mini review http://www.kidney-international.

org
& 2007 International Society of Nephrology

Urinalysis in Western culture: A brief history

JA Armstrong1
l
Department of Physiology and Biophysics, Georgetown University, District of Columbia, USA

Today physicians use urine to diagnose selective conditions Laboratory medicine began 6000 years ago with the analysis
but from ancient times until the Victorian era, urine was used of human urine, which was called uroscopy until the 17th
as the primary diagnostic tool. Laboratory medicine began century and today is termed urinalysis. Today physicians use
with the analysis of human urine, which was called uroscopy urine to diagnose selective conditions but from ancient times
and today is termed urinalysis. Uroscopy was the mirror of until the Victorian era, urine was used as the primary
medicine for thousands of years. From a liquid window diagnostic tool. Physicians spoke of urine as a ‘divine fluid’,
through which physicians felt they could view the body’s or a window to the body.1 Babylonian and Egyptian
inner workings. Numerous, somewhat accurate, physiologic physicians began the art of uroscopy. Uroscopy, from the
theories arose from uroscopy. Then the importance of urinary word ‘uroscopia,’ means ‘scientific examination of urine.’ The
diagnosis became exaggerated, and increasingly complex, word is derived from the Greek ‘ouron’ meaning ‘urine’ and
until physicians required only the presence of urine, not ‘skopeo’, meaning to ‘behold, contemplate, examine, inspect’.
patients, to diagnose disease. Uroscopy then escaped
medical control, becoming first a home health aid and then a THE ANCIENT WORLD
tool of uneducated practitioners. Thomas Brian led a medical Although Hippocrates is credited with being the original
rebellion against all uses of uroscopy and published the Pisse uroscopist, urine diagnosis is believed to pre-date Hippo-
Prophet, a book that devastated uroscopy. crates.1 In ancient times the symbol for urine was a pairing of
Kidney International (2007) 71, 384–387. doi:10.1038/sj.ki.5002057; water and phallus. Sumerian and Babylonian physicians of
published online 27 December 2006 4000 BC recorded their assessment of urine on clay tablets.
Ancient Sumer, one of the earliest civilizations, recognized
that urine characteristics were altered with different diseases.2
Sanskrit medical works from 100 BC describe 20 different
types of urine. Hindu cultures were aware that some people’s
urine tasted sweet, and that black ants were attracted to this
sweet urine, a characteristic of the disease now known as
diabetes mellitus. The word diabetes, which stems from the
Greek word siphon, was coined by Areteus the Cappadocian
in the second century. Areteus did not mention the sweetness
of urine, but described the disease, poetically, as, ‘A melting
down of flesh and limbs into urine’.3
The predominant theory of disease causation, accepted
into the 16th century, was that of the four humors: blood,
phlegm, yellow bile, and black bile, each of which was
thought to originate from a different region of the body. It
was the physician’s responsibility to keep the four humors in
balance; disruption caused disease.
In the fourth century BC, Hippocrates (460–355 BC)
hypothesized that urine was a filtrate of the humors, which
came from the blood and was filtered through the kidneys, a
fairly accurate description. In Aphorisma, Hippocrates
describes bubbles that lay on the surface of fresh urine as
an indication of long-term kidney disease. Bubbles on the
Correspondence: JA Armstrong, Department of Physiology and Biophysics,
surface of urine are in fact often owing to proteinuria and
Georgetown University, Box 571460, District of Columbia 20057-1460 USA. can, in fact, indicate kidney disease or urinary tract
E-mail: jaa65@georgetown.edu infection.4 In Aphorisma Hippocrates also associated urinary
Received 1 June 2006; revised 1 November 2006; accepted 7 November sediment with fever, and noted that sediment increased as the
2006; published online 27 December 2006 fever worsened. The observed sediment may well have been

