On the Street and in the Bathhouse: Medieval Galenism in Action? Coomans,

In this article we combine the perspective of medieval urban hygiene and the fi ndings of medical and intellectual historians by tracing some ways in which medieval urban residents and governments attempted to limit disease and promote health by recourse to preventative measures. In both of the urban regions and domains in focus, namely Italian streets and Dutch bathhouses, considerable thought had been put into reducing the health risks perceived as attending upon them, at times devising arguments and procedures that possibly refl ect insights from prevailing medical theories and the advice of practitioners. We suggest that the relation between medical learning and health practices was more complex than a trickledown process, and analyze them in the context of pre-modern “healthscaping”: a physical, social, legal, administrative, and political process by which urban individuals, groups, and especially governments sought to safeguard and improve collective wellbeing.

Medieval Europe's burgeoning urban centers faced numerous health challenges, much like their modern heirs. Crowdedness, water and air pollution, famine, fl ood, waste, and factors ranging from climate change to factional violence, threatened to turn metropolises into necropolises. The struggle was constant and well documented, but in many ways its annals remain untold. Indeed, pre-modern cities' reputation, especially outside specialist circles, as oblivious to such concerns owes much to our ignorance about their repeated attempts to avoid becoming demographic black holes. For beyond encouraging migration from the countryside, numerous cities introduced health interventions into what were construed as public spaces and incentivized pertinent behavioral changes among local residents and visitors. Borrowing a modern concept, we have termed this multifaceted process of devising safeguards for the wellbeing of urban populations "healthscaping" 1 .
In this article we trace some ways in which medieval city residents and especially governments attempted to limit disease and promote health by looking at two urbanized regions (central-northern Italy and the Lowlands) and two respective urban spaces: one external (the street), another internal (the public bathhouse). In doing so our goal is to continue the reevaluation embarked upon by a growing number of social, urban, and medical historians concerning health and hygiene practices in pre-modern cities. As we shall see, in both of the regions and domains in focus, considerable thought had been put into reducing the health risks perceived as attending upon them. While the latter observation is hardly new among specialists, a well-grounded picture of numerous locales remains a desideratum, at least in the sense that much of the existing scholarship is based on normative sources rather than on documents refl ecting social practice. Furthermore, to the extent that medieval urban hygiene has been described and analyzed by social historians and students of urban planning, it has rarely been juxtaposed with the fi ndings of medical and intellectual historians. By joining these two perspectives we hope to stimulate ANUARIO  non-individual health. Indeed, he was severely critical of those who postulate a so-called common patient; after all, humoral balance needs to be struck within the organism of a particular person, not just any person.
On the other hand, some of the principles Galen and his followers espoused lend themselves to broader application. For instance, he repeatedly elevates hygiene over medicine by claiming that prevention is a superior strategy to curing. And within the realm of hygiene, the dangers that lurk for individuals are by and large the same for groups, be they environmental risks, like polluted air or physical obstacles, or behavioral ones, like bodily or mental exertion: Now the surrounding atmosphere harms us by making unduly warm or cold, dry or moist; but the other agent by bruising, straining, wounding, or dislocating 5 . In other words, while weather conditions affect different people in different ways, removing physical hazards as a prophylactic measure or training people to pace themselves at work or play is universally sound advice, regardless of status, gender, education, or location. Galen also maintains, in a way that is reminiscent of the modern-day Activities of Daily Living index (ADL), that health manifests itself in one's ability to perform basic routines without external help 6 . [T]here are fevers, he reminds us, but so slight that we have no perception of them ourselves and can attend to business, bathe, eat, drink, and do other necessary things. The unimpaired capacity of function determines health 7 . This principle too can be applied at the population level as a diagnostic for the health of populations.
Before trying to assess what role such insights played in medieval public health interventions, it is crucial to note that, among coeval medical practitioners, there were alternative approaches to etiology, such as contagionism. The notion that a disease could be autonomous enough to have the capacity to pass between people and/or animals stretches to and beyond Galen's observations. Indeed, it can be traced both outside a Western medical tradition, for instance in ancient India and China, as well as within pre-modern Europe and the Near East. This is not to say that Galen's aforementioned double etiology of corrupt air and humoral imbalance had been either marginal or else waned with the Middle Ages. For instance, the proliferation of leprosaria since the twelfth century, as François-Olivier Touati has shown, was likely a preventative measure in a social and moral sense, and thus offers little support to the view of a growing consensus about the contagiousness of leprosy as a disease 8 . And in an equally original 5 C. Galen,On Hygiene,Book 1,ch. 4,p. 11. 6 I. McDowell,C. Newell,Measuring Health,A. Bowling,Measuring Health,  article, Ann G. Carmichael has shown for Renaissance Italy that miasma theory continued to have purchase among municipal leaders for nearly a century after the earliest outbreaks of plague in the late Middle Ages (1347-1351), even as theories of contagion became more widely discussed in medical circles 9 . In sum, when it came both to thinking about and acting upon the prevention of disease, traditional Galenism continued to have the upper hand, but this was a contingent rather than an inevitable state of affairs.
