Doctor's Review: Medicine on the Move

October 21, 2021
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Liquid Gold

Urine was once the number-one way to diagnose disease -- and predict the future

The science and art of uroscopy is not one most modern-day physicians would claim as an area of expertise. However, from ancient times through to the technique's pinnacle of popularity in the Middle Ages and then even into the Victorian era, a patient's urine was used to both diagnose and prognosticate. Though today urine is regarded as little more than waste, one's water used to be considered a divine fluid, a window into the body and the soul.

Physicians looked to it as the primary way to determine what was wrong with a patient, attributing variations in colours and smells to illnesses they may easily have selected at random. To be fair, religious restrictions and medical ignorance were huge hurdles to overcome, so healers were left with few effective ways to diagnose their patients' conditions. Occasionally, miraculously, they were right. Urine could indeed reveal certain diseases, most notably diabetes, a diagnosis as difficult for the doctor as it was for the patient, since a taste of the yellow stuff was required.

Hippocrates (460-377 BC) was the original uroscopist, noticing that fever changes the way a patient's urine smells. Old medical papyri point out that both excessive urination and blood in the urine were signs of illness. By the second century AD, people began to believe that all the body's ails could be seen in its urine. Galen (131-201 AD), the Greco-Roman doctor whose influence lasted well over a millennium, believed that urine revealed the health of the liver, the organ where blood was supposedly produced. Evaluating the urine, Galen stated, was the best way to see whether or not the body's four humours (blood, phlegm, yellow and black bile) were in balance.

In ancient Rome, peering into the chamber pot fell not only within the domain of medical diagnosis, but soon became entertainment as well. The art of uromancy -- the study of urine for purposes of divination -- appeared during this time. Like their medical counterparts, uromancers swirled, studied and even tasted people's urine in the hopes of providing them with a peek into their future.

By the Middle Ages, the Catholic Church had emerged as the most powerful force in Europe. From the sixth century until the Renaissance, the Church limited physicians' options considerably. With doctors prohibited from touching certain parts of patients or even seeing patients unclothed, bodily fluids that could be passed discretely from behind a screen soon became the sole method of diagnosis, especially for women.

A very popular book on uroscopy was penned by the seventh-century Byzantine physician Theophilus. His On Urines was a detailed how-to on diagnosing through urine and was translated throughout Europe. About 300 years later, the influential Arab physician Isaac Judaeus developed a portable flow chart of humoural and urine assessment so complex that he claimed it could determine every disease known. The chart was a big hit; with more than 20 hues of pee to choose from, a doctor's work was virtually done as soon as the sample was taken.

During the Renaissance, renewed interest in the scientific, cultural and artistic successes of ancient civilizations took hold, spurring medical advances throughout Europe for the next 200 years. By this time, uroscopy was so deeply entrenched within the medical psyche that instead of being abandoned altogether, it enjoyed a contemporary retooling. Physicians and scientists were finally free to explore links between a patient's urine, the new diseases and conditions being identified, and their findings from more complete physical examinations. Uroscopy blossomed into an art form.

Since gazing into the murky depths of the chamber pot proved problematic, they developed the matula -- a round-bottomed flask made out of clear glass whose shape approximated that of a bladder. The idea was that urine, free to spread out in a shape similar to that of its natural environment, would show its true colour. In fact, the doctor holding a urine-filled matula up to the light became an archetypical image of medicine and chemistry that persists to this day. The matula allowed the physician to identify those urine properties essential for a good diagnosis -- colour, clarity, thickness, sediment, odour, foam and that old favourite, taste.

Colour was perhaps the most crucial. In one famous case, the court physicians saw something amiss in the samples given by Britain's "Mad" King George III (1738-1820), whose water was apparently a royal purple in colour. Red-purple or blue urine is a symptom of the rare metabolic disorder porphyria (though a recent theory suggests the eccentric king's madness was actually fuelled by the arsenic he took as medicine, but that's another story altogether).

And then there was taste, also a very critical part of the analysis. One of the rare instances in which uroscopy was dead-on came in diagnosing diabetes by a sweet taste to the urine. In 1674, English physician Thomas Willis (1621-1675) was the first in modern medical literature to observe this relationship. He may have enjoyed the sampling process a little too much, stating that the pee on his palate was "wonderfully sweet as if it were imbued with honey or sugar." His taste test led him to add the term "mellitus" to this form of diabetes, from the Latin word for honey. Ancient Arab, Hindu and Chinese texts also have anecdotal reports of the same sweet taste in urine from patients who displayed the symptoms of what was later termed diabetes.

Urine, of course, was also used to determine pregnancy. One text dating from 1552 clearly explains how: if the woman's urine was a "clear pale lemon colour leaning toward off-white, having a cloud on its surface," then she must be pregnant. With that description, they likely would have found many men to be pregnant as well. Still, some doctors may have had more success when they added wine to the urine for diagnostic purposes. Since proteinurea is present in several pregnancy-induced conditions such as preeclampsia, and alcohol reacts visibly with protein in the urine, it may actually have worked.

In an equally scientific attempt, urine was also used as a way to identify pure evil. As the witch hunts of Europe reached a fever pitch in the 16th and 17th centuries, self-proclaimed witch-hunters and appointed tribunals determined the guilt of countless "witches" based on whether or not the cork popped out of a bottle containing a combination of their urine and metal objects like pins and nails.

Urine-loving MDs enjoyed their heyday of popularity and respect during the 16th and early 17th centuries. It wasn't until the scientific revolution and subsequent Enlightenment that true empiricism began to emerge in medicine. Once chemistry and, later, medical imaging, came to the forefront in the late 18th and early 19th centuries, useful chemical investigations into urine samples replaced the old swirl-and-taste methods. Soon, doctors were no longer using outdated forms of uroscopy and those who held onto them became known as piss prophets. It wasn't long before they'd turned from healers to quacks in the public mind. But that didn't stop a few stubborn sorts from hanging on to the dream of urine as liquid gold.

The piss prophets took their business underground, catering to those too poor to afford real doctors and those for whom traditional medicine had failed. Eventually, uroscopy -- the science of studying urine -- fell by the wayside and uromancy -- the old scam of using urine for fortune-telling -- made a reappearance. Patients became clients, eager to have their futures revealed by those gifted visionaries who could see all through a simple sample.

Every practitioner had his or her own way of predicting what lay in store for the client. Some simply held the flask up to the light and made up fantastical stories from there; others had people pee into pots and then "read the bubbles." An even less palatable form of uromancy involved urinating in one's own feces then having the bubbles read from there. As it happened, if your urine contained many bubbles, it meant you had a large sum of money coming your way. Of course, this was even better news for the uromancer, who could be sure of a nice big tip from the soon-to-be rich client.

Today, those who concern themselves with the study of their patients' urine are more often called urologists or nephrologists than piss prophets, and few retain the old habit of taste-testing or bubble-gazing. But urinalysis still raises its fair share of controversy, for where would the modern world be without the infamous pee-test? A flaskful of pee has brought down everyone from lowly parolees to professional athletes. Whether taken for child custody, legal, insurance or employment purposes, the results of urine tests still have the power to change lives.

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