[From the Medical and Surgical Reporter, 
February 14, 1891.] 
CLIMATIC TREATMENT OF 
PHTHISIS.1 
BY J. P. CROZER GRIFFITH, M. D., 
PROFESSOR OF CLINICAL MEDICINE IN THE PHILADEL- 
PHIA POLYCLINIC ; PHYSICIAN TO ST. AGNES 
AND THE HOWARD HOSPITALS, AND TO 
THE RUSH HOSPITAL FOR CON- 
SUMPTIVES. 
That change of climate is one of the best 
-and sometimes the only-means of suc- 
cessfully treating phthisis is so universally 
admitted that it seems almost unnecessary 
to make mention of it. There are, never- 
theless, certain details regarding it, which it 
may be not without interest to pass in re- 
view. For centuries this method has been 
in repute. The Romans used to send per- 
sons with ulcerated lungs to Libra that they 
might there inhale the balsamic odors from 
the pines ; and Galen advised that phthisical 
patients be sent to localities in which the air 
was dry. 
Even those who write upon the Home 
Treatment of consumption, admit the value 
of climatic treatment where it can be car- 
ried out. It goes of course without saying 
that the vast majority of phthisical patients, 
owdng to pecuniary or other disability, can- 
not be sent away from home. The all-im- 
1 Read before the Philadelphia County Medical 
Society, January 28, 1891. 2 
portant subject of the means to be employed 
for the recovery of health in these, I cannot 
now treat, but must confine myself strictly to 
the subject of the influence of climate upon 
the disease. 
I am myself so thoroughly convinced of 
the value of climato-therapy in phthisis, 
that were I assured that 1 had incipient 
phthisis, however slight, neither inhalations 
of oxygen, nor the use of compressed or 
rarified air, nor the breathing of hot air, nor 
enemata of foul air, nor trial of Koch's in- 
oculations, nor pulmonary gymnastics, nor 
the ingestion of cod-liver oil, iron, arsenic, 
digitalis, creasote or any other drug should 
prevent me-if in any way I could compass 
it-from leaving a climate such as this for 
some more propitious one'. And yet there 
are the sceptical-there always are, of every 
good thing. Let me, however, give you as 
samples, the histories in brief of two cases 
which were sent to parts of the world far re- 
moved from here and from each other :-the 
Austrian Tyrol and Colorado. They occur 
to me because I have heard from each of 
them within a short time. The first patient 
developed apical phthisis some five or six 
years ago. Being a man of means he trav- 
eled, chiefly to various parts of the eastern 
United States, remaining in each place but 
a short time and returning again home. 
While away he improved, but always lost 
again on coming back, Finally his cough 
grew worse, there was slight hemoptysis, and 
examination showed decided depressions at 
the left apex with dulness on percussion, 
bronchial breathing and rales. I sent him 
to Meran in the Austrian Tyrol, where he 3 
remained for over a year. On his return I 
was astonished to discover that the dulness 
on percussion, the depression and bronchial 
breathing had entirely disappeared ; leaving 
nothing but a few rales. An improvement 
such as this had not been effected by all the 
medicinal and hygienic treatment to which 
he had been previously subjected. I told 
him, however, that he had returned too soon, 
and the event proved the truth of this. He 
was shortly after returning, debilitated by 
a very severe attack of herpes zoster, and 
the subjective and objective symptoms of the 
phthisical affection returned in full force by 
the end of a year. He has again gone to 
Meran, where he now is, and is doing re- 
markably well. He has no cough at all, and 
only slight expectoration on rising in the 
morning. Can he be induced to remain 
sufficiently long, I have no doubt of his com- 
plete recovery. 
The other patient is himself a physician 
from a neighboring city. He called upon 
me last July on account of obstinate cough, 
with loss of weight and strength, which 
drugs, rest and a temporary mountain so- 
journ had failed to relieve. He suspected 
phthisis, and wished to have a diagnosis 
made. Neither bronchial breathing nor im- 
pairment of percussion resonance could be 
detected, but there were a large number of 
rales at the left apex, and a few on the other 
side. Tubercle bacilli were present in the 
sputum. I told him there was no doubt he 
had incipient phthisis, and advised him by 
all means to go to Colorado and begin the 
practice of his profession there as soon as 
he felt able. He did so, and wrote me the 4 
other day, saying that he had gained 22 lbs., 
but asked my advice about coming on to 
take the Koch treatment, as he did not be- 
lieve that he was yet quite cured. My 
answer can be readily imagined. But cases 
like these are known in numbers to all of 
you. Only recently one of the members of 
this Society told me that, visiting in Den- 
ver recently, he sat down to dinner with, 1 
think, fifty men, all of them as hale and 
hearty as one could wish to see, though all 
or nearly all of them had gone West on ac- 
count of trouble with the lungs. 
