Report on Malignant Diphtheria in Northern Vermont

By Dr. E Harris – Dated December 15, 1879
	[This report was undertaken by the National Board of Health after a very serious and fatal outbreak of diphtheria was reported in Newark, Vermont. The report contains extensive reports on the families affected, as well as the families not affected, who lived in the town at the time.]
Dear Sir: In compliance with instructions from the Board I have visited the district of Northern Vermont, in which the alarming sickness and mortality were reported, and which, from the suddenness and fatality of the outbreak, was attributed to the pollution of a stream. Proceeding to visit the locality as soon as practicable after receiving your official request, I conferred, while on my way, with Prof. Henry D. Holton, of Brattleboro and Dr. C. G. Adams, of Island Pond Village, Vermont, as those esteemed physicians had already opened correspondence with me concerning the reported events. Upon reaching the township of Newark, in Caledonia County accompanied by Dr. Adams, we conferred with the "first selectmen" or superior of the town, and began an investigation of every case that had occurred. After three days I had inspected the premises, obtained the evidence and records, as given in the following report. Returning from the afflicted district by way of Saint Johnsbury, West Burke and Lunenburgh, for the purpose of conferring, with the physicians and other scientific gentlemen who had been consulted by the people of Newark, all available information and facilities were afforded to me for reviewing the results of my inspection and the records of the outbreak. The subjoined report may be regarded as complete, with the exception of the record of the last series of events, still in progress, but which ought soon to terminate with the sanitary suppression of the causes that have hitherto propagated and spread the disease. Whatever more occurs worthy of record may be appended to this report as additional information.   Divisions of the Report The information on which the National Board of Health instituted the investigation Why the sick families in Newark suspected poisoning Brief Description of the locality Map, Diagrams and lists Consecutive record of cases   The preliminary cases   Family of A. F. Carpenter   The first series, following     Family of J. Aldrich   Family of E. Morse   Family of John Cole   Family of A. F. Carpenter   Family of F. Simpson   Family of Samuel Park   Family of J. Gero   Family of L. Wilson   Family of D. Fairbanks   Review of the first series   The second series of cases     In the Aldrich family   The Moore Family   John Cole’s Family   The Simpson Family   The Park Family   The Wilson Family   In families that had no school children   Family of Eph. Fairbanks   The third series of cases   The fourth series of cases Notes on the households infected and on those which were not Conclusions Appended Statements First information on the outbreak (A, B and C) Topography and geology of the district (D) Forest and Products (d) Habitations and domestic conditions (e) Water supplies (f) Climate and meteorology (g) Fungi and animalculae The analysis of the brook water Other observations Various contributions of information from physicians in Vermont and New Hampshire Practical Suggestions

Nature of the Information Upon Which the National Board of Health Proceeded to this Investigation
In numerous leading newspapers and by letters from competent medical gentlemen in Vermont, the statements concerning a sudden and destructive outbreak of a malignant disease in Northeastern Vermont warranted the investigation which the Board directed me to undertake. Appended statements and letters, marked A B and C, show precisely the nature of the information received from sources here mentioned.
The Alarm, and Why the People Regarded the Sudden Sickness and Mortality as a Tragedy Caused by Poison in the Water
The township of Newark, Caledonia County, with a population of 600 upon 36 square miles, is reported one of the most salubrious, and its inhabitants are notably temperate, thrifty, and well housed. In the central district of the township, in which dwell 85 persons in 14 households, there were 39 children under 16 years of age, and of these there were 22 who attended as pupils at the opening of the summer term of the common school, May 12, 1879. The school room, having less than 200 cubic feet of aerial space for each child, was occupied during the usual hours from Monday morning, May 12, till Thursday afternoon of the 15th. It is situated in the bottom of a narrow glen that slopes steeply to the southward, and an eddying and tortuous streamlet flows close along by the rear of the school house; of this water all the pupils except one drank freely, for the noonday temperature was 80 degrees Fahr. and upwards. On Wednesday evening several little children of this group were sick, and on Thursday evening several were alarmingly ill with symptoms which to their parents seemed inexplicable. The physician, who was summoned from a distant town at midnight, found his services demanded in four families. The teacher and officers of the school closed its doors on Friday morning, May 16, and before Sunday night, May 18, several of the children were already dying, and 16 out of the 22 pupils were severely sick with the disease, which, before half the number died, caused great alarm. Within three or four days of the beginning of the sickness in the families that were thus represented by the pupils the other children and the care takers in the same families were smitten by the same malady, and at last nearly all who gave themselves freely to nursing the sick, or to the care and washing of the garments defiled by the putrid matters of the mouth and nostrils, were violently attacked by the malady, even in the instances where the dwellings of such persons were several miles apart upon different hillsides. Up to the date of my return from the district there had occurred 18 cases and 14 deaths, and other deaths have occurred since my return. These events were adapted to terrify as well as cause deep anguish in so tranquil and social a community. More than half of all the inhabitants were attacked, and 16% are dead already, while nearly 30% of the cases were fatal. This has occurred in a section of the township which comprises only one seventh part of its area and population, and where only one or two deaths in that section, or in the whole township only eight or nine, usually occur in the whole year; that is, where the annual death rate has steadily been from 14 to 17 per 1,000 of the living,, it now, for the period of five weeks, from diphtheria alone, became 140 per 1,000, yearly rate, and in the district itself, had the same rate of destruction contained for a year, none would have remained alive. The accusation of the water of the streamlet that supplied the school children in that district, and the discovery of obvious causes of pollution of that brook, very readily exaggerated the relation of that suspected source of peril, which the afflicted families denounced in positive terms. This source of suspected defilement of the brook water was carerefully examined, and although the actual causes of the spread of the disease as a virulent contagion are ascertained, as described in this report, the neglect of sanitary care and provisions for that little school room and its pupils will ever be a most important part of the record of this fatal outbreak and propagation of diphtheria. The explosion phenomena of the outbreak and spread of the contagious factor of the malady certainly depended upon causes which were present in and near the little school room in the glen. The children of nine of the ten families that were represented in that school became sick from the same infectious malady, and the 16 pupils who went home infected and rapidly succumbing to the disease unquestionably planted the virus in their widely separate dwellings in the valley and on the hill sides. The alarm and grief which in this insulated region called the attention of the National Board of Health have given occasion for carefully investigating and reporting the preventable causes by which diphtheria produces its ravages and seem to become epidemic. The hillsides of a mountain district and the domestic and social circumstances of their inhabitants have enabled us to place on record the facts which more completely demonstrate the sanitary problems of control and extinction of the infections and transportable factor or cause of diphtheria, than could in cities and populous villages be clearly divested of doubt in the line of evidence. This report comprises, in concise statements, the records of the groups of cases, viz, those cases that constitute the primary group, and those which followed in successive series, a review of the physical circumstances of the households, the locality, and the season, together with an abstract of medical evidence, and the maps necessary for the illustration of the subjects referred to.