The latter examples underscore the complexity of the relations between learned debates and coeval public health practices. Going beyond theoretical and even prescriptive texts, recent social and religious historians of leprosy, for example, have shown that urban residents' multifaceted interaction with lepers and leprosaria had much to do with the explosion of charitable institutions on the one hand and government attempts at centralization on the other 10 . And, as Carmichael and others point out, there was a strong correlation between the degree of a city's political centralization and the relative ease with which a ruler could implement otherwise unpopular measures (in the medico-theoretical but also economic sense) such as quarantine 11 . Nor was this challenge limited to pre-modernity. As Erwin Ackerknecht demonstrated for the eighteenth and early nineteenth centuries, and as New York Mayor Michael Bloomberg's recent bans on smoking, trans fats, and large-size soft drinks illustrates, public health interventions continued to create tremendous antagonism and fear, especially when opponents managed to construe them as a major threat to personal liberties -and a costly one at that 12 . Let us now proceed to explore one medieval urban setting in which such interplays took place.

THE STREET
As the vicissitudes of World War Two reminded millions of disturbed urban dwellers, including the British history teacher and army offi cer G.T. Salusbury, the seeming regularity of "street life" could not be taken for granted. Indeed, studying it in any period can be undertaken with profi t and enlightenment, since its regulation was often based upon custom and refl ect[s] many sides of urban life far removed from the noise and movement of the streets 13 . That much is certainly true for numerous late-medieval Italian cities, which gave rise to committees and government organs directly responsible for supervising "streets" (vie, strade), a term employed here, as it was then, in the wide sense of a site abutting domiciles, workshops, and factories, as well as a conduit of commerce, mission, diplomacy, and military traffi c. In these contexts a "street" could mean any paved or unsealed surface, from alleys to toll roads, but it could equally refer to dykes, canals, rivers, and bridges, including their horizontal and vertical surfaces and any kind of traffi c -human, animal, organic matter, manufactured goods-traveling on it. All these sites could be considered "public works" and as such participated in defi ning public urban space and order.
Activities related to the formation and upkeep of Italian streets are amply documented in medieval narrative and administrative sources. They are particularly prominent in the records of urban governments, above all when the regime created a dedicated organ for monitoring and maintaining these spaces and facilities, with a mandate to prosecute those who violated pertinent regulations 14 . Offenders, as we will show below, were sometimes summarily fi ned or else brought before a relevant court. Where the latter's protocols have survived, which is not often, a rich picture of popular attitudes, practices, and ideas about urban environmental concerns becomes for once accessible, and it is these unique sources that we shall mainly exploit in the following paragraphs, though not to the exclusion of other documents of practice, which on the whole have been neglected by medical historians in their search for the dissemination of ideas and procedures related to population-level health.
In the Tuscan hill-town of Siena, for instance, where no river ran and where water had to be mobilized effi ciently for drinking, laundry, industrial energy, and waste disposal before it was allowed to leave the city, residents were constantly busy conducting this precious substance both above and below street-level and maintaining its desired quality and fl ow 15 . In devising regulations to defend this water system, Siena's rulers cited lofty terms such as honor (onore), beauty (bellezza), and utility (utilità) -but they too knew that residents' very livelihood hung in the balance, especially during the long and hot summer months. Accordingly, along the streets, near gates, and on piazzas, where water gathered above the ground in troughs and fountains, the government placed guards, who were more highly paid the more strategic and multifunctional the location. Here as elsewhere, water management was closely linked to the preservation of life's basic necessities, including nourishment, labor, and personal and collective hygiene, while simultaneously creating a blueprint for a regime's legitimate jurisdiction 16 .
The importance of conducting water effi ciently and its costly infrastructure both above and below the ground was integral to public health, safety, and hygiene elsewhere in the Italian Peninsula. Bologna, home to one of Europe's oldest and most prestigious universities, was no less precocious in providing for its residents' more quotidian needs. In order to protect the course of water arriving from the city's two main sources, the Savena and the Reno rivers, Bologna's statutes provided for the establishment of the notary of the fango (literally "mud" or "dirt") as one of the city's chief offi cers. He was placed fi rst under the aegis of the podestà and periodically under that of the capitano del popolo. Within several decades this offi cial extended his mandate to include the collection and disposal of waste throughout the city's streets, supervising public works, examining market stalls and produce, inventorying the presence of animals such as pigs and goats, curbing the accumulation of fi rewood, and even investigating the presence of false beggars living in local inns. Bologna's waterways, streets, bridges, ditches, pavements, and all forms of litter or "mud" thus became the physical foci of this notary's activity and that of his offi cials, as is refl ected by the offi ce's archival collocation, namely Uffi cio delle acque, strade, ponti, calanchi, seliciate e fango 17 .
