THE 
INFLUENCE OF SEWERAGE AND WATER POLLUTION 
ON THE 
Prevalence and Severity of Diphtheria. 
Read before the Section of Pediatrics, Ninth International 
Medical Congress, Washington, D.C., September, 1887. 
BY 
CHARLES WARRINGTON EARLE, M.D., 
Professor of Pediatrics, Woman's Medical College, and of Obstetrics, College of 
Physicians and Surgeons, Chicago. 
[Reprinted from Archives of Pediatrics, November, 1888.] THE 
INFLUENCE OF SEWERAGE AND WATER POLLUTION 
ON THE 
PREVALENCE AND SEVERITY OF DIPHTHERIA. 
It may truthfully be said that no one cause has, up to this 
time, been named as producing diphtheria which has been uni- 
versally accepted by the great mass of the profession. 
All kinds of dirt, all kinds of emanations from every kind 
of filthiness, atmospheric influence, and germs have been in- 
cluded in the etiology of this disease. 
It has been claimed by many that imperfect sewerage has 
been the cause, and the people, urged on by the opinion of the 
doctors, frequently blame a sewer for poisoning a family and 
producing diphtheria, when, in my judgment, the cause should 
be placed elsewhere. It is much better for us to recognize the 
true cause, if it is possible to find it, rather than to attack an 
imaginary one, for it is possible that, while we are fighting the 
supposed gas as the cause, we are losing sight of the real enemy 
which should engage our attention. 
Jacobi says that cases of diphtheria which are traced to ex- 
halations from sewers or even to filthy habits of life are very 
frequent. This opinion, especially in regard to sewerage, has 
been reiterated by scores and hundreds of physicians. It rep- 
resents the prevailing idea of American physicians. 
English practitioners are particularly the advocates of the 
sewer-gas theory. In the British Medical Journal, Decem- 
ber 1, 1883, J. Emmett Holt gives an account of the disease 
as it occurred in Canterbury. Investigation showed the well- 
water to be extensively contaminated with sewer-gas in every 
instance. In addition to the drinking-water being polluted, 2 
The Influence of Sewerage and Water Pollution 
there was found a drain running under the parlor, letting 
sewer-gas enter the living-room of the family. 
I cannot hope to have discovered the one cause of diph- 
theria, or to prove that sewer-gas does not in many cases 
influence this disease. But I have been impressed for many 
years that undue importance was given it as a causative 
factor, and have thus been led to investigate the prevalence 
of this dreadful disease in locations remote from any sewer- 
gas influence. 
It appeared to me that investigations to demonstrate my 
theory should be conducted at great distance from sewers, and 
the location should have pure air and pure water; and that 
in the great Northwest of the United States of America these 
conditions could best be found. 
In the following briefly-described States and Territories I 
concluded to make my inquiries: 
Minnesota.-Population in 1885,1,117,798; square miles, 
83,531. 
Rolling prairies, dotted with lakes and belts of timber. 
The summers are cool and pleasant, and while the winters 
are cold, the air is dry and clear. 
Dakota.-Population, 415,263; square miles, 150,932. 
In the main, prairie; climate mild and genial; winters cold 
and dry; bracing and invigorating air; average rainfall twenty 
inches. 
Montana.-Population, 1880, 39,159; square miles, 143,776. 
Climate milder than would be supposed from the altitude; 
soil exceedingly fertile; a great grazing country. 
Wyoming.-Population, 1880, 20,789; square miles, 97,980; 
rich in mineral, and its surface is broken by mountain ranges 
and deep river canyons. 
Kansas.-Population, 1880, 996,096 ; square miles, 81,318. 
The surface, which is made up of prairies and river bottoms, 
slopes from the Rocky Mountains to rivers on the east. The 
climate is very healthful. 
Utah.-Population, 1880, 143,963; square miles, 84,476. 
An immense plateau between the Rockies and Sierras, consist- 
ing of smaller mountains, plains, valleys, and basins. 
Climate mild and dry. on the Prevalence and Severity of Diphtheria. 
3 
Idaho.-Population, 1880, 32,610; square miles, 86,294. 
Climate cool and healthful. 
This Territory is rich in mineral, but the cereals flourish 
abundantly. It contains vast forests of fir, pine, and hemlock. 
