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Uroscopy-art - 9/24/16

"Uroscopy: The Tinted Window of Medieval Medicine" by Sir Jaime Von Atzinger.

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Written for the South Oaken Arts and Science event, AS 49.

From the author: "I have lost the photos that show the urine being examined; if I find them I will send them later."

Uroscopy: The Tinted Window of Medieval Medicine

by Sir Jaime Von Atzinger

Physicians of the middle ages operated in a precarious state. They were highly trained, highly respected professionals tasked with fighting ills that were poorly understood with theoretical frameworks that were incomplete and rife with inaccuracy and they had at their disposal diagnostic tools that were imprecise and highly subjective. They comprised a secular view of health at a time when the dominant intellectual institutions, and most of the population, viewed illness as divinely instituted punishment for sins. Recovery was also, often, seen as the province of divine intervention rather than as a natural process that could be sped up or slowed by external forces. Physicians suffered from wildly differing conceptual foundation. By the tenth century training in anatomy was fairly advanced but understanding of physiology remained mired in magical misconceptions, superstition and ignorance. From cadaver studies, before the church forbade human dissection, and from comparing animal anatomy, physicians had an impressively accurate view of the pieces at play and they had impressively advanced surgical skills[1]. They had no idea what was going on under the hood. For a relevant example, Galen, a first century follower of Hippocrates, correctly identifies that urine originates in the kidneys before being stored in the bladder but he incorrectly attributes the production to a kind of magnetic attraction and repulsion that each organ innately possessed[2]. To further highlight the confusion of this period the work where he states the above fallacy was written as a condemnation of a work by a byzantine physician who had correctly identified blood filtration as the role of the kidneys.

Medieval conceptions of health are based around sanguination, the digestion of food into blood, and the balance of the four humors. Medievalist professor Ruth Harvey describes the concept of three part digestion in Life of Pee: The Story of How Urine Got Everywhere:

"They believed that the stomach was set above the liver like a cauldron over a fire and the food was cooked there until it turned into blood. The liver was in charge of the process, but if it failed to cook the food efficiently or over did the process or burned it, all kinds of dire internal consequences ensued."

A further breakdown of the process is as follows. During the first digestion food is taken in, processed and absorbed in the stomach. For the second digestion the broken down food is drawn to the liver and metabolized into chyle, a kind of undifferentiated mass. In the final digestion this chyle enters the heart and becomes blood. This new blood is then cleansed of impurities and of the byproducts of digestion in the lungs, bowel, skin and kidneys.[3] The process depends on forces that we would now call primitive magic. Sir James Frazer noted, in his seminal work The Golden Bough, that pre-modern cultures tend to exhibit what he called magical thinking of two distinct types; sympathetic magic and contagious magic. Sympathetic magic is when things that are similar have an innate interaction with each other. In uroscopy, for example, the vessel which held the urine for examination was shaped like a bladder so that the precipitates would be suspended as they were in the body.[4] In the same way, the organs responsible for heat, primarily the liver, are also associated with fever. This connection is paired with the contagious magical properties at work, which states that objects that come in contact continue to have a connection. It is the process of contagion that makes urine an indicator of the overall health of the body. According to Faith Wallis, a history professor writing for The Society for the Social History of Medicine, physicians from Rome to Byzantium looked to urine because

urine is a filtrate of the blood which is concocted in the liver from chyle. During the process of sanguinification, additional moisture is added to the chyle from drink in order to make it 'subtle'. This extra moisture is drawn off to the kidneys at the conclusion of the sanguinificaiton, and eliminated as urine. None the less, it carries the imprint of the blood from which it is filtered.[5]

Even if the urine is 'pure', as in free from contaminates from the body, it will bear with it signs of the process of digestion.

What the urine revealed to the physician depended largely on what he was looking for. Hippocrates, who is called by many the father of medicine, looked to urine for its prognostic capabilities and indeed we see that being the main use for urine until the third and fourth century. Hippocrates believed that toxic waste products of metabolism are excreted through the urine digested or undigested and because of that one can tell if the fat is melting, the flesh is being eaten or the bones are crumbling.[6] Urine was a tool to determine how likely a patient was to recover more than a diagnostic tool.[7] For many centuries its use in determining the underlying causes of dysfunction was limited mainly to disorders of the bladder and ureters. In the third and fourth centuries physicians like Magnus Emesianus incorporated the four humors and began using urine to determine causes[8]. Emesianus provided one of the first comprehensive guides for what to examine. He proscribed looking at color (white, pale, fire colored, fair, red, black), consistency of fluid (thick, thin), the presence of shaped substances as suspension (smooth/non-smooth, normal/abnormal), as solid residue (like split chickpeas, like flower petals, like bran, like barley) or fluid residue (olive colored, olive hued, oily). It was not until the fifth century that Aetius, a Byzantine physician, connected urine to the four humors and began the practice of using urine as a diagnostic tool.[9]

Much of medieval medicine is based on the four humors. They are yellow bile (choler), blood, phlegm and black bile (melancholy). Each humor is associated with a natural element as well as body parts, seasons, temperatures, humidity, physical symptoms, and the list goes on. For example phlegm is associated with water, it is considered a cold and wet humor that is stronger in the elderly and at winter.[10] Humors are generated during the digestion process when the blood gets to all the various places in the body. The humors were then thought to flow back to the liver and then drain from the liver to different organs. The choler is concentrated in the gall bladder, the phlegm in the lungs, brain, joints, the melancholy in the spleen.[11] In a translation of an anonymous work, unhelpfully titled De Urinis, we can see how the urine relates to the liver and the humors:

It should be known that urine is especially indicative of two things: either suffering of the liver and veins or of the bladder and kidneys. Among other things, urine is correctly considered to consist of three parts, that is, the color, the substance and the sediment. The color, the substance and the sediment have different origins. In the human body, there are four qualities: heat, cold, dryness and humidity. Two of them are the origin of the color, and two are the origin of the substance: heat renders urine colored, cold decreases urine's color; dryness attenuates the substance, humidity gives rise to a dense substance.