The fango offi cial's mandate, however, was neither secure nor its development linear. By the late thirteenth century some of his responsibilities were devolved onto (or reassumed by) the representatives of each of the city's quarters, leaving the central body's offi cials to deal with pertinent violations and policing rather than maintain the streets or other "public works" directly. It is above all the records produced in this context that offer us a glimpse of popular medical thinking at the basis of public health policies. For instance, in 1288 fango offi cials made numerous parish representatives swear an oath that they will vigilantly protect Bologna's infrastructure, specifi cally stating that they will report any violation concerning: All putrid wells that are not cleaned and lack chains and buckets, or if the latter are broken; and those with un-walled ditches; and those [persons] who throw feces or dung in public roads; or those cooking fat or grease, during the day or the night, in that parish or neighborhood; and those burying bones or having them buried in the city or rural settlements of Bologna; and those placing or leaving cloths to soften in a non-draining ditch; and those directing mill waste or its water into public roads; and those possessing lime kilns in the city or its rural settlements; and those stretching hides in front of their shops; …and those having clogged ditches; and those throwing dung or carcasses into public ditches or who keep buckets or any other vessel containing putrid or otherwise dangerous matter 18 .
It would be rash to conclude on the basis of this formulaic text that local residents kept their oaths to the letter; in this sense offi cial records offer no proof for the success (or for that matter failure) of stated policies. Nor do they spell out why fecal matter, grease, and industrial waste were considered to be dangerous (periculosum); they simply take it for granted that they are. Furthermore, as a sampling of this series' court records suggests, there is little to no explication of the relations between violations and increased health risks. Wagon handlers allowing their oxen to roam free, laundresses toiling upstream, wine merchants fi ddling with weights, and residents diverting or blocking ditches are routinely cited for the damage (dampnum) or outright ruination (ruinatio, devastatio) they have or could have caused; but the harm itself remains mostly unstated, or else is expressed in material rather than medical terms 19 . To make matters even more complicated, even on those rare occasions when Bolognese offi cials or witnesses stepping forward to lodge a complaint do articulate their concerns, they draw a strong link between health and propriety. nearby drain, and in so doing affl icted the entire area with a stench (fetor) and an outrage (pudor) 20 .
All of the above, and especially the -collapsing-of health and morality into the same violation, illustrate the diffi culty of either pinning down Galenic infl uences or applying contemporary categories to earlier attitudes towards public or individual wellbeing. Yet it does offer us some insight into one society's common sense about their environment without imposing our own preconceptions of what that common sense was and what kind of infl uence Galen's writings exercised over it. Especially given the substantial presence of learned physicians in numerous Italian city states, including the major university town of Bologna, we can reasonably surmise from the witness's use of the term "fetor" that miasma theory operated at some level among late fourteenth-century Bolognese society. And the institutional context as a whole attests a solid nexus of hygiene and power that had been fi rmly established by that period 21 . If, as Mary Douglas has taught us, dirt is matter out of place, the fango offi cials' records tell the story of one struggle to defi ne just what constitutes such a state of affairs 22 .
Perhaps the clearest illustration of the health risks thought to attend upon the pre-modern street and how these were addressed emerges from a unique set of records found in Lucca, in northwestern Tuscany. Here, as in Bologna, we can follow the activities of a government organ entrusted with supervising streets and other public works, and whose foundation can be dated at least to the late thirteenth century. Comprising a chief offi cer, a notary, and several offi cials and messengers, it was known as the Curia viarum, the court of roads, and was mainly concerned with maintaining urban, suburban, and regional infrastructure, as well as enforcing sanitary, labor, and building regulations, hearing complaints from residents about pertinent violations, gathering evidence on-site, and fi ning offenders 23 . The latter, much like their Sienese and Bolognese counterparts, included men and women from all walks of life who occupied allegedly public ways illicitly for industrial or commercial purposes, landlords who directed gutters into public spaces or blocked sewage canals with domestic waste, and parishes or rural communes that neglected to maintain public facilities 20  under their jurisdiction, such as wells, bridges, gates, canals and, of course, roads.
The parallels between this organ and those of the aforementioned Italian city-states are fairly obvious. What makes Lucca -or at least its extant records-stand out for socio-medical historians of pre-modern Europe is their occasional capturing of popular attitudes towards public hygiene and safety. As in Bologna, so in Lucca, the offi cials' charters and other prescriptive texts suggest (but rarely explicitly link) violations such as spilled industrial waste and abuse of water resources to the corruption of air and the ensuing dangers. The traditional Galenic nexus is however accompanied by others. A number of court protocols, for instance, attest an existing fear of sight and scent pollution. Thus, when on 25 January 1343 the offi cials charged Nucello Arrigi of Pertigliano with neglecting to maintain his latrine (necessarium), they complained about the debilitating sensual experience of passersby, who could detect the rotting and stinking blemishes of the said latrine 24 . Likewise, in late May that year Danino Chichi was accused of neglecting the upkeep of his latrine, which infl icted those using a nearby public road and others visiting the adjacent church with repugnant sights and smells 25 . And those complaining about Datuccio, a reckless steam-bath operator (stufaiolo), blamed him for causing a stench that spread and reached the neighbours 26 .
