Health & Water in the Middle Ages

Health and Water in the Middle Ages: A Historiographical Survey

            As a requirement for life, water has enjoyed an interactive relationship with humanity through the ages, and this is no less true of the medieval era this survey will cover from about the ninth-century to the fifteenth AD. Because of its cleansing properties, symbolic associations, and the importance it is given in the Hippocratic and Galenic corpus, water has also often been associated with health — both as a healing agent itself and as a factor in the maintenance of the all-important equilibrium of the living body. It should come as a surprise, then, that the Anglophonic scholarship surrounding water and its role in medieval health can be best characterized as embryonic and fragmented, and certainly as lacking a developed methodological discourse or unity of approach.[1] Although calls have been made since the early twentieth-century for a more systematic analysis of medieval cleanliness, usage of and beliefs about water, and relationship with bathing and bathhouses, most scholars continue to focus on the early modern and modern periods.[2]

The piecemeal nature of extant work on the topic does, however, provide for an interesting and engaging range of research questions and approaches, in large part due to the myriad types of scholars that have an interest in water and health: these include geologists, archeologists, biologists, geographers, medical professionals (dermatologists, psychiatrists, and physicians), and historians from fields as varied as medical, architectural, cultural, and social history. One can only speculate as to what kind of product would result if these dynamic strands of intellectual work were united under the goal of a multi-disciplinary project on water and medieval health — which is exactly what this survey will attempt to do. By bringing together the many threads of English-speaking scholarship on the topic, I hope to outline the important strategies underlying each disciplinary approach and present a thematic and methodological synthesis — the groundwork, I hope, for further research in a relatively neglected but historically rich and informative area.

In the interest of covering one area in depth, I have neglected a few others. I did not include the scholarship on medieval Islamic beliefs about water’s role in health, nor have I covered its influence on Western beliefs and practice. A few of the sources I reference, however, do discuss this, particularly when they deal with Italian bathing practices, where proximity to Arabic civilizations facilitated especially vibrant intellectual and cultural exchange.[3] The time frame with which I have constrained my study leaves out many excellent studies on Roman, Greek, Germanic, Anglo-Saxon, and Renaissance bathing practices, some of which occasionally cover their influence on similar medieval traditions. I have additionally narrowed my focus to scholarship written in English. The historiography of bathing, spas, and the health regimen (particularly as pertains to water) is far more developed in the French and German tradition.

Water in Medieval Health

Medieval medical theory and practice in recent scholarship has begun to be understood as a system of knowledge and therapeutic methods that play off of and reinforce one another.[4] Indeed, within and without the professional, university-trained class of physicians, those involved in medicine generally adhered to the same basic concepts in their understandings of the body and its health or lack thereof.[5] Within this framework, water’s role in health becomes more intelligible. In the Greco-Roman-Islamic compendium, largely based off of writings passed down from the Hippocratic and Galenic corpus, then supplemented by Islamic commentators, the body is understood as a self-contained system of various elements. These humors — blood, yellow bile, black bile, and phlegm — need to be in the correct proportions to maintain a state of health for the overall organism. This theoretical framework underlay much of the preventative and restorative treatment recommendations of practitioners of the period.

A particularly relevant aspect of this set of beliefs, drawn primarily from Galen, is the group of factors affecting the equilibrium of the body known as the non-naturals. These “physiological, psychological, and environmental conditions,” including “air, exercise and rest, sleep and waking, food and drink, repletion and excretion, and… passions and emotions” were believed to play a vital role in manipulating the balance of the humors, and as such, an understanding of their effects often informed therapeutic practice.[6] This can be seen in the proliferation of regimen sanitatis, or health regimens, from the height of the School of Salerno onwards.[7] Practitioners and lay, literate men and women alike referenced these tracts both during times of health and illness for information on how their activities and lifestyle choices could be maintained or altered in the interest of their well-being.[8] Water appears quite often in this literature, a phenomenon that is reflected in the relative importance it takes on in therapeutic recommendations; baths of many different varieties and the drinking of water are both topics frequently discussed, and ideas about water’s role in human health also informed decisions about other sanitary practices, such as the regulation of communal water supply.[9]

Water: Narrative Absentee

Is water’s role in understandings and regulation of medieval health indeed a neglected area of scholarly endeavor, and to what extent has it been overlooked or underemphasized? To answer that, I consulted a few of what the Oxford Bibliography agrees are the most well received surveys of medieval medical theory and practice.[10]

Nancy G. Siraisi’s survey of medieval medicine, covering the middle of the twelfth to the fifteenth centuries, purports to encompass “western European literate and technical medicine and its practitioners.”[11] Chapter five, titled “Disease and Treatment,” presents an understanding of “the way medicine based on Greco-Islamic tradition worked in practice as a therapeutic system.”[12] To this end, Siraisi discusses the physician’s strategy of regulating the non-naturals through strict regimens designed to maintain a healthy bodily equilibrium, but she emphasizes the role of food and air in such tracts, neglecting the opportunity to discuss how water (applied topically via bathing or internalized via drinking) was also often a matter of import.[13] Hygienic practices are largely neglected. Her work presents the scarcest treatment of water and medicine of the works consulted, which is puzzling considering her focus on the way in which ancient medical theory — of which regulation of the non-naturals was an important aspect — was evident in the writing and practice of literate men of medicine.

