The Wenches’ in-house medical wizard, Dr. Josh, is back again to talk a little about medieval medicine from a nephrologist’s point of view (recently he completed a fellowship in nephrology at Johns Hopkins Hospital in Baltimore). So here’s Dr. Josh, or as he might have been called in the 15th century, the Knight of the Pisse-Pot . . .
Dr. Josh, if you could time-leap through history from 2012 to 1412, what treatments and methods would you use as a medieval physician? (And what exactly is nephrology – would medieval medical practitioners recognize it?)
As a nephrologist, a specialist in kidney medicine, I sometimes need to explain my field even to patients in my office! The word is derived from nephros, Greek for 'kidney,' and is also referred to as renal medicine, from the Latin renalis. Kidney medicine deals with medical disorders of the kidneys and their treatment (including dialysis and kidney transplants). It’s a small but important field of internal medicine. The function of the kidneys is to make urine, so interpretation of a patient’s urine in laboratories and examination under the microscope plays an important part in diagnosing patients and monitoring their kidney conditions.
In the Middle Ages, urine was truly regarded as the elixir of life, the unparalleled window into all disease. Medieval physicians even specialized in this -- "pisse prophet" was a medieval term for those who diagnosed by looking at urine -- color, cloudiness or clarity, and so on. They didn't have lab reports to rely on, but did have some basic ability, since color, cloudiness, etc. can be markers of some conditions. "Knight of the Pisse-Pot" was another term for these docs -- much more interesting than nephrologist!
Medieval pisse-prophets and pisse-pot knights sometimes divined more than health reports from the appearance and smell of the pee in the glass vial. They weren't exactly objective diagnosticians, and some were little better than scam artists – which I’ll explain shortly.
Uroscopy, the ancient art of examining the urine, is still a big part of a nephrologist's medical practice, although now we examine urine with the use of a centrifuge, microscope and various chemical reactions to detect and measure protein, blood, and other substances. In the Middle Ages, urine examination was done by sight, by odor, and, of course, by taste.
And sometimes urine was the only thing physicians examined—they might not even bother to see the patient, regarding urine as the more important source of information. Galen's four humours (black bile, yellow bile, phlegm and blood, which determined the melancholic, choleric, phlegmatic and sanguine personalities or physical types) were key components of medicine from the 2nd century until the 18th and even 19th centuries. All could be ascertained by examining the urine, so it was believed.
But long ago, a more dramatic, mystical--and fraudulent--practice pervaded medieval medicine: uromancy, described as "the bastard brother of uroscopy" in the Journal of the American Medical Association four decades ago. Practitioners of uromancy claimed that urine could diagnose everything about a person -- not only their condition and afflictions, but their sex, age, and the future course of diseases. Uromancy was so popular that medieval physicians were expected to practice that in addition to more reliable methods – and it was less expensive and believed to be very reliable. Physicians could only diagnose and give the limited cures of the day – a uromancer could predict the patient’s future health, a sort of crystal ball-in-a-vial.
Propping up this system were "pisse-bearers" who would run the vials of urine from the patient to the doctor and return to the patient with the diagnosis. A pisse-bearer would extravagantly praise the doctor's diagnostic acumen (this was contingent on getting a cut of the examination fee). Thomas Brian, a Cambridge-trained physician, got so fed up with this system that he published his famous tome The Pisse-Prophet in 1637, a scathing tell-all about the pisse-pot scam, and how competition and patient demand trapped physicians into participating. The book did not manage to take down uromancy (likely because books were difficult to come by, as was literacy, so few read it), but it's now a fascinating historical reminder of how far we’ve come, how what we hope to hear from our doctors may not be what they are able to offer, and why it’s important to for medical practice to be based in reality.
What else might you do as a medieval urine specialist?
Today urine specialists are either nephrologists, who deal with metabolic consequences of kidney disease, or urologists, who deal with conditions involving the “plumbing” downstream from the kidneys. One area where the two overlap is in kidney stones: urologists break up and remove stones, while nephrologists recommend diets and medications to prevent formation of stones.
Medieval doctors who specialized in stones were lithotomists, literally “stone-cutters,” early surgeons who would cut open the bladder to remove painful stones. But without anesthesia and antiseptic technique, their procedures were not only painful but frequently fatal. Lithotomists would often travel from town to town advertising their profession and offering to cut stones from those who were suffering –- and these itinerant lithotomists would often beat feet before the post-operative infections set in.
It was not until modern surgical standards of anesthesia and hand-washing set in before matters improved to any great deal!
One last thought -- while I do enjoy being a 21st century nephrologist -– it would be much more impressive to have “uromancer” on my business cards!
Thanks for another interesting trip through historical medicine! Dr. Josh, Uromancer, sounds pretty good, though Knight of the Pisse-Pot has a certain ring too!
Dr. Josh is happy to address questions about historical medicine if you have any, and if he knows the answer!