While the language of these complaints (or at least its rendering by court offi cials) falls short of employing medical terms explicitly, it does combine two complementary and well-documented strands of medieval thinking about contracting illness. The fi rst concerns a growing consensus among Western surgeons and physicians, namely that unpleasant odors could trigger disease by compounding an already deteriorated atmosphere. The odors' origins could be diverse: sick people, rotting carcasses, stagnant ponds, exposed latrines -all of which were to be avoided, for instance through minimizing contact, applying ointment to the nose and mouth, carefully disposing of dangerous substances, and doing so downwind 27 . 24 "non destruxit seu coperuit vel actavit dictum necessarium set ipsum retinavit et retinet discopertum, ita et taliter quod euntes … aqua ad quemdam fontem ibi ipse existens videre possunt putrida et fetida lebentia de necessario suprascripto." Archivio di Stato di Lucca, Curia delle vie e de' pubblici 6, unnumbered fol. 25  The second and closely related approach possibly refl ects the infl uence of optics theories of emission as well as intromission, according to which the observing or perceiving eye can absorb an object's qualities, including illness or impairment 28 . Of course, the precise mechanisms enabling such processes were the subject of heated debates among generations of scholars and practitioners; and the relation between each voice in the medieval discussion and those of ancient authorities such as Galen will surely continue to occupy intellectual historians and historians of medicine for years to come. Yet it would be safe to say that some contemporaries considered certain sights and scents to have a potentially adverse affect on one's health, or at least that they considered it a practical way to state their case in a municipal court. When urban governments translated such private concerns into public action, with or without consulting the physicians at their disposal, a link between medieval medical theory and public health policies becomes plausible. And when the records capture contemporary individuals who employ a similar discourse as part of an attempt to enforce such policies (for whatever reason), we can reasonably talk about the infl uence of certain ideas, either directly disseminated or otherwise present, and their adaptation or even manipulation by urban dwellers.
At the same time, the invocation of both sight and sound pollution in the above cases hardly guarantees that learned theories were widespread among non-literate medieval urbanites, and this for several reasons. First, we cannot discount coincidence between theory and common sense. Secondly, in the case of Lucca research cannot yet support any argument about how typical or untypical such statements were. Last, it is a perennial thorn in the side of archival research to what extent the records refl ect genuine witness testimony or offi cial formulation. With all that in mind, social historians of medicine still have many miles to travel on Italy's medieval streets before they can make grounded observations on the role of Galenic thought in shaping urban hygiene. But at least the streets are open (and safe!) to travel on.

THE BATHHOUSE
We now move to another domain within the six res non naturales, mostly associated with processes of digestion and expulsion. Medieval physicians, likely infl uenced by Galen, routinely advocated the expulsion of surplus substances from the body, not only through the bowels (by aid of purgatives) or blood (through phlebotomy), but also by applying massage and bathing. Accordingly, bathing could be integrated into a regimen and also used as a prophylactic against a wide range of illnesses, as refl ected in numerous medieval medical texts. 29 Despite this positive appreciation by doctors, the medieval urban bathhouse or stew (Dutch: stove, French: etuve, German: badestube), an urban space that facilitated bathing for health purposes, developed a dubious modern reputation. Scholars have often associated activities within stews with leisure, pleasure, play, festivity, sometimes luxury, but most importantly with illicit forms of sex and especially prostitution. Time and again public baths are construed as a threat, both in the sense of undermining moral values -an incentive to urban disorder 30 -and as a place with an increased risk of contagion, mainly by plague and syphilis 31 .
Reconstructing the realities of urban Dutch bathhouses is a complex task. Unlike the monitoring and maintenance of Italian streets, there were no dedicated government organs or offi cials specifi cally employed for the supervision of stews, who in turn left records of such activities. The absence of such organs and records may itself indicate the degree to which these spaces and their operators and users were considered a threat. In any case, stews occasionally appear in urban prescriptive sources (decrees, ordinances, council minutes) and at times also in administrative documents, such as court records, municipal fi nancial accounts, and sale and rental contracts. When juxtaposed with learned medical texts, these sources reveal possible connections between medical theory, urban policy, popular attitudes toward and practices of urban hygiene. In other words, reading across the full range of available sources suggests that urban residents and governments were motivated not only by moral concerns, but perhaps also by a desire to reduce health risks which they considered to fall under their responsibility.
Current historiography on Western European medieval bathing has a number of different foci, including the history of German bathhouses and bathing culture, the development of medical discourse on spas and mineral baths in Italy, the interaction between Muslim, Jewish and Christian bathing practices in Spain, as well as archeological and architectural reconstructions of private and public baths in these areas 32  bathhouses in the late medieval Low Countries has been clearly established, ranging in numbers from around fi ve stews in smaller towns like Leuven and Maastricht, to between twenty and thirty in the large cities of Ghent and Bruges, and at any rate found in the ordinances of numerous cities in the northern Lowlands, such as Amsterdam and Utrecht 33 . However, their social function in this region remains understudied, a state of affairs this section only begins to address.
To start with, various medical treatises circulating in the Lowlands throughout this period attest the reception and appropriation of a medical conception of bathing inspired by Galenic thought. For instance, the popular late fourteenth-century Tacuinum Sanitatis distinguished between several types of water (hot, cold, fresh, salt) when discussing their different qualities and their specifi c medicinal value 34 . It lists several practices, of which the most common were bathing in a wooden tub or in a heated steam room. In addition, it recommended further variations: treatments with wet anointed cloths, steam treatments above a kettle fi lled with herbs, and bathing in water with herbs or drinking potions while bathing 35 .