A similar situation can be found in the medieval section of the collection of essays on medicine from the perspective of social history edited by Andrew Wear, Medicine and Society: Historical Essays. The compilation presents an attempt to integrate trends in social history into the field of medical history, pushing the discipline beyond great men and great inventions into looking at “how medicine has affected society and how society has shaped medicine.”[14] As bathing had its roots in social practice but was also associated with its effects on the body, historians concerned with society and medicine would do well to include at least a brief discussion of hydrotherapy in a survey. Katherine Park was chosen as the historian to cover the medieval period, and her treatment of water’s role in health is surface-level. She discusses hospitals’ preoccupation with hygiene, but she perpetuates the idea that medieval people had “low level[s] of collective hygiene” that “contributed to disease, particularly in the cities, where sewer systems were inadequate and water supplies often polluted by animal and human waste…”[15] This image of medieval filth and disregard for sanitary practice would likely be strongly contested by the historians of public health that will be discussed below.

Lastly, she argues that historians of health cannot possibly expect to paint a holistic picture of health in the middle ages “without considering the whole, including some kinds of health care — faith healing, for example, nursing, or midwifery — that no longer form part of our own more narrowly defined professional medicine.” To neglect these alternative forms of healing, she claims, “would yield a picture both incoherent and incomplete.”[16] Yet she does just that by failing to mention the important role of balneology and hydropathy — both of which would qualify as alternative medicine in the modern world — in preventative and combative therapy.

The last survey work consulted is an encyclopedia of medieval science, technology and medicine edited by Thomas Glick, Steven J. Livesey, and Faith Wallis. A brief historiographical summary of medieval medical scholarship can be found in the introduction; in it, the authors highlight a trend in the past two decades of the increased influence of social history, which has had the effect of directing interest to new areas of emphasis that include public health and the “medical marketplace” as opposed to the idea of a monolithic, university-trained monopoly on medical practice. Historians, they argue, have began to attempt an understanding of “medieval medical knowledge as a coherent system of ideas about the body, its disorders, and the potential for intervention…” and have looked at “how this knowledge did or did not affect actual practices… on the level of individual care and… social or political arrangements.”[17] Like Park and Wear, then, the editors of and contributors to the encyclopedia want to emphasize the many treatment options open to medieval people, and they also want to understand beliefs about health as a system in which various approaches to treatment fit.

Hydropathy and balneology embody the type of history many of these authors are attempting to write; it is a therapeutic practice outside the modern-day norm, practitioners recommending its use came from a variety of backgrounds, and its effectiveness was explained through the set of ideas about the body that make up humoral theory. Yet again, however, it is largely absent. The “Water Supplies and Sewerage” entry at least does medieval actors justice in portraying them as having the knowledge of and desire to regulate their water supplies and keep their cities relatively clean, but it does not delve deeper into how beliefs about the cleanliness of water and its effects on the body played into such decisions. The six non-naturals are mentioned on several occasions — in the “Meteorology” and “Regimen Sanitatis” entries — but the discussions under both are largely limited to the role of air and food in maintaining bodily equilibrium. To the book’s credit, it does emphasize the importance of the regimen sanitatis on “medieval practice and the lifestyles of millions of Europeans” due to its extension of “the physicians’ sphere of influence from the sick to the healthy,” an important distinction to be made about health and water in the Middle Ages.[18] Water was not only used in treating diagnosed illnesses, but was also a major player in preventing them.

