Algiers, in North Africa, the island of Madeira, are all regarded with favor, though the latter, owing to constant heat and to the implantation of the bacillus, is not so popular as in former years, and Algiers is lacking in suitable accommodations.

The British physicians early recognized the benefits of the climate of southern Africa. Residence in the interior of Cape Colony, and particularly in the Transvaal, which has an elevation of between 5,000 and 6,000 feet, and dry pure air, has proved curative in numbers of cases.

The location selected should be as nearly as possible free from dust, not subject to sudden and extreme changes of temperature, and protected from high winds. It is claimed by many that high altitudes affect patients favorably in more than one way; but it may be stated in brief that the benefit is mainly, if not solely, due to the necessity for more thorough expansion of the lungs for the full supply of oxygen and the complete aeration of the blood. Other advantages, except that the air of mountains, from sparsity of population, is generally free from infectious organisms, are fanciful and unworthy of consideration. Equal advantage may be obtained anywhere by walking up and down hill.

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While good results are obtained by residence mountainous regions, other conditions being equal, it is better to select localities with temperate climates, as of North Carolina and Colorado, in order that the patient may take as much out-door exercise as is compatible with his strength.

A location with some elevation and a dry and equable climate is better, generally speaking, than one having but little elevation, more moisture and greater changes. But persons easily excited, and prone to hemorrhages and febrile attacks do better at points near the sea level and where there is more moisture. Persons with weak or diseased hearts should not be sent to high altitudes.

If possible, it is preferable in all cases to have the

patient occupy a room, hut or tent alone. Two invalids should not be permitted to occupy the same apartment.

The modern plan of placing tuberculous patients in special sanatoria or hospitals is based upon the ideas which have been expressed and upon others equally important, of which the first is the separation of the sick from the well; the second, that the destruction of the bacillus can be more effectually accomplished; and third, that the sufferer can be more systematically fed and treated than in the average dwelling or in a general hospital. The plan has been successfully followed at Saranac Lake in the hospital under charge of Dr Edward J. Trudeau, for a number of years, and has been adopted in many other places in the United States, Germany, England and other countries, and will probably rapidly become general. There are already more than 30 such hospitals in the United States in full operation and several in process of construction. The United States Government has established a hospital at Fort Bayard in New Mexico for the treatment of tuberculosis among soldiers, and the official reports in regard to the results are singularly favorable, bearing out the general impression of the good influences of the climate of the region in which Fort Bayard is located. It does not appear from recent reports from various countries that the location of such hospitals, when properly constructed, if the air is free from impurities (the tubercle bacillus included), is a matter of consequence. A high and dry locality is to be preferred, but with proper regulations in regard to diet, cleanliness, dress, air and out-door exercise patients seem to do as well in one place as another.

While it is important that the patient should be required to take as much muscular exercise as his strength will permit, fatigue should be avoided.

Sleep is as important an element of the treatment as exercise. Patients, until they have regained strength, should spend from 8 to 10 hours of the 24 in sleep, or at least in bed. The advantages claimed for high localities are

in a measure balanced by the difficulty which many experience, especially those who are anemic and neurotic, in such localities in obtaining sleep. In the Denver Medical News (June, 1900), Dr J. T. Eskridge published an analysis of the relation of the climate of Colorado to sleep in the acclimated and in the unacclimated. In his summary he states that although people of regular habits have continuous and refreshing sleep, those or irregular habits sleep badly and are more depressed than at the sea level. "Slight disturbances affect the sleep to a greater degree than at sea levels. Less time is required to be devoted to sleep in Colorado (just why, Dr Eskridge does not inform us). In people who are mentally over-worked the sleep is broken and less refreshing and shorter than at lower altitudes. Persons of nervous tendencies do not sleep well unless they avoid excessive physical exercise. Neurasthenics are troubled with disturbed sleep unless they have an abundance of physical and mental rest, thus avoiding all things that disturb the mind and digestive organs. Tuberculous subjects sleep well if they avoid over-exercise and as their nutrition improves. The unacclimated tourist who exercises freely suffers from disturbed sleep. Among nervous subjects the unacclimated is especially irritable and his sleep disturbed. Unacclimated tuberculous subjects sleep worse unless precaution is taken to lessen the usual amount of exercise." In order to secure unbroken sleep the room should be well supplied with pure air. The temperature should be such as is agreeable to the patient. The bed should be a hair mattress, and the covering should be sufficient but neither too thick nor too thin.

Circumstances permitting, a tepid sponge-bath before retiring, which many tuberculous subjects avoid from the impression that they are more liable than other persons to take cold, greatly promotes comfort and the probability of sound sleep. The bath may be repeated at the hour of rising.

Strict attention should be given in every case to the

condition of the digestive organs, so frequently disordered in tuberculosis, and the diet should be nourishing, prepared in palatable shape and regulated in quality and quantity to suit existing conditions.

The clothing should be comfortable, neither too heavy nor too light. Changes should be made to suit variations in temperature, and a complete change should be made at night.

It is gratifying to note the rapid improvement in health which occurs under the course which has been described; when it fails the office of the physician becomes, as Voltaire wrote, "a melancholy attendance upon misery," too often aimless, and always hopeless.

CHAPTER IV SURGERY

A Case of Acute Tuberculosis of the Peritoneum By DUDLEY P. ALLEN, M. D., Cleveland

A single case of tuberculosis of the peritoneum would scarcely seem worth reporting, but the unusual character of the one which I am about to describe is so unique as to warrant a short report. The special points of interest in the case are the rapid development of the symptoms and the resemblance which the case bore to appendicitis. The young lady, 19 years of age, had ordinarily good health, although she was not robust. During the winter of 1901-2 she had been attending school. In the last of March she says that she had had some chilly sensations, afterwards had felt a little feverish and had had also a slight cough, but the symptoms were not of sufficient severity to keep her from her regular school work. On account of these symptoms she visited her physician, and he had examined her, but found nothing serious. No trouble of any kind was found in the lungs. The physician gave the patient a tonic, and after a few days she reported herself well, the cough having entirely ceased.

On April 15, 1902, at 9:30 a. m. the patient went to her classes. While in class she had a feeling of chilliness, but remained in class until 11:30. Her physician, Dr Jameson, of Oberlin, was called to see her at 3 p. m. She complained of some abdominal pain, which was general, but in the evening she referred this to the right iliac fossa. At this time the doctor telephoned to me and arranged to bring the patient to the hospital, a distance of thirty miles, the next morning.

At the time of admission to the hospital the patient's