The Locality
Newark is the most northern township of Caledonia County, Vermont, and is 6 miles square, situated about 60 miles in a northeasterly direction from Montpelier, in latitude 44 25 north and longitude 70 55 west. Its deepest valleys have an altitude of nearly 1,250 feet above the level of the sea, while the crests and plateaus of its hills vary from 100 to 300 feet above the beds of the valleys. The eastern side of the town is flanked by a sharp spur of the Green Mountains range, shutting off a view of Mount Washington, and having an altitude 1,700 feet above the sea. Ridges and smoothed slopes of diluvial gravel and disintegrated calciferous mica schists and the eroded valley and glens that are worn in the latter, as left in the glacial period, now are prolific grass lands and forests. The valleys have a general direction from north to south, bearing eastward, and their streamlets converge to make up the west branch of the Passumpsic River, which flows onward to the Connecticut. The accompanying map shows the geographical and historical points which are to be mentioned in this report. It presents the outlines of school  districts and indicates the location of the dwellings, public roads, hills, valleys, and water courses in the township. The outbreak of diphtheria was in district No. 4, and extended to district 2 and 9, and has also been transplanted in a remote quarter of No. 7. The pond and its sluggish outlet in district No. 4 occupy the most swampy depression in the main western valley of the town. That water way, notably the half mile south from the Center Pond, with a hundred acres of boggy land on either bank, comprises the most stagnant water in the town. The map will serve as a road and chart, but the profile view from a standpoint on the most Southern hillside in district 4 shows the several hills and streamlets converging in the valley southward from the school house and Center Pond. The small circles inclosing numerals mark the site of the dwellings invaded by diphtheria, those which are beyond the limits of the fourth district (Nos. 11, 14 and 15), being the exceptional dwellings, marked like the other afflicted households, by a red circle and number.
Consecutive Record of Cases
	The Preliminary Cases
April 13, 1879 – The family of Mr. A. F. Carpenter, whose dwelling is marked 1 on the map, called a physician from the neighboring town of West Burke, a post village, 7 miles distant, to attend two of his children. There were two children younger than those in the family not then sick. A teamster and his invalid wife resided in the family as boarders. The two sick children, and soon the teamsters wife, were sick and under treatment until the 23rd of April. The physician pronounced the disease to be diphtheria. The invalid wife had a difficult convalescence, with her nostrils and mouth loaded repeatedly with the diplitheritic membrane. The husband recovered more rapidly, but with ":sore eyes: from which he had not recovered a the time I saw him, six weeks later. One of the children, Emma, aged about 11 years, recovered to such a degree as to be able to run about for a fortnight before the school was opened; but during the few days previously to the opening, and most notably on the day of opening (May 12), both eyes, particularly the eyelids, were loaded with "an offensive discharge". Pain in the eyes, added to this offensive condition of the eyelids, led the child to stay away from school after her first day’s attendance. I saw this child and took her own testimony; and, aside from any events which we know ensued upon her attendance at school, I should have inferred that her oplithalmia was diphtheritic. Probably the teamster, who lived in the same apartments and ate at the same table and had been sick with diphtheria at the same time, suffered this form of disease, as before mentioned, for his eyes were not fully recovered when I saw him in June. The four cases of diphtheria in the carpenter dwelling, upon the bog, certainly had a slow and dubious convalescence; two of them were vexed with aphthalmia that continued until June; their sore throats and nostrils gave ample evidence of the nature of their sickness even at the time I saw them; therefore these four will be entered in this report as the preliminary cases. I was unable to trace these to any antecedent cases that would in any manner account for transmission of diphtheritic contagion to them. But whether this malady may spring up indigenously and take on the contagious quality, or, on the other hand, may depend on the specific germinal matter of the disease itself, conveyed by whatever means possible in air and substance, the occurrence of these from primary cases was obviously natural so far as personal, domestic and local circumstances were concerned. The type and history of the ophthalmic troubles must not be overlooked, and we have to add to this the testimony of the patient, Emma, that at the opening of the school she wore the same unwashed chemise that she wore when sick with diphtheria. This is important, if true, and all persons who undertook to test this child’s memory and veracity believe her statements. Having studied these four preliminary cases that occurred in the same apartment, we have now to consider the several series of cases that followed the primary group (whose medical history was supposed to have ended with the third week in April), In recording these successive series we found that the evidence classes them in four distinct and clearly dependent groups. Therefore, in reporting them consecutively, it will be logically correct, as well as convenient, to allow them to appear in four successive series, as we found them on our personal inspection from house to house. First Series of Cases in May The school children – The common school in district No 4 opened its summer term the 12th of May, with 22 pupils, and as only one family escaped the seizure of some or all of the children they sent to this school, we will mention these families in their order. Family of J. Aldrich In school there were: James, eight years of age; Jennie, five years of age; Frederick twelve years of age. James was attacked with all the throat symptoms of diphtheria on Wednesday evening, May 14 and on Thursday night he was very sick. The case proved excessively malignant the diptheritic exudation and masses invading all the mucous passages from the lips to the stomach. He died on the _____day. Previous to and closely following this first fatal case the two other little children (not pupils at school) and the father, mother and an uncle, which constituted the household of eight persons, took the same disease; Jennie, aged five years, was attacked on Friday, the 16th of May and died on the ____, Frederick, past twelve years old, was attacked about the same time as his sister, and was dangerously sick on Sunday, and died on the 26th of May, after unusual endurance of a virulent form of the malady a full week. He was carefully nursed during the last two days by a gentleman to whom he was affectionately attached, and who came from a distant part of the township to give his attendance. This boy died on the 26th, and at that date the five other members of the family had come down with the same malady, and made the second series of cases more numerous and formidable that the first series. The residence of this family is marked No 2 on the map. Family of K. Morse Delia, six years and ten months of age, became very sick in school on Thursday, the 15th of May. Symptoms: dipheritic throat, headache, stiffness, and vomiting. The physician who was called to her at midnight from a distant town had three other families to demand his attention before the next sunrise, May 16. Delia died on the 6th day from the attack. Irving, aged five years, was sick n the 16th and died on the 7th day from the attack. Uncontrolled epistaxis seemed to be the cause of his death, after the throat had become clean. The septicaemia was so marked in both these cases as to give currency to the belief and statement that the flesh was falling from their bodies while being wrapped hastily in blankets for burial immediately after death. The fact that necraemia and excessive sloughing and putridity of the parts attacked by diphtheria rendered the dying children the objects of intense commiseration in such a community sufficiently accounts for the extravagant expression by which the sufferings of the families were described. The father’s careful description of his dying children’s symptoms was definite and correct. The residence of Mr. Morse is No. 3 on the map.   The Family of John Cole Alvah and Frank, four and a half and six and a half years of age respectively, were attacked on Friday, the 16th of May and died on the fifth or sixth day of their sickness. Their residence is marked No. 4 The Family of A. F. Carpenter Charles, aged thirteen, who had escaped attack during four weeks of exposure to causes at his father’s house, where his brother and sister and Mr. and Mrs. Woodrough were sick, was seized with diphtheria the fourth day of school (at noon). He recovered. This case is in evidence that the conditions that favored his becoming infected at school were greater than at home. His home is marked No. 1 on the map. Family of F. Simpson Carrie and Eliza, aged eleven and twelve years, respectively, came down with diphtheria on Friday, May 16. Their residence was nearest the school room, in the glen. They recovered, but were suffering serious sequelae of the malady when I examined them, June 12. Their residence is marked No. 5. Family of Samuel Park Emma and Etta, aged eight and six years respectively, were attacked violently on the last school day, May 15. The younger girl died on the _____of May. Their residence, upon the crest of the steep hill northwest of the glen, is marked No. 6 on the map. Family of J. Gero Warren, aged twelve years, the only pupil at school from this large family of ten persons, came down with diphtheria on May 16, and, after a comparatively mild attack, recovered. This is in a family of French Canadians who live much in the open air, and who, fortunately, were only little exposed to this the mildest case of series first. This house is marked No. 7 Family of L. Wilson Clifton Hudson (a boarded child), aged eight years, and Nettie, aged five, came down with the sickness on the 14th day of May. The girl died the eleventh day of her disease. The boy recovered sufficiently to be removed to his father’s residence, twelve miles eastward. The Wilson house is marked No. 8 on the map. Family of D. Fairbanks Mystie, aged ten years, was attacked severely during the afternoon of May 14, the third day of school. As her home was upon a distant and steep hill and her younger sister an object of care, the teacher kindly led these children down home. The teacher and this youngest child had resolutely refused to drink the brook water, and as each of them mentioned this fact thus early, it is part of this record. D. Fairbanks house is marked No. 9 on the map. Review of Events in First Series Of the 22 school children 16 were attacked so nearly at the same time, and were so significantly sick with the same malady, and the mortality was so startling, that panic was inevitable, where in a whole township there was neither a physician nor a clergyman to explain the causes nor assuage the fears of the families in which these events occurred. The death of 9 out of these 16 certified the malignancy of the disease. The question, whence came the infectious virus of the malady, was urgently asked, and erroneously answered by the parents and their neighbors. That query now admits of a correct reply, yet the circumstances under which the pupils in the school room by the brook in the glen were gathered into close contiguity during the four hot days, drinking copiously of the polluted water, and crowded into a close little room that stood upon and beside a muck bed, may fully account for the explosive phenomena of the contagious outbreak and spread the disease. Besides these local and domestic circumstances there were others, chiefly associated with the intercourse of the family with the people of the towns where diphtheria was present. It is certain that the preliminary cases were slow and imperfect in their recovery.
