Urinalysis, Part 3

William of Malmesbury tells us that William the Conqueror fell from his horse in summer of 1087 while fighting on the continent and suffered painful internal damage. Physicians examined his urine and predicted imminent death. William died in September of that year. The diagnosis prompted him to receive last rights and arrange for his demise.

Abbot John of St. Albans was practiced at medical diagnosis through examination of urine. In 1214, John was ill and, suspecting the illness to be fatal, examined his urine and predicted he had three days to live. He was right.

The Trotula suggested a urine test to determine fertility. A husband and wife seeking to have a child should each urinate into a pot of bran. If in ten days the bran was stinking and full of worms, the person who urinated into it was the infertile one.

Raoul, the Count of Vermandois (reigned 1102 - 1152), fell ill, and his physician recommended he abstain from sexual relations with Raoul's just-married third wife. When the physician later examined Raoul's urine, he realized the advice was going unheeded. He told Raoul that he would be dead in three days. Raoul (we are told) died in three days. The urine told the tale of his activities in bed.

What happens if you pretend to be a physician and get caught? Let's look at the case of Roger Clerk of Wandsworth. Roger charged Roger atte Hacche 12 pence for a diagnosis and cure for Roger's wife that turned out to be a blank parchment wrapped in cloth of gold. Roger Clerk was brought to trial before the Mayor and Aldermen at the Guildhall of London in May 1382. It turns out Roger had no license or training to practice medicine, and the "cure" was fake. His punishment was to be paraded in the streets, sitting backwards on a saddle-less horse, two urine flasks hanging around his neck.

But enough about urine for now. What other punishments might be meted out for offenders? Let's look at some of the judgments set out for those who committed crimes in Medieval England, starting tomorrow.

Urinalysis, Part 2

We started a conversation yesterday on the use of urine by medieval Western European physicians to determine health. I thought today we'd go into exactly how the urine was an indicator of health.

Examining sediment in the urine was one case, which was described yesterday in a paragraph from Giles Corbeil's (fl.1200) poem De urinis. Later elaborations on this suggest the urine would settle into layers of different colors. A large layer on top could indicate a problem with the head. Some sediments indicated kidney stones.

Smell and taste were also ways to examine urine. Smell was obvious, but taste was also used at times; sweetness was an indication of diabetes.

Visual examination was the first and most common method, and was the reason why a glass flask became the symbol in illustrations of a physician. Hippocrates (c.460–375 BCE) started the business of the look of urine having significance. He felt it was the output of all four humors of the body, could indicate which was deficient or superabundant, and could be used to predict the progress of a disease.

White or pale yellow urine was healthy, but black or foul-smelling urine predicted an increase in disease. White sediment meant the illness would be long but not fatal. Completely colorless urine was the sign of a disease of the brain (these days it means excess hydration with water).

If there were bubbles in the urine, long-term kidney disease was the cause. The modern term proteinuria is now used for this condition, denoting protein in the urine and indicating damaged kidneys.

In the circular diagram above (found in the 14th-century manuscript Bodleian Library MS Savile 39), we see the "color codes" for urine. They range from the pale urine of decent health to the reddish-gold denoting healthy digestion to the dark flasks of impending death.

Urine travels in containers, and could be collected and sent to a physician or an expert urologist if you had none nearby. Isaac Judaeus, an expert on urology, criticized this idea; he believed diagnosis without seeing the patient in person was pointless.

Tomorrow we'll discuss the punishment for urinal malpractice, and look at a couple urinalysis patients.

Urinalysis, Part 1

Last post mentioned that a medieval illustrator indicated a physician by showing him holding a flask. There was a very specific substance in that flask, and it wasn't blood; it was urine. Blood's color rarely looked different from person to person or ailment to ailment, but urine could be different in many ways.

I talked about a book all about urine a few years ago, but let's get into some more detail now.

Medieval physicians saw at least 20 different visual cues in urine when assessing a patient's health. This was such a common practice in Western Europe that William of Rubruck, writing about his travels in the Mongol Empire for Louis IX of France, mentions his surprise that their physicians didn't examine urine.

Let's look at some of the statements made by Giles Corbeil (fl.1200) in his 352-verse De urinis, written for students about uroscopy. He starts with the basics:

The physician who wishes to be considered an expert judge of urine must consider with care the following things: what sort, what it is, what is in it, how much, how often, where, when, age, nature, sex, exercise, anger, diet, anxiety, hunger, movement, baths, ointment, drink.

He explains what healthy urine looks like; it seems the flask of urine is swirled and then sediment is allowed to settle:

Color, consistency, duration, form, and place are the determining characteristics of urinary sediment. The color should be white, the consistency continuous, the form conical, the place the bottom of the vessel, and the duration marked. If the sediment is all these – white, continuous, lasting, conical – digestion will be good, virtue strong, and natural action will flourish with a triple activity: it whitens, it cleanses, and it condenses, concentrates, and unites.

The smart physician could also predict death from urine:

A very limited quantity of urine, passed with difficulty, livid and oily, foreshadows death. Urine tinged green indicates jaundice, spasm, severe fever, and finally death.

We'll look at more methods of diagnosis tomorrow, as well as some specific cases.

The Book of Pee

One of the medical texts composed by Isaac Israeli ben Solomon was translated from Arabic to Latin and called De Urinis ("Concerning Urine"). One manuscript copy (Ms. 690) in the University of Utrecht Library shows signs of frequent use, and yet has survived for 800 years with its original binding, showing extreme care being taken by any of its owners.

De Urinis was not one of the books translated at Toledo; the Latin version that was used in the Middle Ages was translated by Constantine the African, a Benedictine monk and physician who spent the first part of his life in Ifriqiya, then brought Isaac's work and others from Tunisia to his retirement at the Benedictine Abbey of Monte Casino. Unfortunately, Constantine often did not include in his translation the name of the original author, leading many to think that he himself wrote the medical texts. It took other references to these works to be able to affix the proper author's name. (The illustration here shows a dog's head added to the margin by a bored copyist.)

There are ten sections to De Urinis, as follows:

1. The science of uroscopy, placing it in context of the four temperaments*, particularly in relation to the blood;
2. The importance of nocturnal urine;
3. Types of urine in relation to pathology;
4. Urine as humor-discharging fluid;
5. Types of urine by colour;
6. The state of the body judging by its colour;
7. Types of urine based on clarity and viscosity;
8. Sediment in relation to pathology;
9. Types of urine in coherence with sediment;
10. Different types of urine and sediments and their meaning.

According to the Utrecht summary of the manuscript:

This text influenced islamic medicine to a great extent (where uroscopy was of great importance) and contributed to the rise of uroscopy as one of the most important branches of medicine in the Middle Ages (Prioreschi 2001). Ms. 690 is a remarkably early witness of this.

If you would like to see the manuscript in digital form, click here.

This is the second post in a row that mentions Ifriqiya, which sounds like "Africa" and should be addressed. I shall do so next.

*Referring to the four humors whose proportions determined a human being's temperament and health: yellow bile, black bile, phlegm, and blood.