reprinted from 
»»»« 
FEBRUARY, 1893. 
The Gause and Prevention of Diphtheria 
BY DANIEL STROCK, M.D., 
Of Camden, N. J., 
Surgeon to the Cooper Hospital; Lecturer on Dietetics in the Camden Training School 
for Nurses ; Member Executive Council of the New Jersey Sanitary Association, etc. The Cause and Prevention of Diphtheria.1 
BY DANIEL STROCK, M.D., 
Of Camden, N. J., 
Surgeon to the Cooper Hospital; Lecturer on Dietetics in the Camden Training School 
for Nurses ; Member Executive Council of the New Jersey Sanitary Association, etc. 
■< cause °f diphtheria is a problem the 
+ solution of'which has engaged the attention 
IW I °f scientific men in all parts of the world, 
Wt I and while it cannot now be asserted that 
our knowledge of the subject is complete, 
/ '' yet enough has been ascertained to enable 
' us to formulate certain rational plans of 
treatment, and to guide us in our efforts to 
prevent the dissemination of this dread disease. 
The demonstration, by Pasteur, that morbid processes in the 
animal body were due to the presence of micro-organisms, pointed 
out the line of investigation that would possibly reveal the cause 
of diphtheria. And, therefore, as a result of patient effort, Klebs, 
in 1883, and Loeffler, in 1884, isolated a bacillus that now is 
recognized as the agent concerned in the production of the train 
of symptoms and phenomena known as true diphtheria. 
While it is agreed that the Klebs-Loeffler bacillus is the cause 
of diphtheria, yet we must not fail to note that fatal pseudo- 
membranous inflammations of the tonsils, pharynx and larynx 
occur in which the Klebs-Loeffler bacillus is absent, and instead is 
found a streptococcus, which appears to be identical with the 
streptococcus-pyogenes. Although this variety of pseuflo mem- 
branous inflammation may be uncomplicated, yet it is frequently 
found associated with scarlet fever or measles. 
Recently Professor Prudden and Dr. W. H. Park, of New 
York, have published the results of their investigations of the 
agents, concerned in the production of true and false diphtheria. 
Prudden made bacteriological examinations in twenty-four fatal 
cases of pseudo-membranous inflammations of the tonsils, pharynx 
and larynx, and in all of them the Klebs-Loeffler bacillus was 
absent; in all but two cases streptococci were found. Park has 
reported 159 cases of pseudo-membranous inflammations, and of 
this number in fifty-four only were the Klebs-Loeffler bacillus 
i Read before the New Jersey Sanitary Association, at the meeting held at hakewood, 
N. J., December 9 and 10, .1892. 2 
found. In the other 105 cases streptococci were present in 
abundance. Martin, of Paris, in an examination of 200 children 
supposed to have diphtheria, found the Klebs-Loeffler bacillus 
absent in seventy-two, and of this class twenty-nine were croup 
cases. Various investigators, «as Boginsky, Kolisko, Sevestre, 
Wurz, Bourges and others have found streptococci without the 
Klebs-Loeffler bacillus in pseudo-membranous inflammations 
occurring in scarlet fever. 
From this we learn that not every case presenting the gross 
appearances of diphtheria is really true diphtheria in the sense 
that the causative agent is the Klebs-Loeffler bacillus. But in 
view of the fact that the other varieties of pseudo-membranous 
inflammations, due to the presence of streptococci, are infectious 
and fatal, even when unassociated with scarlet fever, the lesson to 
the doctor is that his duty to the patient and the family is just as 
grave as it would be if the bacillus of Klebs-Loeffler were present. 
Clinically, no distinction should be made so far as precautionary 
measures1 are concerned. Scientifically, efforts should always be 
made to differentiate; and this can only be done with the micro- 
scope and culture media. 