384 Kidney International (2007) 71, 384–387

JA Armstrong: Urinalysis in Western culture mini review

due to white blood cells and bacteria from a urinary tract conform to the vessel in the same way that it conformed in
infection. The presence of blood in the urine was attributed the body. Ismail also recognized that food and aging altered
to kidney or bladder ulceration. Hematuria can indeed be urine, and required a good nights sleep and empty stomach
due to ulceration, although we now know that it can also be before collection. He wrote about this in the most
caused by, among other conditions, urinary tract infection, comprehensive instructional book on urine collection and
glomerulonephritis, nephrolithiasis, cystolithiasis, cystic kid- examination. The teaching from Persia was dispersed
ney disease, sickle cell anemia, bladder cancer, several other throughout the world and was thought to reflect the best
diseases, and even exercise.5 Not all ancient diagnoses and medical system for centuries.13
theories have borne the test of time. For example, the first Gilles de Corbeil (1165–1213), royal physician to King
century physician Rufus, of Ephesus, hypothesized that Philippe-Auguste of France, built on Protospatharius’ and
patients urinated blood owing to the widening of the channel Judaeus’ writings. His teachings related 20 different types of
therefore letting blood and other thick substances into the urine to conditions of the body, he noted differences in
kidney.6 sediment and color. De Corbeil also introduced the matula,
The doctrine of urine did not change until six centuries also called a jorden, a glass vessel in which a physician viewed
later, when Galen (AD 129–200) began his scientific findings urine, assessing color, consistency, and clarity.14 Rounded at
in Rome. Galen refined Hippocrates’ ideas, theorizing that the bottom and shaped like a bladder, the matula was made
urine represented, not a filtrate of the four humors and of clear, thin glass, and was held up to the light for proper
overall condition, but rather, a filtrate of the blood. Galen inspection.11 It was to be held only in the right hand
sought to make urine diagnosis more specific. He used the (Figure 1). De Corbeil believed that different parts of the
phrase, ‘diarrhea of urine’ to describe excessive urination, and vessel represented different areas of the body. The increasing
noted that it was an atypical symptom. We now know that complexity of uroscopy led to the creation of charts of all the
polyuria is a symptom of diabetes and other conditions. urine categories. Originally these charts were only published
Galen thought that the liquid ingested equaled the urine in Latin, which allowed only the most educated to under-
expelled in a healthy person. Today, a decrease in urine stand them (Figure 2). De Corbeil, who taught at the Medical
output is known to be a symptom of dehydration or chronic School of Salerno, wrote a piece called, ‘Poem on the
renal failure.7–9 Judgment of Urines,’ in which he incorporated his ideas along
with those of Protospatharius and Judaeus into a lyrical tune
THE MIDDLE AGES (AD 500–1500) that made it easy for medical students to memorize. The
Uroscopy reached new levels of diagnostic dominance during poem remained popular for centuries. So did the matula,
the Middle Ages, when nearly every condition or disease was which become not only a tool, but as a badge of honor, a
identified with different features of urine.10 Theophilus symbol that distinguished physicians in the same way that a
Protospatharius, a seventh century physician, wrote De white coat and stethoscope does today.2
Urinis. This manuscript from Byzantium, was the first During the 13th century, William of Saliceto, an Italian
publication exclusively on the subject of urine. The book physician, noted and accurately described what would later
described a range of colors of ‘the urines’ and their be known as chronic nephritis.3 He stated, ‘The signs of
implications. De Urinis remained influential throughout the hardness in the kidneys are that the quantity of the urine is
Middle Ages.11 Isaac Judaeus (AD 855–955), a Hebrew diminished, that there is heaviness of the kidneys, and of the
physician, published manuscripts that clarified Protospathar- spine with some pain: and the belly begins to swell up after a
ius’ writings. Urine became unrivalled as a diagnostic tool.
Five hundred years after Galen, Protospatharius, who had
the idea that adding heat to urine might present more
insight, invented the first documented laboratory technique.
Heat would precipitate proteins, causing proteinuria to
manifest through cloudiness. Hundreds of years later, in the
16th century Paracelsus used vinegar to bring out cloudiness;
acid, like heat, will precipitate or ‘cook’ proteins. A century
later physician Fredrick Dekkers matched these laboratory
findings to proteinuria,12 which remains a useful diagnostic
indicator today.
The technique of collecting urine was thought to be
important for accurate interpretation. Ismail of Jurjani, an
11th century physician, recommended collecting the full
amount over 24 hours in a large clean vessel and keeping it
out of the sun or heat, which could alter color. The vessel was
to be shaped in the form of a bladder, in the belief that a
more accurate diagnosis would arise if the urine could Figure 1 | Physician holding matula into the light for inspection.

