The Art of Uroscopy

     The art of urine diagnosis, or uroscopy, is an important part of traditional Greco-Arabic, or Unani Medicine.  Avicenna devotes considerable space to it in his Canon of Medicine.  Case studies in the Hippocratic writings show that careful note was made of the patient's urine.
     The medical treatises of Unani physicians like Ibn Sina, or Avicenna became the basis for medical practice in Europe in the high Middle Ages, and an important part of this was uroscopy, or urine diagnosis.  So important was uroscopy as a diagnostic method that taking a sample of one's morning urine before going to see the doctor was almost obligatory.  Many doctors, when hanging out their shingle, would have signs shaped like urine flasks. 
     Nowadays, taking a urine sample is still done for some things, but the modern doctor uses microscopes, test strips, and all manner of sophisticated biochemical tests to analyze the urine sample.  Traditional methods of urine analysis were much simpler, utilizing observation and the five senses in simple tests; they're still employed by Unani physicians today, as described by Avicenna about a thousand years ago.
     Just because traditional methods of urine diagnosis were technologically simple doesn't mean that they were primitive or unsophisticated.  On the Middle Ages page in the History section, for example, I relate how a medieval doctor was able to diagnose pregnancy through nothing more than urine inspection.  This was long before the advent of ready-made, foolproof urine pregnancy test kits that are now available at your local drugstore.

The Clinical Significance of the Urine

     As long as there is life, there is pepsis, or digestion and metabolism.  Elimination, or the excretion of unusable wastes, is the final stage of pepsis; all metabolic processes generate waste.
     The wastes generated by the metabolic processes of the body can tell the physician a lot about these processes.  And so it is with urine, which is the principal liquid waste of the body; the urine provides the physician with a window into the inner metabolic processes of the organism.
     The wastes of the First Digestion are excreted via the stool.  But the wastes from the Second through Fourth stages of digestion, from the initial coction and generation of the humors in the liver until their final assimilation and transmutation into living tissue, are excreted mainly via the urine.
     Besides excreting liquid wastes, the kidneys, through the production and discharge of urine, also work to balance the humors and chemistry of the bloodstream.  Any excesses or superfluities are thrown off, while that which is in short supply is conserved.  But what is most apparent and visible in the urine are those superfluities which are being eliminated.
     Although careful inspection of the urine will yield much information about many metabolic processes of the body, the urine most directly indicates the state of the liver and the condition of the genitourinary organs and their passages and vessels.  Less directly, the urine yields information about the condition of the other organs.

Technique of Urine Diagnosis

     To obtain accurate and reliable results from urine diagnosis, it's important that the urine sample be collected and prepared in the right way.  And here's how it's done:
     The urine to be collected for the urine sample is to be that of the morning's first urine, unless instructed otherwise by the physician.  And the urine to be collected in the urine jar or flask is to be a mid-stream catch, avoiding the initial flow as well as the final portion.
     The urine jar or container should preferably be of clear glass or crystal, freshly washed, cleaned and dried, both inside and out.  For accurate color observation, the glass should be free from any undue tinting or coloring.  Glass is preferable to plastic, since it's more chemically inert.
     The urine collected in the jar should be collected upon arising, before one has had anything to eat or drink.  In particular, within the previous day or two, one should refrain from eating foods that might unduly color or tint the urine, such as saffron (yellow-orange) or beets (red).  Also, avoid sex before taking the urine sample, as well as any activities or conditions that would drastically alter the humoral balance or metabolism from its usual state, such as fasting, sleeplessness or purgatives.
     Of course, a label with one's name on it should be affixed to the lid of the jar, as identification for the physician.  The physician should not inspect the urine sample right after it has been collected, but should wait a while, so any sediment that might be present can form and settle out; an hour or so after the initial collection is ideal.  Six hours or more, according to Avicenna, is too long.
     Before the urine sample is inspected by the physician, the patient should take care to keep it away from extremes of heat, coldness, direct sunlight, or other undue exposure to the elements.  These can damage or alter the urine sample.