The Second Series of Cases
Before the cases in the first series were terminated – in death or recovery – and, indeed, at the time when the first two of the nine fatal cases of that series were dying, the second series of cases began to be prostrated. The parents, nurses, and infants in the families of the first series patients or school children cases being now the victims. This second series, exceeding thirty in number, was widely distributed, and wherever it extended beyond the households of the series of school children it took hold of inhabitants of the most elevated and salubrious dwellings, that had no other cause for the presence of diphtheria than such as was accounted for in their voluntary and very unguarded exposure to it in their personal attention to the sick and their defiled clothing. The account of all cases in the second, third and fourth series, extending to the date of my departure from the district, will here be given as briefly as possible, and with no other details than such as are necessary for identification of the groups and their causes. In the Aldrich family The five members of this family not included in the first series of cases consisted of the two parents, a brother of the father, an infant of seven months, and a son, William E. aged three years. William was attacked with the disease May 19, nearly five days after his brother James came from school sick with it. Death ensued on the fifth day of the malady. The infant, Mary, who had been removed to A. F. Carpenter’s for care as soon as its mother became ill, immediately came down and died with the disease. The mother, who became ill while attending upon her three dying children in first series, was taken to a new little cottage adjacent to her own garden, and there was nursed by its occupant and recovered. Mr. Aldrich and his brother, forty years of age, were at the same time sick in the family residence, where four apartments were being occupied by patients. The acre of ground where that house is situated is an alluvial terrace neat the foot of a northern hill, the house and terrace looking southward, the cellar being were from springs, the surrounding grounds sodden with organic matter and covered with the waste of rotting wood, and the well water and grounds generally being foul with all sorts of excremental soakage. Here was the most populous and virulent focus whence radiated the disease by many carriers. The Moore Family A child two years of age was attacked by the disease the day its sister Delia died May 22. It recovered. The case of another child three and a half years of age who escaped by removal to a distant dwelling belongs to the record of escapes. Father and mother seem to have escaped, and the healthy babe born June 4 was still doing well. John Cole’s Family The father, mother, and father’s brother, all the family, were seized with the disease the day the two school children were buried. recovered. The Simpson Family The mother and an infant of two and a half years took the disease while the two school girls of the family were recovering. The infant died on the 6th day of sickness. The Park Family The eldest son, Orlo, aged thirteen, came down severely on the 10th of June, while his surviving sister was recovering. His brother Warren was seized on the 12th instant. I examined him and observed the local malady in the fances six hours before any other than the throat symptoms appeared. The result in these two cases was dubious up to the 14th instant, since which I have no tidings. The Wilson Family The disease of the two school children extended to the four adults in the family. These recovered. There was another adult(Mr. Hudson, of East Haven), the father of one of the children, who became slightly ill with the throat symptoms, but he removed with his child to his home eastward of the mountains as soon as they could go safely to themselves. In Families that had no school children The cases in the second series appeared as follows: Mr. and Mrs. McLucas, in the residence No 10, attended upon the dying in first series and suffered mild attacks. Family of Eph. Fairbanks George F., aged 31, attending the sick and school children at Mr. Aldrich’s, was severely attacked May 26 at his house, 2 1/2 miles away upon the mountain side . His step-mother, Mrs. E. Fairbanks, attended upon him continuously, and his step[-brother, Robert, shared in the duty. What occurred to the family subsequently we shall mention. This homestead is marked No 11 on the map. Miss L. Bill, a maiden of twenty eight years, attended upon Aldriches, and became sick at her house, a mile distant. Whether from exposure to cases of children in first or second series is unimportant, as she became sick soon after her attendance upon both at the same time. The children in her home had been exposed in the school, but did not suffer. They had the diphtheria last year in a distant town. That homestead is marked 12 on the map. Mrs. Gray, aged fifteen and a half years, residing with her mother in a large family (Mr. James Cole’s) of field and forest workmen, came down with diphtheria while the Wilson family was recovering. She had been exposed to the personal contagion of the malady only by the visits of the non-resident (Mr. Hudson) who removed his child from the Wilson’s, and, more notably, by her mother’s laundry work in the little apartment where she was some five or six days before her illness compelled her to call a physician. I saw this case making a slow recovery. The house is marked 13. Mr. and Mrs. Woodruff – O. C. Woodruff, aged 23, farmer, residing upon a salubrious high plateau nearly 3 miles southeast from Mr. Aldrich’s, after two nights and a day’s watching and ultimate attendance of the dying lad, Fred. Aldrich, lay down near the sufferer for some time on the 26th of May. He was seized that day, and has made a slow recovery. Even after his throat and mouth were entirely clear of the diphtheritic membrane, the same virus attacked a slight abrasion upon the back of his hand, and this was still unhealed at the time I saw it, June 12. Mrs. Woodruff, the heroic but unadvised wife, sent for the most necessary portions of the defiled personal clothing &c., at the Aldrich house on the 25th of May. She washed and ironed it at her distant and most healthful dwelling, and sent the cleaned garments and bedding to the afflicted house whence it was taken. She became severely ill on the 28th, and was dangerously so before the end of May. Those two cases, and unquestionably the latter one, clearly fix certain important points in history if the incubation as well as portability of the diphtheritic virus. The home of these thrifty people is marked No 14. The Third Series of Cases Whatever may possibly be true in such cases as those of Mrs. Gray, Miss Bill, and George Fairbanks, who were briefly in attendance on cases (or in their presence) in the second series, and had full and positive exposure to the infection from the sick in the first. Mrs. Ephraim Fairbanks, at residence No 11, attended constantly upon her step-son, George, at their mountain home, where everything was cleanly, fresh, dry, and well kept. On the ninth day of that exposure, worn down with care and toil, she came down severely. She continued to nurse her child at night until her milk failed. She died the morning of June 8, attended by her son (Mr. Roberts) and a vigorous lady friend, Mrs. Kelly, whose residence was 4 1/2 miles distant. The infant, of 22 months, had ceased nursing and been taken from the sick room three days before the mother died. It became sick the day of that death and followed the mother five days later. I visited this child when dying. Possibly these cases may be the last of the third series, though fatal cases of "some sudden sickness" have occurred during the second week of this month beyond the mountain eastward, whither the school child Clifton Hudson was removed by his father from the Wilson family in Newark, before complete recovery. The Fourth Series of Cases Charles Robert, aged 18, son of the deceased Mrs. Fairbanks, was sick with diphtheria during the last day of his attendance upon his mother, He convalesced slowly. Mrs. W. Kelly, a vigorous and heroic woman, whose residence is marked No 15 on the map, was sick the morning she returned from her attendance upon her dying friend, Mrs. E. Fairbanks; was taken sick while walking home, a distance of 4 1/2 miles. I saw her when dangerously sick with her family around her. Her condition continued critical for ten days, and she convalesced slowly. Special nursing and the exclusion of all needless attendants were advised in this case on the 11th of June. This began the new system of sanitary precautions as supported by the selectmen of the town. Here terminates the record of cases in Newark, as far as any information could be obtained at the time of my inspection. There appear to have been 44 well declared cases. There were 15 deaths, 9 of which were school children of the fourth district. Note Respecting The Households That Were Invaded and Those Which were Not Fifteen households had been invaded by diphtheria previous to my inspection of the district. Eight of them were free from the malady until the school children brought home the sickness, which was accredited to the school room and