Granted that the important part assigned to the Klebs-Loeffler 
bacillus in the etiology of true diphtheria is warranted by the 
results of the latest investigations, and there are but few who do 
not admit this, we are not thereby informed as to the laws 
governing its propagation and growth. Many of us know from 
observation that the life of the bacillus may be prolonged for 
many months and finally demonstrate its activity by causing the 
disease, to develop in those brought in contact with the infected 
locality. Instances have been given where the contagion of diph- 
theria has been conveyed in clothing, in sewers, in water, and in 
milk; agar-tube cultures, after seven months' growth, are still 
alive; bits of membrane no larger than a pin point, kept in cloth, 
give evidence of activity after six months. These facts indicate 
that the germ of diphtheria is tenacious of life, and perpetuates 
its species under varying conditions of soil and environment; yet 
they do not inform us as to the circumstances dominating its 
development. 
If we believe that the cause of diphtheria is a definite variety 
of living germ, with characteristics and a life history unlike any 
other living entity, then we must assume that there are certain 
positive conditions necessary for its growth and continued exist- 
ance, as is the case with all other living things in nature. 3 
To claim that its presence in a given locality is accidental, or 
that, because of unsanitary environment, by a process of rapid 
evolution, a harmless germ was transformed into one with patho- 
genic attributes; or, that by a special creative act it is caused to 
be where it did not exist before, are untenable theories. 
No culture experiments have ever resulted in the develop- 
ment of a new type of disease germ; and we have no basis for 
the idea that nature is engaged in the special work of rapidly 
creating or evolving these minute agents of destruction, contrary 
to her methodical processes, as observed in the higher orders of 
animal or vegetable life. 
We are constrained to believe that there are certain laws 
governing the origin and perpetuation of the bacillus diphtheriae, 
but what they are cannot now be definitely formulated. But we 
do know that filthy or unsanitary conditions are co-existent with 
outbreaks of diphtheria, and there can be no doubt but that 
moisture, ordinary temperature and absence of sunlight and pure 
air, are important factors in developing endemics and epidemics of 
this disease. Farther than this, we enter into the domain of 
doubt and conjecture. 
Some observers have thought they traced outbreaks of 
diphtheria to the spreading of human or animal manure upon 
land in the vicinity of human habitations. Others attribute its 
prevalence in cities to the frequent tearing up of the streets for 
paving, or trenching for various purposes. Some consider the 
prevalence of continued dry weather an important factor in develop- 
ing the disease. Still others think it is due to drouth alternating 
with successive rain. It is supposed that variations of barometric 
pressure of the atmosphere, over foul and moist soils, causing 
'1 ground respiration ' ' and possible liberation of pathogenic germs, 
may be one of the causes. But it is probable that the theories 
mentioned above represent coincidental conditions only; and they 
certainly do not enable us to determine why there should be a 
rapid proliferation of the germs at one time, under what seems to 
be conditions identical with those that obtain at another time, 
when diphtheria does not prevail. 
Diphtheria is known to be contagious and infectious, and its 
prevalence in communities, after the appearance of one or two 
cases, is largely due to this fact. It is a matter of daily observa- 
tion that if a member of a family takes the disease other cases 
occur in the household, Children sent from an infected house, as 4 
a precautionary measure, may convey the affection to those who 
have not previously been exposed to contagion. The disease may 
be spread by the dried membrane or expectoration upon pillow- 
cases, sheets and articles of clothing. Investigation will demon- 
strate that a large proportion of those having the disease have 
been in contact with infected individuals or localities ; and locali- 
ties may be centres of infection for a year or more, if not radically 
disinfected. As bearing upon this point, I have knowledge of a 
house that was vacated the day following' the 'funeral of a child 
dead of diphtheria, and it remained unoccupied for one year. It 
was then taken by a family consisting of parents and one child. 
In three weeks thereafter the child died of diphtheria. In the 
absence of any history of exposure to contagion elsewhere, we are 
forced to the conclusion that the second case in that house was 
the direct sequel of the first. 
In my opinion the most potent agents in causing the spread 
of diphtheria in communities are the public schools, private and 
Sabbath schools. When we consider that it has been proved that 
the bacillus of this disease is found in the mouths of patients some 
days after the apparent recovery of the throat lesion, we cannot 
avoid the conviction that it must also be in the mouth of the 
destined victim for a variable period before their presence is mani- 
fest by the usual symptoms denoting invasion. Therefore that 
individual is a menace to her or his companions even during this 
period of apparent immunity. In many other instances the chil- 
dren are really victims of diphtheria while yet in daily attendance 
at school. In some of these cases, no doubt, the child, being 
anxious to continue its studies, does not feel ill enough to ask to 
remain at home. In others, where the little one speaks of feeling 
ill, the parents may not think it necessary to keep her from school; 
as it is not an unheard-of occurrence for some parents to reason 
that a complaining child must necessarily be a malingerer. In 
still other instances, the disease may be well advanced before the 
individual's attention is called to her condition by symptoms of 
pain and fever. 
