The Jeremiah Metzger Lecture: Jeremiah Metzger and the Era of Heliotherapy

“… soft! What light through yonder window breaks? It is the east, and Juliet is the sun! Arise, fair sun, and kill the envious moon…” Shakespeare W. Romeo and Juliet, Act II, Scene II.

The sun has been a central factor in human existence, iconography, as well as a variety of religions in ancient Egypt, Indo-Europe, and Meso-America since the beginning of recorded or archeologically defined history (1−4). That this should be so is not surprising since human beings are dependent on the sun to warm the environment where they live and to grow plants for sustenance. Archeological exploration in the Middle East has shown that sun worship dates back to at least the 14th B.C. in Egypt. Indeed, the Egyptian god, Ra, was identified with the sun and was believed to be the dominant force among the high gods. Civilizations with well-developed urban centers and a powerful ruler often developed ideological beliefs with the king as the sacred image of the sun on earth. This tradition of the king as a metaphor for the sun has been carried down into modern historical times with Louis XIV of France calling himself the Sun King.

Given the deep-seated nature of sun worship and mythology throughout the world, it is not surprising that medical practitioners would embrace sunlight as a healing and restorative element in the management of illness. Although folk medicine probably recognized sunlight as a therapeutic force for millennia, the first scientific writings concerning the benefit of sun therapy, so-called heliotherapy, emanated from the investigations of the Danish Nobel prize winner Niels Ryberg Finsen (5−7). This clinical scientist was born on the Faeroe Islands, a small collection of wind swept isles located in the North Atlantic between Denmark, Norway, and Scotland. Niels Finsen graduated from the medical school of the University of Copenhagen in 1890. By 1893, he had become interested in the potential use of sunlight to heal illness.

Finsen was plagued by poor health his entire life. He suffered from a rare condition known as Pick's disease, an unusual form of polyserositis that eventually leads to pericardial and peritoneal fibrosis with resulting constrictive pericarditis, ascites, and low cardiac output. Finsen's poor health and restricted functional capacity led him to consider sunbathing as something that might help his illness and restore some of his limited energy. In 1893, following some observations in animals, Finsen wrote of his musings concerning the use of sunlight for his own illness:

My disease has played a very great role for my whole development…The disease was responsible for my starting investigations on light: I suffered from anemia and tiredness, and since I lived in a house facing the north, I began to believe that I might be helped if I received more sun. I therefore spent as much time as possible in its rays. As an enthusiastic medical man I was of course interested to know what benefit the sun really gave…I collected all possible observations about animals seeking the sun, and my conviction that the sun had a useful and important effect on the organism became stronger and stronger…My intention was even then to use the beneficial effects of the sun in the form of sun bathing or artificial light baths, but I understood that it would be inappropriate to bring it into practical use if the theory was not built upon scientific investigations and definite facts [italics my own — JSA]. During my work towards this goal I encountered several effects of light. I then devised the treatment of smallpox in red light (1893) and further the treatment of lupus vulgaris, [TB of the skin — JSA] (1895)…During the last few years, I have, however, become convinced that it does not help to wait until I find the answer [scientific reasons underlying the clinical observations — JSA] I am looking for in the laboratory, but that it is justified to work also with clinical experiments. Thus, both approaches can be carried out simultaneously in the effort to reach the final goal.” [italics my own — JSA] (5,8).

Thus, it is clear that Finsen's own observations in animals and on himself led him to develop heliotherapy for two skin conditions, smallpox and tuberculosis of the skin. The dermatological lesions of both conditions responded to natural sunlight exposure in Finsen's early experiments. Subsequent observations revealed that smallpox lesions could be ameliorated with filtered artificial red light and that lupus vulgaris lesions responded to filtered blue light. The artificial light source used by Finsen was carbon arc lighting. In a country as far to the North as Denmark with its limited supply of natural sunlight, it was natural that Finsen would seek an artificial source of light for his heliotherapeutic endeavors (5). His successful laboratory and clinical experiments resulted in a number of important publications that led to widespread interest in Finsen's work. The Royal Family of Denmark and the government were introduced to Finsen and his observations resulting in considerable financial and social support for his work. A light therapy institute was established for Finsen and his colleagues near the University Hospital in Copenhagen. This institute exists to this day, although the focus of its investigation and therapy has shifted to oncology. In 1903, Finsen was awarded the Nobel Prize for his innovative investigation and therapeutic successes with light therapy. Finsen died as a result of his disease in 1904, 1 year after he received the Nobel Prize (5).