Many of these treatments can also be found in the Trotula. This corpus of texts on women's diseases from twelfth-century Salerno enjoyed great popularity in the late Middle Ages, as its translation into several vernacular languages affi rms 36 . Among these, one Middle Dutch translation from the fi fteenth century prescribes the following as a treatment for infertility: Take rainwater and in this one will boil: plantain, shepherd's purse, oak leaves, plum peels, seeds of a pomegranate, wild roses, These examples imply that medicinal bathing was usually applied in a private setting. However, in the original Trotula text, the last chapter on cosmetics, which is not included in the extant Dutch translations, speaks clearly of going to the baths 38 . This indicates that, at least for elaborate cosmetic treatments and more leisurely practices of bathing, the public bathhouse was an acceptable, even normative place to frequent.
Original vernacular tracts likewise promote the medicinal use of bathing, as can be seen in the works of the fourteenth-century Dutch surgeons Jan Yperman and Thomaes Scellink van Thienen 39 . Yperman mentions the use of baths and steam treatments as a cure for scabies, apostemes, hearing loss, and leprosy. On his part, Scellink mentions baths no less than forty-fi ve times in his Book on Surgery (1343), and always in a positive way. Both authors frequently refer to Galen, mainly by opening prescribed treatments with the phrase Galen says, or this is Galen's medicine, that I have tried many times 40 . Unfortunately, these texts are unclear about the use of public stews. For instance, in a remedy for leprosy, Yperman states that when the patient starts to "swell up" and the skin begins to peel off, the patient should be laid down in a stew and anointed with oil 41 . Yperman uses the term "to steam" (stoven) in many different ways, so when he advises to "go into a stew" (in stove te gaan), it is unclear if he means a privately prepared steam bath or a public bathhouse.
In 1514, the Brussels-based publisher Thomas van der Noot issued Tregiment der Ghesontheyt, a Middle Dutch translation of the extended regimen by the Parisian physician Maginus Mediolanensis (ca. 1295Mediolanensis (ca. -1368. Following the original text, the work devoted an entire chapter to the correct ways of bathing. For instance, the benefi ts of bathing -especially for the heart and veins-are compared to the cleaning of a city's fountain and sewers. One should, however, not take a bath just before bloodletting: 37 "Nemt reghenwater ende daer in sal men sieden: plantago, kerspillen, eekinbladeren, de scorssen van prumen, garnaken, elegentier, agrimonie. Dit doet alte gader wel sieden in dat vorseide reghenwater, ende daer in doetse baden in een cupe, aldus, dat si toten navele, ende toten lendinen der in sitten mach." J. Hulsker This metaphor beautifully captures how bathing was regarded as an important instrument to purify the inner body by excreting dirt or superfl uous liquids through the skin 43 . It also shows the conception of taking a bath not as a single "act" but as a process: bathing could set the humors in motion and, in combination with herbs, be applied as a medicine for a wide range of illnesses.
Although the use of baths in medieval medical texts is still an understudied topic, this small sample of Dutch vernacular treatises suggests a continuity of an elaborate and refi ned medical discourse on bathing from the twelfth to the early sixteenth century. Furthermore, the assumptions of medical writers strongly imply the availability of bathing facilities and customs, if only for a small upper layer of medieval society. Yet such texts were continuously adapted to suit new local circumstances, including urbanization. The vernacular translation of the Trotula from Bruges, for instance, contains a redaction of the original work, in which many herbs have been adjusted according to more easily accessible alternatives 44 . Thus, the continued inclusion of Galenic ideas on bathing in medical treatises refl ects a positive if limited awareness of bathing in late medieval Dutch society.
A different perspective on bathing emerges from medical tracts on plague. Three of the fi ve known medieval Dutch plague tracts mention urban bathhouses as places to obviate. Echoing the 1348 Parisian Compendium, a large part of these texts is devoted to techniques of bloodletting, dieting, and the avoidance of corrupt air 45 . The advice on bathing forms part of the 42 "Den bade ontbinden en evacueren de humoren die nabi sijn, ende alsoe en vertrecken die onreynichheden niet uiten cleynen aderen in de grote aderen als de fl eubothomie ghesciet ende dbaden en laet die onsuyverheden die omtrent der huyt sijn niet vertrecken ten grooten aderen. Ghelijck oft in den cleynen rioelkens vuylichheyt ware ended at de evacuatie ghesciede van de groote fonteyne, so soude die onsuverheyt ofte vuylichtkeit wederom moghen komen tot de groote fonteyne." M. Mediolanensis,Tregement der ghesontheyt,p. 166 instructions on how to keep the body in balance and not expose it to extreme changes 46 . The tracts offer different explanations why stews should not be visited during epidemics: they are crowded, and infected people could be among the visitors. Also, baths are not benefi cial to an already feverish body, and warm water opens the pores, so corrupted air could enter more easily 47 . Given their emphasis on reasons to avoid public baths, such references to stews in the plague tracts more than imply that bathing was integrated into personal and collective hygiene practices.
