Venereal Disease Hospitals and the Urban Poor: London's "Foul Wards," 1600-1800 (review)

This is a very significant contribution to our understanding of the relationship among poverty, gender and social welfare in early modern London. It fills in some major gaps in our knowledge about London's VD institutions, and provides a clear narrative of the changing basis of that provision up to the institutional and ideological watershed of the 1780s. In short, it is an exemplary piece of research, and clearly the fruit of countless hours in the archives. But it also asks why and how London's poor sought help with their afflictions, what they were prepared to accept, and what steps they took to try to secure and control their treatment. Siena's ambitions here extend to the attempt to recover patients' own experience of illness and healthcare; and he has succeeded to a remarkable extent in conveying the desperate human costs of the 'foul disease'. This is a book then that is marked not only by erudition and sound scholarship but also by humanity and empathy. It is a major achievement.

In the first place, this study serves as a convincing rebuttal of previous arguments concerning the provision of care for VD patients. Far from being shunned and excluded, a system of institutional charity emerged in response to the unprecedented growth of London and the public health crisis it precipitated. Siena's careful narrative demonstrates how this institutional response began with the foul wards of the Royal Hospitals, expanded with the workhouses' assumption of responsibility for the afflicted poor, culminating with the opening of the London Lock Hospital in 1740. These elements, diverse and ill assorted as they were, nevertheless formed what Siena characterises as "a multi-level healthcare network" (p. 6). They represent genuine compassion, and a deeply held sense of civic, professional and societal obligation. This did not mean that charity was equitable or unprejudiced, of course: this was at the same time a two-tiered health system in which the privileged could secure greater privacy and consideration than the destitute poor, and in which poor women were systematically disadvantaged. Stigma reveals itself in the segregation of foul patients, and in the fact that they attracted higher charges and were the first to face budgetary cutbacks; there is no question, as Siena puts it, that VD patients occupied the lowest rung on the medical ladder. Young diseased and destitute women, in particular, far less likely than men to find either securities or nominations, found themselves increasingly neglected by the Royal Hospitals, so that the capital's workhouses largely took over responsibility for their care until the eighteenth century and the supplementary provision provided by private charity. The Lock Hospital itself, moreover, though it initially refused to ally itself with attempts at moral and social policing, by the end of the century became the kind of penitentiary institution that we associate with the Victorian era: and recognisably modern in the belief in the power of institutions to effect internalized transformation. Siena can leave his study here, on the threshold of the modern era, with such afflicted women left literally to the mercies of a modern gender culture.

There are a few quibbles with this account, naturally enough. Structurally, Siena puts the emphasis fairly and squarely on the key demographic shifts, but the exact role of changing ideologies and discourses is not easily apparent. He appeals to the changing gender culture of the 1780s, affirming the ideological power of the double standard and the culture of separate spheres, and there is a rather vague nod to the possibility of linking this to "larger changes in politeness and the effects of the civilizing discourse" (p. 262). These elements are presumed to have this power only in the later period, however, leaving the relationship between culture and demography unclear. Nevertheless, Siena's account is persuasive and will be widely noted. And it is worth signalling the fact that Siena is particularly astute on the related...