what occurred there. The house marked No 1 on the map, that certainly had been a nidus of infection for weeks, makes this list of sick school children’s homes number nine, and in these nine households we find the 16 sick pupils. In five of these dwellings there died 9 of the 16 pupils (in the first series) and 3 other children, but no adults; but in the same nine dwellings 13 adults and 5 children, (all of second series) took the disease and survived. In the six dwellings invaded by diphtheria, where no pupils were sick, there were 11 cases and two deaths, all adults save two, and the fatal cases being Mrs. F and her child. In the total 15 dwellings there resided 92 inmates at the time diphtheria appeared; 48 were attacked and 14 died, 9 of the latter being pupils in school. There were 16 households in school district No 4, and cases of diphtheria occurred in twelve of them. In districts 2 and 9 four caretakers of the sick pupils became ill in three dwellings, and in one of these (viz. Dr. F’s) the disease was communicated to other persons proving fatal in two of the latter. In district No 2 there are some twenty six dwellings. The two in which I saw the only cases of diphtheria in that district were as little liable to invasion by it as any of the twenty six, except that the victims of it had become infected while attending the sick elsewhere. The dwelling of Mr. Woodruff (No 15) is remote from that of Mr. Aldrich (No 2), whence the infection was contracted. The dwelling of Mrs. Kelly (No 15) is upwards of 4 miles from No 11 (E. F.’s) where the occupant of 15 tarried two nights and a day, until she became sick. In the long interval upon the road between the latter two households there reside six families which have not been invaded by the malady, while upon the broad area between the dwellings No. 2 and the homestead of the Woodruff’s (No 15) there reside nearly twenty families who have wholly escaped. Instances of Escape By Timely Adoption of Sanitary Measures The following are worthy of note: The teacher and one of her pupils – They refused to drink the water of the brook at the schoolroom. This is regarded as an evidence of the influence of the polluted waster in exciting and aggravating the disease, where all the inmates of the school room were exposed by some means to the infection. One of the Morse children – The aunt of a child of three and a half years, who was most exposed to infection from the sick brother and sister, was removed to a distant district and so carefully guarded by the aunt, who was attending the sick of her sister’s family, that she would not come into its presence, in her daily visit home, until after ablutions and an entire shifting of her clothing. Her family and herself, as well as this child, have remained unharmed. The Woodruff Family – The young couple who became sick (dwelling No 14) had the discretion to insulate themselves upon the upper floor of the house, and to maintain a scrupulous separation of themselves and all appertaining to them or that was done for them. Physician and nurse enforced this duty perfectly, and with entire protection to the numerous family and to all neighbors. That these were malignant cases was proved by results I witnessed. Numerous other illustrations of the importance of sanitary measures were found but, unfortunately, the greater part of all the experience in Newark was in evidence of calamitous results of the neglect of such measures in the presence of the sick. Memorandum of the Groups of Cases of Diphtheria Planted by the Convalescent Boy Hudson and the Girl Simpson June 26, the following facts were verified by one of the town officers of Newark who had accompanied my in the house to house inspection in the latter district. That gentleman reports by letter on the 18th of June, as follows: *  *  *  June 26 I went over to East Haven and the "Lost Nation" district, 9 miles by road from the district where diphtheria prevailed in Newark, and I found – 1st: Ida Hosford, aged eight and a half years, after two or three days exposure to Clifton Hudson, the convalescent schoolboy who had been removed from Mr. Wilson’s, in Newark, to his relations on the east side of the mountain, died of diphtheria after being sick five days, the death occurring June 13, at the residence of Mr. Seth Hudson. 2nd. Ada Hosford, a sister, three and a half years of age, died June 20, after five days illness. This little girl had been exposed to no one except the mother, with whom she slept at night. The mother nursed Ida when dying (June 13) at Seth Hudson’s whose house is only 20 rods from Mrs. Hosford’s. 3rd. Hattie Cole, eight years of age, who was daily exposed to the convalescent boy from Newark, as he was now domiciled in her father’s home. It was on the 12th day of his residence that Hattie became sick. 4th. Frank Down, in same family as Hattie and the boy Clifton, was attacked the same time as the girl. 5th. In another neighborhood nearer to Newark, but 2 1/2 miles from the "epidemic district" there. Myrtle Simpson, who had been exposed in a visit with Eliza Simpson, who was convalescent and thought nearly well. She was attacked ion 25th of June. 6th. Susan Walters was attacked about the middle of June. She has had another exposure than the presence of her mother, who has been much occupied in voluntary care of the sick in the "Newark epidemic". Her residence is three miles from that district and separated by the mountain. The first four of these six cases have occurred in an insulated neighborhood containing twelve families; and in the three families in which the disease has appeared there were 16 inmates.   Mr. Bruce furnishes the annexed sketch of the localities here referred to:                        Conclusions The outbreak of diphtheria in Northern Vermont has presented the usual characteristics of the malady in its malignant form. The preliminary cases in a single little group in Mr. Carpenter’s family, during the month of April, seem to have been comparatively mild, but slow to recover, and attended with an ophthalmic complication that became a source of peril to school children on the 12th of May. The polluted water of the brook by the school house; the crowded little school room and the damp mucky ground beneath and around it; the surface flow and soakage of the open privy by its side and into the brook from which the children drank; the heated glen in which the noon day temperature was excessive; the thirst of the pupils and the frequent and copious drinking of the defiled water, together constituted adequate conditions to give fatal activity to the virus of diphtheria in whatever way it was present. That the virus of diphtheria was present is unquestionably certain, and that the immediate infection and rapid sickening of the entire number of pupils whoa t the time and until now seem to have been susceptible to attack, the malignant progress and fatal termination of the malady in 9 of the 16 who were then attacked, must be regarded as proof of the intensified virulence of diphtheria when excited into renewed activity by agencies such as are described in this report concerning the school children (or first) series of cases. The chemical and microscopical examination of the water of the brook which was accused by the citizens and the public press has only shown that there was sewage pollution. Inspection of the school room and the premises about it, of the glen, the dwelling houses, and all the evidence, warrants the conclusion that the virulence of the infection and the fatality of the cases were caused by the cooperation of these several circumstances which became accessory to the outbreak. The continuance of malignant virulence and rapidly repropogating activity in the contagious factor, even the fourth series of cases in less than five weeks, in connection with the evidence afforded in the records of each successive series and each individual and group, vividly impress the duty of complete sanitary care of the first cases and groups wherever diphtheria appears. That the sanitary precautions which have been adopted will soon terminate the progress of the malady in the township of Newark is so probable, that it was deemed expedient to give this assurance, based upon action that was being taken by the medical men and the selectmen. That the events of this outbreak and of four others which we have recently investigated in rural districts warrant the conclusion that, while diphtheria is apparently liable to appear in almost any region and in remote mountain neighborhoods (especially where it has previously prevailed), from causes which are as yet imperfectly understood, its contagious propagation and malignant prevalence may be prevented by timely sanitary measures. The cheerful and prompt endeavors of the inhabitants, especially of the town authorities and the medical advisors, to give full effect to the necessary sanitary regulations in the care of the sick and of the dwellings and of all who have intercourse with them, is an immediate result worth far more than the labor bestowed in this investigation and inspection in the afflicted district. The extension of the infecting cause of the disease to an insulated population in an adjacent mountain town will give another series of facts, depending, as we now believe, upon the injudicious removal of the convalescing school boy from the Newark district to the region here referred to: but as regards the people of Newark, as now advised they can protect themselves with reasonable certainty. The chief sanitary measures recommended and found practicable by the authorities and physicians are briefly as follows: 1. Regulated and competent nursing by persons separately engaged in such duty; medical regulation of the sick room and all that pertains to the sick. 2. The separation of all children, and as many others as possible, from the sickrooms and from all other exposure to the sick and their care takers. 