In any of these conditions the patient is a source of danger to 
her companions, and her presence at school may result in their 
infection and death. 
I have recently had under my care a family in which five 
cases of diphtheria occurred. Two years ago an elderly lady died 
in that house with diphtheria. A few months subsequent to her 5 
death the premises were vacated, and the present occupants moved 
in. This family of six small children lived there for eighteen 
months without illness, until two years had elapsed since the 
death above noted, when diphtheria developed simultaneously in 
four of the children. Naturally, the impression would be that 
here was an instance where diphtheria germs had remained inac- 
tive for two years, but finally conditions favorable to their 
renewed vitality had developed, and as a result a severe local out- 
break occurred. But I really did not believe that was the solu- 
tion of the problem, and upon questioning the mother closely I 
ascertained that another child had remained from school a day or 
two, because it did not feel well; and this child occupied a seat 
adjoining a scholar who had a few days previously been taken ill 
with diphtheria. Here was the explanation of- the outbreak in 
that household. A child with an attack so mild that the true 
nature of the illness was not recognized by the family, and which, 
it was thought, did not require the doctor's attention, infected 
four other members, and caused one death. 
This is but one instance in a great many where I have 
endeavored to trace a case of diphtheria to its source, and have 
been led to the school-house. 
The milk supply is frequently the means of disseminating 
the bacillus of diphtheria, and as one of the causes of the spread 
of this disease it is worthy of serious attention. It is really a 
culture media for the germs, and is peculiarly susceptible to con- 
tamination. Within a few months past an outbreak of diphtheria 
in the town of Melrose, tylass., has been traced to the dairy of a 
man in whose family several cases of the disease occurred. 
While it is not definitely known that prominent outbreaks of 
diphtheria are due to contaminated water, yet it is reasonable to 
suppose that in some instances this is the case. It is known that 
colonies of the bacilli will survive for months or years in favor- 
able situations, and it is not improbable that the getms may 
remain active in water for a short time, at least. Wells in prox- 
imity to cesspools may thus become a source of danger to those 
who drink therefrom; and the water supply of cities, contaminated 
with sewage, may cause the diffusion of the specific poison. ■ It 
is a well known fact that epidemics of cholera and typhoid fever 
have occurred in this manner, and it is not improbable that the 
prevalence of diphtheria, in certain localties, has been due to this 
cause. The folly, not to say criminality, of allowing cities, con- 6 
taining thousands of inhabitants, to take their drinking water 
from a source polluted by the refuse of a city containing hundreds 
of thousands, should be fully appreciated; and let us hope a day 
of advanced enlightenment may come when the police power of a 
State can be successfully invoked to save the people from them- 
selves. The importance of guarding the water supply from con- 
tamination should be so thoroughly appreciated by all that the 
question of cost will not be a deterring factor. The so-called 
contagious diseases-diseases communicated through the agency 
of living germs-can never be eradicated as long as a large per- 
centage of the people use water contaminated with human 
excreta. 
In concluding this division of my subject, it may be stated 
that it is not known positively what are the conditions necessary 
for the infection of the individual, but it is supposed that a lesion, 
an abrasion of the membrane of the nose or throat, favors it. No 
doubt individual or family susceptibility is a predisposing cause. 
Having what we may now deem to be definite knowledge 
that the cause of diphtheria is a living germ, we are in a position 
to understand the importance of preventive measures, and are 
enabled to intelligently resort to such agents as investigation and 
clinical experience have shown antagonize its propagation and 
growth. 
The problem of preventing diphtheria has been simplified by 
the discovery of its bacillary origin, for we know that if we 
destroy the germ we will remove the cause. 
The destruction of the bacillus maybe affected by the various 
agents known as antiseptics or bactericides, and by a temperature 
of 2i2° or more. 
