Tim Hitchcock, Heather Shore, eds. The Streets of London from the Great Fire to the Great Stink. London: Rivers Oram Press, 2003. xvi + 256 pp. $55.00 (cloth), ISBN 978-1-85489-130-3.

Kevin P. Siena. Venereal Disease, Hospitals and the Urban Poor: London's "Foul Wards," 1600-1800. Rochester: University of Rochester Press, 2004. viii + 367 pp. $80.00 (cloth), ISBN 978-1-58046-148-1.

Reviewed by Vanessa Harding (Birkbeck, University of London)
Published on H-Albion (September, 2005)

Syphilis and the Streets: Sex and Station in Early Modern London

Among the most familiar and memorable images of eighteenth-century London is Hogarth's print of Gin Lane (1751).[1] It is an appropriate link between these two books: though it obviously targets the demoralizing and debilitating effects of gin on the urban populace, it shows pox as natural component of poverty and draws attention to the gendered nature of both. The drunken, tattered woman in the center of the scene is blotched and pocked on face and body; her own affliction leads to the destruction of her helpless child. The teeming streets witness and underline her public shame. Hogarth cannot be considered a transparent recorder of the London landscape, as Lisa Forman Cody notes in her paper on graffiti in the Hitchcock and Shore collection, but his didactic purpose requires a certain truth-to-life and in depicting the poor as poxed and disreputable he expresses both a contemporary reality and a contemporary perception of reality. Kevin P. Siena's important and illuminating study overturns many unexamined beliefs about the incidence, experience, and treatment of venereal disease in seventeenth-and eighteenth-century London, but his picture certainly fits with Hogarth's. The pox was widespread in the London population; it could debilitate and impoverish as well as disfigure; and it was particularly likely to drive poor women into pauperism and dependence. There is also some truth in Hogarth's implication that the typical female pox sufferer was young, certainly of childbearing age.

Siena's book is the first full account of pox in seventeenth- as well as eighteenth-century London, and it will force historians to acknowledge the significance of this appalling disease in any discussion of poverty, welfare, health, and mortality in future. The word "disease" is perhaps misleading; Siena is rightly cautious about retrospective diagnosis, and does not seek to distinguish between syphilis, gonorrhea, and other possible venereal diseases. Given the negotiated nature of diagnosis in the early modern period--specific to an individual rather than an objectively identified agent of disease--and the variety of symptoms exhibited, such precision would be impossible. As he notes, "one single diagnostic term--'the venereal disease'--served to describe a host of conditions that we now separate." Conversely, this single diagnosis might be expressed in a number of different ways: "the venereal disease, "lues venera," "the pox," "the French Disease," and "the foul disease," "all ... stood for the same single disease-concept" (p. 15). Instead, the book focuses on those who sought admission to hospital, or hospital treatment, for complaints that they or others believed to be venereal. This ends up as a large but rather amorphous category, certainly larger than the number of beds available or occupied at any one moment, since many failed the series of tests required to gain admission. At all times potential patients would be required to acknowledge their complaint before one or more inquisitive superiors, and perhaps to give details of their infection and way of life; they might also have to pay an admission fee, post a bond against their potential burial expenses, or produce evidence of settlement. They had to be desperate enough to accept this loss of privacy and confidentiality (which wealthy pox patients clearly valued), to undergo the stigma of admission to a so-called foul ward, and to confront the painful and protracted mercury salivation that was the principal therapy practiced in the public hospitals. Even so, there were waiting-lists, and some whose eligibility was accepted disappeared or died before they could be admitted. And as Siena shows, application to the foul wards was not the only option explored by sufferers: many either believed they had some other disease, or concealed the venereal nature of their complaint, and sought admission to the "clean" wards of the hospitals, though if detected they were liable to ejection. Hospital care at times extended to out-patients as well as inmates, sometimes to save costs, though the majority of apothecaries' and commercial remedies were probably beyond the means of most of the poor people who are the focus of the book.