3. Complete cleansing and disinfection of all things and places defiled by the sick. 4. Temporary seclusion from or closure of schools in the districts in which the malady is present. 5. Instruction of families and nurses concerning the causes which spread the infection and which render it necessary to keep up the sanitary precautions until all signs of the disease disappear in those who are recovering from it. Fortunately the people readily comprehend such instructions and sanitary regulations and though it seems to be one of the laws of diphtheria, as a domestic pestilence, that its obviously contagious factor may gain force and a most destructive virulence which makes it sometimes truly epidemic, all well studied experience goes to prove how true it is that the infection and propagating causes of diphtheria is the one essential cause which sanitary science lays hold upon to arrest and to prevent its epidemic prevalence, while all its accessories should also be controlled and abated, for, in the words of M. Gendron, "Lepidemic est l’effet et non la cause de la contagion". Respectfully submitted. ELISHA HARRIS M.D.   Appended Statements  A, B, & C National Board of Health Washington, D.C. , June 6, 1879   Dear Dr. Harris:   I am directed by the National Board of Health to refer to you the accompanying newspaper report of a wholesale poisoning of school children by drinking polluted water, with instructions to visit the locality (Newark, Vt.), to investigate the matter thoroughly, and after returning to submit a report in writing to the board. I am further directed to say that while on this duty you will be entitled to receive, in lieu of your present pay, a per diem of $10, and your expenses not to exceed $5 a day for hotel charges.   Very Truly Yours,   J.L. Cabell President National Board of Health   Vermont’s Sickening Horror – Drinking from a Brook Full of Dead Animals   The number of school children poisoned here by drinking water from a brook into which the carcasses of a dead horse and several sheep had been thrown is 27, instead of 9 as first reported. Ten of the children are dead, and it is feared that the other 17 will not recover. The stream flowed near the school house and the farmer who threw the  carcasses into it will probably be arrested. There is the most intense excitement, and crowds visited the houses where the dead bodies lay, but the sight was disgusting, and the corpses were buried as soon as possible after death. The parents of the dead children are objects of general sympathy. Nearly all the children in the school are down, and it would not be surprising if the men who are in the habit of throwing dead animals into the water instead of burying them would be the subjects of legislation. It is ascertained that a number of persons living along the banks of streams have been subject to typhoid fever and supposed affections of the bowels for years past, while persons who used water from springs and wells on their own premises were seldom affected. In some villages and towns supplied with water from streams the same thing has been observed, and the matter is attracting considerable attention. It is ascertained that the sewage from barnyards and stables and the refuse from factories and other well known fact that hundreds of people must drink the water or none at all. In many places privies are built out over the water, and every sort of filthy and decaying matter which, if used as manure, would fertilize the earth, is mercilessly dumped into the flowing streams. It has been stated by indignant physicians that pestilential diseases are God’s punishment for the wickedness and laziness of the people of whole counties and States who permit such a state of affairs to exist. Now that the matter is brought home to the people in the neighborhood of Newark, they are horrified at the number of instances in which the laws of health are violated and the lives of whole communities endangered by the lazy people, who throw all dead animals into the water or drag them into the woods to fill the air with the pestilence and death. A farmer near Newark, who buries all dead animals in his manure pile under a shed, says that in the course of a few weeks such bodies are completely absorbed except a few clean bones, and that the fertilizing strength of that portion of the manure is wonderful. Other farmers bury dead animals at the roots of grape vines; but the effect of this is to disgust all persons of weak stomachs who are aware of the fat. It is alleged that the farmer who has caused this wholesale slaughter of children is in danger of personal violence ore even of a trial for manslaughter; but his neighbors say he had not given the matter any thought, and that he has done no more than others in Vermont and many other states have done for years and are still doing. The people of this part of Vermont are quiet and orderly, but as one child after another dies in agony, becomes a repulsive and bloated corpse, and is hastily buried before it can fall to pieces, the wails of some of the mothers are heart rending and the feeling among the men as the news flies around the neighborhood is a very dangerous one for the cause of the disease. The indignation is spreading into the towns where owners of factories are pouring the refuse into streams, and old laws on the subject are being hunted up, with the intention of punishing all who have habitually violated them. One prominent manufacturer on Bullock creek admitted that all the fish in the streams died from the poisonous substances poured into it. In the words of a farmer near Newark, "There is lightning in the air". and himself a number of his neighbors are burying such dead animals as may still be above ground. Another great danger has evidently just been thought of. The carcasses of dead horses and cattle, when dragged out and left in the woods, are devoured at night by dogs from far and near, and for days afterwards they are sullen and dangerous from the effects of their bloody feast. The singular death of a child some time since from blood poisoning is now believed to have been caused by a pet dog which had been gnawing at a dead horse, having licked his face soon after returning from his horrid feast; and another singular case of the death of a man from the bite of a dog, which was afterwards chained up and found not to have hydrophobia is now explained in the same way. So indignant have the people become that it is even proposed to memorialize Congress to pass a general law for the prevention of this horrible practice of befouling streams; and it is claimed that, as the yellow fever in the South last year originated from just such a cause, there would be no difficulty in finding strong reasons for its passage.   Later   It is now reported that three more children are dying, and the mews passes from one to another with remarkable rapidity. A few of the rougher class hint that it would be as well for the farmer who caused the trouble to emigrate without waiting to pack his trunk, but the mass of the people discourage any attempt at violence, as they say he is no more to blame than some of those who now find the most fault. For the information of Dr. E Harris T.J. Turner Secretary National Board of Health June 5, 1879   (Appended Statement) B. Island Pond Vt. June 2, 1879   Dear Sir: The water drunk by the children in Newark was taken from a little brook running from springs on a  hillside. A horse was buried about 75 feet from the brook one year since. The grass from the carcass to the brookside (about 8 feet wide) is much more luxuriant then elsewhere, showing that the influence extended to the brook. This is about 2 rods above where the children took the water. The sewage from a farm barn and yard entered the brook about 20 feet above the place where the water was obtained. Diphtheria of a mild type had been in the district for four weeks before the school commenced. No fatal cases. School commenced May 12; most of the cases were taken from the 14th and 17th; 22 scholars; 17 sick; 8 deaths; 3 deaths of children who had not attended school – making 11 deaths in all; 5 now sick, but with a fair prospect of recovery. I saw some of the cases on the 19th day of May, and again yesterday, June 1. The disease differed in no way from epidemic diphtheria that I have repeatedly seen. That the water was poisoned, I have no doubt. That it determined the nature and type of the disease, I cannot admit. That it had much to do with the fatality of the disease, I can readily believe. Yours, Truly, C. G. Adams, MD   (Appended Statement) C   Saint Johnsbury, Vermont June 2, 1879   My Dear Sir: I am in receipt of your