Now as to the way in which climate can 
act in curing phthisis. If it is the fact, as 
most of us certainly firmly believe, that 
phthisis is the direct result of the growth of 
the tubercle bacilli in the lungs, the ques- 
tion naturally arises how climate can in any 
way affect the growth of these organisms 
after they have once found a nidus in the 
system. This question cannot be answered 
with positiveness. One matter bearing upon 
it is, however, nearly certain. It would 
seem probable that the only reason that 
all of us do not take the disease is that, 
either from the good condition of the gen- 
eral health, or from some peculiar, unsuit- 
able state of the respiratory tract, the bacilli 
which we all probably inhale at times, do 
not find in certain individuals the conditions 
suited for their development. Given, then, 
a patient with pulmonary phthisis, our ef- 
forts must be to render the lungs again of 
such a quality that bacilli already present 
can no longer thrive and multiply. It seems 
beyond question that certain climates have 
the power of accomplishing this desideratum 5 
in some way unknown to us, but certainly 
more effectively than any other known 
agent. What peculiar climatic features they 
are which have this power is, as yet, not de- 
termined with definiteness. The most gen- 
erally accepted view is that high altitudes, 
as a rule, are inimical to the development of 
phthisis, and conducive to the recovery of 
those already affected ; while a low eleva- 
tion above tide-water, especially if combined 
with dampness, continued high temperature, 
or frequent changes of temperature, favors 
its development. Particularly are writers 
almost at one in reference to the favorable 
action of high altitudes. Phthisis is of rare 
occurrence, for example, in the high moun- 
tain cities of Mexico, in spite of the unfav- 
orable influence exercised by the bad hygiene 
and the employment of the inhabitants 
largely in mines. 
The disease is almost unknown in the 
high plateaus of South America, and rare in 
the high portion of the western United 
States. Switzerland is, on the whole, re- 
markably free from it, and it is very rare in 
the highlands of upper Egypt. In the 
western Highlands of Scotland, too, it is 
uncommon as compared with other parts of 
the British Isles. 
It is not yet definitely understood whether 
the immunity of the dwellers in high alti- 
tudes is due to the low barometric pressure 
or to the purity of the air. The view has 
not found favor that it is in any way con- 
nected with the greater depth of the respi- 
ratory act; nor does the statement that 
microbes live with greater difficulty at a 
high elevation satisfactorily explain it. That 6 
the influence of high elevation is not due, 
at least entirely, to the low barometric pres- 
sure seems probable; since, as is well known, 
prolonged sea voyages are often of great 
benefit to phthisical patients. Moreover, 
some islands, as Iceland and the Hebrides 
and Shetland Islands, are singularly free 
from the disease; and the Kirghis enjoy an 
absolute immunity, although they inhabit 
steppes only 100 feet above sea level, 
It has been long assumed that odors of 
turpentine and allied substances coming from 
pine forests were of value in the treatment 
of phthisis, and it has been claimed that to 
this factor sojourn in the Adirondacks owes 
the undoubted advantages often exercised 
by it in many cases of phthisis. There are 
clearly, however, other important factors; 
since otherwise all regions filled with these 
woods should exert the same favorable influ- 
ence. Yet there are many such districts- 
as Maine-where the mortality from phthi- 
sis is high. One might argue that the mor- 
tality in such places was the result of too 
great a degree of dampness ; but in answer 
it may be noted that many islands, as already 
stated, where the air is, to an extent, damp, 
suffer but little, if at all, from phthisis. In 
fact, the prevalence of the disease does not 
seem to be connected with any geographical 
position or condition of temperature. 
Our knowledge in this regard may be 
summed up by saying that change of climate 
is very often of the greatest benefit to phthis- 
ical patients, and that, as a rule, this ben- 
efit seems to be intimately associated with 
elevation above tide-water, though there are 
many localities with no considerable alti- 7 
tude where a good effect is often exerted 
upon the disease. 