California.-Population, 1880, 864,494; square miles, 
188,981. 
Climate variable, on account of extent of territory along 
the Pacific coast. Temperature ranges from 50° below, in 
the north, to 70° above at the south. 
These States and Territories help to make up the great 
Northwest of our country. Part of this immense region is 
traversed by our highest mountains and watered by rapid 
rivers. Much of it is prairie. The purest air in the world 
is abundant, and many of the habitations, particularly in the 
early times, were built on posts some distance from the ground. 
There is not a sewer within a hundred miles of some of these 
houses, and yet diphtheria is found. 
To the physicians in this great country I addressed a com- 
munication with the following questions: 
1. Does diphtheria occur frequently in your vicinity? 
2. What season of the year to the greatest extent ? 
3. How far are you from any sewers ? 
4. Have you ever attended cases exceedingly remote from 
any supposed source of infection ? 
5. Have cases occurred in your practice in habitations 
raised from the ground so that no possible decomposing ma- 
terial under the house could act as a cause? 
6. Have cases occurred in your practice among the moun- 
tains, where the water-supply is from pure springs or running 
brooks, where pollution from cesspools, water-closets, or sewers 
was absolutely impossible? 
7. Does proximity to barns or stables seem to predispose to 
the disease ? 
From among many who have kindly answered my commu- 
nication I select the following as having some bearing on the 
questions involved. 
Dr. Hurlburd says that our cases are, almost without excep- 
tion, traced to some infected person or clothing. He also gives 
another cause, which I think demands attention,-that is, 4 
The Influence of Sewerage and Water Pollution 
railroad cars as & means of conveying the contagion from one 
place to another, and as the place where the contagion may be 
taken into the systems of little people who are riding in the 
coaches. 
Dr. Spaulding says that he passed through a severe epi- 
demic with great fatality two years ago. "Our drinking- 
water is free from all organic matter and the habitations are 
upon high ground." 
Dr. Cushman says that cases appear sporadically, and then 
other cases appear miles away with no visible connection. 
" Cases occurring in sod houses, and houses situated on low 
ground, seem more virulent." 
Dr. Spooner, whose experience has been great according to 
the testimony of others, answers my questions very fully, to 
such an extent that I produce nearly his entire letter: 
" Lake Preston, Kingsbury Co., Dakota, 
July 14, 1887. 
" Dear Doctor,-I am pleased to receive your letter of in- 
quiry, and will endeavor to answer to the best of my ability. 
" Query 1. We have cases of diphtheria almost every month 
in the year. Since May 9, last, there have occurred in my 
practice in this vicinity eight cases. In the practice of others 
four cases, and two cases that were undoubtedly diphtheria 
that were unattended by any physician, but which did not 
originate here, making fourteen cases. Two of them un- 
doubtedly contracted the disease in transit from Norway, as 
one of the same family, a babe, died on shipboard from the 
same disease, if the statements of the parents are to be relied 
on. Five of my cases contracted the disease from the two 
survivors of the family who had the disease after coming to 
Dakota. So the disease, so far as we are able to ascertain, 
really originated here in one-half these cases only. In the 
four treated by others the origin of the cases is unknown. 
In the three remaining cases treated by myself one visited a 
family where a patient had had the disease and was supposed 
to be convalescent, but that was the only possible source of 
infection, so far as I could gather from carefully questioning 
the patient and friends. The remaining two cases of mine on the Prevalence and Severity of Diphtheria. 
5 
were patients who had had the disease before; origin at this 
time unknown. 
" Query 2. I cannot say positively, but, in my practice, the 
majority of cases have occurred from January to September. 
" Query 3. We are forty miles from any sewers; so farthat 
it does not enter into the consideration of this question at all. 
I may say, perhaps, that a lack of proper drainage seems to 
furnish suitable conditions for both the development and the 
propagation of the diphtheria germ. 
" Query 4. I have attended cases where it was impossible to 
decide the cause of the disease; and as far as being remote 
from any 1 possible source' it would be exceedingly difficult 
to decide; but I can say they were remote from sewers; in fact, 
all cases coming under my observation have been those where 
the sewerage did not enter into the consideration of the case 
at all. 