Word of Finsen's work spread rapidly throughout Europe and North America. There were constant visits to the Finsen Institute in Copenhagen by many of the most outstanding clinicians and medical research scientists of the time. One of those clinical scientists most interested in Finsen's work was Dr. Auguste Rollier (1874–1954), a Swiss physician who was convinced of the value of Finsen's work (9–12). Rollier established numerous sunbathing clinics in the Swiss Alps and treated patients with skin, skeletal, and pulmonary tuberculosis at these institutions. The most famous of Rollier's clinics was at Leysin, Switzerland. The basic tenet of Rollier's heliotherapy was intense solar radiation obtained only at high altitude where there was absence of wind and great purity of air. At the Leysin sanatorium, we have the first connection to the American Clinical and Climatological Association (ACCA). The donor who supports one of our annual lectures, Dr. Jeremiah Metzger from Tucson, Arizona, traveled to Switzerland and studied Dr. Rollier's techniques at the sanatorium in Leysin. It is highly likely that Metzger met Rollier and discussed at length the new heliotherapy technique pioneered by Finsen (see below for further discussion of heliotherapy, Metzger, and the ACCA).

Dr. Jeremiah Metzger was born in Oak Harbor, Ohio, on December 9, 1876, to Emma and John C. Metzger. Oak Harbor was a small German farming community of approximately 1200 citizens. His father made his living selling real estate and insurance. Jeremiah attended public school in Oak Harbor and then went for his freshman year of college to Ohio State University. He then transferred to the University of Michigan where he did his premedical studies followed by enrollment in Rush Medical School of the University of Chicago, graduating in 1901. His internship was performed in New York City at the New York Skin and Cancer Hospital, and he thereafter served 3 years in the Ohio state hospital system. Dr. Metzger also spent a year of post-graduate training at the University of Berlin. During the 47 years that he called Tucson his home, he took additional classes at the University of Arizona (Figure 1).

Fig. 1.

Dr. Metzger began practicing medicine in Toledo, Ohio, following his extensive training, but ill health (presumably tuberculosis) caused him to move in 1909 to Monrovia, California, where he worked as an assistant physician at the Pottenger TB Sanatorium until 1911. In that latter year, Dr. Metzger moved to Tucson, Arizona, where he opened the city's first tuberculosis sanatorium. After operating the sanatorium for several years, he spent a year in Leysin, Switzerland, studying “sun therapy” (heliotherapy) under Dr. August Rollier. He continued to practice after his return to Tucson and helped to found another sanatorium, the Desert Sanatorium, in conjunction with two other Tucson physicians in 1925. The Desert Sanatorium later evolved into Tucson Medical Center, today the largest private hospital in Southern Arizona. During the Spanish-American War, Metzger served in the medical corps and remained in the Army medical reserve corps during World War I.

Metzger retired in 1926 and traveled widely, going around the world three times and attending several Olympic Games. Despite his retirement and his traveling, he continued to study various aspects of medicine, and became interested in psychiatry. During 1931–32, he studied specialized medicine at the general hospital in Vienna, Austria, including a period spent with Dr. William Stekel, an early student of Sigmund Freud. In 1941, after his return to Tucson, the governor of Arizona appointed him as the superintendent of the Arizona State (psychiatric) Hospital, a post he held for a short time before joining the governing board of this hospital as its chairman. The governor had appointed Dr. Metzger to this post because the latter was highly regarded in the southern Arizona medical community. The state hospital had gone through challenging and controversial times and Metzger's appointment first as superintendent and later as chairman of the board of the hospital served as a stabilizing influence.

Metzger was a member of the county, state, and American Medical Associations as well as a member of the New York Academy of Medicine and the ACCA. He was active in Tucson community affairs and was a member of the Old Pueblo Club, a social organization. He was a founding member of the Tucson Country Club.

In 1928, he married Mrs. Julia Turner, a widow of a US Army Colonel. At the time of his death in 1958 at the age of 81, he was survived by a sister, Mrs. Gertrude Heller of Yardley, Pennsylvania.

Metzger probably became an active member of the ACCA because of his interest and study of heliotherapy during his time at the Leysin sanatorium. As noted above, Metzger himself may have contracted TB during his clinical training since he worked for 2 years as an assistant physician at the Pottenger Tuberculosis Sanatorium in Monrovia, California, before moving to Tucson.

