The Evolution of the Urinalysis: From Hippocrates to Modern Techniques

1. The Evolution of the UrinalysisLeslie Gewin

3. Major Events in the Evolution of the Urinalysis400BC Hippocrates 2000200AD Pseudo-Galen De Urinis (Magnus?) and Hermogenes’ Liber 400 medicine orinalibus600800 Theophilus De Urinis (7-9th century AD) 1200 Salerno School of Medicine using Maurus De Urinis1400 1600 1590 discovery of compound microscope1800 mid 1800’s first routine use of urinalysis2000 early 1900’s invention of dipstick

4. Pseudo-Galen Master of Scientific Observation

5. Theory of the Four HumorsUrine was not diagnostic of underlying pathology, but reflective of the balance of humors. Yellow Bile Blood Black Bile Phlegm

6. Many colors of urine:1. White- apepsia (lack of blood)2. Ocher- due to yellow bile3. Tawny- increased bile4. Yellow5. Red- blood6. Black- hypercoction of blood

7. Achievement of a Balanced UrineWhite BlackThin ThickInsufficiency Excess of body of substance componentsElderly Various deadly pathol. Yellow Proper association of blood and bile Thin Young patient who hasn’t eaten

8. De Urinis… Position of sediment in glass:1. Upper third: ‘cloud’ and indicates flatulence and precedes progression to recovery2. Middle third: ‘procidentes’ suffering of body’s strength and reflects serious infirmity3. Lower third: ‘splanatione’ stomach’s strength able to destroy humor that caused infirmity “Those who teach that the interpretation of these three signs based on the ‘clouds’ [sediments] is to be considered misguided practice and think that there are other signs, base their science on fantasy” (Hermogenes)

9. Urine: from prognostic significance to diagnostic significance – Salerno SOMRubea and multum spissa pleurisyAlba and increased urination hydropsyAlba and >age 14 in women retention from menstruationLight urine with small round bodies arthritisLight liquid becomes dark jaundice without remedy

10. Cracks in the foundation of uroscopy led by James Primrose 17th century Evidence against:1. Urine is the whey of humors and will not identify diseases, only causes 2. Urine of a patient varies from day to day 3. Identical urine can be found from a healthy man drinking ale and a sick man with frenzy or diabetes 4. Diseases that have no etiology in the veins can’t be diagnosed by urine5. Urine altered by meat, drink, exercise, and air

11. Lubeck’s Dance of Death 1463“Just face yourself, your sick-glass leave behind/your body substance is not made of any other kind./One blow will break the glass, and man decays when he deceases./What will remain of both? Nothing but pieces.”

12. 17th and 18th Centuries: Episodic revelations, nothing revolutionaryNicholas Claude Fabri de Peiresc (1580-1637)- probably first to use microscope to examine urine, noted ‘calculus sand’ like ‘a heap of rhomboical bricks’ that might cause pain and irritation with passage of urine Hermann Boerhaave (1668-1738) examined normal urine and found it to have all the elements of urinary stones Galeazzi (1686-1775) reported case of Italian woman with black urine, sweat, and black skin and found “minute globules with acicular saline crystals”

13. 19th Century Introduces Urine Microscopy

14. Revolution in urine microscopy began early 1800’s because…- increased interest in clinical medicine- development of achromatic lenses by Chevalier and Lister in 1820’s reduced distortion factor 19-3%- compound microscope less expensive and therefore more widely available

15. “There will be a revolution in science…Woyzeck, does he not have to piss again?” “I can’t, doctor.”

16. Pierre Rayer and Eugene ViglaFirst to perform routine urine microscopy on patients (at Hopital la Charite in Paris)First to identify elements other than crystals (blood, lipids, epithelial scales, mucous globules, pus cells) and related them to pathologic conditionsDescribed method for handling and examination of urine

17. Other advances…1841- Becquerel found “irregular” erythrocytes in Bright’s disease1842- Simon and Henle describe the first casts noted to be “contemporaneous with a certain amount of albumen in the urine”1844- Bird wrote first book dedicated to urinary deposits1846- Johnson noticed lipid particles in Bright’s disease1869- Beale differentiated tubular cells from epithelial cells1890’s- Ernst Abbe introduced apochromatic objectives further reducing aberrations and improving magnification and resolution of microscope; introduction of centrifuge

18. The old way: glucose detection by taste “wonderfully sweet as honey” (Thomas Willis describing taste of urine 1679)

19. The new way: Wet ChemistryFehling reaction (1849): detect glucose based on its ability to reduce copper hydroxide (add copper sulfate, salt, sodium and potassium tartrate and sodium hydroxide to urine)Specific gravity: pycnometer – small bottle connected to calibrated capillary tube and compared wt of urine to waterNitric acid rxn to detect albumin- urine heated to boiling point and then nitric acid added producing a precipitate (a phosphate precip. Also occurred but only albumin persisted upon adding more nitric acid)Litmus paper to determine pHHydrometer (designed by Prout) – 2 small discsof glass to discriminate pus from mucous

20. “It is no joke, to have a bottle of this [nitric acid] burst in the pocket” (complaint from 1874 family doctor)Transition from Wet to Dry ChemistryWilliam Pavy- 1880 dry powder reagent for protein detection based on acid precipitation (“Pavy’s pellets”)George Oliver- 1883 “Urinary Test Papers”Fritz Feigl 1921- realized capillary function of filter paper able to magnify chromatic reactions and developed into systematic microchemical analysis tool

21. Modern Dipstick

22. Advancements in Counting UrineAddis Counter- quantifies cells and casts based on use of counting chambers and timed collection of urineYellow Iris- the first semi-automated counter in which cells were stained and then passed through optical pathway to allow for sorting based on length, then data presented to operator for editing

23. Clinitek Atlas: completely automated reflectance spectophotometer

24. What’s new in the world of urine?

25. Particle Flow Cytometry

26. Microscope Still Needed…

27. Protein Profiling:What is it? A way to better define exactly which proteins are in the urine so that tubular damage can be differentiated from glomerular damage.How does it work?A protein chip coated with target spots (chemical or immunoabsorptive) to isolate certain proteins is dipped in urine, then laser beam ionizes proteins and molecular masses determined by TOF (time of flight) technology.

28. Protein profiling of patients with impaired renal function before and after contrast for cardiac catheterization (J Am Soc Nephrol 12: 1026-1035, 2001) Albumin B2M

29. Supravital Microscopic Fluorescence Technique (SMFT) For detection of bacteriuria: wet slide prep with unspun urine and acridine orange (non-specific staining).Edges of coverslip sealed with paraffin and epi-fluorescence microscope used to examine.