Besides bathing prescriptions in medical texts, traces of bathing practices appear in a broad array of sources. Noblemen and ecclesiastics constructed bathrooms or even pools in their palaces 48 . People also took ritual baths before a wedding, coronation or knighting ceremonies. Even monks were not entirely hostile to bathing: In his infl uential monastical Rule, St. Benedict prescribed bathing once a month, and more often for the ill, and monasteries often used running water and sometimes owned bathing facilities 49 . Apart from descriptions of private bathing among elites, the existence of spas is attested in the works of, for instance, Poggio Bracciolini (1380-1459) and in medical treatises, mainly produced in Italy, discussing the particular healing qualities of the springs 50 .
In contrast to these predominantly private and rural practices, urban stews hold a somewhat separate position in this fi eld and have been discussed particularly in the context of medieval urban prostitution. Research on this subject in the past decades has supplied information about stews in many parts of Europe 51 . Despite the different portrayals of the stews in these works, they seem to share the use of one central concept, namely "honesty". The term not only indicates a concern for morality and social order, but also for both the health risks and benefi ts of urban life.
For instance, in her work on prostitution in medieval Languedoc, Leah Otis notes that considerable efforts were made by the authorities to maintain the "honesty" of public bathhouses. The adjustment was implemented by a system that distinguished between honest and dishonest stews. Instead of trying to keep every bathhouse free of prostitution or other illicit sexual practices, some were labeled dishonest. In those stews, "public women" were allowed to work, but only for a limited clientele: married men and clerics were not permitted to enter. According to Otis, the system of distinguishing honest from dishonest stews was partly motivated by a concern for public morality and safety 52 . Because prostitutes were widely regarded as vectors of disease transmission, limiting or denying access to them likely refl ects a desire to safeguard urban residents' and visitors' wellbeing 53 . As such, we can see in such policies attempts at public health interventions.
In Das Frauenhaus, Paul Schuster took discussions on German baths in a new direction by inveighing against the "myth" of prostitution in local stews, which he claims is based on rather thin evidence. Earlier artists depicted couples naked in a tub, embracing each other, often with the man reaching for the woman's breasts. According to Schuster, these images overemphasized the erotic atmosphere of bathing, which later historians mistook for proof of prostitution or sexual promiscuity 54 . Heeding such calls for a critical reexamination of the sources, however, led in one case to enhancing the traditional view. In his analysis of prostitution in Bruges, Guy Dupont identifi es many dishonest stews. Stew keepers were fi ned for letting people stay overnight, or for offering prostitutes a working space in the backrooms of their stews. Some had already lost their original function in the fourteenth century, and acted solely as brothels. Moreover, a geographical reconstruction shows the presence of stews in neighborhoods where prostitution was widespread 55 .
The separation of honest and dishonest stews is also evident in Maastricht. This town had at least fi ve stews in the fourteenth and fi fteenth centuries, two of which were designated as brothels. The town council minutes (raadsverdragen) ordered in 1373 that No one shall keep a brothel in Maastricht, except for the two old stews behind the Church of Our Lady, on pain of being exiled from the city for one year 56 . This and very similar restrictions regarding the location of prostitutes were often repeated. Sometimes the town board described the locations more vaguely and ordered that prostitutes should only work in the stews, without mentioning any stew specifi cally. This renders uncertain the "honesty" of the other stews in Maastricht 57 .
Prostitution was common in the stews of the London suburb of Southwark. Local customaries, drafted by episcopal offi cials who owned the land the stews were built upon, included specifi c guidelines for punishing prostitutes and contained actual lists of questions that all prostitutes were required to answer while working in the stews, which shows that the stews were acknowledged brothels 58 . In her analysis of the customaries, Ruth Mazo Karras also touches upon the subject of the "honest" stews, a distinction that London governments made in their policies. In 1417, London magistrates forbade the exploitation of stews in the city and in the suburbs under its control because of the many grievances, abominations, damages, disturbances, murders, homicides, larcenies, and other common nuisances. However, individuals were still allowed to keep bathhouses for the cleanliness of their own households, and moreover, that those who could prove to keep an "honest" stew were allowed to stay within the city 59 . So while we encounter baths through negative references, it is clear that baths and some of the stews were integral to public hygienic practices.
How to keep an honest stew, or a stew honest? Banning mixed bathing seems to have been paramount. Women were not allowed in men's stews and vice versa. We fi nd comparable regulations for Germany, Spain, southern France, England and the Low Countries. From the early fourteenth century on, many German towns issued various ordinances against the indecency or dishonesty (Unehrlichkeit) in the stews. Women were assigned their own day -or parts of days-in the week, in, for instance, Luzern and Hamburg 60 . Stews in Holland and Flanders were similarly restricted, with the particular solution of keeping separate stews for each sex. Ordinances in Utrecht and Amsterdam referred to the bad reputation of the stews because of mixed bathing, the former city deciding that every stew holder must declare whether he or she 56 "dat nyman bordeel halden sal te Triecht sonder die II aulde stoven achter Onze Vrouwenkerke. So wye dat breke, die sal sijn aen den here den hi tuhoert op III march als decke dat ghevelt ende I joer uter stat." M.A. van der Eerden-Vonk, Raadsverdragen van Maastricht,p. 8. 57 Ibidem,pp. 13,64,294,444 wanted to keep a male or a female stew 61 . In Bruges, the rosary makers' guild (paternostermakers) ordered its members to refrain from keep[ing] any stew, playcourt or playhouse, except for women's stews 62 . Apart from the fact that the rosary makers were apparently able to combine the keeping of a stew with their profession, this ordinance points to the special status of the women's stew as particularly "honest". The keeping of separate stews was easier in bigger towns; in smaller towns and villages such practices might not have been fi nancially sustainable 63 .