favor of the 30th ultimo, and have written by this mail to Dr. Holton upon the matter of an investigation and a report of the poisoning case in the town of Newark. I think Dr. Holton will give attention to the matter at an early day and report to you. I am yours, very truly, Horace Fairbanks   (Appended Statement) D. Topography and Geology of the District   The surface geology of the district and of the entire township may be described as belonging to the schist formation, and the soil as being made up of the fragile and decomposed schists and the diluvial gravel and bowlders from the granitic regions northward. The central portion of the town is marked by a deeply eroded valley of variable breadth extending from the line of ponds, as marked on the accompanying map, southward, and having several accessory and converging valleys and glens, like that where the school house in district 4, and that in which the three starch factories are. The hillsides and crests of the smoothly rounded ridges above the valleys are the favorite sites of dwellings and are the best farmlands. A steep mountain spur extending southward along the eastern border of the township has an altitude of nearly 500 feet above the waters of the east and west branches of the Passumpsic River, whose confluence is at the southern point of the spur. Springs of water appear at frequent intervals along the hillsides. The boggy flanks of Central and Mud Ponds and their sluggish outlet, in the midst of which the preliminary group of cases of diphtheria occurred, is the most salubrious region in the township. The periphery of that boggy area is marked on the map by a double line of black points. The calciferous mica-schists of the mountain sides have contributed the basis of a soil that with the humus and alluvium of the deep valley of this outlet makes the boggy ground. Elsewhere than in the valleys, which are narrow and tortuous, the surface geology resembling the sandstone regions which have been subjected to glacial action. Yet these schists are older than the granitic upheavals which have penetrated the thick strata of the former, and now appear as mountain crests. The entire region northward from the town of Newark and the headwaters of the Passumpsic, in Vermont, i.e. the water shed northward towards the Saint Lawrence is granitic, and is very deeply eroded, so that it is a wilderness of ponds and lakes which rest on granitic bowl bottoms, the worn gravel from which now constitutes the beautiful ridges of farm lands of the regions southward. The water courses are now traced in the pathways of the old flow of a glacial period, and the streams have a very tortuous course. The streamlet in the school house glen of district No. 4 issues from springs and preserves its purity until it receives the farm yard soakage and the sewage filth of the ditch and the school privy. Though there are numerous factories for making starch from potatoes located in the upper valley of Newark, and the numerous sawmills cast into the streams on which they are located a vast quantity of saw dust and waste from the mills which becomes mixed with the pulp that is cast away from the potato starch factories, the water courses, except from these causes, are quite free from nuisances. Copious springs supply nearly all the families and fields.   Forests, Farms and Products   Pines, larches, red cedars of great size and value, hemlock, maples, beech, and a great variety of cherry constitute the forests. But these have been so denuded that the hills are bare in most places, the woodlands covering only a small fraction of the lands available for culture and pasturage. The farms are devoted to grazing and the production of the spring cereals and potatoes (the latter for the manufacture of starch), and they enable the farmers to live comfortably and have large families. Food supplies are of excellent quality, and no blights or fungoid parasites afflict the fields.   The Habitations   The rural cottage, built of wood, and usually having an extensive wood shed for the grains, fuel, a dairy room with its appurtenances, and lastly and at the extremity of the line an earth pit privy, with farm buildings or shops, &c, further removed from the domicile, make up the structures of the homestead. It is a notable fact that, while the outbreak in school district 4 spared no household because of its cleanliness or healthfulness of situation, the excessive mortality occurred chiefly in dwellings that worst kept, and where the yards and outhouses were neglected. The preliminary cases and the first few deaths occurred in the midst of exceptionally unclean surroundings. The latest two series of cases I visited certainly were found in the midst of domestic comforts and habitual cleanliness. The virus of diphtheria had selected its victims according to the degree of their individual exposure, and without regard to any special conditions that may have been present or absent at domiciles where they reside.   Water Supplies   With the single exception of the school room, scarcely a house is destitute of a copious supply of pure spring water that is conducted to the domestic hydrants under high pressure of gravity.   Climate and Meteorological acts   The mean annual temperature in this region of highland valleys is about 41 1/2 Fahrenheit. Snow is deep in winter, and it covered the whole region this year until late in April. The records of temperature and humidity at the nearest station corresponding with this district in eographical position and altitude, viz, in the town of Lunenburg, read as follows for the ten days the outbreak was coming to its maximum intensity:    Date Noonday Temperature (Fahrenheit) Humidity (100 being saturation) May 12 78 32 May 13 85 40 May 14 81 35 May 15 74 80, showers May 16 70 70 May 17 72 65 May 18 74 50 May 19 75 68, showers May 20 65 45   This record suffices to show that the weather was intensely hot and dry during the four days the school in the glen was in session, from May 12 to 15, and that the heated term continued. Vegetation advanced rapidly, and, in the narrow little valley in which the children were at school, the heat was much greater than was marked by the observer who has kindly furnished the annexed record of temperature.   Atmospheric And Parasitical Fungi   Professor cutting, the State geologist, and eminent as a naturalist and teacher, resides in a neighboring town, and by his courtesy we are informed that "the entire region is remarkably free from any of the minute cryptogamia which are manifested as blights and molds, or that otherwise produce visible effects; that the blights and mildews which are sources of danger in the Lower Valley of the Connecticut River are rarely found in this highland region, and that even the Puccinia graminis, as usually found in abundance in the lowland districts are where the cereals are grown, have seldom produced any obvious effects in this region of Vermont.   The Chemistry and Microscopy of the Brook Water   The streamlet which was so much accused of being the cause of the fatal outbreak among the school children has its source in numerous springs up the glen in the woodlands. Samples of the water from the woodland portion of the stream just above the point where the soakage from the meadow and barnyard have remained for four weeks free from odor and from any growth of algae and other visible organisms; while the samples which were taken at the same time from the places at which the school children obtained water are found to have become intolerably offensive, and to have become densely turbid with spore growth and animalculae. Five or six samples of the water from the last mentioned places in the brook were submitted to Prof. Hiram A. Cutting, for analysis, by the selectmen of Newark, who hoped, by the help of the professor’s explanations and account of his analysis, to quell the panic, and either to disprove or justify the current accusations in the district. By Professor Cutting’s kindness I am permitted to present the annexed statement of the results of his analyses:   Appended Statement of the Chemistry and Microscopy of the Waters of the Brook in Newark   State of Vermont Office of State Geologist Lunenburg, June 14, 1879   My Dear Sir: On May 29 I carefully examined the water brought me from a small stream in Newark. I found 24 4/5 grains of impurity to the gallon, consisting of animal, vegetable and mineral matter. The water was slightly ammoniacal, containing a trace of chloride of sodium, but no salts of lead or copper, and but slight traces of iron. Animalcule like as it appeared under the microscope was abundant, including Ratifers, Daphnia pelex, Hydrachna, and other common varieties. It was, as the tests show, but slightly contaminated by sewerage, and the impurities from animal, vegetable and mineral matter was no greater than is usual in the small streams of Vermont in the spring time. While I consider it unfit for drinking purposes, I find nothing that would seem to be immediately detrimental to health. In the water as it came to me were the usual algae found in what is supposed to be our purest waters. The most abundant was "Batrachospermum moniliforme". I also found in connection species of the Volvox; but nothing in the vegetating life that was abundant and in vigorous