What Did Mediaeval Doctors See in Wee?
The curious history of urine, medicine and the medieval physician.
Imagine visiting a doctor in the Middle Ages.
There is no blood test. No X-ray. No ultrasound. No CT or MRI scanner. There isn't even a stethoscope.
Instead, your doctor asks you to do something rather more familiar:
Provide a urine sample.
They pour it into a specially shaped glass flask, hold it towards the light and study it carefully. They look at its colour. Its clarity. Its consistency. Whether anything has settled at the bottom.
And from what they see, they attempt to work out what is happening inside your body.
Welcome to the mediaeval world of uroscopy, the examination of urine as a means of understanding health and disease.
It sounds strange to us now, but for hundreds of years urine was one of the most important diagnostic tools available to a physician. By the fourteenth century, uroscopy had become an integral part of assessing a patient's health and the urine flask itself had become a recognised symbol of the mediaeval physician.
And while mediaeval physicians got plenty wrong, the fundamental idea behind what they were doing was remarkably enduring:
Our urine can contain clues about our health.
Why urine?
Mediaeval doctors faced a fairly obvious problem: they couldn't see what was happening inside a living person.
Their understanding of anatomy and disease was very different from ours, and medicine was heavily influenced by ideas inherited from ancient Greek and Roman authorities such as Hippocrates and Galen.
Central to mediaeval medicine was the theory of the four humours:
blood
phlegm
yellow bile
black bile
Health was thought to depend upon these substances remaining in the correct balance.
Disease could occur when that balance was disturbed.
Mediaeval European medicine was also profoundly shaped by medical scholarship written and developed in the Islamic world. Works associated with physicians including al-Razi (Rhazes), Ibn Sina (Avicenna) and Ali ibn al-Abbas al-Majusi (Haly Abbas) became important authorities in European medical learning through Latin translations.
We can actually see this intellectual inheritance in a remarkable illustration from the Fasciculus medicinae, printed in Venice in 1500. The physician Pietro de Montagnana is depicted surrounded by books attributed to figures including Hippocrates, Galen, Avicenna, Rhazes and Averroes while patients arrive, carrying urine samples for him to examine. The Royal College of Physicians describes the image and the medical authorities represented in it here.
Urine offered something particularly valuable within this medical system.
It came from inside the body.
If the body's internal balance had changed, physicians reasoned, perhaps those changes would reveal themselves in the urine.
And so they looked.
Very, very carefully.
Meet the matula
The mediaeval urine sample had its own specialised container: the matula.
This was a transparent, usually bulbous glass vessel in which the physician could inspect urine against the light. The visual examination of urine in the matula formed the basis of mediaeval uroscopy. You can read more about the history of the matula and mediaeval uroscopy in Clinical Medicine.
The physician wasn't simply deciding whether the urine looked yellow or clear.
They considered its colour, consistency, clarity and sediment, interpreting these characteristics within contemporary theories about the body.
By the fourteenth century, the image of a doctor contemplating a matula had become so familiar that the flask effectively became an emblem of the physician.
Think white coat and stethoscope today.
Except mediaeval.
And considerably more wee.
This extraordinary illustration shows a physician examining a flask of urine surrounded by different examples of urine colour.
Image credit: Urine Chart, Epiphaniae medicorum, 1506, U. Binder. Wellcome Collection. Public Domain Mark.
The medieval urine colour chart
One of the most fascinating survivals from mediaeval medicine is something that looks oddly familiar to modern eyes:
a urine colour chart.
Today, we might encounter a chart explaining that pale yellow urine usually indicates good hydration while darker yellow urine may suggest that we need to drink more.
Medieval physicians had their own, much more complicated, version.
These diagrams are often known as urine wheels.
One particularly beautiful example survives in the Royal College of Physicians' collection.
It appears in an edition of the Fasciculus medicinae attributed to Johannes de Ketham and printed in Venice in 1500. The medical texts contained within the book had already circulated in manuscript before the first printed edition appeared in 1491.
Around the edge of its urine wheel are 20 descriptions of the colour and characteristics of urine. Inside them are illustrations of urine flasks divided into seven categories according to what physicians believed they revealed about the patient's health.
At the centre is essentially an instruction manual:
This is how you diagnose by the colours of urine.
What were they actually looking for?
Colour was only part of the story.
According to the Royal College of Physicians' description of the Fasciculus medicinae, physicians considered:
colour, consistency, clarity and sediment.