The number of those affected by pox in seventeenth- and eighteenth-century London was considerable, therefore, and there is no doubt that their sufferings were severe. While some of those infected may have got away with the symptoms of a mere urinary tract infection, others experienced ulcers, sores and skin lesions, and acute pains in the limbs. These could make people unfit for work or, equally cruelly, unacceptable for employment: servants were turned off when symptoms appeared, individuals marked by the pox were less likely to find good jobs or even lodgings. The "cure," even when available, was both painful and uncertain. The pox brought physical misery and existential despair, and not surprisingly a number of sufferers took their own lives. Siena is particularly good at exploiting complementary or corroborative sources, and uses the Westminster Coroner's records to illuminate the desperation of pox sufferers: some killed themselves to end their immediate suffering, others because they saw no prospect of a cure, or could not endure the agonies of mercury treatment, or knew they faced destitution even if cured. Likewise, some of the narratives given in Old Bailey trials tell of the experience of the poxed poor: sacked on the allegation of infection, driven to steal to pay for treatment, turned out of overnight accommodation and left to die in the street.

But Siena's main source is the records of the hospitals that treated poxed patients, and one of his most striking and useful contributions is to show how significant the pox was in sixteenth- and seventeenth-century London, and that considerable efforts were being made to treat poor sufferers, well before the more visible foundations of the eighteenth century. The records of the royal hospitals of St. Bartholomew's and St. Thomas's (from their mid-Tudor re-foundation) show that poxed patients were admitted and treated from the first. It would be interesting to know what evidence there is for treatment before c. 1550, but it certainly seems likely to have been the case. The transfer of the City's leper hospitals to Bart's in 1549 may well have been a response to an existing demand for venereal beds. This move may have both reflected and reinforced the belief, shared by Paracelsus, in a connection between leprosy and venereal disease, either superficial or causative. At any rate, according to William Clowes, a surgeon at Bart's, over one thousand venereal patients were treated in or at the hospital between 1574 and 1579. Venereal patients were treated both in the six former leper hospitals and in the main hospital, at least until 1622, when Bart's governors decided to close all but two of the former, leaving open the Lock in Southwark and the Kingsland in Hackney, and to transfer all the foul patients thither. Thereafter they seem to have maintained a strict segregation between the "clean" wards of the main hospital and the foul wards in the outhouses. St. Thomas's, by contrast, treated foul patients in the main hospital, but in designated wards.

The activities of the royal hospitals in treating venereal disease were far from negligible in the seventeenth century. Using accounts and registers, Siena has compared the overall capacity of the hospitals with the capacity of the foul wards and outhouses, and found that at both hospitals some 20-25 percent of beds were occupied by foul patients for most of the period from 1622 to the Great Fire (pp. 69-75). This does not exactly translate into proportions of patients treated (though at times it almost reads as if it does), since it is based on the number of days of care provided in different wards per annum, and poxed patients may well have spent longer than others in hospital. Eighteenth-century data indicate that the average stay was forty days, and while comparable statistics for other diseases are not given here, it seems unlikely that most ordinary hospitalizations lasted that long. Bart's devoted an average of fifty-seven beds to foul patients between 1622 and 1666, while St. Thomas's had some forty beds in the early seventeenth century and about fifty-two by the 1660s. If all foul patients stayed forty days then the hospitals were treating some 885-995 patients a year (these are my calculations). Since it appears that quite a number of patients absconded before their treatment was complete, and a few may have died, the numbers actually treated in most years in this period probably exceeded one thousand.

This demonstration of the scale of hospital care is enormously valuable to our understanding of the seriousness of venereal disease in seventeenth-century London. As is clear from Siena's discussion of the obstacles would-be patients faced to get into the hospitals, those actually hospitalized can have made up only a proportion of all poor sufferers, so the numbers infected but unable to secure hospital treatment could have been as great again. Siena makes only one reference to the contemporary demographer John Graunt, but the latter's comments in his Natural and political observations on the Bills of Mortality (first edition 1662) are worth examining, for Graunt believed that the disease was very much more prevalent and deadly than the Bills would imply, given that very few were returned as dying of the French pox.[2] He concluded that under-reporting was due to a mixture of ignorance and negligence: "forasmuch, as all dying thereof die so emaciated and lean (their Ulcers disappearing upon Death)," the searchers (being bribed or intoxicated) "cannot tell whether this emaciation, or leanness were from a Phthisis, or from an Hectick Fever, Atrophy, &c. or from an Infection of the Spermatick parts, which in length of time, and in various disguises hath at last vitiated the habit of the Body, and by disabling the parts to digest their nourishment brought them to the condition of Leanness above-mentioned."[3] Graunt's comments are useful both for his identification of the particular evidential issue but also for his taking for granted that pox was widespread. He directed his comments at the general public who might foolishly believe, from the small number of deaths recorded, that pox was not deadly.

