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the invasion of these houses is explicable on the hypothesis that some of the milk from N.'s farm
was distributed to these vendors in small proportions. These vendors were spoken of by the vanman
as "the small shops," and what is known of the distribution of the infective milk does not
negative the possibility that some of this milk reached these vendors during the period under
consideration, except after the 4th May. The dates of attack among the customers supplied
by these vendors undoubtedly suggests distribution of N.'s milk at the close of the week, and if
supplied to the small shops on the 3rd or 4th May, as in the case of the one churn which E.
received on the 4th, the result would probably have agreed with the result in E.'s milk walk.
Upon the question of the disposal of the milk on the 4th May Mr. X. was, however, quite positive
that the whole of this milk, with the exception of that received by E., was thrown away; hence
the 3rd must be regarded as being the date on which it is most probable "the small shops"
received this milk.
The short period which in some cases intervenes between consumption of infective milk
and the onset of the illness is indicated by the diagram. Thus some of the milk in question was
distributed on the morning of the 4th May, one churn of it being supplied to the vendor E., and
scarlet fever occurred on the following day in two house supplied by him. It needs, however, to
be pointed out that too much precision must not attach to the actual day shown on the diagram
as the date of commencement of illness. Illness beginning during the night might be returned
as belonging to either of two days even if the inquirv had been made with sufficient exactitude to
eliminate other error. Moreover, parents may have confused the dates on which they observed
illness in their children, and it is quite likely that iu some cases illness may have commenced at
an earlier date than that on which it was observed.
Age incidence of attacks.
Another point, to which attention has been called by Dr. Bryett, may here be referred
to. The age incidence of the disease in this outbreak differed in his district from what may be
regarded as the usual age incidence of scarlet fever in Shoreditch. The age incidence in Shoreditch
and Bethnal-green combined will be seen on reference to diagram III. This diagram shows
that the proportion of persons attacked at the age periods 5 to 10 and 10 to 15 (and to less extent at
ages 0 to 5) among consumers of Mr. X.'s milk was less than the corresponding proportion
obtained in Shoreditch and Bethnal-green under normal conditions. On the other hand, the
proportion of persons attacked at ages 15 and upwards was greater in the milk outbreak than
in the two districts generally.
The history of this outbreak is particularly instructive as showing the need for amendment
of the law with regard to outbreaks of iufectious disease attributed to milk. The procedure
contemplated by section 71 of the Public Health (London) Act involves, as has already been
pointed out, in the report of the Public Health Committee to the Council on 9th May last,
considerable delay. In the present instance the distribution of the infected milk was discontinued
at the instance of Mr. X., who, acting upon advice which I gave him, stopped its supply some
days before it would have been practicable to put in force section 71.
The fact that the milk supply involved was that of Mr. X. was readily demonstrated, but
the need of being able to differentiate promptly between the farms supplying him was acutely
felt. The infective milk was as a matter of fact distributed in Finsbury, Islington, and St. Pancras
at a time when the risk attaching to consumption of Mr. X.'s milk had been demonstrated in
Shoreditch and Bethnal-green. Local vendors in the two districts last named, who had been
urged by the medical officers of health to change their supplies, were content to leave it to
Mr. X. to send them milk of different origin from that they had hitherto been receiving, and he,
in the absence of knowledge as to which farm was at fault, was unable, save by abandoning
altogether the whole of his sources of supply, to limit the spread of mischief. As a matter of fact
the milk of all the farms supplying Mr. X. was distributed until the morning of May 4th,
alterations being made merely with regard to the allotment of churns to particular vendors.
These alterations led in at least two instances to vendors iu Shoreditch and Bethnal-green, who
were not previously receiving infective milk, being supplied with it, and also to consignments of
infective milk, which would otherwise have been consumed in Shoreditch and Bethnal-green,
being sent to other parts of London. The medical officers of health of other London districts, if
they had Known of the danger with which their districts were threatened could not have prevented
it, and the County Council had no jurisdiction in regard to such a matter.
The lessons of the outbreak illustrate the need for such alteration of the law as will obviate
unnecessary delay in dealing with the supply of infected milk, and for giving sanitary authorities
and the Council the powers referred to in the report dated 18th June, 1901, of the Public Health
Committee to the Council.
SHIRLEY F. MURPHY,
Medical Officer of Health.