Sun therapy, also known as heliotherapy (Helios = sun in classical Greek), was a popular modality in the early 20th century in the United States. Following Finsen's observations and Rollier's use of heliotherapy in many sanatoria throughout the Swiss Alps, American physicians quickly adopted these European techniques. Patients with skin, bone, and pulmonary TB received heliotherapy at institutions in California, Arizona, and even in upper New York State (the famous Saranac hospital) (13). Many famous patients were treated at Saranac including Bela Bartok, Somerset Maugham, Robert Louis Stevenson, and Christy Mathewson (13). Anecdotally, the founder of the Saranac Sanatorium was Edward Livingston Trudeau, grandfather of the cartoonist, Gary Trudeau.

In the United States, early TB sanatoria that used heliotherapy at altitude, following Rollier's model in Switzerland, were established in the Rocky Mountains of Colorado (10,11,14). A number of scientific papers were published by American physicians touting the beneficial effects of heliotherapy in their tuberculosis patients. However, once effective antimicrobial therapy became available, heliotherapy for TB was discontinued and eventually all TB sanatoria in the United States were closed or converted to other purposes. Examples of the efficacy of heliotherapy for the treatment of various forms of TB taken from published statistics can be found in Table 1.

TABLE 1.

Statistics Showing the Beneficial Effects of Heliotherapy in Patients With Tuberculosis

Finsen's results with skin tuberculosis (lupus vulgaris) (5)

Small lesions: 177/244 cured (73%)

Medium sized lesions: 123/213 cured (58%)

Large lesions: 68/184 cured (37%)

Widespread lesions: 37/159 cured (23%)

40 (5%) patients were deemed “unsuitable for therapy” and 71 (9%) patients were lost to follow-up.

Results from US publications of results with heliotherapy for bone TB

Roland Hammond, Providence, Rhode Island (12)

Total number treated: 70 in 1911 and 60 in 1912

Number of weeks of sun bathing: 14 in 1911 and 13 in 1912

Average age of patients approximately 7 years

Range of gain in weight with heliotherapy: 3–4.2 pounds

Range in percent of gain in hemoglobin values: 0.8–17%

Results from Rollier's Alpine sanatoria on patients with bone TB (14)

Total Patient n = 650

Cured = 530/650 (82%)

Improved but not cured 70/650 (11%)

Unimproved = 25/650 (4%)

Died = 25/650 (4%)

Relapsed after cure = 6/530 (1%)

Results from Canada using Rollier's therapeutic regimen for bone TB

R.I. Harris, University of Toronto, Ontario, Canada (25)

Total patient n = 49 with bone TB

Cured or apparently cured = 35/49 (71%)

Improved but not cured = 10/49 (20%)

Unimproved = 1/49 (2%)

Died = 3/49 (6%)

Presently, heliotherapy is still practiced for a number of conditions although not tuberculosis. Psoriasis and a variety of other skin conditions, as well as rickets, seasonal affective disorder, and even childhood failure to thrive are currently treated by many clinicians in North America and Europe with heliotherapy. Sun therapy is routinely used at a variety of heliotherapy centers in California, Poland, Hungary, and the Czech Republic. It is still used as a therapeutic intervention in Denmark as well. The general population in the United States became enamored of sunlight and a deep suntan in the 1920s and 1930s at the same time that heliotherapy was being exploited for many patients with TB. During this period, a suntan meant that one had the financial wherewithal to indulge in prolonged beach visits. Thus, a sun bronzed skin became a sign of affluence and was eagerly sought by many before the oncologic dangers of excessive sun exposure became known (15).

Current indications for judicious use of heliotherapy include severe cases of acne vulgaris, psoriasis, and eczema, seasonal affective disorder with depressed mood, jet lag, and vitamin D deficiency (16–21). The mechanism of sunlight therapy's beneficial effects has been studied and discussed extensively in the medical literature. It appears that exposure of microorganisms to sunlight can destroy potential harmful bacteria. This is thought to be the mechanism involved in acne therapy and cutaneous TB. There is also some evidence that exposure to sunlight results in endorphin release, perhaps contributing to a sense of well-being following exposure to sunlight and thereby ameliorating seasonal affective disorder (16,21). The beneficial effect of sunlight on psoriasis appears to be the result of suppression of immune system−mediated inflammatory responses in the skin (16,17,19,20). Current clinical thinking emphasizes that heliotherapy must be used cautiously given the fact that prolonged exposure of the skin to sunlight increases the likelihood for developing skin cancer (22,23). Unsubstantiated contemporary claims for heliotherapy also include benefit for patients with various types of cancer (24).

In conclusion, heliotherapy was one of the first successful therapeutic interventions used for patients with tuberculosis, particularly TB of the skin. This therapy was superseded by antibiotic therapy. However, heliotherapy has remained an important tool in current medical therapeutics albeit for different indications than when it was first shown to be useful clinically more than 100 years ago.