This also reinforces another important theme of Siena's, the much greater level of prejudice and disadvantage faced by poxed patients over "clean" ones. Graunt's language ("vilest," "miserable," "uncleanness") chimes with much popular and elite discourse, and although the seventeenth century was more forgiving towards foul patients than the eighteenth, they were still very much second class. "Authorities ... privileged the care of clean patients over foul ones as a kind of unwritten rule" (p. 94). Individuals seeking admission had to admit publicly to a disease many found shameful, and they might undergo searching personal inquiry before admission. At Bart's foul patients were exposed to some kind of moral correction or instruction; at St. Thomas's they might be subjected to corporal punishment. When the hospitals experienced financial crisis as a result of the Fire of 1666 (both were heavily dependent on city rent-rolls for their income), they cut back treatment of foul patients sooner and more drastically than that of clean ones. Foul patients lost their free treatment temporarily in 1666 and permanently from 1696--something that could itself have contributed to the sense of social and moral crisis in the 1690s. The eighteenth century saw still further disadvantage, as the royal hospitals turned from charitable access to charging admission fees and requiring guarantees. These fees were higher from the beginning than those for clean patients, starting at 4s.-5s. in the first half of the eighteenth century and rising to 10s. in the second, compared with 2s. 2d. to 2s. 6d., rising to 3s. 6d., according to Siena. In addition, foul patients sometimes had to secure sureties and/or a recommendation from a governor or influential person.

The higher admission threshold probably raised the social level of those seeking and gaining admission to the royal hospitals in the eighteenth century, and it had an impact on another important aspect of treatment for the pox, the unequal support available for men and women. Although, whenever this can be measured, there were fewer venereal hospital beds dedicated to women than to men, this does not mean that they were not equal sufferers. Siena argues that it was probably psychologically and certainly practically easier for men to gain admission than women. There are many possible reasons for this. The publicity of admission to and treatment in the royal hospitals--especially when they began to teach students in the wards--may have been a real deterrent to female demand. And, men were more likely, it appears, to have the resources--personal or by way of friends and associates--to fund their admission to one of the hospitals. A far higher proportion of the women entering the foul wards of the royal hospitals in the eighteenth century were reliant on parish or city charity to get them a place. The hospitals continued to provide a significant number of venereal beds in the eighteenth century, though not necessarily in proportion to London's increasing population, but more of these beds were designated for men. By 1770, the proportion at St. Thomas's was more than 3:2, while at Bart's it reached 2:1 by 1788. Women were, by contrast, well represented in the parish infirmaries that became an important further (and lower) tier of venereal treatment in the eighteenth century. Parish workhouses founded in the first decades of the century rapidly developed into or added infirmaries, and while all diseases were treated, pox was certainly significantly present. Representative figures are hard to come by because of local variation (probably in both the incidence of the disease and the attitude of parish authorities), but 5 to 10 percent of cases seems plausible. What is clear, however, is that women made up the majority of However, in the final element in venereal hospital care in eighteenth-century London, the charitable Lock Hospital (not to be confused with the earlier hospital of the same name run by Bart's), opened in 1747, men again outnumbered women, though as Siena shows, the disparity of treatment was not confined to availability of places.

The Lock began with an uncertain mission, but its governors gradually identified it as the last resort for the unsettled poor of London, those who had no local parish settlement and no patrons to help them into one of the royal hospitals. There is a complex story to be told about the interaction of increasingly tight settlement laws and the provision of relief for the sick poor, and not all the elements are available here. John Landers's 1993 study Death and the Metropolis, not cited in the bibliography, might have been helpful here.[4] Siena argues that "the medical social welfare system that had evolved [under the Old Poor Law] was simply not equipped to handle massive migration" (p. 234), but migration in general was a major concern of the legislators of 1598-1601, while migration to London had probably reached 6,000-8,000 a year by the 1660s. It is not clear that it was in itself a massively greater problem in the 1760s: the size and spread of the metropolis by the mid-eighteenth century meant that it generated a larger number of its own inhabitants than before, despite high infant mortality rates. While Siena is undoubtedly right to point to the unsettled poor as an important constituency for hospital care, for whom provision was lacking until the Lock's foundation, lack of demonstrable settlement was not always caused by migration, though intra-metropolitan mobility may well have contributed. However, there may be connections to be made between the revisions of settlement law in the 1660s and 1690s and the development of hospital and infirmary care then and thereafter. It seems likely that the 1690s was a crucial decade, with considerable distress resulting from war and taxation; this was the period at which the royal hospitals ceased to provide free care for venereal patients, but it was also one in which the laws on settlement and entitlement to relief were given further precision. Forms of healthcare provision may have had to proliferate in the eighteenth century to fill the gaps opened up by these developments.