Thus, it is clear that while many of the survey texts discussed above employ methodology that would seem to predicate the inclusion of medieval balneology and hydropathy, the practices and theories that underlay them remain largely absent from the ongoing narrative of health in the Middle Ages. In order to find scholarship that does discuss the role of water in healing, one must look beyond mainstream medieval medical history into the fringes of the discipline, and sometimes entirely outside of it into the realm of the sciences — a sure sign that a historical inquiry is in its infancy.[19]

Physicians and Scientists on Water and Health

            A physician by the name of Arnold C. Klebs, M.D., wrote one of the first historical accounts of bathing practices in the Middle Ages in his role as a member and contributor to the American Clinical and Climatological Association. The organization was founded in 1884 with the goal of improving medical education, research, and practice, and incorporating worldly, preventative, and environmental medical perspectives into scientific and medical literature.[20] With a view to that objective, Klebs aims to shed light on an era commonly assumed to be superstitious and relatively useless to medical men of the modern world; he hopes to understand medieval medicine within its own context, and with an awareness surprising for an early twentieth-century physician-turned-historian, discusses how the practice of balneology has been neglected due to the difficulty it presents those attempting to characterize medicine as an exact science. He advocates for an approach that considers actors outside what are typically thought of as men of early medical science, such as Antonius Musa, who made his mark in history as the founder of hydrotherapy when he cured Augustus with a cold bath.[21]

Klebs does not present an overarching argument other than his contention that medicine in the Middle Ages was not “dark” and uninformed, but was based upon knowledge about the body and how water affects it from a variety of authoritative sources. He traces the development of balneology from antiquity through the Middle Ages, using strategies borne out of etymology, archeology and architectural history, medieval history (with an emphasis on tracing the dates, authors, and influences on and of texts) and geography, and he employs sources as varied as letters, the songs of troubadours and minstrels, poetry, regimens, manuscripts, and governmental and monastic edicts in substantiating his claims regarding the nature of bathing and the factors that influenced its practice. Already, we can see that German scholarship in water and health is outpacing English interest in the same area; of the seven secondary sources Klebs cites, four are German, one is Italian, and two are English, and one of the English sources is a translation as opposed to critical work.

Thus, while Klebs’s work is largely descriptive, the methods he uses are very sophisticated (especially for someone not trained as a historian), and the general narrative he presents is roughly congruent with the current one — the rise of the bathhouse in the Middle Ages, influenced by Arabic, Germanic, and Greco-Roman practice, its development alongside that of university-stimulated medical theory, and its “degeneracy” in the later fifteenth century as the rise of Christianity and syphilis raised moral concerns. Where Klebs account excels in method, it lacks some measure of depth; beliefs are not explained in the context of medieval medical theory, which he seems to assume had very little to do with the actual practice of bathing. This could be attributable to the lack of scholarship on regimens and medical theory at the time of the piece’s composition.

Klebs’s thorough treatment, however, is the exception rather than the rule as far as scientists’ writing about medieval hydrotherapy is concerned. The next three sources will be dealt with in tandem, as their approach and relative emphasis on the Middle Ages render them comparable. They are all three from the mid-twentieth to the early twenty-first-century, at least a few full decades after Krebs’s contribution, and none of them cite Krebs’s work.

The first is probably the most respectable in that it does not get hung up on whether water actually works by modern standards as a therapeutic strategy. Written by four dermatologists and published in the scientific journal Clinics in Dermatology, the article attempts to outline the ways in which water — its prevalence in our daily lives rendered invisible by its integration into daily routine — has been understood in relation to health “throughout the centuries.”[22] The authors present a periodization, which includes the Greco-Roman world, the Dark Ages, the Medieval Period, the eighteenth and nineteenth centuries, and lastly, the twentieth. While giving due credit to Greco-Roman influences on medieval understandings of water and health, citing Hippocrates, Galen, and Asclepiades as developers of the theory and proliferators of the practice of bathing in and drinking water, they paint the Middle Ages as a period steeped in Christian influence and morally opposed to the evidently sexually-inundated practice of public bathing. They then skip directly to the sixteenth century with a brief mention of Arabic developments in the eleventh. Of the six columns of text, about half of a column concerns the medieval period, while the ancient, early modern, and modern periods receive at least a full column each. Klebs would have been horrified.

This relative neglect of the Middle Ages is also characteristic of the other two articles written by scientists.[23] Both cite as their goals the same as that of the dermatologists — to trace the historical use of water in therapy — although they add an important ulterior motive of discussing the efficacy of hydrotherapy in the context of modern medical science. It is in asking these types of questions that the authors’ lack of historical training and presentist tendencies become manifest. The narrative proposed in these pieces is almost identical to that of the one discussed above, but van Tubergen and van der Linden perpetuate the myth (to be discussed in further depth below) that the Middle Ages were a time of incredible filth. Due to the influx of Christianity and its institutional abhorrence for bathing, the authors claim, “People abstained from bathing, sometimes for years.”[24] All three pieces emphasize the pleasurable and recreational motivations for bathing, downplaying the role of medieval medical theory as an impetus for engaging in bath or spa therapeutics. It should be said in defense of these works, however, that they are at the very least asking questions and instigating investigations, rudimentary though they are, into the relationship between water and healing, and they include in their surveys the medieval period, which is oftentimes more than can be said for historians of medicine.

