stomach. Our first procedure is to give him a tumbler full of warm water in which has been dissolved 1 dram of sodium bicarbonate. We request him to drink all of it, hoping that one of two things will happen: either that the pyloric sphincter will open and the stomach empty itself into the small intestines; or that it will act as an automatic lavage by a complete emptying of the stomach into a pus basin. In a great majority of obstinate cases this simple procedure will suffice and the patient goes on to convalescence without further difficulty. Occasionally, the patient vomits in spite of this treatment, and it becomes necessary to institute further measures. We repeat the above measure before resorting to the stomach tube. If vomiting persists after the second automatic lavage, then the stomach tube should be used without further delay. We do not hesitate to use it after any type of abdominal section, including a resection of the stomach. In the latter type of case it should be passed with great care, it should not be inserted so far as in those cases where the stomach is not operated upon, and less fluid should be instilled. Ordinary water at a temperature of 110° F. containing a dram of sodium bicarbonate to the pint is an ideal fluid to use in these cases. The lavage should be continued until the fluid that returns is clear, care being taken that the amount of fluid recovered each time is the same as the amount instilled. The continued retention of a large amount of fluid may cause a rupture of the gastric suture line. DISTENTION. The proper application of adhesive straps will allow for a moderate amount of distention without discomfort. If, however, the patient is distinctly "blown up," then measures should be immediately instituted to relieve him. Our first step in this direction is in the insertion of a rectal tube. If this is properly inserted beyond the internal sphincter, it frequently allows the painless passage of gas. (If the patient is still receiving protoclysis, the latter is temporarily discontinued.) Failing in relief by the use of the rectal tube, we resort to one of. the various enemas. Those mentioned below are all eminently satisfactory: Soapsuds enema-1,000 cc. water at 110° F. thoroughly mixed with soapsuds. Milk and molasses enema-1 pint of milk and 1 pint of molasses at 95° F. Ox-gall enema-2 ounces of ox-gall, 2 ounces of glycerine, 2 ounces of turpentine, 1 pint of soapsuds, at 110° F. Alum enema-2 ounces alum sulphate, 1 pint of water, 110° F. Ward enema-2 ounces saturated solution magnesium sulphate, 2 ounces glycerine, 3 drams turpentine, 1 pint soapsuds, at 110° F. When, after operation upon the colon, an enema is necessary, not more than eight ounces of any fluid should be used at one time. Frequently an ox-gall enema will give an excellent result. ACUTE DILATATION OF THE STOMACн. When this unfortunate complication occurs gastric lavage is the only treatment of any real service. The patient's stomach should be kept empty of fluid and gas, even though it be necessary to lavage it every hour. Frequent change of position to the right lateral or knee-chest may be of some benefit. Pituitrin or eserine given intravenously are of questionable value.-The Trained Nurse and Hospital Review. PROBLEMS OF HOSPITAL STANDARDIZATION 1 wish to apologize for choosing such a shopworn subject as Standardization of Hospitals, but I justify my choice by the fact that I have never before written anything on the subject and that every hospital head must be guilty of at least one article upon this important matter. There has been much in the literature upon this subject. Most of the articles have been editorials, and few have given practical ideas as to how standardization can be accomplished, and what shall be the actual basis of the standardization. I shall first deal with some of the hospital conditions in North Carolina, and then I shall make some suggestions for a basis of standardization. Eighty per cent. of the North Carolina hospitals are privately owned and conducted. This fact speaks handsomely for the professional pride, ambition and ideals of our physicians. The counties and cities have been slow to build hospitals, but our physicians have said, "We will go forward." Every private hospital represents a magnanimous gift to the community by some philanthropic physician. It also represents the very best there is in medicine, where some man with ideals is striving to do something and do it right, and so it will stand out, knowing that his institution will be just what he makes it, and that the character of the hospital and the character of the work turned out represents the character and ability of the man. Therefore we have a great percentage of hospitals in North Carolina that invite standardization and are willing and ready to meet any reasonable requirement. tax. Every city and county should feel honor-bound to assist every private hospital where there is no public hospital. First: The State should give the hospitals the legal machinery for the collection of all hospital fees. Second: The county and cities should guarantee the physicians conducting a hospital a reasonable remuneration for the care of the poor. Third: Every city and county should extend to every hospital, free water, free light, and exemption from This would not enrich the doctor in charge of the hospital as the selfish would think, but it would enable him to have an up-to-date equipment, and such professional and trained help as would enable him to conduct the type of hospital which the public demands, but does not wish to help. At the Mary Elizabeth Hospital, this would secure a full time pathologist, and purchase one thousand dollars' worth of extra equipment every year. With this simple