Much has been written on the reforming impulse and institutions of the later eighteenth century already, but Siena's research provides important insights into the subject. In particular, he shows that the Lock Hospital was not in origin concerned with reform or moral correction, but that a takeover of its government by evangelicals around 1780 was crucial to its evolution in that direction. It was only in the second half of the eighteenth century that London acquired several intentionally reformist institutions such as the Magdalen Hospital (1758), the Misericordia Hospital (1774-c. 1783) and the Lock Asylum (1787). As with other aspects of provision for the sick poor, gender distinctions were central. As Siena points out of the Lock Asylum, "it is not an overstatement to assert that it institutionalized the double standard" (p. 214). While male patients at the Lock Hospital were allowed to leave once their course of treatment was completed, women were transferred to the Lock Asylum for moral correction and training. It is not surprising that they were far more likely to run away from the asylum than from the hospital. Where once the hospital had advertised its mission to save innocent women infected with the pox (however inaccurately that represented its real clientele), the Lock Asylum now claimed to save society from infected women. However, given that parish workhouses had a disciplinary and corrective mission as well as a relieving one, it is significant that more women were exposed to this kind of regime well before the major reforming initiatives of the later eighteenth century.

If his sympathies are always with the poor, for whom treatment sometimes seems to have been as much a trial as the disease itself, Siena is nevertheless sensitive to the problems faced by the authorities, for whom demand was overwhelming and resources limited. He notes "the ethical and economic struggle that churchwardens faced when confronted by foul paupers who sought help" (p. 159), and if there is disapproval in his statement that seventeenth-century hospital authorities "seemed unable to consider providing care for a foul patient if it meant withholding care from someone else" (p. 94), he does document the considerable provision that existed. He acknowledges that patients practiced deceptions and did not always sit out the therapy they had so painfully obtained. He avoids simplistic judgments or generalizations, and is always careful to outline the multiple possible interpretations to be read into any single statistic. Even "the birth of the clinical gaze" in the eighteenth century, which depersonalized doctor-patient relations and arguably deprived the latter or agency and voice, could, he submits, conceivably have come as a relief to some poor venereal patients, no longer obliged to explain themselves as supplicants to a series of judgmental social superiors (pp. 127-129).

Siena's book is a substantial and valuable contribution to the historiography of early modern and eighteenth-century London, telling us more about disease, therapeutics, poverty, welfare provision, and social and gender relations. It would surely have been enthusiastically welcomed by the late Roy Porter, whose writing on hospitals, syphilis, and on patients' attitudes--only a fraction of his huge oeuvre--is naturally cited by Siena. Porter wrote a characteristically lively preface to the second volume reviewed here, a collection of papers on The Streets of London from the Great Fire to the Great Stink, edited by Tim Hitchcock and Heather Shore, and in a nice acknowledgment they dedicate the volume to his memory. Many of Siena's themes and preoccupations are echoed in the collection, which contains an introduction and thirteen papers, fairly evenly spread over the period from the 1660s to the 1860s. Poverty, sexual activity, reputation, and the disciplining authority all figure in these stories of the streets, as does the wider question of privacy versus publicity. John Marriott examines the spatiality of the poor in eighteenth-century London, considering particularly vagrancy and begging, and "the nexus between poverty and crime"; John Black looks at the location of illicit sexual encounters (at least, those that led to the birth of bastard children and an examination before parish officials); Tim Hitchcock tells the terrible story of "the St. Martin's roundhouse disaster of 1742," when twenty-four women picked up almost at random on the streets of London were stuffed into the parish gaol overnight, where all suffered extreme physical distress and four actually died. These and other papers--such as Deirdre Palk's on pickpocketing and shoplifting--also supply yet another confirmation of the impact of the online Old Bailey Sessions Papers on current research into this period of London's history.[5]

There are many interesting points in this collection, and it certainly adds a number of insights into the streets of London in this period, but most of the papers are too short to make a substantial contribution, and between them they are too miscellaneous to explore any single topic in full. The volume derives from papers read at a conference, and at such a venue a series of tasters can be very stimulating, but a collection of essays should offer authors the opportunity to present a more extended and substantive piece, and perhaps also to make explicit connections with other papers presented. Some papers are tantalizingly brief, others just slight. Read one after the other they do give a sense of changing street culture over time, but this is often impressionistic rather than verifiable. Lawrence Klein writes thoughtfully on "Shifting Possibilities of Urbanness, 1660-1715," but what would a nineteenth-century historian have said on the same theme? Where, if anywhere, did Restoration Londoners engage in the discussions and debates that Anna Davin documents for streets and public places in the 1850s and 1860s? Could the St. Martin's roundhouse disaster have happened fifty years earlier, or later, and if not, why not?