In a twofold relationship urine was said to be affected by the humors, such as when a hot humor darkens urine, and urine can be said to contain humors, such as when there are white clouds of phlegm in the specimen. This combined with Magister Maurus' twelfth century proclamation, in another work titled De Urinis, that each strata of urine could be related to a particular zone of the human body, provided a substantial diagnostic framework.[12] Color, substance and sediment in the upper stratum indicates imbalance in the head; if it is in the second stratum, the parts affected are the heart and the lungs; the third stratum relates to intestinal infections, while the fourth stratum of the urine indicates genital disease or a disease of the bladder.

Uroscopy was considered to be one tool a physician used, among many including taking pulse and examining the environs and habits of his patients. Practitioners who used uroscopy exclusively were denounced by medical schools and trained physicians as quacks.[13] Despite its superstitious and esoteric origins the practice of uroscopy continued to develop into more and more complex forms until it fell out of favor in the 1500s.

For my purposes I provided modern specimen cups for my subjects and asked them to store their urine in refrigeration until I was able to examine it. I then used a funnel to transfer the specimen into a 500 ML boiling flask, which is the closest I could find to an easily attainable matula. For the refrigerated samples I utilized an early modern technique and placed the matula in hot water until the specimen returned to or close to, body heat, so that any crystals formed by the chill would dissipate before examination. I then compared the color to the chart provided in de Ketham revisited: a modern-day urine wheel as I did not trust the color representations of the period sources to remain accurate through time and the various reprintings. For substance I relied on Willis for determining substance (thick or thin); if I could distinguish my knuckle joints through the liquid it was thin.[14] For descriptions of the sediments I was left more or less to my own interpretations. As WIllis points out in the same work, examining urine is somewhat like becoming a wine connoisseur in that words like smooth and non-smooth, bran like sediment and even coloring are next to meaningless without experience and guidance. I recorded my findings, along with any humoral insights, on a chart that I have provided in the appendix.

In future journeys into medieval medicine there are things I will do differently. Despite many false leads I was unable to find translations of the central portion of the urine wheels, which contain common diagnosis related to the various colors. This further highlighted for me the limitation of not knowing Latin. There were a number of primary sources that dealt with the subject that were unavailable to me due to the language barrier. I may have to employ, and possibly bribe, brighter minds than mine to provide insight into these texts. I would also change my collection method. I realized quickly that modern specimen cups are not designed to hold a bladder's worth of urine. Many of the texts mention that quantity is important, some even mention collecting a day's worth. I was able to collect a full sample to illustrate the difference in volume, see appendix XX. I also found issue with the available volume of my modern matula. To properly examine the strata the urine should occupy some of the space in the neck of the vessel; this space constitutes the first strata. The matula I used was too large by half, even for the full samples. It's method of construction also gave it a very slight yellow tint and horizontal undulations that very slightly distorted the findings. My biggest hurdle was also the most predictable; I need sicker friends. There was a fair amount of variability in my samples but none of the participants were experiencing as much as a fever at the time of collection. This led to fairly uninformative and repetitive prognosis. They were all in the normal range, their humors acceptably balanced, none of them are expected to die in the next few weeks. It was mentioned in several of the papers that period physicians often started their works with an examination of healthy urine[15]; perhaps this was my study. I feel more confident that I would be able to distinguish abnormal urine now than when I started!

Armstrong, J. A. (2007). Urinalysis in Western culture: A brief history. Kidney International , 71, 384–387.

Castellano, A. D. (1988). Theory of urine formation and uroscopic diagnosis in the Medical School of Salerno. Kidney International, 273—2 77.

Company, B. W. (1911). The evolution of urine analysis; an historical sketch of the clinical examination of urine. London: British Medical Association.

Diskin, C. J. (2008). de Ketham revisited: a modern-day urine wheel. Medical Journal of Australia, 658-659.

Galen. (c. 140 AD). Therapeutics.

Galen. (c. 150 AD). On the Natural Faculties.

Hippocrates. (c. 300 BC). On the Sacred Disease.

Magnusson, S. (2010). Life of Pee: The Story of How Urine Got Everywhere. Aurum Press Ltd.

Oldon, M. (2004). Monastic nephrology in the school of Salerno and in an unpublished treatise in middlelatin and Italian volgare of the manuscript 2Qq C63 in the public library of Palermo. Journal of Nephrology, 17(2):334-6.

Pardalidis, N. K. (2008). Uroscopy in Byzantium. American Journal of Nephrology, 17:222-227.

Willis, F. (2000). Signs and Senses: Diagnosis and Prognosis in Early Medieval Pulse and Urine Texts. The Journal for the Social History of Medecine , 265-278.

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Copyright 2012 by Jaime Haley, 4100 Laurelwood Ave, Louisville KY 40220. <Jaime.H.Haley at gmail.com>. Permission is granted for republication in SCA-related publications, provided the author is credited. Addresses change, but a reasonable attempt should be made to ensure that the author is notified of the publication and if possible receives a copy.

If this article is reprinted in a publication, please place a notice in the publication that you found this article in the Florilegium. I would also appreciate an email to myself, so that I can track which articles are being reprinted. Thanks. -Stefan.