growth that would indicate any uncommon condition of the water. Truly Yours, Hiram A. Cutting   Other Observations   After conferring with all the educated physicians who had made observations on the town or among the sick during the season, I ascertained that nothing unusual or worthy of note seems to have marked the occurrences in nature, or among the people, the past two months. The diseases have been of a mild type; enteric fever has not been prevalent, though it is the malady most feared among the people. Diphtheria seemed to have nearly disappeared until April and May, and only a few small groups of cases of it have yet been reported in this region of Vermont, but none so destructive as this in Newark. The season has been peculiar in the suddenness of the advent of hot summer weather the second and third weeks in May, before the ice had disappeared from the neighboring mountains. The very nicely exact observations of Professor Cutting upon the presence and variations of ozone in the northern regions of Vermont have warranted him in stating that for many days in May it was entirely absent on several days; yet this, he says, is not unusual at the beginning of summer in these mountain towns. It is a fact to be noted that the several days of excessive heat, beginning May 11, were exceedingly dry, the hygrometer marking as low as .35 of saturation, while shortly before the earth was flooded by rain. The outbreak of diphtheria occurred just at the time when the minute fungi could be most favored.   Other Outbreaks of Diphtheria This Season   In the town of Barre, 70 miles southwestward from Newark, and Tunbridge, some 80 miles south, sharp and fatal outbreaks have occurred, and caused the closure of the district schools. These manifestations have not ceased. It was noticed last year that several insulated cases and small groups of sufferers from diphtheria occurred in the five northern counties of Vermont and in the two northern counties of New Hampshire. The chief of these records are appended under the head of "Recent Outbreaks in Northern Vermont and New Hampshire". Special importance attaches to the record of that in Northumberland, N.H. where 110 cases occurred in one school district which I visited. (See statements E, F, G.)   Lessons From these Outbreaks   Though diphtheria has prevailed in the State to some extent from 1858 until now, its specific self propagating virus was not generally recognized until recent years among the country physicians. In 1863, when it destroyed nearly 1400 lives in the State, this contagious attribute began to be anxiously noticed; and in 1866 Dr. A.J. Hyde, of Sutton, reported for the committee on epidemics in Caledonia County, to the State Medical society of Vermont, that diphtheria had attacked some patients upon abrasions on the hand, the ankle, the os uteri, and in one instance, with fatal blood poisoning and death ensuing, it had attacked the eyes. That report awakened the medical profession to the duty of more closely observing the first cases and first groups of cases, and carefully recording the progressive events of the local outbreaks and epidemics of diphtheria. To facilitate the inquiries now in progress respecting this malady, and also add valuable facts in connection with this report, we here refer to recent investigations by most trustworthy medical observers in the regions of Northern Vermont and New Hampshire, where the present outbreak occurred, and may be permitted to add some further testimony from the physicians in those regions, who have voluntarily opened correspondence with the National Board of Health upon this subject. Dr. S. H. Colderwood’s report – A valuable study of 55 cases of diphtheria occurring in a region some miles northward from Newark was contributed to the Vermont State Medical Society two years ago by the late Dr. Colderwood. The events of the Newark outbreak, like those of numerous epidemics of diphtheria, have prepared the people in the regions afflicted, and probably the entire State, to accept and act upon the necessary sanitary instructions for repressing and preventing the propagation of the contagious and all known accessory factors of this malady. The numerous physicians and other enlightened citizens whom I met in the North have expressed an earnest wish that a State board of health shall be organized in every state. Note upon an outbreak of diphtheria in the town of Northumberland, N.H. – Hon. Dr. J. A. Watson, a member of the legislature of New Hampshire, communicates the following facts concerning the remarkable prevalence of this disease in the district where he resides: In the little hamlet of Groveton, where the Grand Trunk railroad touches the Connecticut River, diphtheria appeared in a public school, at which 125 pupils were in attendance, in May 1878. The local conditions under which the disease rapidly spread to 25 of the pupils, regardless of the domestic relations and distance of their families, induced me to inspect the locality and the great school house in the mountains, for the special facts which Hon. Dr. Watson has since contributed seemed to be very important, as communicated to me by a citizen of that district.   Groveton, NH June 30, 1879   Dear Doctor: Your letter received, and should have answered before, but have been sick, and am not yet well. I inclose you a rough diagram of the field of the epidemic of which you write and also some points relating to its origin.   Respectfully,   J.A. Watson, M.D.     On the 12th day of May last a case of diphtheria made its appearance in a family of means and respectability in the village of Groveton. Everything around the premises was neat, clean and orderly, and the hygienic and sanitary surroundings were above the average. The patient was a boy of about eight years of age. There was no other case of diphtheria in town, and no connection between this and any other case could either directly or indirectly be traced. The boy was attending school at the time of the invasion of the disease and was in excellent health.   On May 19, seven days after the onset of the first case, a little girl about 10 years of age was taken with the same disease. This patient lived nearly a mile from the first case, a little out of the village, on a farm. Here the sanitary conditions were also good, though the case was of a most malignant character, and the patient dies on the sixth day after the invasion of the disease. This little girl was also attending school.   May 21. Another case, remote from the other two, and in no way exposed to the former cases: was attending school.   May 22. Two new cases in different localities, remote from all former cases; both scholars.   May 23. One new case – a scholar   May 24. Five new cases – scholars.   May 25. Five new cases – scholars   May 26. Six new cases – scholars.   May 27. Six new cases – scholars   May 28. Two new cases – scholars.   By this time the whole village was thoroughly infected and the disease was no longer exclusively confined to school children, but attacked others in the family that already had a case, and in many instances seeming to spring up independently of any connection with any case, and without regard to individual sanitary conditions.   Origin – It will be remembered that the first twenty five cases were from among children attending school, and that their homes were in many instances quite widely separated; that as many as twenty two cases occurred in the short space of six hours. What, then, must be the conclusion arrived at, even by those whose philosophy does not extend outside the lappet of their purse?   No one can doubt for a moment that these cases originated from a common source, and nowhere else could a common origin be found but at the school house or its immediate vicinity; so a most careful examination was instituted, with the following results.   There was at that time no diphtheria in any of the surrounding towns; there was no case of the kind within the limits of Northumberland; not one of the school children or any resident of the village had been away and returned; so it was not imported: and yet twenty five scholars were almost simultaneously stricken with this fearful disease. A common origin must be undoubted. Eliminating then, considerations which might under other circumstances have been factors, I would ask you what remains as a cause? The answer is given in one small word – a word to which should be attached the death emblem of the skull and cross bones ad a warning to every community, every family, and every individual – the word filth.   