Physicians, psychiatrists, and dermatologists are not the only scientists to have contributed to the historiography of water and health in the medieval period. Geologists have also contributed to knowledge of the topic in the form of two articles within a collection of works titled A History of Geology and Medicine. The collaboration’s goal is to “explore the historical links between geology and medicine,” an endeavor, the editors claim, that is the first of its kind.[25] In addition to covering minerals, gems, fossils, and stones of all sorts, the work addresses groundwater as a geological phenomenon. One of the articles addresses British spa culture and is largely concerned with more recent history, but the contribution by Nick Robbins and Pauline Smedley, “Groundwater — Medicine by the Glassful?” takes up human interaction with water from natural springs as far back as the ninth-century BC. While, like the most other scientists, their primary questions are centered on whether or not groundwater was actually therapeutically effective, their explanations of how groundwater is stored, infused with minerals, and brought again to the surface are useful to any historian trying to understand some of the more geological aspects of water content and accessibility.

In addition to describing the processes that make groundwater available and imbue it with unique chemical properties, the article discusses the religious, mythical, and symbolic associations surrounding various historically famous springs and spas and correlate such beliefs with the actual properties of the water. The copper content at Llangamach Wells in central Wales, for example, was made famous and thought to be healthful due to its metallic taste — a characteristic, Robins and Smedly argue, that can be explained by the water’s high copper content.[26] They similarly point out that particular combinations of mineral content may have rendered some celebrated medicinal sources of water powerful diuretics and purgatives.[27] While the authors’ questions are problematic to the medical or medieval historian, geologists’ insight into the chemical composition of medieval water could prove helpful in understanding why certain sources acquired particular reputations, symbolic associations, and mythologies, and why medieval practitioners and patients may or may not have undergone different forms of hydrotherapy at various locations.

Since the historical scholarship on water’s place in medieval health is still very much in development, it is necessary to include work done by non-historians. Scientists and physicians have shown an interest in the subject matter, having seen in their experience working with hydrotherapeutic practice and water itself the important role today and in the past that water has taken on in narratives of health and disease. While their questions are not of the same nature as that of the historian, they have much to offer not only in bringing the subject to the attention of others but in developing strategies — some quite foreign to those trained in history — for understanding how water came to be associated with health and how such beliefs came to be reflected in medical maintenance, theory, and practice.

Archeology and Architectural History

            Archeologists and architectural historians have also had cause to discuss the role water has played in health in the Middle Ages. Jill Caskey’s case study of five bathhouse sites in Southern Italy is an excellent example. She approaches the topic from the perspective of an historian, hoping to integrate the recent interest of archeologists in excavating medieval bathing structures into her study of the architectural properties and attributes contained within them. She claims that, through a study of the physical structure of these bathhouses, the historian can hope to uncover not only trends in architecture that can shed light on the origins of medieval bathing practice, but in medieval bathing culture itself. She cites the tendency, exemplified by the articles surveyed in the previous section, to focus on Christianity’s ambivalent feelings toward bathing in the early Middle Ages and on the decline of the bath later on in the period and argues that a study of bathhouse structure can elucidate the far more complex way in which bathing was “deeply embedded in Campania’s architectural, social, economic, and scientific fabric.”[28]

She begins with a detailed description of the five medieval bathhouses from which she will base her conclusions, bringing to bear her knowledge about various architectural traditions on the structures to construct systems of possible influence; in the second half of the paper, she extends this to include cultural influences as well, weaving the two together to paint a picture of how Roman and Arabic building strategies and medicinal beliefs and practices made their mark on medieval Italian ones. Integrating the architectural and the cultural proves to be a very helpful explanatory strategy for understanding why and how medieval people chose to build and use bathhouses. She traces baths’ integration into the homes of wealthier Italians, monasteries, and even smaller rural homes — an excellent way to uncover the prevalence and importance of baths, for cultural or medicinal purposes. She comments as well on the technologies employed in these sophisticated structures. They often contained complex systems for acquiring, heating and cooling, steaming, and disposing of water, which speaks to medieval architectural ingenuity, Roman and Arabic influence, and the varied services the bathhouses were built to supply.