It will repeatedly be observed that the 
relation of a patient to a certain climate is 
very much like that which exists, or should 
exist, between a man and his wife. Just as 
one man finds in his wife's character and 
disposition that which entirely satisfies his 
moral nature, while his neighbors, perhaps, 
can see no good in her at all; so one phthis- 
ical patient may thrive in a certain locality, 
while the next patient, with lungs in appa- 
rently the same condition, is never comfort- 
able there, and suffers a continual deteriora- 
tion in health. 
It is this fact which renders the matter of 
choice of climate so exceedingly difficult. 
It is impossible entirely to determine the 
nature of what might be called climatic 
idiosyncrasies in patients. We are, there- 
fore, obliged, in the choice of a climate for 
a patient, to follow certain general rules. 
First is to be investigated the individual 
susceptibility to cold and heat respectively. 
We must carefully inquire whether the pa- 
tient is always chilly in winter, or whether 
he is exhausted and depressed in summer. 
It seems to me to be folly as well as cruelty 
to compel an anemic, emaciated individual, 
who is always chilly and whose circulation 
is feeble at the best of times, to spend a 
winter in a cold, bleak, windy, northern 
elevation. While the Adirondacks in winter 
are certainly of benefit to many, it would 
seem almost proved that they cannot but 
disagree with others; in fact, experience 
proves that they do. On the other hand, 
there are many patients to whom even the 8 
early spring warmth of Florida is invariably 
depressing, and who reap no benefit from 
sojourning there. It is, after all, hygiene 
throughout which we must keep in mind, 
and not merely the effect of a certain cli- 
mate upon the lung alone, as though it did 
not belong to the body. 
Another factor of some importance in se- 
lecting a locality is a knowledge of the 
diurnal range of temperature. The annual 
average temperature, and the average for 
each month, can usually be ascertained 
without difficulty for the more frequented 
health resorts, but the daily variation is not 
so easily to be learned; and yet it is on just 
this factor that the comfort of the patient 
may depend. A perfectly equable temper- 
ature is certainly of great advantage. Un- 
fortunately it is not so apt to be found with 
dry air and elevation above the sea as it is 
at lower regions. Although elevation is, as 
a rule, much the most important, yet in 
some cases it will appear best to select the 
sea on account of the smaller diurnal tem- 
perature range. 
Still another matter is the nature of hotel 
accomodations and other creature comforts ; 
and this has to be considered most carefully 
in reference to the individual. Though a 
strong man with beginning phthisis, which 
has had but little effect upon his general 
health, may do well if sent to a region where 
he will spend his days in the saddle and his 
nights in the open air ; it is clear that, for 
women and many male patients, no such re- 
gimen can be prescribed. 
Patients want to know all these and simi- 
lar details before leaving home, and it is 9 
well if the physician can help them in this 
respect. In many cases, however, circum- 
stances prevent more than the pointing out 
of a general plan of action ; especially as 
the number of places recommended as health 
resorts in phthisis is so large. 
Individuals, with beginning phthisis, who 
are unwilling to make a radical change; or 
in whose case the physician does not deem 
it expedient, might seek Florida in winter, 
returning northward in the spring by slow 
stages, stopping en route in Georgia and 
North Carolina. In the summer some moun- 
tain resort should be selected, preferably the 
Adirondacks. There are, nevertheless, 
weighty objections against this course. It 
is very difficult to return North without feel- 
ing the bad effect of the change of temper- 
ature ; while a still greater objection is that 
the length of time, during which this con- 
tinuation of travel must be persisted in, is 
too great for the patience of the invalid, 
thus kept so near home and occupation, and 
yet debarred from them. I have, however, 
seen cases, presumably of phthisis in its 
earliest stages, apparently entirely cured by 
a short absence from home in some such 
manner as this. It might be well in some 
instances to begin treatment in this way; 
but if the physical signs are well marked, 
only the shortest trial should be given to 
this plan, as valuable time may be lost there- 
by. These more advanced cases, if in fairly 
good condition, and offering good hope of 
final recovery, should at once be subjected 
to a radical change of climate-either for an 
indefinite period, or for life. 