" Query 5. In a number of instances the cellars have been 
perfectly clean and free from decaying vegetables. In at least 
six or seven instances of separate families it has been the case 
that there has been no possible source of infection from the 
presence of decomposing material under the house. 
" Query 6. I have never practised in mountainous districts; 
but some of my most violent and malignant cases have 
occurred on the highest points of land in the country. The 
cause to my mind was evident,-i.e., an unclean cistern, with 
no attention to hygiene, in-doors and out. 
" Query 7. My opinion is that proximity to barns and 
stables enhances the liability to the disease. I cannot say it 
causes it, but believe, the diphtheria germ being present as the 
prime factor, these other conditions are potent factors in the 
propagation of the disease and in the continuation of it. 
" In Dakota my practice has been on the prairie exclusively, 
as there is nothing but prairie here. Our prairie has scattered 
all over it ponds of water during a wet or moderately wet 
season. We are in close proximity to a number of lakes, 
which are really the head-waters of the Vermilion, a stream 
one hundred miles in length, a tributary of the Missouri. We 
are on a point of land which has nearly the greatest elevation 
in Southern Dakota, unless it be the Wessington Hills. The 6 
The Influence of Sewerage and Water Pollution 
surface is undulating. Winds prevail from the south and 
southwest. The soil is a black sandy loam ; underlying this 
a yellow clay; except in the vicinity of the lakes the clay is 
shallow and more sand appears in the soil. The atmosphere 
contains less moisture than in Iowa or Minnesota; it is what 
is termed a dry atmosphere. 
" The wells in this vicinity are generally dug through the 
humus or loam, and the water is found at variable depths in 
either sand and gravel or clay, at a depth varying from eight 
or ten feet to thirty. The majority of wells average about 
twelve feet." 
Dr. Kreychie says that he has seen cases in houses where 
potatoes and other vegetables were stored under the building. 
Several gentlemen seem to think that decomposing material, 
such as vegetables, especially with moisture, predispose to the 
disease. Two and three children will die in the same house 
within a very short period. Indeed, the virulency appears 
quite as terrible as in our large cities. The same gentleman 
narrates the history of a family of five persons living in a sod 
shanty with filthy surroundings, a cesspool and a lot of 
manure in front of the shanty. Three children were taken 
with the disease, and all died within the space of about ten 
days. Some miles from his home there live a few families on 
the banks of a sluggish stream of water that flows only in the 
spring. There has not been a spring since he settled there 
that some of those families have not had a case of severe 
diphtheria occurring. 
Dr. Kelly has attended cases of malignant diphtheria remote 
from sewers and all possible sources of infection. He attended 
one case five miles from another habitation. He believes 
proximity to stables, where there is a good deal of filth, seems 
to predispose to the disease. 
Dr. Watkins says diphtheria is rare in Wyoming; that he 
has seen only one case in eight years, and that of a very viru- 
lent type. He thinks that was caused by the child's stirring 
up the town dump of manure. 
Dr. Hazlett says that in one epidemic in his county, in a 
town on the high prairie, he had a number of cases, many of on the Prevalence and Severity of Diphtheria. 
7 
which died in spite of all that could be done. In one of his 
families, where all possible pains had been taken in regard to 
cleanliness and to escape any effect of decomposition, the house 
standing on raised ground and some distance from barns, fatal 
cases occurred in his practice. 
Dr. Ormsby writes that he has found diphtheria in houses 
miles from any others, at the mouth of a canyon where the 
purest of mountain air prevailed and no possible chance for 
decomposition existed. He does not see how sewer-gas 
or decaying vegetables can have anything to do with the 
disease. 
Dr. Gregor says that in the epidemic of 1882, which was 
particularly fatal in a little settlement near the top of the 
mountain, at an elevation of nine thousand feet, this settle- 
ment consisted of probably a dozen houses built around what 
used to be a small lake, but at that time dry. The water had 
been drained off from the lake by a mine below. The water 
used by these people, however, for household purposes, is per- 
fectly pure, coming from watercourses from above and where 
it was not possible that contamination existed. 
Dr. Kahler says that it occurs frequently in elevated situa- 
tions, where no possible decomposing material existed. It takes 
place frequently in mountainous districts, where the water is 
pure and no cesspools or water-closets are present. 