As already mentioned, keeping some stews free of prostitution was not only motivated by moral concerns, but also by fear of disease transmission. In medieval society, where moral sin and disease were intrinsically linked, prostitutes were closely associated with diseases like leprosy, pox, and plague 64 . The health threat they supposedly posed to citizens occupied policy makers in restricting prostitution. For instance, in an attempt to avoid the concealing of prostitutes as legitimate employees, some cities restricted the number of servants stews were allowed to hire. We can fi nd these conditions both in ordinances and private contractual agreements recorded by urban offi cials. For instance, in 1460 Gent, Gillis Hunne agreed to pay Arent Donckerwolcke for the rent of his stew called the Roosendaele, including the beds, blankets (saergen), bedlinen (slaeplakenen), and bathtubs (beckine), on condition (besprec) that neither Gillis nor his wife will keep any outside servants (butedienelinge) nor keep any "indecent" (unhonorable) company 65 . Since it is explicitly stated that the tenant is not allowed to exploit the stew as a brothel, the beds may have been primarily used for resting after bathing 66 . The city of Dordrecht had a slightly different approach, and prohibited stew owners or operators from hiring young women. It ordained that in every stew there can be two maids, one outside and one inside who should be over thirty years old, and can keep no brothel in there 67 . Another preventative strategy of urban governments concerned the keeping of curfew. People were not allowed to spend the night in a stew, or even be there after midnight. In Bruges, male and female stew holders were fi ned for letting people stay the night. This restriction is more ambiguous, because it implied that although exploiting the stew at night was regarded as against the rules of the city, prostitution was tolerated in some stews during the day 68 . The restrictions on opening hours also concerned the prohibition of heating the stews on Sundays and festive days, or during religious processions 69 . In any case, it is often unclear whether stew owners kept a policy of separate bathing or permitted prostitutes to work inside, especially since they are only occasionally fi ned 70 .
How the regulation of stews integrated with concerns over public health, safety, and order also emerges from the annual municipal accounts of Breda, which contain an elaborate record of the expenses incurred by the construction of a new stew in 1492-1496. These records give a detailed survey of the materials used, among which there were 92,400 bricks, nine glass windows (two for the kitchen, fi ve for the room with the baths, and two in the room upstairs, where the girls sleep 71 ), a big cooking kettle, and an oven. The city received payment from the tenants, which successively (each for a period of about a year) were a woman named Janne, another called Grieten, and one Jan Rits together with his wife Airtke. Stew keeping was evidently a profession both men and women practiced 72 .
The town board's decision to build a stew and the way in which it chose to construct it sheds much light on coeval preventative practices, especially since it seems to conform to a broader plan for promoting public health and safety. Due to a large fi re in 1490, Breda was severely damaged, and the town board decided to contribute fi nancially to the rebuilding of towers, walls, gates, market squares, and several houses 73 . In order to improve fi re safety in the process, the board promoted the covering of roofs with loam instead of straw. It was in this context that the expenses for every craft guild were listed, each with a special paragraph concerning expenses for building the stew. Judging from the extant accounts, it was the town's largest construction project during these years, and was thus highly unlikely to have been an afterthought. On the other hand, this does not mean that the Breda offi cials objected to recuperating some of their investment by renting out the new stew, even as a brothel. At any rate, the stew was not particularly profi table. The city received payment from the tenant, but the rent had to be reduced every year. Thus, even if it was their intention to make some profi t from the stew, local magistrates had to justify it, either as a worthwhile public service or as a tool for maintaining social order 74 .
The case of Breda, along with the information surveyed in this section underscores how modern views on medieval stews are potentially biased or distorted. Many historians of prostitution or sexuality understandably focus only on limited aspects of the stews, or, in terms of the dis/honest dichotomy, almost exclusively on the former. In this they make selective use of the available primary sources, in which the stews commonly appear when their activities are restricted or in descriptive sources when they violate regulations: stew holders are fi ned for prostitution, and their costumers for public disturbances or graver crimes committed in or around the bathhouses. But these events are more likely exceptions that broke through the documentary surface; using them as representative events risks marginalizing a major positive role allotted public bathhouses in medieval urban life 75 .