Map showing the locality of the epidemic in Groveton (Northumberland) NH   Dear Sir: I have been waiting for the terminating of the last cases of diphtheria. Mrs. Kelly has had a bad time from the toxic effects of the diphtheria. I thought, or rather, was fearful, she would die from the paralysis, but she is getting along finely. We kept the people and the children from going into the sick room, and no one has contracted the disease from her. One of the Simpson children went to their uncles, near East Haven, three weeks ago last Saturday and stayed a few hours, and in four days two of the children were taken with diphtheria. One lived five or six days and other eleven days. The mother and two more children were taken with diphtheria and sent for me. They are all getting better. There are three cases now in East Haven. Dr. Ide is attending them; three have died and he thought one more would die. The people have done something towards disinfecting the Muse Hollow, but have not done what they should. I have said and done all I can to have things thorough with the disinfectants, but know how people after the excitement is over are apt to cease from trying to cleanse their houses. I shall continue to do all in my power to correct unsanitary families in the Hollow. I would like to see you and learn all I could. I hope the diphtheria is arrested. If they are careful in East Haven I think it may stop. There is no other way to do. Mrs. Wilson, of Newark, called on me today with a bad throat, effect of former disease.   Park’s children were very sick after you left, but they are all well now. I do not think of more cases that have occurred. I should like to call and see you; I thank you for the instructions you gave me; I shall always remember you, and my earnest prayer is for your success in arresting the diphtheria and all kindred diseases of like nature. I hope toy may live long and be permitted to relieve the suffering [-art of community. If you come to Vermont, call and see me.   I am truly your friend,   WW Carpenter.   East Burke, Vt. July 19, 1879   Dear Doctor: Yours came duly to hand. I have delayed answering sooner from the fact there has been a succession of cases in the neighborhood to which you refer. The man whom you mention, Mr. Henderson, brought his child from Newark to his former home, a distance of about eight miles, before it had recovered from diphtheria. This child was visited by a playmate, a little girl, on Friday; on the following Monday I was sent for and found the child to be suffering from a severe attack of diphtheria. The disease ran a rapid course, the child dying within a week. This was an adopted child, one of a family of six belonging to a Mr. Hosford, and lived in the family of a Mr. Henderson (not the one whose child was sick in Newark). During its illness no one saw it except its parents, who lived at a distance of forty rods from the dwelling of Mr. Henderson, The remaining children have all been attacked, two have recovered, two have died and one is yet sick. I have seen the teacher of District No 4, in Newark, who informs me that she noticed nothing until the third day of school, when two of the scholars vomited and complained of headache, and manifested a disinclination to play or study. The next day they were unable to come to school, and by night there were several cases. Those that I have seen have been cases of pure, simple, if I may so use the word, cases of diphtheria uncomplicated by ophthamalia or anything else. There have been some other cases of imported diphtheria very near the village of East Haven, that have been treated by Dr. Carpenter, who will be very glad to give you the particulars. If I can oblige you any further in this matter please command me.   Yours, Very truly,   HC Ide, MD   PS. If there are any details that I have failed to give you that would be of service to you please remind me of them, and I will very gladly give them to you. I might perhaps mention that the sanitary condition of the Hossford’s resembled very much some of those you saw in Newark.   H.C.I.   Island Pond July 9, 1879   Dear Sir: I have learned that diphtheria was carried from Lyndon to Lunenburgh, and that some cases occurred near a lumber mill in Lunenburgh, and that some of the men from the Lunenburgh mill went to the Carpenter’s in Newark. If this is true it furnishes the missing link in our research. If I get positive evidence I will inform you. I have no doubt the disease was introduced in this manner, and the time is coming when seclusion and disinfection will be practiced as closely as in smallpox. Then we shall have the thing under control. Up to July 3 four cases and three deaths in the "Lost Nation" (East Haven), every one of them traceable to contact with the disease in others.   Yours, Truly,   CG Adams   Practical Suggestions     No other disease in or Northern States has been more generally regarded as unpreventable and none more capricious and fatally obstinate in its mode of prevalence than diphtheria. Its apparently and very probably sporadic origin in numerous instances, its invasion of the most salubrious as well as the most insalubrious quarters, its variable malignancy, and its rapid fatality in numerous cases, wherever it prevails, have furnished ample occasions for the unsettled opinions and sanitary regulations which prevail in regard to this destructive malady.  Medical men no longer reject the conclusion which experience has taught concerning the personally contagious attribute of diphtheria; but as this attribute is variable in its intensity in different cases and on different occasions, apparently, sanitary precautions and regulations adopted to extinguish or wholly control the virus of this disease are only occasionally applied and enforced. Fortunately, the leading physicians of Vermont have correct views upon this subject; but in the scattered population of the State, and with no central board of health, there has been no general diffusion of precise information and sanitary advice in regard to regulations and duties required in the presence of diphtheria in a community.   All the physicians and other educated men I met in Vermont and New Hampshire expressed an earnest desire that a State Board of Health should be created in each state for the special purpose of accumulating correct and needed information and diffusing the king of knowledge and advice, as well as aiding to establish regulations which the people need for protection against disease.   The fact that immediately upon learning of the outbreak of diphtheria in Newark, and of the interest taken by the National Board of Health, no less than twelve experienced physicians communicated to me important information of other outbreaks and the sanitary lessons they presented, is good proof of the cordial interest of medical men in the beneficent ends sought in this particular investigation. Each physician and every public man who I have consulted, or form whom information has been received, advises that even for the smaller states, like Vermont, there should be an efficient State Board of Health.   The tragic results of the outbreak of the disease in the little mountain district, as we have studied the facts, show that whatever were the sources of the first case – which was so mild as to awaken no concern –  the conditions under which the contagious attribute of the malady became fatally intensified ought to have been prevented by a kind of sanitary supervision which should be exercised over all school buildings and their outfitting. The neglect to supply pure water and insure the exclusion of all foul water for use of the pupils, the neglect to protect the school room against impurity of the ground, air or sodden ground of the locality, and altogether, the bad location of the school house, would have been worthy the advisory care of a State sanitary officer. The local school officer in any district in Caledonia County, and particularly in the afflicted school district we have described, would respond to such counsel from such a responsible source. Even before I left Newark the school officers of the smitten district called a meeting of the inhabitants to determine upon a more suitable site for a new school house, and as the wealthy citizen who had been accused of wanton defilement of the brook was the largest tax payer, I obtained from him an earnest expression of his purpose to give success to the project for a new and better location and building.   The readiness of the hard working farmers, who as "selectmen" are the town council, to act immediately upon their responsibility as a local board of health, and to provide for necessary advice to the families and for skilled nurses, and specific sanitary regulations for the sick from the hour the suggestion was given, teaches a lesson never to be forgotten where local authorities need to be advised in regard to public health duties. Medical practitioners everywhere urge the necessity of a central and authorized source for specific public advise and directions to the people when peril from preventable causes of disease is imminent. The more scattered the population and the less intimate and near the relations of the families to their medical attendants, the more necessary the central source of advice and direction to the people. Physicians say they wish to repeat and promulgate such advice, and prefer, also, that it be communicated with adequate official significance.   This is not the proper occasion for presenting an array of evidence upon the subject of control and extinction of the preventable causes of diphtheria, yet I must say that the reward for a tedious inspection from house to house in a mountain region has been unexpectedly ample in the one result which was most desired, namely, the prompt and successful suppression of panic and error, and an equally successful suppression of the farther propagation of the disease by the adoption of simple and adequate sanitary measures.      Diagram showing location of school room