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

Venereal Disease, Hospitals, and the Urban Poor is a historical view of the treatment of venereal disease in early modern London, spanning the 17th through 19th centuries. The author seeks to understand how the English social welfare system responded to the considerable problem of sexually transmitted diseases among its poorest urban residents. Siena provides a broad variety of perspectives, including demographic and institutional analysis from official records, along with the lived experience of dealing with the disease as reported in diaries and letters. Both cross-sectional and longitudinal perspectives are used to provide a good comprehensive coverage of the subject.

A diagnosis of venereal disease during this period could include a range of conditions such as urinary tract infections, gonorrhea, and syphilis. Treatment consisted primarily of mercury, which caused intense salivation and other, toxic side effects. This was consistent with the contemporary medical paradigm of disease as an imbalance of humors. Alternative therapies were available to those who could afford them, but nothing is known to have been effective before the age of antibiotics. The author emphasizes throughout that the delivery and availability of services differed greatly between classes and especially genders, essentially constituting a two-tiered system.

Personal privacy and shame played central roles for patients. It was difficult if not impossible to hide the condition from peers, employers, or neighbors. In addition to any visible, dermatological effects of disease, the treatment itself required weeks of isolation and mercury-induced salivation in a "foul ward." A certain amount of privacy and discretion was available, but only at a price. Some physicians would keep late hours, provide treatment by mail, or provide a female practitioner for examinations. For the poor, the only choice was to submit to the public shame of visible examination and interrogation, which led many to delay or avoid treatment. The stigmatizing nature of these diseases was disproportionately hard on the poor and, as the author notes, just having the disease could impoverish its victim.

The admissions process for the public hospitals varied somewhat over the period, but typically required the patient first to obtain a nomination from the local parish official or hospital administrator. Once eligible, patients had to gather periodically so that a committee could choose which patients received the limited number of beds in the wards. Patients or their sponsors had to post a bond for burial expenses should the patient die during treatment (an early form of life insurance). In addition, for most of the period the patients who were assigned to foul wards were charged higher fees than "clean" patients.

Once admitted, patients were isolated in foul wards, with movements and activities severely restricted. Most poor patients were expected to work at chores during their stay, especially with the emergence of the workhouse infirmary. The length of treatment was typically several weeks long, and consisted almost exclusively of mercury-induced salivation. Some religious instruction was commonly required, with greater emphasis placed on moral reformation later in the period. At the extreme end, corporal punishment was sometimes administered prior to discharge.

The author challenges two conventional assumptions about the period. The first is that venereal disease in early modern England was mostly confined to the upper classes. Records show that venereal disease constituted a significant percentage of all admissions in the public hospitals, and constituted a major public health problem across class lines. The second is that the poor were systematically rejected for treatment due to their class and condition. Significant resources such as bed space and food were allocated to treating poor patients suffering from venereal disease, which shows that while institutions may have shunned these patients, they nevertheless made significant efforts to treat them.

The book will be of most interest to those working in the fields of public health or health policy, especially those who work with low-income and other underserved...