The issue of change over time is directly addressed by Mark Jenner and Robert Shoemaker, the former in a study of Hackney coachmen from c. 1640 to 1740, the latter by examining the shifting locus of fights and insults between 1660 and 1800. Jenner charts an amazing expansion of provision, as the statutory maximum of 300 coaches in 1654 was raised successively to 400 by 1662, 700 in 1694, 800 in 1715, and 1,000 in 1771; though London's streetplan expanded too in this period, extending the distances between residence, business, and entertainment, the streets must have become much more congested and also much more dangerous for humble pedestrians. Jenner also emphasizes the growing distinction between those toiling through the crowds on foot and the elite, traveling relatively rapidly and safely and above all privately in coaches and chairs. Shoemaker picks up on this theme, noting the increasing importance of learning street manners; by the 1760s, he argues, "expectations of the spatial respect required by pedestrians expanded to the point where being pushed and shoved was ... intolerable" (p. 67). Insights such as these also help to focus on the particularity of, for example, the graffiti-collector in the eighteenth century, or the flaneur in the mid nineteenth, in but not of the streets, observing or sampling rather than participating.

Shoemaker's paper also adds a pointer to understanding the developing nexus of poverty, relief, charity, and reform in eighteenth-century London, a crucial part of Siena's story. He argues that the physical transformation of London's streets was matched by social and cultural change: "early modern notions of community became unsustainable in a rapidly growing metropolis with more than half a million inhabitants. In a society subject to high levels of geographical mobility and fragmentation ... individuals began to ignore public responsibilities" (p. 65). Hitchcock too, in depicting the personnel and attitudes of parish disciplinary administration, shows us more of the world that Siena's poor patients had to contend with. The careless brutality with which the women were treated, largely on the grounds of their being female and out on the streets, underlines the prejudice against women of questionable reputation. The judicial hierarchy distanced itself from the tragedy, closing ranks against William Bird, the watchhouse keeper immediately responsible for the disaster. Although "the mob" expressed outrage at the event, and forced the release of the remaining women, a middle-class jury at first failed to convict Bird of murder, though a later one did so. As Hitchcock says, this point of conflict illuminates "a complex map of gender and class relations" (p. 80). If the collection of essays on the streets of London offers several such points of illumination, Siena turns a more searching gaze on the same topics. In answer to the question, what did it mean to live in early modern London and contract what you thought was the pox?, he shows convincingly that "the options available, and therefore one's ultimate illness-experience, would have varied immediately according to time and place and even further according to sex and station" (p. 253). In the case of syphilis, as elsewhere, "the dynamics of class converged with the force of gender to inform the medical exchange" (p. 14).

Notes

[1]. "Gin Lane" can be viewed online at <http://collage.cityoflondon.gov.uk/collage>, image 25277. See also J. Uglow, Hogarth. A Life and a World (London: Faber and Faber, 1997), pp. 494-497.

[2]. John Graunt, Natural and Political Observations on the Bills of Mortality (London, 1662). Text available online at <http://www.ac.wwu.edu/~stephan/Graunt/>.

[3]. Graunt, Natural and Political Observations, p. 23.

[4]. John Landers, Death and the Metropolis: Studies in the Demographic History of London, 1670-1830 (Cambridge: Cambridge University Press, 1993).

[5]. The Proceedings of the Old Bailey London 1674 to 1834, <http://www.oldbaileyonline.org/>, reviewed on H-Albion, <http://www.h-net.org/mmreviews/showrev.cgi?path=397>.

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Citation: Vanessa Harding. Review of Hitchcock, Tim; Shore, Heather, eds., The Streets of London from the Great Fire to the Great Stink and Siena, Kevin P., Venereal Disease, Hospitals and the Urban Poor: London's "Foul Wards," 1600-1800. H-Albion, H-Net Reviews. September, 2005.
URL: http://www.h-net.org/reviews/showrev.php?id=11149

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