Basic Parameters of Urine Diagnosis

     The physician inspects the urine for the following basic parameters:
     1)  Color
     2)  Consistency -
degree of thickness or thinness; viscosity
     3)  Clarity - degree of clearness or turbidity (cloudiness)
     4)  Sediment - presence or absence, and type of sediment
     5)  Foam - characteristics of foam formed either initially, or when shaken vigorously
     6)  Odor - either absence of odor or the presence of strong, offensive or unusual odors

     In addition to the above six parameters, which can be observed in the urine sample directly, the physician usually makes inquiries as to the patient's urinary habits.  These inquiries concern the following:
     1)  Urinary frequency and volume - used to ascertain whether the patient suffers from oliguria (deficient urination) or polyuria (excessive urination); or, if his/her urinary output is moderate.  Sometimes, the physician will ask the patient to collect all the urine voided within a 24 hour period in order to get a more accurate assessment of total daily urine output.  A normal or average daily urine output is 1400 - 1500 ml, or about 1.5 quarts.
     2)  Frequent, urgent, and/or painful urination - these are the cardinal signs of a urinary tract infection.
     3)  Nocturia, or getting up at night to urinate - a cardinal sign of chronic urinary weakness or debility.
     4)  Dribbling, retention or incomplete voiding of urine - besides indicating the possible presence of obstructing urinary stones, sand or gravel in both sexes, these signs, plus frequent or urgent urination, are usually indicative of an enlarged prostate in mature or elderly men.


Basic Parameters of Urine and Temperament

     The first two of the six basic urine parameters listed previously concern the Four Basic Qualities and basic parameters of temperament.  Color most pertains to the primary or active polarity of Hot / Cold.  Consistency most pertains to the secondary or passive polarity of Dry / Wet.
     The basic color continuum starts with white or colorless at the cold end of the scale, and moves through increasingly darker shades of yellow until a very dark yellow is arrived at at the hot end.  And so:
     Cold = white, or colorless
     Hot = dark yellow
     Moderate = straw colored
or citron yellow.
     With urine consistency, the basic continuum is quite simple:
     Dry = thin or light, watery urine
     Wet = thick
or dense, heavy urine
     Moderate = neither too thick nor too thin.

     And so, the four compound temperaments, or the Four Temperaments, typically produce the following basic types of urine:
     Sanguine (Warm and Moist):  bright yellow, showing moderate heat; and slightly thick, showing moderate moisture.
     Choleric (Hot and Dry):  dark yellow, showing extreme heat; and thin, showing dryness.  Urine may also be concentrated and scanty due to dryness.
     Melancholic (Cold and Dry):  white, or colorless, showing coldness; and thin, showing dryness.
     Phlegmatic (Cold and Wet):  white or colorless, showing coldness; and thick, showing wetness.
     In addition, there's the all-important dimension of urine volume.  White or colorless urine indicates coldness prevailing in the organism, and a deficiency of the Metabolic Heat, which isn't ripening sufficient uric acid and other toxins for elimination.  It is with white or colorless urine that abnormalities or extremes of urine volume most commonly occur.
     With colorless scanty urine, a deficient Metabolic Heat is getting flooded or drowned out by excessive Water.  Deficient urine output means undue retention of water and fluids within the body.  The basic temperament of this condition is Phlegmatic; the urine is usually thick.
     With colorless abundant urine, or polyuria, a deficient Metabolic Heat is unable to reabsorb, re-circulate, and re-metabolize fluids back into the organism.  Excessive urine output means a deficiency of fluids remaining in the body, and is therefore Dry and Melancholic in temperament.  This urine picture is often associated with aesthenic or wasting conditions.  Diabetes insipidus, or the passing of large amounts of watery, tasteless, insipid urine, also fits this picture.