The structures provide other evidence of what their intended uses were. The sizes of bathing areas varied, some obviously designed for a single occupant. Shelving along the sides provided space for “a lamp and the accouterments of bathing — perfumes, oils, herbs, towels, and drinking vessels.”[29] The buildings contain rooms off of the side of those intended for bathing purposes for dressing and relaxing. Caskey does not limit her source base to the buildings themselves, but also includes the plans for their construction, artwork inside and outside of them, medical sources (like regimens and treatises), and even poems, deeds of sale, dowries, and wills that comment upon them in one way or another. She uses these documents to place the baths within their cultural and scientific context, and the result is a narrative that challenges notions of the Middle Ages as having been a time of filth and presents a multi-faceted hypothesis for why medieval bathers participated in the practice. Caskey relies heavily on archeological scholarship as well, citing items found at the sites she includes in her study as evidence of certain practices and understandings.

In Caskey’s methodological approach, architecture and culture exist in a reciprocal relationship — one that can be understood by historians and used to explain the important, varied, and ambivalent role bathing played in medieval beliefs about health and tradition. Including archeological and architectural sources provides a wealth of information very difficult to access from written sources about the origins of the practice, how it was conducted, and who participated, and supplemented by written sources, enable the historian to place this knowledge within a system of beliefs about health and the body. Indeed, including physical evidence adds considerably to the historical understanding of water’s role in health and is a strategy that should be employed more frequently in many areas of medieval medical history.

Hygiene and Cleanliness

            A growing number of medical historians have turned their attention to the study of cleanliness and dirt, a topic that invites many interesting questions about what historical actors have considered acceptably clean and why, and studies of this kind often naturally touch on the use of water for health purposes. Virginia Smith’s book Clean: A History of Personal Hygiene and Purity is part of this tradition, and hers is the first attempt at writing a history of cleanliness in over fifty years.[30] She views the study of hygienic practice as “a social and cultural history of preventative medicine,” as ideas about the maintenance of dirt are almost always intertwined with conceptions of “what we did… for ourselves in order to preserve our bodies.”[31] She thus gives primacy to medical concerns about cleanliness, a reflection of the relative importance such beliefs have played in decisions about hygienic practice. The book covers the beginning of humanity to the modern era, with two chapters that deal with the Middle Ages.

The first chapter concerns asceticism and presents an account that complicates the narrative of the religious aversion to bathing in the early medieval period. While early Christian concerns about nudity are not refuted, they are placed into context and shown to not always lead to an antagonism toward bathing. In fact, the early Christians’ belief in their duty to heal — coupled with medical understandings of health and cleanliness — often led them to construct bathing facilities in the hospitals and monasteries they built.[32] Smith additionally draws attention to the importance of water in religious cleansing rituals, most notably in baptism. This spiritual dimension no doubt played a major part in the health-giving attributes medieval people often ascribed to water, and its inclusion helps paint a fuller portrait of the more ethereal, less “scientific” reasons that individuals integrated water into their maintenance routines.

The second chapter tackles the myth of medieval filth head on, calling it an “exaggeration,” and a denigration of “the honor and dignity of [medieval housewives’] households.”[33] Smith uses a wide range of sources including manuscripts on household duties, accounts of the habits of men and women of note, clerics’ accounts and commentaries, songs, tapestries, and regimens in the vernacular (“the basis of public health education for the next eight centuries”). Particular attention is given to the regimens, which Smith claims were the avenue through which “the morning grooming session was institutionalized in medieval life” through the assertion that the cleansing recommendations they provided were backed by theoretical medicine.[34] She goes on to discuss the equally important role plague tracts played in establishing a normalized idea of medieval hygienic practice. Lastly, Smith touches on traditions that integrated bathing into their practice; springtime, for instance, was considered a prime season for bathing, as “it was also the Galenic time for bleeding and purging” — time for cleansing the body, inside and out.[35] Festivals were often organized with this in mind.

The strategies used in Clean are unique in their emphasis on the cultural and social aspects of bathing, and the way in which Smith contextualized such practices within a framework of medical theory provides a holistic account of why bathing would have appealed to a medieval audience. Her approach affirms the importance of cultural ideas in determining behavior, inviting the inclusion of sources sometimes neglected by historians of other fields like songs, vernacular texts, and descriptive accounts of court or monastic life. The mythologies and symbolic associations that surround water can be more clearly understood when their cultural backgrounds are supplied, and “cleanliness,” a cultural construct itself, is an effective framework for gaining access to this context.

