'Piss Clear and Defy the Physician' by Karen Maitland

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I imagine most historical fiction authors have a collection of favourite reference books they dip into on many occasions, and one of my treasured volumes is The Medical Mind of Shakespeare, written by Aubrey C. Kail. The author uses extracts from the plays of Shakespeare to reveal not only the diseases and their symptoms, which were familiar to Shakespeare’s audiences, but the medical and surgical practices of the time. The book covers everything from childbirth to geriatrics, including venereal disease, medicines, mental illness and the four humours.

One of the practises the author examines is ‘water casting’, the examination of urine as a key to diagnosis. Macbeth says,

‘If thou couldst, doctor, cast the water of my land,
find her disease

And purge her to a sound and pristine health.’

While in Twelve Night, Fabian urges that the urine of the supposedly mad Malvolio should be examined.

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‘Carry his water to th’ wise woman.’

This either suggests that lay people or cunning women in Shakespeare’s time were also using this art, or that Shakespeare was slightly scornful of this medical practise.

But using urine as a major diagnostic tool was nothing new. Throughout the Middle Ages, most physicians relied on examining the urine of the patient as one of the best aids to diagnosis. So much so, that whereas now a doctor is generally depicted with a stethoscope, in the Middle ages, the profession of a physician was shown by them holding a urinal in the shape of the bladder. 

In 1180’s in St John’s Hospital in Jerusalem, physicians were required to visit each patient twice daily accompanied by two servants, to check their pulse and urine. The servant would hold the urine sample up to the light, so that the doctor could examine it, then quickly deposed of it because of the heat. The second servant carried the medicines and syrups, including oxymel, made from vinegar and sugar syrup which the Arab physicians considered helpful in treating fevers, opening obstructions and preventing putrefaction.

Physician Constantine the African at

Schola Medica Salernitana

The Statutes of Roger de Moulins, in 1182, state that the hospital in Jerusalem must employ four ‘wise’ physicians (miegesl medici) who were qualified to examine urine and make a diagnosis. In 1177, 750 wounded crusaders were admitted to the hospital which already had 900 sick and wounded patients. So, these four wise physicians must barely have reached the end of their first round of urine samples before they had to start again on their second visit of the day.

Physicians employed by a town would often have to sign contracts obliging them to inspect the urine of any townsperson who requested it. Physician’s guilds warned their members that some citizens would try to test how competent they were by bringing in a sample taken from someone else and giving false symptoms that did not match those suffered by the person who’d produced the urine. They taught their members which questions to ask to try to uncover the truth.

Urine Colour chart c. 1506

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By the early 15th century, almost every physician would have owned a colour-chart in the form of a wheel pattern of around 20 little urinals, each varying slightly in colour, against which he could match the patient’s sample. He would also look for the different stages of ‘digestion’ of the urine, depicted by a tree-like diagram, as well noting density, content, cloudiness and how the clouds moved or precipitated out. Each sample of urine was examined at the top, middle and bottom of the flask which indicated the health of different parts of the body.

15th Century Urine chart showing colour

linked to 'digestion' of urine.

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This emphasis on urine being an indicator of the state of health of a person may have partly been responsible for the life-token superstition in a which persisted right up into the 19th century. If a family member was setting out on a long journey, a bottle of their urine was hung on the wall. If the urine remained clear, their loved ones knew they were well. If the urine became cloudy, they had fallen ill or were in danger. If the urine dried, they were dead. When relatives were sailing to the other side of the world, it might be months or years before any word was received of them and such life-tokens became hugely important.

But the other reason for using urine in life-tokens was that along with blood and saliva, it was considered to have magical properties. In folk medicine, if an animal or human’s illness was believed to have been caused by witchcraft, the evil-eye or a curse, the spell could be broken by boiling the victim’s urine in silence in a sealed room at night. Other items might be added such an iron horseshoe nails or the victim’s hair or nailclippings. It was boiled until the victim cried out, which was taken as sign the spell had been broken.

Witch-bottle buried under a house floor after 1820

Credit: Portable Antiques Scheme

If witchcraft was suspected urine was added to a ‘witch jar or bottle,' together with pins, nails and anything made from iron, and also items that would bind the evil such as thread or brambles. It would be hidden in a chimney or near a fire where it would heat up. As it boiled and the pins moved, the ‘witch’ would be racked with pain until she or he confessed or lifted the curse. In later centuries, the bottle was simply placed under a floor or in the roof space to ward off witchcraft and evil.

As the 16th century proverb wisely says – Piss clear and defy the physician.

Physician with Urine Flask 14th Century

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