Urine Color

     Basically, the level of color present in the urine indicates the level of Metabolic Heat that the kidneys have at their disposal to ripen and eliminate uric acid and other wastes and     superfluous humors from the body. 
     White or colorless urine generally indicates a Cold temperament prevailing in the organism; there is insufficient metabolic heat to adequately ripen the toxins and other wastes for elimination.  Besides coldness, colorless, watery urine can also be due to excessive fluid consumption, and consequently fluid elimination, which is diluting the urine; if such is the case, the volume of urine being passed will usually be copious.
     The basic normal color of urine, if it is to have color, is various shades of yellow.  This typical yellow color we now know to be due primarily to the presence of uric acid, but it was traditionally considered to be a manifestation of the action of the Metabolic Heat; the greater the heat, the darker the shade of yellow.  Galen considered the yellowness of the urine to be a byproduct or waste product, of the hot, bilious humor in the liver.
     Avicenna, in his Canon of Medicine, describes the various possible shades of yellow as: straw yellow, citron yellow, reddish yellow, orange-yellow, flame yellow; saffron yellow, also called perfect yellow; and saffron colored, or bright red.
     Straw yellow and citron yellow, Avicenna states, denote a balanced, normal heat level and an equable temperament.  Lighter shades of yellow would be colder in temperament.
     The darker saffron and flame shades of yellow denote a hotter,  bilious temperament.  This is particularly true of acute hot natured diseases.  With extreme heat, the urine  can even be brownish in color.  Insufficient fluids can also concentrate the urine and turn it a darker color.  And then, a bright yellow colored urine can also be due to the consumption of vitamin supplements.
     Generally, tints or shades of urine other than yellow denote more abnormal, morbid conditions.  Often, the tint of the urine will  indicate the nature of the morbid humor or superfluity.
      Obviously, urine tinted red usually indicates the presence of blood, or hematuria; most commonly, there is bleeding in the bladder, kidneys or urinary tract.  Some foods, like saffron or beets, may color the urine red.
     Brown urine is usually a very concentrated form of yellow, denoting an extremely hot or bilious temperament.  Brown urine is usually associated with biliousness, jaundice, or the abnormal charring of bile.  The heat level is even greater if the urine burns when being excreted.
     Urine which is the color of fresh meat washings is a grave sign.  It can indicate an excess or superfluity of blood, but most often, it indicates a weakness or unbalanced, bad temperament of the liver; in such states, there is also a weakness of pepsis, or digestion, and a dispersion of vitality.
     Green urine generally indicates a lack of Innate Heat, and an insufficient combustion or coction of the humors.  A bright rainbow green is usually indicative of poisoning, and is particularly serious if no sediment is present.  A green resembling bronze rust or patina indicates a total extinguishing of the Innate Heat, and is usually terminal. 
     Black, dark brown, gray or ashen shades of urine are generally associated with black bile.  A greenish black denotes the presence of normal black bile.  A brownish black is associated with Sanguineous forms of black bile.  Black urine that is very dark is a grave sign; it can either indicate a high level of charring, or oxidation; great interior cold; impending death; or a great catharsis of superfluous black bile.
     The passing of dark or abnormal shades of urine can be a good sign if it occurs in acute diseases, especially at the time of the crisis, which is a catharsis, or cleansing of morbid matter from the body.  If seen at the commencement or at the end of an acute illness, however, it is generally an ominous sign.  Dark urine passed in the elderly, or in the chronically ill, does not bode well, and often indicates a great destruction of the internal organs and tissues.

Urine Consistency, Viscosity or Texture

     Determining urine thickness or viscosity isn't as simple or straightforward as observing its color.  Nevertheless, there are a number of ways this can be done.
     The most obvious and direct way to test for urine viscosity is to rub a little bit of the sample between your thumb and forefinger to see how it feels.  But this is somewhat messy and distasteful.
     Avicenna mainly equates thick urine with a subtle kind of inconsistency or turbidity.  When a specimen of thick, clear urine is held at a distance, it will appear to be perfectly clear, but when carefully examined up close, fine lines or markings will become visible in it, somewhat like the veins running through marble.  Thin clear urine, on the other hand, will appear perfectly clear and uniform whether examined up close or from afar.
     Another way to test for urine viscosity is to shake the sample vigorously and see what kind of froth or foam appears on its surface.  The foam formed in thin urine will consist of smaller, finer bubbles, which will burst or dissolve more quickly; thick urine will form larger bubbles, which will linger for a long time before bursting or subsiding.
     Another way to test for urine viscosity is the oil drop test.  Take a dropper filled with Olive oil and drop a drop into the urine sample.  The greater the urine viscosity, the less that oil drop will disperse; conversely, the thinner the viscosity, the more the oil drop will disperse.
     In extremely thick urine, the oil drop will not disperse at all, remaining suspended just below the surface like a round pearl.  Such thick, clear urine shows that the kidneys are secreting a lot of superfluous thick phlegm into the urine.  Such urine is Phlegmatic in temperament, and is often seen in Phlegmatic diseases like epilepsy or diabetes.
     In extremely thin urine, the oil drop will disperse widely, creating an extremely fine, iridescent film on the urine's surface.  Thin urine denotes conditions of Dry temperament prevailing in the organism, and is often seen in aesthenic, wasting conditions and deficiency states.  Thin urine is generally dry and Melancholic in temperament, especially if also white or colorless.