Public Health Scholarship

            A subset of medical history, scholarship on public health has been scarce for the Middle Ages relative to other time periods, in large part due to the idea, discussed a few times already, that the period was mired in filth and had a general disregard for communal sanitation. This is rather astonishing considering that calls for a reevaluation of medieval cleanliness in general and of public health measures in particular has been trumpeted since at least 1928, the year Lynn Thorndike’s still oft-cited article on the topic was published in Speculum. In it, he identifies a three-headed Cerberus[36] of faulty beliefs about the Middle Ages: that the streets of medieval towns were disgusting; that bathing was rarely if ever practiced; and that organized public health measures were wholly absent. He asserts that such beliefs result from the tendency for people to assume a progressive historical narrative, and since “the survival of some such conditions [reaches] into rather recent modern times,” historians could only conclude that it must have been much worse hundreds of years ago.[37] To dispel the false assumptions he has identified, Thorndike cites historical evidence to the contrary in the form of government documents outlining sanitary practice and the appointment of town physicians, tracts describing medieval medical theory and its concern with filth, fleas and rats, and bathing as important for health, and the many architectural remnants of bathhouses and hospitals.

After such a sound refutation and a century’s worth of scholarship, it is surprising that public health historians of the twenty-first-century are still addressing and refuting the myth of a filthy Middle Ages in their work. Christopher Bonfield takes up the challenge in a 2009 article that argues not only that communal sanitary practice was prevalent, but that “medieval attempts to supply water often drew on medical, social, political, legal, and economic strategies.” He thus hones in on water sanitation in particular and attempts to explain why and through what logic the goals of such efforts were undertaken. Very prominent in his argument is the role of medical beliefs about water, which he asserts were the main impetus for public health legislation. Bonfield describes in detail the role of the non-naturals in Galenic literature, highlighting the importance of water, “which,” he claims, “was regarded as a real substance that could pass easily into the blood vessels and purify the human body.” Equally critical, and only understandable in the context of medieval humoral theory, was the “widespread awareness that, once contaminated water… entered the digestive tract, illness or even death might ensue.”[38]

In addition to explaining humoral theory, Bonfield tries to prove its pervasiveness by paying particular attention to its dissemination through vernacular texts like regimens and plague tracts; who was reading or being exposed to these texts, and how widespread were they? He cites statistical evidence that about 392,000 copies of vernacular texts containing medical advice were printed before 1500 and that literacy was more widespread than commonly believed.[39] The author also discusses how “spiritual investment” in clean water influenced medieval public health; he describes the way in which civic and church authorities funded sanitation enterprises in exchange for salvation. Again, religiosity is shown to be intimately linked to water and cleanliness. Like most other authors considered in this survey, Bonfield employs regimens and commentaries, but his focus on public health necessitates the inclusion of legislative and punitive sources. These provide evidence of the ubiquitous concern about the cleanliness of water, largely the result, Bonfield argues, of beliefs about water’s ability to effect health.

Coomans and G. Geltner take up a similar argument in their collaborative piece published in 2013. They extend their study into Dutch bathhouses as well, asserting that adherence to Galenic medical theory underlay both bathing practices and public health initiatives in the Middle Ages. The authors assess the role of Galen’s work in shaping popular understandings of the body, emphasizing his belief that preventative medicine should take precedence — which, they assert, helps explain why “water management was closely linked to the preservation of life’s basic necessities.”[40] This applied both to keeping communal streets and water sources clean and to maintaining the integrity of bathhouses, which, in accordance with the importance bathing was ascribed in medical texts, was paramount to preserving the overall health of a town. Coomans and Geltner utilize sources as diverse as legal statutes, officials’ charters, the records of city officials, and the customary treatises and regimens to substantiate their claims.

Thus, as the scholarship on public health initiatives in the Middle Ages has developed, the medieval understanding of water’s role in health has become a topic of increasing import. Why regulate the purity of something unless it is understood to be a useful endeavor for those exposed to it? When placed into the context of the Galenic understanding of health and the body, it becomes clear that clean water and reputable bathing establishments would have been desirable to people in the Middle Ages, just as public health legislation sheds light upon how deeply ingrained medieval medical theory was in popular understandings of the body, health, and water’s capacity to influence both.


Although mainstream medical historians have largely neglected water’s relationship to the theory and practice of medieval health, work in other areas has provided a foundation for a more thorough treatment of the subject. We can learn from extant work in social history how informative viewing medieval medical theory and practice as two complementary and reciprocally reinforcing parts of a larger system of knowledge can be. In the context of humoral medicine, water was seen as one of many factors (albeit an especially important one) that influenced the ever-changing body, and as such, its place in health becomes intelligible. The regimen sanitatis and plague tract are two source bases that have been widely used to place hydrotherapeutic practice within the wider framework of humoral medicine.