It is unnecessary to enter into the details of isolating and 
caring for patients; of cleansing and disinfecting bedding, clothing, 
premises and attendants; the rules to be observed by the family 
in the event of the recovery or death of the patient; the precau- 
tions as to ventilation; the mode of sterilizing the discharges from 
the patient's throat, and the duties of undertakers. These points 
have been admirably set forth by Dr. Bzra M. Hunt, the able 
secretary of the State Board of Health, in the annual reports and 
in special circulars, and they are accessible to everyone. 
But we may, with propriety, consider some of the questions 
of public policy in relation to the management of diphtheria, 
whether it occurs as an isolated case or a general outbreak. 7 
Probably one of the most serious questions that may present 
itself to the health authorities is that of domiciliary quarantine. 
If thoroughly enforced, combined with disinfection of the premises 
and the effects of the occupants, there can be no doubt of its 
efficacy as a measure for the suppression of epidemics. But the 
hardships entailed upon the occupants of the house thus isolated 
from the community is fully recognized, and frequently the proper 
authorities hesitate to inaugurate this extreme measure of repres- 
sion. The legality of house quarantine does not enter into this 
problem as a distinct issue, as it is a settled point of law that 
municipalities, in common with nations and States, may resort to 
this measure as a safeguard to the public health. But when we 
consider that the family quarantined may have been infected 
because of some previous dereliction upon the part of the health 
authorities of the city or town, the question of compensation 
might be raised. 
In instances where, due to the lack of means, individuals ill 
with diphtheria cannot receive the proper attention or isolation at 
home, they should be removed to a hospital provided for this 
class of contagious diseases. Frequently several members of a 
family are infected consecutively because the premises are too 
small to allow of perfect isolation of the original case. It is to 
this class that removal of the patient to a hospital is particularly 
applicable; and it then becomes a measure of consideration for 
their own safety. 
Prophylaxis involves supervision of the schools, both the 
week-day and Sabbath-schools. There can be no doubt that this 
disease is largely propagated through the instrumentality of these 
agencies, where large numbers of children gather and intimately 
associate during the hours of study and play. As between the 
sexes, the relations existing between the girls of a school are 
more intimate than the fellowship between the boys; and herein is 
an element of increased danger to the girls. The reprehensible 
practice of indiscriminate kissing is largely in vogue in the female 
department of schools, and is directly responsible for the trans- 
mission of this disease in a certain number of cases. As bearing 
upon this point, my own experience has been that the large pre- 
ponderance of school children attacked have been girls. When 
we consider that, after invasion, there is undoubtedly a period of 
local activity, without pronounced symptoms, during which the 
germs are elaborating the ptomaine that will subsequently infect 8 
the entire system, we can understand what a menace a child un- 
consciously affected with diphtheria in this incipient stage must 
be to her companions in a school room. I have met with a number 
of instances where children ill with diphtheria have passed 
directly from the school to the sick bed. 
Therefore, as a measure of safety to the young, in whom 
there exists marked susceptibility to this affection, during the 
prevalence of diphtheria all public schools should be closed, and 
what are known as the infant classes of Sunday-schools should be 
dismissed until such time as the disease is in abeyance. If this 
were done, there can be no doubt that the progress of diph- 
theria in any community would be largely controlled before its 
ravages had made so many homes desolate. 
My convictions upon this subject are very decided, and I feel 
that too much emphasis cannot be placed upon the assertion that 
attendance at school during the prevalence of contagious diseases 
constitutes one of the most grave perils of childhood. I am well 
aware of the difficulties that attend the solution of the problem, 
for we all admit the importance of these agencies for the educa- 
tion of the youth of our land. But when we reflect how many 
valuable lives have been, and may be, lost by reason of the dis- 
semination of infectious diseases among school children, the clos- 
ing of the schools during the prevalence of such diseases in neigh- 
borhoods should be considered one of the most important measures 
to be instituted for their eradication. 