Urine Clarity versus Turbidity

     Is the urine clear, or is it cloudy, or turbid?  Obviously, clear urine is healthier, and preferable to cloudy urine.
     There are basically two major phases of pepsis, or the process of digestion and metabolism, which are reflected in the urine:
     The first phase of pepsis is called coction, which starts with the initial digestion of food into chyle in the GI tract, and culminates in the liver, with the coction, or generation of the Four Humors.  This phase of pepsis is reflected mainly in the basic color and texture of the urine.
     The second phase of pepsis is called maturation, which starts with the Four Humors after they are generated in the liver, and culminates with their  formation, or maturation, into living tissue.   Errors, imbalances and defects in this maturation process are seen mainly in the turbidity and sediment that forms in the urine.
     Cloudy urine also indicates interior cold and a lack of vitality, which is impeding the maturation process.  Since the cloudiness is usually white in color, the unripened humors are usually of a cold, Phlegmatic nature and temperament.
     According to Avicenna, a cloudiness or smokiness that lingers right above the bottom of the urine sample indicates that the illness will be prolonged.  If this condition of the urine persists throughout the course of the illness, it could indicate impending death.  Urine that's clear when passed, but then becomes cloudy shows that the Metabolic Heat is having a harder time maturing the humors then if the urine is cloudy when passed, but soon clears.
     Cloudy urine usually indicates the presence of unripened Phlegmatic humors.  Cloudy or milky white urine with an offensive odor indicates the presence of pus, which is usually due to a ruptured abscess in the urinary tract. 
     Cloudiness in the urine usually is due to the presence of superfine particles that are in a state of colloidal suspension.  Bigger, heavier particles tend to separate out as sediment.

Urine Sediment

     There are many types of sediment that can be found in the urine, of various colors and textures.  Generally, the quicker the sediment separates out, and the more completely it does so, the better the sign, or prognosis.  Quicker and cleaner settling sediment shows that the morbid matter was closer to being properly matured and ripened at the time of urination.
     Sediments are usually white, but can also be of some other color, like red, yellow, dusky or black.  Sediment can also either be smooth in texture or rough.  The daily passage of sediment in the urine is worse than the occasional passage of sediment, as it indicates that new unripened residues build up before old ones can be completely eliminated; usually, the texture of such daily sediment is not uniform or smooth.
     The occasional passage of smooth white sediment in the urine isn't necessarily a bad thing, and can be noted in the urine of healthy persons as well.  Avicenna notes that sediment is much more common in patients who are sedentary and overweight than in those who are lean and active.  The precipitation of sediment in the urine is preferable to turbidity that doesn't settle or precipitate, and shows better maturation of the superfluous matter.
     White is generally the best color for sediment, and after that, a reddish tint.  Then comes yellow or dusky colored sediment.  A black residue, or sediment, can be due either to intense heat or to intense cold.  If the sediment is first dusky, then turns black it is due to cold; if first yellow, then black, it is due to heat.  Rough sediment is usually due to flatulence, or the presence of thick, crude, undigested air or gases in the urine.
     The most serious and abnormal kinds of sediment are various kinds of flaky sediment, which modern medicine calls casts.  These flakes can also often resemble bran.  Most often, these flakes are from the destruction of tissue, usually from erosion or degeneration of the mucous membranes and passages of the bladder and urinary tract.  Generally, the larger the flakes, or casts, the more serious the condition.  Flaky sediment that looks brown like fish scales is a particularly bad sign.  Red flakes can be due to particles of clotted blood.
     Sand or gravel in the urine will often cause problems and difficulties in voiding the urine.  This is usually due to urinary stones forming in the kidneys or bladder.