Kidney International (2007) 71, 384–387 385

mini review JA Armstrong: Urinalysis in Western culture

melancholic. Urine stemmed from the third digestion. Yellow

urine was considered healthy, darker urine was due to an
increase in waste, and light urine was due to some type of
bodily weakness.16 Actuarius also concentrated on urine’s
sediment, hypothesizing that the body’s elements separated
based on their densities. Fire and air, being light, rose to the
top whereas the heavier elements earth and water would sink
to the bottom. Therefore, a physician could detect imbalance
area of the body by the abnormal region of the matula.
Bubbles on the surface could represent a disparity in the head,
whereas heavy sediment sinking to the bottom would indicate
a lower extremity ailment.14 Actuarius altered the shape of his
matula in an effort to refine diagnostic precision.

THE RENAISSANCE (1450–1600)

During the renaissance, uroscopy entered the household
through the best selling book Fasiculus Medicinae, published
in 1491 by Johannes de Ketham from Germany. De Ketham
explained current theories and included a self-diagnostic
color wheel, with which individuals could self-diagnose their
condition.17 This book became exceedingly popular. Some
authors have compared it to the Merck Manual (which is sold
Figure 2 | A chart used to categorize urine. in consumer bookstores and arguably used more by
consumers than physicians). During this era, physicians
time and dropsy is produced the second day.’ In this case, the began to adopt aggressive therapies, treating many ailments
reduction of urine output together with other signs and with bloodletting and purging. Some patients turned away
symptoms, constituted an accurate diagnostic aid. from doctors, relying instead on this home diagnostic tool.
Urine diagnosis became increasingly popular. Patients and Two similar books in the 16th century self-diagnostic books
physicians thought it as a rational, painless way to distinguish became frequently used in place of medical treatments.17
and measure humoral imbalance. Urine offered a noninvasive Hippocrates believed that no harm should be done to the
method for evaluation.2 patient, used gentle therapies, and approached medicine with
The potency of the matula as a symbol of medical powers a holistic attitude. By the 15th century urinary diagnosis had
also increased. In some European cities the matula would transformed the patient–doctor dynamic. The author Vos-
serve as a billboard.2 Physicians would dress in long robes, winckel describes the situation, ‘The belief in progress and
and would make a ritual of holding the matula to the light the overestimation of instrument and experiment led to a
and rotating it before confidently disclosing the patient’s fate. deep change in both the understanding of disease and the
This impressed the patient and instilled assurance in the relationship between doctor and patient.’17
physician’s intelligence.15 An increasing number of physicians were diagnosing from
Urine became the exclusive diagnostic tool, reigning urine alone; examination of the patient was seen as
superior to the pulse. Some physicians began to diagnose unimportant. Thomas Linacre, the founder of the College
without ever seeing the patient. This lack of patient contact of Physician in London, was opposed to the primacy of urine
was controversial within the medical community (perhaps in diagnosis, and mockingly commented that if patients
the same way that physicians who prescribe over the Internet brought in a shoe instead of their urine, either specimen
are castigated today). Some physicians, including Joannes would have an equal chance of an accurate diagnosis.2
Actuarius (1275–1328) from Constantinople, warned of the Translations of scientific and medical manuscripts, previously
dangers of diagnosis based on urine alone. Actuarius, who available only in Latin made uroscopy accessible to more
became chief physician to the empire, wrote On Urine, a people. As texts circulated outside the circle of the university
treatise so extensive that it was divided into seven books. educated, laymen began to take on the roles of healers. The
More sophisticated than previous scholars, Actuarius amateurs were called ‘leches’; the term was used to describe
sought to explain metabolism by examining all waste, any medicinal practitioners who were not physicians.
predominantly urine. He categorized urine into different There were clear educational, social, professional, and
kinds, diagnostic values, abnormalities, disease, and prog- economic distinctions between physicians and leches. Physi-
nosis. Actuarius believed in physiology based on four humors, cians held at least a bachelor degree in medicine, although
but modified the theory by classifying the body into four most possessed a doctorate of medicine. Leches, on the other
types of digestion, based on temperature. The four funda- hand, had no formal training. Leches concentrated on
mental temperatures were sanguine, choleric, phlegmatic, and practice and patient interaction. Physicians concerned

