Urban public health in the medieval period has not previously been studied as a phenomenon, although numerous forays have been made since Ernest Sabine’s groundbreaking articles of the 1930s on city cleaning and butchery. It is a subject of considerable significance both for historians of medieval urban society and for archaeologists seeking to understand the context of many of the features they may encounter.

Rawcliffe’s work is a superb and deeply researched reference resource for these linked areas of study. In a similar vein to her earlier work on leprosy (on which there is a chapter here too), she convincingly overturns Victorian and subsequent historical assumptions about the laziness and ignorance of medieval urban communities in the face of filth and squalor. This is not just welcome revisionism. It is a fundamental demand to adopt a new starting point from which to understand medieval urban hygiene, health and identity. Assessing the value of the efforts of town authorities in the context of a modern understanding of disease and environmental impacts misses the entire point and Rawcliffe instead sets out to see such efforts through contemporary eyes. The body corporate was quite literally a body, subject to assault by the miasmas of dumped offal, improved by cleansing (‘phlebotomy’) of the arteries of roads and rivers and enhanced by the individual and communal investment in schemes to promote civic welfare. Cleanliness was a manifestation of civic virtue, and the maintenance of a town’s health, just as of that of an individual, was as focused on the control of moral contagions as it was on the removal of physical dangers. Thus we are invited to see, for example, the management of ‘lewd women’ and ‘sturdy beggars’ in parallel with the management of swine in the city streets – both, in late medieval eyes, capable of harbouring and spreading different kinds of damage to the inhabitants.

Having established the context for her enquiry, Rawcliffe presents us with a logical sequence of chapters on environmental conditions and management, water in the urban context, food, drink and diet, and the range of approaches to sickness and debility. Each chapter is broken down into useful sub-sections, enabling a rapid navigation of the book and quick cross-referencing – so, for example, one can compare and assimilate the wider medical beliefs related to environmental health, water and food from each relevant chapter. Following the concluding chapter is a very useful gazetteer of plague or health crisis events from 1257 to 1530.

Throughout there are intriguing new insights into the character of medieval towns. Take, for example, the practice of passing substandard meat to hospitals catering for the sick poor (p 236). Not, as one might initially think, a result of greed and disregard, but rooted instead in the notion that since already sick, there was little chance of worsening their plight. Think further on the likely resulting animal bone assemblage recoverable through excavation that might have otherwise suggested a very high-status diet. The link between diet and moral concerns may need further consideration if Rawcliffe is right to connect the increasing popularity of beef and the decline of pork to medical concerns regarding the latter (pp 242–3).

There is real force behind the proposition that as a body, citizens and authorities did aim to introduce and maintain increasingly sophisticated approaches to urban health. This effort was not always explicitly communal and was very often achieved through harsh and repeated regulation: despite Rawcliffe’s initial plea to abandon the lazy caricature of the medieval town as perpetually filth-ridden and miasmatic, from the evidence then presented one cannot escape the feeling that behind the regulatory pressure lay repeated offences, so there is some tension evident here. There are also one or two examples of the ‘moral’ and ‘environmental’ controls being a little too closely connected: were the efforts to slaughter dogs and cats at times of pestilence really ‘of a piece’ with legislation to control rootless beggars (p 156)?

However, overall, the unity between the physical and spiritual aspects of the town is convincingly offered, and gives archaeologists and historians a refreshing new way of looking at the agencies involved in environmental and health management and its impact on communal identity and civic character. Rawcliffe offers us a striking range of civic Comfortable Works – latrines, paving, drainage – to set more illustrious examples – guildhalls, almshouses, conduits – in a new context, and through a collective investment which far exceeds the value of specific individual campaigns on the latter. In doing so she has delivered a very valuable and important study.