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82
been most brought under notice as attaching to London poverty are facts of
over-competition for employment and for house room."
In a survey of London life and labour undertaken in 1889, Chas. Booth and his
associates found that 30.7 per cent. of the population were living in financial poverty
and that 31 per cent. lived in overcrowded conditions.
A survey on similar lines in 1929 by a group of investigators from the London
School of Economics estimated the London population below the "poverty line"
to be 9.6 per cent. of the total, while 16 per cent. of the people were overcrowded.
And in this pre-1900 setting, what of tuberculosis? Accurate measures of
incidence and prevalence of this disease in London's population are not available
for the years before 1911, when the disease was first generally and compulsorily
notifiable. Mortality figures, however, are reasonably accurate and offer a sufficiently
reliable guide for secular comparison.
The earliest measures of tuberculosis mortality for London are to be found
recorded as deaths from consumption, in the "Bills of Mortality," but there are no
accurate estimates of the population at risk in the area of the London to which the
Bills of Mortality apply. However, the ratio of recorded deaths from phthisis to
the total of deaths from all causes is of value, within limits, for investigating conditions
in the seventeenth century. This mortality ratio rose continuously from 12
per cent. in 1700 to 26 per cent. at the end of that century and thereafter lessened
steadily to 8 per cent. in 1900. It may be postulated that a long epidemic wave of
phthisis spread steadily over London in the eighteenth century, reached a peak
about 1800 and then declined.
In 1850 the tuberculosis mortality rate (pulmonary) for London was nearly
three per 1,000 of the population, in 1880 it was 2.2 and by 1900 it had fallen to
1.7 per 1,000 though remaining higher than the corresponding rate for the whole of
England and Wales, and in fact London's phthisis death rate was higher than that
for any other county or town in the kingdom.
In this connection it is well to recall that the causative organism of tuberculosis
was discovered by Robert Koch in 1882. This discovery had a very considerable
influence on medical thought and practice in relation to the disease, which was now
more widely acknowledged to be an infectious condition. Diagnosis became more
accurate and surgical intervention for the non-pulmonary forms now gave way to
rest as the cardinal treatment. In 1890 Dr. Koch first devised the tuberculin skin
reaction, then used mainly as a diagnostic agent in veterinary practice. In the next
ten years a Royal Commission investigated bovine tuberculosis and showed how
widespread was tuberculous infection of dairy herds and raw milk in England.
The turn of the century
In 1901 the hygienic evolution of London advanced a further step with the
passing of the Factory and Workshop Act which provided for inspection and reports
by the Medical Officer of Health on workshops and the homes of outworkers.
In 1907 routine medical examination of school children was started. A year
earlier the Provision of Meals Act had been passed, enabling local authorities
to provide meals for needy children at elementary schools. In 1908 the Public
Health (Tuberculosis) Regulations placed on all sanitary authorities and boards of
guardians the duty of making provision for tuberculous patients who came under
the care of poor law medical officers either at home or in poor law institutions.
Sanitary authorities were enjoined to make by-laws to prohibit spitting in public
places. Further social legislation included the Old Age Pensions Act in 1908 and
in the following year the Labour Exchanges Act and the Trades Boards Act, the
latter establishing machinery to ensure reasonable minimum wages in industries
which had hitherto yielded a competitive, uncertain and insufficient return.