aid I am sure practically every private hospital in the State could meet the most rigid requirements of standardization. In all the public hospitals of the State as far as I know, the staff is elected or appointed, and the element of politics blunts the efficiency and supplements the necessity for study. All public hospitals should select their staff by competitive examinations, and these examinations should be open to all physicians in the county or city, according to classification. This would insure study, promote scientific attainment, and create a spirit of progressiveness, and give the positions to those who by virtue of their proficiency best merited them. This would mark a great step forward in developing real physicians, and would place the honor where honor is deserved, and would insure to the city and county physicians a parallel inspiration to that of the physicians who conduct private hospitals. Every physician in every city then would have a goal to work for. The man who then would hold a position on the staff would have to work to hold it, and the man who wanted it would have to work to get it. There has been a tendency during the last few years to discharge patients too early from the hospital. Sufficient time is not allowed for proper healing of incisions and for new created conditions to adjust themselves. To quote Dr. Stewart McGuire, "This is partly due to improved results, but also influenced by a desire to advertise the surgeon, to make the patient more willing to consent to an operation, to increase the number of cases cared for by a ward of limited capacity, and finally to lessen the money paid to the hospital so, there may be more left for professional services." Many excellent operations are wrecked after leaving the hospital, and this practice brings surgery and hospitals into disrepute. Every hospital should have the right of some degree of autopsy of cases dying in it. Legislation should be enacted giving such rights, for there is nothing that will reveal the pathology like autopsies and nothing will give physicians greater insight into their errors. It would also have a tendency to make them more careful in their diagnosis and care, and cause greater study anti-mortem. The American College of Surgeons have never given a definite rule for standardizing. Their rules are very general. No exact specifications have been given. An inspector visits the hospital and one does not know when he leaves where the hospital stands. There should be a definite programme, so that it will be known before the inspector comes that the hospital is complying with and meeting every requirement. They have formulated a working rule for the medical colleges, and the hospitals should insist upon the same. To standardize hospitals, two things must be considered. The hospital equipment, and the class of work done. Let us take up first the hospital equipment. The equipment of a hospital should be graded on a scale of 100, dividing the hospital into ten divisions, allowing operating department 15 points, laboratory 15 points, X-ray department 15 points, examining department 15 points, obstetrical department 10 points, wards 10 points, kitchen and serving 10 points, laundry 5 points, and post-mortem and pathological rooms 5 points. Then each department should be graded upon a basis of 100. The operating room should be allowed 10 points for adequate sterilizers, 10 points for etherizing apparatus, this to include gas outfit, etherizing outfits, and local anesthesia outfits such as Dunns, 10 points for lung motors and resuscitation outfits, 20 points for radium, 10 points for transfusion outfits, 10 points for adequate instruments, 10 points for adequate tables and stands, 10 points for modern accessories, such as cautery, suction apparatus, and bone drills, and 10 points for modern rooms. The X-ray department should be marked 40 points for X-ray and tube, 10 points for cassets, 10 points for Bucky diaphragm, 20 points for fluoroscope, 10 points for modern developing outfit, and 10 points for accessories. This scheme should be carried out throughout each of the ten departments. Each department should be thoroughly inspected and graded. If the total figure is 80 the grade of the hospital should be A. In my opinion this is the only way to fairly grade a hospital's equipment and arrive at an accurate conclusion. Second: The class of work done. This will show what use is made of the equipment and should be based on a scale of 100, allowing 60 points for records, 10 points for monthly staff meetings, 15 points for monthly reports, 10 points for filing system, and 5 points for literary contributions. If these items show a grade of 80 per cent. the hospital should be classed A as to work. I shall not devote much space to staff meetings, filing system, literary contributions, and records, except to say that an accurate detailed record should be kept and should always include comments and conclusions on the case. Any record that shows an operation or treatment that does not set forth the reasons and indications for operation or treatment is a very poor record. Each hospital of the State should be required to get out a monthly report on a sheet prescribed by the organization, setting forth its monthly work and upon this report the hospital should be graded and its standing maintained. This monthly report should represent the real work and results of the efforts of the hospitals. It would determine the character of the work done, and would determine if an A hospital was doing A work, or B work, with an A or B equipment. To make up a hospital report, we must standardize the reports, and to do that many things must be considered. One is, how should deaths be reported? Shall we report cases as |