The question whether a station in the 10 
mountains or at the sea level is to be se- 
lected must be decided to some extent in 
accordance with the idiosyncrasy of the pa- 
tient, as far as this can be. determined in 
advance. As a rule, a mountain resort is 
far preferable and should be chosen when- 
ever practicable. Statistics certainly show 
that the results in the mountains are better. 
Our own country offers several excellent 
localities for phthisical patients. Of all of 
them perhaps the high altitudes of Colorado 
are to be preferred, since here can be found 
comfortable accommodations combined with 
pure, dry air and high elevation. In the 
" Parks" of this State we find table-lands of 
10,000 feet elevation above the sea, pro- 
tected by surrounding mountain peaks, and 
with an annual range of temperature less 
than in the Eastern States of the same lati- 
tude. Sudden diurnal changes do occur, it 
is true, but to no greater extent than in all 
elevated regions. The rainfall is, also, very 
slight. It has been stated that the dust 
prevalent as a result of this is irritating to 
the respiratory tract; but this is denied by 
those who have accurate knowledge in the 
matter. In spite of the thousands of phthis- 
ical patients who'frequent the State the 
death-rate from consumption is very low. 
New Mexico and Arizona offer somewhat 
similar advantages in the way of climate ; 
but the facilities for living are not so great. 
'Phe summers, too, are apt to be very hot. ' 
There are localities in Texas, too, which are 
excellent. 
Southern California presents many ad- 
vantages, not the least of which is that 
patients can easily vary their elevation from 11 
that of the sea level to a considerable moun- 
tain height, according to the different sea- 
sons of the year, and to what is found to 
best suit their health. 
Florida is not so favorite a resort as for- 
merly, and physicians preferring high alti- 
tude will not, of course, recommend it at all. 
Phthisical patients in Europe can make 
choice from a large number of summer sta- 
tions, all equally good, or can go from one 
to the other as fancy dictates. A winter 
one may be chosen in like manner. The 
passage from one to the other may be made 
gradually by means of intermediate stations 
whose climate is midway between that of the 
others. 
Nowhere does the climatic idiosyncrasy 
come into play more than in the choice of 
quarters in Europe; what suits one patient 
for winter, for example, being entirely too 
rigorous for another. For summer time 
there is, as a rule, probably no better place 
than the high valleys of Switzerland, and 
prominent among these is the Engadine val- 
ley. This valley, however, is scarcely free 
from snow before the middle of June or the 
first of July, and becomes cold early in the 
fall; so that, as a pure summer resort, it is 
not long tenable. It is also subject in sum- 
mer to cold and disagreeable winds. In 
spite of this it is unexcelled by other locali- 
ties for the climatic treatment of phthisis. 
Davos-Platz also enjoys a similarly good 
reputation. The neighborhood of Zermatt 
also fills the requirements of elevation and 
coolness during the hotter summer months. 
There is no difficulty in choosing among a 
number of other places equally well adapted. 12 
Lower valleys may be selected if the summer 
is unusually cool, but the higher elevations 
are much to be preferred, as far as freedom 
from phthisis is concerned. Farther east 
there are various resorts in the Dolomite re- 
gion which are highly recommended. There 
are numerous other places throughout the 
mountains of Germany, but for American 
patients Switzerland and the Tyrol offer 
every advantage to be derived from climate, 
while they possess other desiderata not to be 
found elsewhere. 
For early summer and early fall other lo- 
calities than those mentioned are to be pre- 
ferred. The choice of such a station is a 
rather more difficult matter. Some of the 
lower portions of Switzerland may be se- 
lected ; as Interlaken, the neighborhood of 
Lucerne, and the shores of Lake Geneva. 
Probably the latter situation is the best. 
Vevey and Montreux form here excellent 
intermediary stations. Ischl and Reichen- 
hall, in Austria, are also recommended, and 
the Black Forest, in Germany, presents many 
attractions. One station which offers in 
some respects peculiar advantages as an in- 
termediary station is Meran, in the Austrian 
Tyrol. It is beautifully situated and shel- 
tered from the winds; and patients are able 
to spend a great deal of the time in the open 
air. 