Urine Foam

     The degree of foam or froth present in the urine generally indicates the amount of dissolved gas present in the urine when it's passed.  Persons who pass very foamy urine generally suffer from digestive gas, bloating and flatulence.  A dark or orange colored froth denotes jaundice.
     If the bubbles are large, and their bursting or resolution slow, this denotes, besides the presence of gas, that the urine is thick, sticky or viscid.  Thin, light urine produces small bubbles that burst or resolve rather quickly.  If urine with small, fine bubbles persists for an extended time in kidney diseases, the disease will not be resolved quickly.
     If the urine doesn't have much foam when it comes out, then gas is not an issue.  However, shaking the urine sample vigorously and noting what kind of bubbles and foam are produced is one way of testing the urine for its overall thickness, stickiness and viscosity level.

Urine Odor

     When normal urine is passed, it has a characteristic odor.  However, if its odor should be strong, offensive, or otherwise strange or unusual, this indicates imbalance and pathology.
     Normal urine should have a readily apparent, characteristic odor.  Urine with absolutely no odor shows abnormal coldness and a deficiency of the Metabolic Heat.
     An offensive odor, if the urine should be milky and white, is usually due to pus.  If foul smelling urine is passed with good signs of maturation, it generally indicates scabies or ulcerations of the urinary organs.  If foul smelling urine with poor or no signs of maturation is passed, the foul odor is due to raw, unripened humors, or to putrefaction.
     Urine with a sweetish odor points to a predominance of blood, or a Sanguine condition.  Everyone is familiar with the sweet, fruity smell of urine in diabetes. 
     Urine with a foul odor generally indicates the predominance of yellow bile.  Urine with a foul and sour odor indicates a predominance of black bile.
     The passage of foul or abnormal smelling urine need not be a cause for alarm, and often happens in healthy persons as well as sick ones.  When fasting, or when undergoing a healing crisis or catharsis, foul smelling urine indicates the release of toxins.  If passage of such urine should bring the healthy person a feeling of relief, and of increased health and wellbeing, it is a good sign that a beneficial catharsis has taken place.

Final Thoughts on Urine Volume

     Although you could say that the average normal daily urine volume is about 1400 ml, or one and a half quarts, what constitutes normal, healthy urine function is all relative to the volume of fluids consumed.  Drink more, urinate more; drink less, urinate less.
     Where the real abnormalities come in is if someone drinks a lot, yet urinates relatively little; this is oliguria.  Conversely, polyuria can be defined as someone who drinks moderately or very little, but nevertheless urinates a lot.  Normal versus abnormal urinary function and output is always defined as relative to the fluid volume consumed.
     Difficulties passing urine, dribbling it drop by drop, or obstructions to the urinary flow are also causes for concern.  Particularly if urine of a dark, abnormal color or a strong odor, or other abnormalities has difficulties being passed, it is a bad sign; for a good catharsis, such urine should be passed freely.  Dribbling urine, involuntary urination, and urinary incontinence are signs of neuromuscular degeneration in the urinary organs.  Urination that is too frequent, as well as nocturia, are signs of urinary debility.

Conclusion and Acknowledgments

     I wish to extend my thanks to Hakim G.M. Chishti for his excellent book, The Traditional Healer's Handbook.  As the first major book on Unani medicine popularly available in the West, it is truly a groundbreaking work.
     I am indebted to the information in this book on urine diagnosis, contained in chapter 8, titled, "The Cycle Completed: Elimination" on pages 97 to 106.  It was a most helpful reference to me on this highly specialized diagnostic technique of Unani medicine. 
     Particularly inspiring and enlightening about this chapter were Dr. O. Cameron Gruner's introductory remarks about the significance, value and basic principles of urine diagnosis.  I suggest that everyone interested in urine diagnosis read what Dr. Gruner has to say.
     Dr. Gruner's introductory remarks, plus Hakim Chishti's information on urine diagnosis, in condensed format, is up on his website, www.unani.com, on a page by the same name as the above chapter in his book.  Please go and read it.