating from tubercular coxalgia and Pott's disease; I have found them from the broad ligament, and the most frequent ones I have found connected with appendicitis. I have seen half a dozen abscesses around the rectum that I could trace to the appendix, and they have recovered by drainage down below. My friend, Dr. Paul F. Munde, of New York, says he has cured a number of cases of appendicitis by opening abscesses and draining them through the rectum or perirectal space. It would therefore be presumptuous for me to attempt to state the source of an abscess that I never saw.

In answer to the question of Dr. Duncan, with reference to these pockets or the crypts of Morgagni, they are undoubtedly anatomical and normal pockets. I stated in my paper the necessity and method of examining them. They are there for a purpose, to retain the mucus for lubricating the parts, to assist the action of the bowels, to prevent unnecessary friction about the sphincter, and the indiscriminate cutting of them open or removing them is criminal. It is malpractice. A surgeon has no more right to destroy these pockets than he has to take off a man's leg that is not diseased.

SOME EXPERIENCES IN A COUNTRY PRACTICE.

BY W. L. STORY, M.D., SYCAMORE, GA.

It is not my purpose in reading some of my experiences in a country practice to indulge in any fine-spun theory, or dilate on the etiology or histology of any of the cases that I may mention; but to mention a few of the difficulties that confront the country practitioner, and a few cases that I have had that seemed to me to be of some interest.

When I began the practice of medicine in wire-grass Georgia, eleven years ago, with the exception of one old physician who had moved into that community a year before, there was not another physician within fifteen or twenty miles.

There were several midwives and a few self-constituted doctors, who could put the twisters on an aching molar, bleed a man or horse, and sometimes make a fracture box. It is useless to mention the egotism that midwives and would-be doctors possess, for it is well known to every country doctor.

None but those who have had a country doctor's experience can fully appreciate the difficulties he has in fighting superstition and introducing modern methods of surgery and gynecology; the greatest difficulty is the general illiteracy of the inhabitants. "Where ignorance abounds, superstition doth more abound." A large per cent. of those people look with a degree of superstition on the doctor, and to simplify a remedy or a medical proposition to them costs you your reputation as a physician; they seem to prefer things of a superstitious nature. For instance, there is an old negro woman in my town (a combination of midwife, doctor and hoodoo), who don't know A from B, that does a big practice among both the whites and negroes; tells them that she has been through two colleges, and gives buckshot as one of her remedies, for what purpose, the Lord only knows. We have a holiness or faith-cure idea that disregards doctors or medicine in any form until they get seriously ill. A large number of the country women are overly timid in regard to their ills if they affect the reproductive organs. A higher education is the greatest need among these people.

There are many things possible that the country doctor can do (if he has tact) with a few well-selected instruments and keeping one point in view--that is to keep his instruments and field of operation clean. I amputated a leg with a pocket-knife and carpenter's saw; obtained union by first intention, and the patient was going where he pleased in three weeks. It requires a very few instruments to do a great many things that we do in the country. With one pair of curved scissors, an Emmet's needle, needle-holder and tenaculum, I have made several successful operations for lacerated perineum and sphincter ani muscle; a box of plaster Paris rolls will serve the country doctor's purpose in all his fractures. I mention a few of these things, not becauses I do not admire fine operating-rooms and all the modern advantages that our big institutions have, but for the benefit of the country doctor and his patients who could never have those advantages. There is not an operation that the country doctor can do that will give his patient more pleasure and the doctor more reputation in the community than to restore a lacerated perineum and sphincter ani muscle. It requires a careful technique and one hard to carry out in the country. I use a combination