One of the potent factors in the dissemination of disease, and 
one to which but too little heed has been given, is the vacating of 
houses after the recovery or death of a patient ill with a contagious 
disease, and its occupancy by another family that up to this time 
was free from infection. As in the instance that I have noted, 
many houses are vacated as soon as a patient has recovered, or 
soon after the funeral; and in some instances almost immediately 
re-occupied by another family, who are ignorant of the danger 
they incur. It should be the province of health boards to prevent 
this. Physicians are required to give information of cases of con- 
tagious disease, and to report deaths due to such causes. For the 
purposes of preventing the evil above referred to, the original 
notice of the existence of a contagious disease in a house should 
be sufficient, and it then should be the duty of the inspector of 
the local board of health to caution the head of the family not to 
vacate the premises without first notifying the board of such inten- 9 
tion to move, under the penalty of a fine sufficient to exert a 
deterring influence. 
After the health authorities have received such notification 
of intention to move, then all the effects of that family should 
be thoroughly disinfected before they are allowed to be taken from 
the premises. 
After the house is vacated, it should be unlawful to rent it 
again until it has been properly cleansed and disinfected; and the 
cleansing and disinfecting should be under the supervision of the 
Board of Health. 
Boards of health should also be vested with authority to 
prevent families from vacating infected premises when in their 
judgment such removal would be detrimental to the health of the 
community. 
As inspectors of boards of health are public agents, charged 
with the grave anel responsible duties of stamping out contagious 
diseases, it should be mandatory upon them to give personal 
supervision to the cleansing and disinfection of premises imme- 
diately after notice has been given by the attending physician 
that such disease prevails in a house; and not wait, as is now the 
custom, until the malady has spent its force in the family. Then, 
after the recovery or death of the patient, the premises should be 
redisinfected. Failure upon the part of a health inspector to 
personally examine infected houses at least once during the 
progress of a case of contagious disease should render him 
liable to penalties equally as severe as may now be visited upon 
the physician who fails to make prompt report of the existence of 
such patient in his practice. 
To enact sanitary laws for the guidance of busy doctors, and 
impose penalties to insure their observance, and at the same time 
make other sanitary regulations and select men at a liberal salary 
to carry out their provisions, without the imposition of a penalty 
for non-observance of duty, is an unfair division of the respon- 
sibility of conserving the public health. 
It should be impressed upon all who have to deal with this 
disease, whether in the capacity of sanitary officials or as medical 
advisors, that prophylaxis is the true and, perhaps, only sure way 
of combatting diphtheria. 
If we accept as true the bacillary origin of the disease, then 
must we acknowledge that it is primarily a local affection, 
followed later by systemic involvement. But it is the general 10 
symptoms that first attract attention to the patient, and frequently 
while yet there are no signs of pharyngeal invasion. Now, if the 
general involvement is due to a poison generated at the seat of 
local lesion, we must assume that such poison had been formed 
prior to the onset of malaise and fever. If so, then there is but 
one conclusion to be arrived at, and that is that the bacilli were 
present in the nares, pharynx or larynx, and had already generated 
sufficient poisonous products to infect the system before the char- 
acteristic exudate was apparent to ocular inspection. Thus, when 
the doctor is called upon to treat the patient, what was a local 
affection has now become a systemic disturbance, with perhaps, 
even at this stage, only slight evidence of localization. Hence it 
is now too late to prevent general infection, although treatment 
may modify the progress of the malady. Unfortunately the 
chances are that farther advance of the disease will not be pre- 
vented, for we must admit there is no known specific for this 
affection once it has seized a victim. Despite all treatment, the 
seemingly mild cases are liable to die of heart paralysis, and the 
severe cases may pursue an uninterrupted course to the grave. 
But this sweeping assertion must be qualified by saying that the 
death rate has been lessened within recent years, as the value of 
the recumbent posture as a life preserver is better understood; 
and the early use of antiseptic washes does modify, in some in- 
stances, the severity of the systemic poisoning. But, after all, 
these agencies are not specifics. 
But if we anticipate the results thus depicted, and when the 
disease threatens a community or family, institute pre invasion 
treatment of the cause by cleansing the unclean places, isolating 
those who are sick or have been exposed to the contagion, and 
remove the risk of the healthy coming in contact with infected 
localities, we may then have the satisfaction of securing the ideal 
results contemplated by the votaries of sanitary science.