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

Venereal Disease Hospitals and the Urban Poor: London's "Foul Wards," 1600-1800. By Kevin P. Siena (Rochester, NY: University of Rochester Press, 2004. Pp. 367).

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 issues of prostitution and social discipline. On prostitution, Siena questions Hitchcock and Trumbach on their proposed sexual and gender revolutions, and the role of prostitution in these accounts. Certainly there is a striking similarity in the profiles of women in foul wards, single mothers and prostitutes. But on the other hand Siena cautions us against the assumption that all single women in the wards were prostitutes, and the implications of this view. What is indubitably evident is an ideological shift towards a focus on the conjoined dangers of poverty and prostitution: a new (or renewed) conjunction of anxieties about female sexuality and destitution. But this was largely a product of the later period. What is notable about the London Lock for instance, is that for four decades it concentrated on the medical rather than the moral, on salivation rather than salvation. Accordingly, the evidence for the disciplinary function of these institutions is ambiguous. The gendered penitentiary approach was largely a modern phenomenon with the real target of the early institutions being VD. In many cases the disciplinary regime was a mundane one--even surprisingly lax--and, tellingly, little different from non-foul wards. These were clearly disciplinary institutions, and workhouses were of course designed to be so. Siena agrees with Temkin's suggestion that medical treatment was a kind of punishment, with salivation operating as a form of social discipline. The public discussion of illness before one's betters would also have acted as a kind of disciplinary process. But Siena claims (convincingly) that this was a fight primarily against disease, not immorality, at least until the later eighteenth century. In any event segregation was routinely compromised through collusion and concealment; and patients could find ways to avoid the stigma and shame of their condition, contesting diagnoses and struggling creatively to procure treatment. The fact that London's poor (again particularly the female poor) kept coming back for treatment speaks volubly. As Siena has so capably demonstrated here, the attempt to secure care in the face of such systematic discrimination and stringent discipline testifies to the terrible sufferings endured.

Philip Howell

University of Cambridge