Finally, as to the choice of a winter sta- 
tion. For weakly individuals who shun any 
degree of cold or variation of temperature 
it may not seem best to select an elevated 
station. For such the south of France, the 
south of Italy, Sicily or the Riviera, have 
long and justly been popular. Or the pa- 13 
tients may pass from Europe into Egypt, 
Algiers or Morocco. But for uniformity of 
temperature and of barometric pressure 
there is probably no place known equal to 
the Canary Islands. Madeira, once so pop- 
ular, has fallen off greatly in general favor. 
For a large number of phthisical persons a 
dryer, colder and more bracing climate at a 
greater elevation is more suitable, even in 
winter. For these Meran is eminently 
adapted, provided only a moderate degree 
of cold is desirable. The sunshine here is 
always quite warm, and patients are able to 
sit out of doors in it the greater part of the 
day. 
Still more popular have the Engadine 
valley and Davos-Platz become, even as win- 
ter stations. The cold, it is true, is severe, 
but it is dry cold, and the unpleasant, raw 
winds of summer are absent at this period 
of the year; while the thermometer in the 
sunshine registers high, as is usual in all 
climates of high altitude. 
It is to be borne in mind as an inviolable 
rule, that such a climate is to be selected 
either for summer or winter, as will allow 
the greatest amount of exercise in the open 
air with the least discomfort to the patient, 
and with the greatest advantage to the gen- 
eral health. 
What has been said is but the briefest and 
a necessarily incomplete outline for govern- 
ing the choice of climate for the patient. A 
few words must be added on what might be 
called the choice of the patient for the cli- 
mate. 
There has existed a wide-spread prejudice 
against high altitudes in cases of decided 14 
tendency to hemoptysis. This prejudice is, 
in the opinion of the best authorities, un- 
warrantable. Patients with this tendency 
are perhaps even safer in the mountains 
than at the sea level. The cases most suited 
for climatic treatment of any kind-as, in- 
deed, for any other method-are those with 
but slight infiltration, with but few symp- 
toms of the disease, and with strength suffi- 
cient to permit of abundant exercise. These 
patients should, as a rule, be sent to high 
altitudes for summer, and very probably for 
winter also. Other cases with a greater ex- 
tent of pulmonary lesion, and with a less 
degree of strength or of resistance to cold 
will probably need the lower, warmer win- 
ter resorts, followed by the intermediary 
stations, and these again by the highest 
elevations for the summer months. In a 
still more advanced stage of the disease, 
especially where there is much elevation of 
temperature with severe subjective symp- 
toms, the patient is not in a condition to 
stand much traveling nor to take much exer- 
cise. In such cases cold situations are out 
of the question. A warm, equable climate 
is to be chosen, and the nearer home the 
better. If improvement take place a more 
mountainous locality should be sought as 
soon as possible. The existence of fever is 
not, however, per se a contra-indication to 
high altitudes. It has often been observed 
that patients lose all fever soon after reach- 
ing the mountain resorts. Nor is the pres- 
ence of a cavity a contra-indication in the 
selection of high elevations, provided the 
lung is not evidently rapidly breaking 
down. Cases which are very far advanced 15 
and evidently hopeless should not, of course, 
be sent away at all : for only a hastening of 
the final end of the disease can come to the 
• patient, with disappointment to the family, 
and reproach to the physician. It should 
be further clearly explained to patients, in 
whatever stage the disease is, that change of 
climate is not an infallible cure, and, fur- 
ther, that with it must be conjoined all 
other necessary hygienic and dietetic meas- 
ures, together with the employment of such 
medicinal agents as are indicated by the 
disease. 
[The author would acknowledge his in- 
debtedness to the writings of a number of 
authors, to whom no direct reference has 
been made in the text. Among these are 
the following: Wanderings in Search of 
Health, H. C. Taylor, 1890 ; Phthisiology, 
G. A. Evans, 1888; Climate and Health 
Resorts, Burney Yeo, 1890; Treatment of 
Disease by Climate, by Hermann Weber, in 
Ziemssen's Hand-book of General Therapeu- 
tics ; Etiology, Diagnosis and Treatment of 
Tuberculosis, H. V. Ziemssen ; Articles by 
Shattuck, Loomis, Solly, Westbrook, Platt, 
Gihon, Curtin, Knight, Bowditch, Bruen 
and others in the Transactions of the Amer- 
ican Climatological Association; Ruehle, 
Article on "Consumption" in Ziemssen's 
Hand-buch der spec. Path. u. Therapie.~\