The interpretations, however, were very different from ours.
The Fasciculus, for example, suggested that black urine could mean that the body's “natural heat” had been extinguished.
We certainly wouldn't make that diagnosis today.
But the attention being paid to the urine itself is interesting.
Modern medicine also recognises that changes in urine colour, concentration, clarity and contents can sometimes provide clinically useful information.
The science has changed.
The sample hasn't.
Your family could take your wee to the doctor
Perhaps one of the most extraordinary aspects of historical uroscopy is that sometimes the patient didn't need to be there at all.
Someone else could carry the urine sample to the physician.
An illustration from the Fasciculus medicinae shows patients arriving with urine samples for the physician Pietro de Montagnana. According to the Royal College of Physicians, the samples are carried in wicker baskets and brought to the physician in his library.
In an age when travelling to a university-trained physician could be difficult and expensive, there was an obvious attraction.
Urine became, in effect, a messenger between patient and doctor.
But it also created a problem.
How much could you really know about somebody from their wee alone?
Middle Image: Pietro de Montagnana in his study, Fasciculus medicinae, 1500.
The middle image depicts the physician surrounded by medical books while three patients bring urine samples to him in wicker baskets. Attributed to Johannes de Ketham, Venice, 1500. Royal College of Physicians Museum.
When looking at wee went too far
Mediaeval physicians weren't universally convinced that urine could tell them everything.
There was a difference between using urine as one piece of medical evidence and claiming that a flask of urine could reveal practically everything about a person.
And some practitioners did exactly that.
Historian and physician Henry Connor describes how uroscopy became vulnerable to abuse by practitioners who would offer treatment solely on the basis of examining urine without even seeing the patient.
Eventually, the image of the uroscopist began to attract ridicule.
And mediaeval artists had a particularly entertaining way of expressing it.
They turned the doctor into a monkey.
By the fifteenth century, carvings on misericords, the small wooden ledges beneath folding seats in mediaeval churches, sometimes depicted monkeys holding urine flasks.
The joke wasn't particularly subtle.
The monkey could symbolise foolishness, vanity or imitation, turning the familiar image of the learned physician examining his matula into a parody.
You can read more about these wonderfully strange mediaeval monkey uroscopists in Clinical Medicine.
Image Credit: Doctor monkey examining an owl, Book of Hours, Arras, France. ca. 1296-1311.
But were mediaeval doctors completely wrong?
No.
Their explanations for what they observed were frequently wrong because they were working within a model of the body, particularly humoral theory, that modern medicine has abandoned.
But their basic observation was important:
Urine can change when something changes within the body.
Today, urine can be examined for things including:
blood
protein
glucose
ketones
white blood cells
nitrites
bacteria
crystals
abnormal cells
The mediaeval physician might have interpreted a particular colour as evidence of an imbalance between the humours.
A modern clinician has access to biochemistry, microbiology, microscopy, imaging and molecular diagnostics.
But both begin with the same substance.
Urine.
From urine wheel to urine dipstick
Perhaps that is the most interesting part of the story.
It is very easy to laugh at a mediaeval physician holding a flask of urine towards the sunlight and consulting a colourful wheel.
But imagine medicine without laboratories, imaging, microbiology or modern knowledge of physiology.
Urine was readily available.
It came directly from the patient.
It visibly changed.
And physicians correctly recognised that those changes sometimes mattered.
They were trying to read signals from the human body with the tools and knowledge available to them.
Today, we can read those signals much more accurately.
The matula has become the specimen bottle.
The urine wheel has become the dipstick, microscope, culture plate and laboratory analyser.
And uroscopy has become urinalysis.
But more than seven hundred years after a mediaeval physician raised a flask towards the light, one surprisingly simple principle remains:
Our wee can tell us something about our health.
So perhaps the mediaeval doctors deserve a little credit.
They didn't always know why urine changed.
But they knew it was worth looking.
Explore the history
Royal College of Physicians Museum: The Urine Wheel – Fasciculus medicinae, 1500
Royal College of Physicians Museum: Tools of the Trade – medieval physicians, medical books and urine samples
Wellcome Collection: Health and the Medieval Church – including the 1506 urine chart
Henry Connor, Clinical Medicine: Medieval uroscopy and its representation on misericords – Part 1: Uroscopy
Henry Connor, Clinical Medicine: Medieval uroscopy and its representation on misericords – Part 2: Misericords
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