Cultural historical methods also prove useful; the mythologies and symbolic associations water has historically been ascribed can often be grounded in cultural, religious, or spiritual influences as well as theoretical ones, which helps to explain how such practices endured so long and maintained such ubiquity. To this end, historians have employed an incredibly wide variety of sources that include but are certainly not limited to commentaries and personal accounts, religious texts, poetry, and the songs of minstrels. Additionally, “hard” evidence like architecture, artifacts, and even the geological properties of water sources can be harnessed to provide ways to trace influence and to elucidate the practice and prevalence of hydrotherapy and balneology in the Middle Ages. Some of these strategies fall outside the traditional purview of the historian, but as proven in Jill Caskey’s, Nick Robin’s, and Pauline Smedly’s work, they can be incredibly revealing.

Historians of public health have insightful work to offer up as well. Their focus on medieval efforts to maintain public well-being have included the use of sources like legal and administrative statutes, official documents, and city records to prove that medieval people were very health-conscious and often based their health decisions within the context of a loosely unified medical theory. They saw the value of preventative medicine. Indeed, the study of water and health in the Middle Ages helps facilitate scholarly inquiry into preventative medicine, the relationship between medical theory and practice, therapeutic practices that are no longer considered “scientific,” and the cleanliness of the period, all aspects of the medieval era that are in need of further consideration. Work focused distinctly on the topic, as it stands only pursued by scientists and physicians, is long overdue. The foundations have already been laid and simply await an historian to build upon them.


“American Clinical and Climatological Association.” The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions. Accessed Apr. 20, 2017.


Bonfield, Christopher. “Medical Advice and Public Health: Contextualizing the Supply and Regulation of Water in Late Medieval London and King’s Lynn.” Poetica 72 (2009): 1-20.

Caskey, Jill. “Steam and ‘Sanitas’ in the Domestic Realm: Baths and Bathing in Southern Italy in the Middle Ages.” Journal of the Society of Architectural Historians 58, no. 2 (1999): 170-195.

Coomans, J. and G. Geltner. “On the Street and in the Bathhouse: Medieval Galenism in Action?” Anuario de Estudios Medievales 43, no. 1 (2013): 53-82.

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Glick, Thomas F., Steven Livesey, and Faith Wallis eds. “Medieval Science, Technology, and Medicine: An Encyclopedia. New York: Routledge, 2005.

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Porter, Roy ed. The Medical History of Waters and Spas. London: The Wellcome Institute for the History of Medicine, 1990.

Routh, Hirak Behari, Kazal Rekha Bhowmik, Lawrence Charles Parish, and Joseph A. Witkowski. “Balneology, Mineral Water, and Spas in Historical Perspective.” Clinics in Dermatology 14 (1996): 551-554.

Siraisi, Nancy G. Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice. Chicago: University of Chicago Press, 1990.

Smith, Virginia. Clean: a history of personal hygiene and purity. Oxford: Oxford University Press, 2007.

Thorndike, Lynn. “Sanitation, Baths, and Street-Cleaning in the Middle Ages and Renaissance.” Speculum 3, no. 2 (1928): 192-203.

van Tubergen, A. and S. van der Linden. “A brief history of spa therapy.” Ann Rheum Dis 61 (2002): 273-275.

Wear, Andrew ed. Medicine and Society: Historical Essays. Cambridge: Cambridge University Press, 1992.


[1] This assertion does not extend to work on the topic in the French and German tradition, where the scholarship is far more developed. Both sources listed on the Oxford Bibliography for Medieval Medicine under “Regimen and Bathing,” for example, are French.

[2] Take, for instance, Roy Porter’s 1990 Medical History supplement, The Medical History of Waters and Spas — the closest thing to a collaborative survey of medicine and water. Of the ten contributions, one deals with the classical world, one with the Renaissance, and the other studies address topics temporally located from the 17th to 20th centuries. The Middle Ages are thus entirely neglected.


[3] See Jill Caskey, “Steam and ‘Sanitas’ in the Domestic Realm: Baths and Bathing in Southern Italy in the Middle Ages,” Journal of the Society of Architectural Historians 58, no. 2 (1999): 170-195.

[4] See Nancy G.. Siraisi, Medieval and Early Renaissance Medicine (Chicago: University of Chicago Press) 1990, 78-79 and Thomas F. Glick, Steven Livesey, and Faith Wallis, “Introduction,” in Medieval Science, Technology, and Medicine: An Encyclopedia eds. Glick, Livesey, and Wallis (New York: Routledge, 2005).

[5] Nancy G.. Siraisi, Medieval and Early Renaissance Medicine (Chicago: University of Chicago Press, 1990), 78-79.

[6] Siraisi, Medieval and Early Renaissance Medicine, 101; Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: W. W. Norton & Company, 1997), 107.

[7] Porter, The Greatest Benefit to Mankind, 107.

[8] Porter, The Greatest Benefit to Mankind, 107-108; Christopher Bonfield, “Medical Advice and Public Health: Contextualizing the Supply and Regulation of Water in Late Medieval London and King’s Lynn,” Poetica 72 (2009), 6-7.