Dr. Dubois, two hundred and ninety miles from a railroad, 
in a vicinity where there are no sewers, has passed through one 
epidemic of diphtheria. Water-supply is from springs, and 
the climate is particularly unfavorable to the conditions usually 
producing this disease. 
Dr. Croweler says that the worst case he ever saw was in a 
habitation upon the sandy soil, in the hills, and fifteen miles 
away from any point of infection. He knows from experi- 
ence that it will and can exist in all its malignancy where there 
are no sewers. 
Dr. Frank H. Payne says, " I have had considerable ex- 
perience with diphtheria, especially during the winter of 
1885-86, when about seventy cases occurred in my practice. 
I found that the disease occurred under every condition and 
circumstance of life; sometimes as divergingly different as 8 
The Influence of Sewerage and Water Pollution 
could possibly be. In miserable, filthy hovels, with poor 
sewerage and every condition favorable for its propagation, 
and again in well-ventilated, well-sewered houses, where disin- 
fection is constantly practised and cleanliness observed. 
" I have had isolated cases in the mountains where no sewers 
existed and every condition seemed favorable to health. But 
I must confess that it is very difficult to stamp out the disease 
when it exists in an unfavorable, bad-sewered locality. Such 
conditions seem to favor its spread, and I am also inclined to 
believe have some influence upon the disease as to its virulence. 
" In a region swept by the fumes from an acid factory (sul- 
phuric acid) I have never had cases, except once, which was 
directly traceable to exposure to a virulent form of the disease 
while in the city." 
Dr. Tyrrell says that, inasmuch as he is a strong believer in 
the specific cause of diphtheria, he thinks that sewer-gas has 
nothing to do with it. His belief is,-" no germs, no diph- 
theria." 
However hard we may try to avoid accepting the germ 
theory of diphtheria, there is coming to be such a mass of 
evidence in favor of it that it is almost irresistible. 
Some of the facts which I have presented in this paper seem 
to militate against the theory. It is, however, facts that we 
want, and upon the foregoing it seems I am warranted in 
making the following conclusions : 
First. Diphtheria occurs in the mountains and prairies of 
the great new Northwest with the same malignancy as in cities. 
Second. Diphtheria takes place with equal virulence in 
vicinities remote from sewers. 
Third. Diphtheria, once present, the inhabitants living in 
damp sod houses, or over cellars containing decomposing vege- 
tables, or in proximity to manure heaps, or poorly-constructed 
sewers seem to be in surroundings which increase the severity 
of the malady. 
Fourth. The fact is again demonstrated, although developed 
incidentally, that the contagious element may be carried or 
transported thousands of miles in a manner difficult to under- 
stand. 
Fifth. Testimony is abundant that the poison may be trans- on the Prevalence and Severity of Diphtheria. 
9 
ported by means of cars and steamers. This fact calls for 
increasing watchfulness and more efficient means of disinfection 
than have been heretofore practised by our transportation 
companies. 
Sixth. To such a degree is this terrible disease contagious,- 
a few in our profession, however, declining to acknowledge 
it, and the majority of the people persistently refusing to iso- 
late their children,-it appears to me that the only method 
by which we can prevent the spread of diphtheria is by the 
enactment of laws compelling the people to assume some re- 
sponsibility in regard to contagious diseases.* 
* The following-named physicians have kindly contributed information 
embodied in this report: 
Drs. J. S. Kreychie, I. R. Spooner, and R. A. Cushman, from Dakota. 
Drs. G. G. Tyrrell, Charles Ambrook, H. C. Croweler, C. M. Bates, and 
F. H. Payne, from California. 
Drs. W. W. Hammond, J. D. Carnahan, August Boucher, Gilbert 
Gregor, F. S. Kahler, A. C. Ormsby, and John Alfred, from Utah. 
Drs. E. A. Spaulding and Herbert Hurlburd, from Minnesota. 
Drs. G. B. Snyder, E. E. Hazlett, and J. M. Wade, from Kansas. 
Drs. A. D. Kibbie and J. K. Dubois, from Idaho. 
Dr. J. C. Watkins, from Wyoming. 
Drs. B. B. Kelly and Alex. McLeod, from Montana. ARCHIVES OF PEDIATRICS 
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