386 Kidney International (2007) 71, 384–387

JA Armstrong: Urinalysis in Western culture mini review

themselves with the philosophy of disease. Leches did not tion of uroscopy by the medical profession and in the end,
have the prestige or wealth of physicians, but they did not uroscopy became a source of ridicule.
lack for customers. Some patients preferred the practical Today, uroscopy is no longer practiced, but urine analysis
experience of a leche to the lofty knowledge of a physician. In remains an effective diagnostic tool, with a long and colorful
general, however, it was the underprivileged population that history.
saw leches most often. Leches diagnosed based only on the
color of urine. Patients would seek to trick the leche by ACKNOWLEDGMENTS
I thank Dr Adriane Fugh-Berman for her contribution to the
combining their urine with animals or with other people’s
development of this paper.
urine in order to garner a desirable diagnosis (perhaps in the
same way that a modern patient undergoing drug testing may REFERENCES
submit a friend’s urine for analysis). An oft-repeated story in 1. Rosenhek J. History of medicine: liquid gold. Doctor’s Rev: Med Move 2005;
the literature is that of a woman who combined her urine 23.
2. Connor H. Medieval uroscopy and its representation on misericords – part
with cow urine, in hopes of avoiding a pregnancy diagnosis. 1: uroscopy. Clin Med 2001; 1: 507–509.
Unfortunately, the leche announced that both she and her 3. White WI. A new look at the role of urinalysis in the history of diagnostic
cow were pregnant.18 By the 17th century, the uses of medicine. Clin Chem 1991; 37: 119–125.
4. Simerville JA, Maxted WC, Pahira JJ. Urinalysis: a comprehensive review.
uroscopy had spiraled far beyond the edge of reason. Am Fam Physician 2005; 71: 1153–1162.
Physicians and leches started telling fortunes and predicting 5. Stoller M, Carroll P. Urology. In Harrison’s Current Medical Diagnosis and
the future with urine, a practice known as ‘uromancy’. Witch Treatment. Chapter 23, 45th edn. 2006.
6. Eknoyan G. Rufus of Ephesus and his ‘diseases of the kidneys’. Nephron
hunters mixed urine with nails to distinguish witches from 2002; 91: 383–390.
non-witches. The abuses of urine finally caused a backlash. 7. Andreucci M, Russo D, Fuiano G et al. Diuretics in renal failure. Miner
Electrolyte Metab 1999; 25: 32–38.
Activist and author Thomas Brian led a medical rebellion 8. Cripwell M, Patterson D. Chronic heart failure. Occas Paper R Coll Gen
against all uses of uroscopy over the centuries. In 1637, Brian Pract 1992; 158: 24–27.
published the Pisse Prophet, a book that devastated uroscopy. 9. Webb A, Starr M. Acute gastroenteritis in children. Aust Fam Physician
2005; 34: 227–231.
Physicians seen with a matula became objects of ridicule 10. Diamandopoulos AA. Uroscopy in Byzantium. Am J Nephrol 1997; 17:
Those who used urine diagnoses were called pisse prophets, 222–227.
pissemongers, water-caters, pisse-procrastinators, and uri- 11. Jasin J. The transmission of learned medical literature in the middle
English Liber uricrisiarum. Med Hist 1993; 37: 313–329.
narians.19 12. White WI. A new look at the role of urinalysis in the history of diagnostic
medicine. Clin Chem 1991; 37: 119–125.
CONCLUSION 13. Haber MH. Pisse prophecy: a brief history of urinalysis. Clin Lab Med 1988;
8: 415–430.
Uroscopy was the mirror of medicine for thousands of years. 14. Harvey R. The judgement of urines. Can Med Assoc J 1998; 159:
From a liquid window through which physicians felt they 1482–1484.
15. Guder WG, Kutter D, Bonini P. From uroscopy to molecular analysis –
could view the body’s inner workings, urine led to the improving diagnostic information from urine analysis. Clin Chim Acta
beginnings of laboratory medicine. As the role of physicians 2000; 297: 1–3.
became elevated, the importance of urinary diagnosis became 16. Diamandopoulos AA. Joannes Zacharias Actuarius. A witness of late
Byzantine uroscopy, closely linked with Thessaloniki. Nephrol Dial
exaggerated, and increasingly complex, until physicians Transplant 2001; 16(Suppl 6): 2–3.
required only the presence of urine, not patients, to diagnose 17. Voswinckel P. From uroscopy to urinalysis. Clin Chim Acta 2000; 297: 5–16.
disease. Uroscopy then escaped medical control, becoming 18. Jasin J. A Critical Edition of the Middle Ages Liber Uricrisiarum in Wellcome.
PhD Thesis, Tulane University, New Orleans, United States, 1983.
first a home health aid and then a tool of uneducated 19. Gardner Jr KD. The art and gentle science of Pisse-Prophecy. Hawaii Med J
practitioners. Perhaps this exploitation led to the renuncia- 1971; 30: 166–169.

Kidney International (2007) 71, 384–387 387