[9] Bonfield, “Medical Advice and Public Health”; J. Coomans and G. Geltner, “On the Street and in the Bathhouse: Medieval Galenism in Action?” Anuario de Estudios Medievales 43, no. 1 (2013): 53-82.

[10] Peter Murray Jones, “Medicine,” in Oxford Bibliographies in Medieval Studies. Accessed 25-Apr-2017.

[11] Siraisi, Medieval and Early Renaissance Medicine, 115.

[12] Ibid., 116.

[13] Siraisi, Medieval and Early Renaissance Medicine, 120-123.

[14] Andrew Wear, “Introduction,” in Medicine and Society: Historical Essays ed. Andrew Wear (Cambridge: Cambridge University Press, 1992), 1.

[15] Katherine Park, “Medicine and society in medieval Europe, 500-1500,” in Medicine and Society: Historical Essays, 62.

[16] Katherine Park, “Medicine and society in medieval Europe, 500-1500,” in Medicine and Society: Historical Essays, 60.

[17] Thomas F. Glick, Steven Livesey, and Faith Wallis, “Introduction,” in Medieval Science, Technology, and Medicine: An Encyclopedia eds. Glick, Livesey, and Wallis (New York: Routledge, 2005), viii.

[18] “Regimen Sanitatis,” in Medieval Science, Technology, and Medicine: An Encyclopedia eds. Glick, Livesey, and Wallis (New York: Routledge, 2005), 439.

[19] The first generations of medical historians were largely comprised of physicians, just as practicing scientists generated much early interest in the history of other sciences. Pierre Duhem provides a good example; he was a mathematician and physicist who became interested in European science in the Middle Ages, and he was one of the first to see the importance of medieval contributions to science.

[20] “American Clinical and Climatological Association,” The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions, accessed Apr. 20, 2017.

[21] Arnold C. Klebs, “Balneology in the Middle Ages,” Transactions of the American Clinical and Climatological Association 32 (1916), 17.

[22] Hirak Behari Routh, Kazal Rekha Bhowmik, Lawrence Charles Parish, and Joseph A. Witkowski, “Balneology, Mineral Water, and Spas in Historical Perspective,” Clinics in Dermatology 14 (1996), 551.

[23] A. van Tubergen, and S. van der Linden, “A brief history of spa therapy,” Ann Rheum Dis 61 (2002): 273-275; William A. Frosch, “’Taking the Waters’ — springs, wells, and spas,” The Journal of the Federation of American Societies for Experimental Biolgoy 21 (2007): 1948-1950.

[24] van Tubergen and van der Linden, “A brief history of spa therapy,” 273.

[25] Christopher J. Duffin, “Geology as medicine and medics as geologists,” in A History of Geology and Medicine eds. C. J. Duffin, R. T. J. Moody, and C. Gardner-Thorpe (London: The Geological Society, 2013), 3.

[26] N. S. Robins and P. L. Smedley, “Groundwater — Medicine by the Glassful?” in A History of Geology and Medicine (London: The Geological Society, 2013), 264.

[27] Ibid., 265.

[28] Jill Caskey, “Steam and ‘Sanitas’ in the Domestic Realm: Baths and Bathing in Southern Italy in the Middle Ages,” Journal of the Society of Architectural Historians 58, no. 2 (1999), 172.

[29] Ibid., 173.

[30] Virginia Smith, Clean: a history of personal hygiene and purity (Oxford: Oxford University Press, 2007); Douglas Biow, review of Clean: a history of personal hygiene and purity, by Virginia Smith, Bulletin of the History of Medicine 82, no. 3 (2008): 709-710.

[31] Virginia Smith, Clean: a history of personal hygiene and purity (Oxford: Oxford University Press, 2007), 3.

[32] Ibid.,141-142.

[33] Ibid., 145.

[34] Virginia Smith, Clean: a history of personal hygiene and purity (Oxford: Oxford University Press, 2007), 154.

[35] Ibid., 176.

[36] His brilliant wording, not mine.

[37] Thorndike, Lynn. “Sanitation, Baths, and Street-Cleaning in the Middle Ages and Renaissance,” Speculum 3, no. 2 (1928), 192.

[38] Christopher Bonfield, “Medical Advice and Public Health: Contextualizing the Supply and Regulation of Water in Late Medieval London and King’s Lynn,” Poetica 72 (2009), 4-6.

[39] Ibid., 7

[40] J. Coomans and G. Geltner, “On the Street and in the Bathhouse: Medieval Galenism in Action?” Anuario de Estudios Medievales 43, no. 1 (2013), 59.


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