Did urban governments intend to contribute to the preservation of their citizens' health by keeping some of the stews honest, or in the case of Breda, by fi nancing stew construction? And if so, did they have a potential medical or other social theory in mind? Like their Italian counterparts, Dutch towns too employed physicians beginning in the late fourteenth century. While somewhat removed from the main centers of medical scholarship, they were often originally trained in universities abroad, such as Paris and Bologna 76 . Moreover, as we have seen in the aforementioned medical treatises produced in the Low Countries, Galenism and the related medical conception of bathing for health were integrated into Dutch medical thought. Town physicians were primarily involved in providing healthcare for the poor, but were also in the position to advise policy makers on broader matters. Although we do not have explicit references of the city physicians interfering with the stews, they can be regarded as a possible vector transporting medical theory into urban policy.
Moreover, evidence for the medical or public health use of the stews can be found in Germany, where some stew holders (Bader) and barbers or "shavers" (Scherer) were united in the so-called Bader guilds (Zunfts). The Bader performed a variety of tasks in the stews, from purifying and grooming the body -scrubbing (schropfen), shaving and massage-to simple medical procedures such as bloodletting, cupping and purging treatments. Still, the stew holder held a stained reputation. Martin notes that Bader were excluded from public offi ces and town boards in some towns, and the daughters of Baders were regarded as poor marriage candidates. Moreover, from the fi fteenth century on, surgeons and barbers increasingly and successfully contested the Bader's medical competences, thereby further degrading that profession and often securing the exclusion of the stew holders from the guilds 77 .
"Stew keeper" (Stover) appears as a profession and as a surname in Middle Dutch sources, but as yet there are no indications of the existence of Dutch Stover guilds. Perhaps some barbers occasionally practiced their profession in the stews, but there is no evidence available. However, the absence of sources on stew holders in comparison with German Bader guilds cannot entirely be explained by a lack of research in the fi eld. The silence may imply cultural differences in the function of the stews. It is thus possible that the German stews were more closely connected with medicinal bathing and medical procedures, and contributed more to public hygienic practices than their Dutch counterparts.
The distinction between honest and dishonest stews implies that urban policy makers were concerned with keeping some bathhouses "clean", that is, offering an urban space with a potential of bathing for good health. We have seen similar distinctions and similar urban policies in England, Germany, and the Low Countries, but also a very different cultural signifi cance of the stews in different areas. Indeed, the differentiation between honest and dishonest stews allows for a great variation in social function and signifi cance even for individual stews within cities. This makes it impossible and undesirable to establish a unifi ed vision of medieval stews. Yet, it is clear that we need to complicate the view on pre-modern stews by moving beyond the context of prostitution and plague and further explore this urban space in all its aspects and possibilities, including how it was meant to address medieval public health concerns. Moreover, asking to what extent the positive Galenic discourse on bathing in medical texts, with its elaborate treatments and a great variety of techniques, infl uenced urban practices in the stews and town policies, is an important tool in broadening our view.

CONCLUSION
Studying the theory and practice of managing streets and bathhouses illuminates a peculiar form of pre-modern healthscaping: a physical, social, legal, administrative, and political process by which urban individuals, groups, and especially governments sought to safeguard and improve collective wellbeing. Without numerous benefi ts associated with modernity, these agents sought to promote health and curb disease at the population level, at times devising arguments and procedures that may refl ect insights from prevailing medical theories and the advice of practitioners. It would have been odd had policy makers completely ignored physicians. Yet, as we have seen, the relations between medical learning and health practices were more complex than a trickle-down process according to which theory informed policy, which in turn shaped practice. Indeed, there is abundant evidence that key pre-modern practices took their cue from Hygeia rather than Asclepius. As such, they are reminiscent of the behaviorism currently being espoused by numerous legislators, service providers, and advocacy groups that, while not dismissive of medical knowledge generally, decry the disproportionate emphasis Western societies lay on curing at the expense of prevention.
In a recent blueprint for revamping US public health, for instance, Tom Farley and Deborah A. Cohen both challenged the belief in and fi xation with medical science as the main solution to today's health problems, and exposed the systemic failure of medicine on the one hand and a reliance on a rational-educational approach on the other substantially to improve health outcomes. By recourse to several historical examples, they argue that medical-scientifi c knowledge neither offers a guarantee nor even amounts to a prerequisite for improving our environment in substantial ways: [W]e don't have to fully understand how our environment makes people sick in order to change it to improve our health, any more than John Snow and Edwin Chadwick needed to understand bacteriology to recognize that we needed better sewers and water systems. It really isn't very hard to identify the types of situations, the relationships, and the designs of neighborhoods and communities in which people are the healthiest 78 .
While perhaps somewhat overstated, the authors are certainly correct that dismissing earlier attempts to address population-level health concerns as "misguided" or "naïve" is not only patronizing and anachronistic, but also obscures their immense contribution. As Alfons Labisch put it in his 1998 Presidential Address to the Society for the Social History of Medicine, public health has in fact developed for centuries without, sometimes even against medicine and doctors 79 . The observation no doubt ignores the achievements of pre-modern medicine to a certain extent, yet it is justifi ed in challenging a view of public health as merely an epiphenomenon of scientifi c and technological progress and as operating solely within an epidemiological paradigm. Our own case studies echo Labisch's approach by illustrating that public health is not always and everywhere reliant upon developments in medical sciences and that preventative interventions at all levels could be profoundly shaped by commercial, political, religious, and social interests 80 .