J Clin Pathol 1996;49:623-626 623 Origins of... J Clin Pathol: first published as 10.1136/jcp.49.8.623 on 1 August 1996. Downloaded from Urinalysis in clinical diagnosis J Bolodeoku, D Donaldson It is appropriate to commence this article on link his observations with the doctrine of the the history ofurine examination with the words four humours-namely phlegm, blood, yellow of Auguste Comte (1798-1857), who wrote in bile and black bile, which had been proposed Positive Philosophy that "To understand a earlier by Aristotle (384-322 BC). Aristotle science it is necessary to know its history".' In had regarded health as a balance between these this context and with special reference to urine, four biological components.4 the most freely accessible of all biological In Hippocrates' Book ofPrognostics there is a fluids, it is not surprising to know that over the paragraph on uroscopy, in which he described course of history it was probably the first body the changes he observed in the composition of fluid to be studied scientifically. Indeed, it was urine during the course of fever, both in Count Antoine Francois de Fourcroy (1755- children and adults; he also included differ- 1809) who stated in A general system ofchemical ences in colour and odour.4 Inspection of urine knowledge, and its application to the phenomena of in its container was at that time considered to nature and art, Volume X, Article 25 (translated be an effective way of demonstrating, not only by W Nicholson), that "The urine of man is fundamental changes in balance of the four one of the animal matters that have been most humours, but also location of disease within examined by chemists, and of which the the body; this practise was used for prognostic examination has at the same time furnished the purposes, too. Uroscopy (which comprised most singular discoveries to chemistry, and the observations on colour, consistency, quantity, most useful application to physiology, as well as transparency, odour, and the presence or the art of healing. This liquid, which com- absence offroth) was to be part of the diagnos- monly inspires men only with contempt and tic repertoire for some considerable time and, vile was of disgust, which is generally ranked amongst indeed, practised by Galen Pergamum http://jcp.bmj.com/ and repulsive matters, has become, in the (129 to approx. 199), the Byzantines and the hands of the chemists, a source of important Arabs. Avicenna (980-1037), whose full name discoveries".I was Abu Ali Husain ibn Abdullah ibn Sina, in One of the earliest references pertaining to his vast tome of medical knowledge entitled the diagnostic value of studying urine is found Canon, developed the art further by taking into in the ancient Sanskrit literature. Ants and consideration the conditions that should be other insects were observed to accumulate observed prior to collection of a urine sample; on October 1, 2021 by guest. Protected copyright. selectively around the sites of urination of cer- he included observations that would enable tain individuals; this was referred to as "honey differentiation of urine samples from other urine" or "sugar cane urine", the insects having similar liquors that might have been brought been attracted to the sweet flavour and meaty with the patient in order to "test the compe- smell. The urine had, ofcourse, been passed by tence of the physician".5 (Perhaps this was one people with diabetes mellitus; similar observa- of the earliest attempts at quality control!) Department of been ancient In the thirteenth Pathology and tions had already reported by century Gilles de Corbeil Bacteriology, Chinese physicians.2 Ancient medical texts (?1 165-1213), in his analysis of urine inspec- University of Oxford, from Mesopotamia also reveal carefully docu- tion, regarded the sample in the urinal as being John Radcliffe mented observations on the appearance of divisible into four each of which Hospital, Headington, levels, Oxford urine; there was note, in particular, of the represented the various parts of the body; the J Bolodeoku changes in odour and colour.' uppermost level represented the head, the next The earliest procedure described in the the chest, the third the abdomen, and the low- Departments of Chemical Pathology, literature which could be specifically regarded ermost level, the urogenital organs.6 East Surrey Hospital, as a diagnostic test was used, not only to During the middle ages there was no further Redhill, Surrey, and confirm pregnancy, but also to identify the sex progress and uroscopy became the trademark Crawley Hospital, a Crawley, West Sussex of foetus. These tests were performed about of physicians, even being portrayed in some D Donaldson 1000 BC by Egyptian priests who poured urine paintings in which it was not uncommon for a over mixed cereal seeds. It seems that if germi- urine glass to represent the sign of a physician Correspondence to: nation occurred then the Dr J Bolodeoku, Department test was regarded as (fig 1). This should not, of course, be confused of Pathology and positive; however, it is stated that only by not- with the uromancers who were popular at that Bacteriology, University of ing the actual type of seed that Oxford, John Radcliffe germinated was time; they claimed to possess the ability, not Hospital, Headington, it possible to predict the sex of the foetus.' only to define disease states by examining the Oxford OX3 9DU. Uroscopy, which was inspection of the urine urine, but also to foretell the future. Uromancy Accepted for publication for diagnostic purposes, had been practised by was soon to be practised quite widely, being 21 November 1995 Hippocrates (460-370 BC); he attempted to accepted by surgeons, charlatans, apothecaries, 624 Bolodeoku, Donaldson and physicians; the consequence was to slowly brought orthodox uroscopy to an end. It discredit the whole practise of uroscopy, was Jan Baptista van Helmont (1577-1644) of leading later to the a of William derogatory phrase pisse- Brussels, contemporary Harvey J Clin Pathol: first published as 10.1136/jcp.49.8.623 on 1 August 1996. Downloaded from prophet being quite commonly used.5 Abuse of (1578-1657), and one of the unorthodox indi- the art of uroscopy was reflected in the viduals of the time, who believed that chemis- literature of the time, as is evident from Shake- try would ultimately play an essential role in speare's play, Henry IV, Part II Act I, Scene II, the diagnosis of disease. Sir Thomas Willis where Falstaff says "Sirra, you giant, what says (1621-1675) was sufficiently perceptive to the doctor to my water?" and to which Page know that a normal urine sample would not replies "He said, sir, the water itself was a good necessarily equate with perfect health and healthy water; but for the party that owed it, he should not, therefore, be used as the only diag- might have more diseases than he knew for". nostic tool. He was, moreover, critical of the Thomas Linacre (1460-1524), founder of doctrine that all bodies comprised a combina- the Royal College of Physicians of London and tion of particles of spirit, sulphur, salt, water, Physician to Kings Henry VII and Henry VIII, and earth; nevertheless, he carried out chemi- was one of the earliest to doubt the diagnostic cal analyses on urine and firmly believed that value of uroscopy (which was ultimately excess or deficiency of one or more of these banned by the apothecaries towards the end of particles (or an unstable mixture thereof) the sixteenth century), although he received, could explain the mechanism behind some dis- not surprisingly, severe opposition from those eases.6 groups sympathetic to the practise of that art.5 In 1674 sweetness of the urine of certain It was in the same century that Cardinal Nico- patients was noted by Sir Thomas Willis (fig laus Cusanus (1401-1464) suggested that the 2), who stated that such urine tasted like weighing of urine might be of clinical im- honey; he attributed this taste to the presence portance5; however, the value of knowing the of salts and sulphur. He quoted, in relation to specific gravity was not to be appreciated for diabetics, "...wherefore the urine of the sick is another two centuries and then only after so wonderfully sweet, or hath an honied introduction of the urinometer for measuring taste...". However, little true progress had been specific gravity had been made in 1849 by made as no elements had actually been Johann Florian Heller (1813-1871). detected and no chemical compounds identi- In Basel, Switzerland, Philippus Aureolus fied. Another century was to elapse before Theophrastus Bombastus von Hohenheim Matthew Dobson (?1731-1784) of Liverpool (1493-1541)-whose name was Latinised to published his famous paper entitled Experi- Paracelsus following the acquisition of his ments and Observations on the Urine in Diabetes medical degree-claimed that there was also in 1776, in which he established by chemical much valuable information to be gained from analysis that sugar was the agent responsible examining urine constituents that were invis- for the sweetness. It is of interest that at the end http://jcp.bmj.com/ ible to the naked eye. Accordingly, he proposed of the seventeenth century Frederick Dekkers the introduction of chemical analysis, thereby (1648-1720) ofLeyden is said to have detected introducing the iatrochemical school; this proteinuria by a test involving the use of heat and acetic acid. This had, interestingly, been described in some patients with dropsy in 1765 by Domenico Cotunnius Cotugno (1736- 1822) and it is possible that it was this to which on October 1, 2021 by guest. Protected copyright. Hippocrates was referring when he stated over 2000 years ago "...when bubbles settle on the surface of urine, they indicate disease of the kidneys and that the complaint will be protracted".