A talk based on the essay Unyttig om urinprøver by the same author in Tidsskrift for Den norske lægeforening nr. 8, 1999; 119:1178-9.
One Friday afternoon in August, 1999, an exuberant colleague called me on the telephone. He obviously couldn't wait to tell the good tidings: Listen, you've been awarded the 1999 Ig Nobel prize of medicine! You may even be going to Harvard in the US for the occasion!
I had a close look at my telephone, at the leads, at my wife... Was somebody trying to pull my leg?? Next day, I received a friendly but improbable letter from a certain mr. Marc Abrahams of Harvard. Then I started to really realize that if this was a joke, it was a serious one... And as you know: "Taking fun as simply fun and earnestness in earnest, shows how thoroughly thou none of both discernest", in the quaint quasi-Elizabethan English of Piet Hein.
A new world opened up to me, the world of the Ig Nobels, and I got mixed feelings when I discovered what prizes had been given for: A peace prize for exploding atomic bombs, a medical prize for a report of a man who pricked his finger and smelled putrid for five years, and so on...
Then I read in the letter of Marc Abrahams that the Igs are intended to celebrate the unusual, honor the imaginative, and spur people's interest in science. Reading some of the history of The annals of improbable research and it's predecessor The journal of irreproducible results made me realize that the people behind this really have an important contribution to rend. The story about The emperor's new clothes came to mind. We do need someone who can tell us that the emperor is naked... like the child did in the fairy-tale of Hans Christian Andersen.
In any case, I have chosen to regard it as a great honour to receive the medical Ig prize for 1999. What had I done? And what am I doing to be able to do what I did?
As a matter of fact, I have always been an awful dilettante or amateur in different areas. I wanted to become a medical historian, to be able to combine my interests in languages, history, literature, art and medicine. Therefore, I went to Germany with my expectant wife to a well known institute and became an apprentice in the art of medical history. The most valuable result of our stay in Germany was the birth of our first son. Longing for the mountains, fjords and the people of Norway made us return to the island community of 23 populated islands where I had been the only general practitioner.
I could not make a living out of medical history in Norway. I remained a general practitioner to this day, but not in the same community. As a sideline I now and then produce an article on medical history, ranging from Asklepios, the healing god of ancient Greece, to Sir William Osler.
In my general practice, I have always been amused by the different sorts of containers in which my patients brought their urine samples. I agree with the well known Spanish philosopher Ortega y Gasset that the main task of a physician is healing, not research (well knowing that this sounds heretical in many ears). But, I embarked on a study which was to become what Marc Abrahams of Harvard regards as being a landmark in medical history... I decided to register every home made urine sample container brought to me in the course of one year. Little did I know of the far-reaching consequences this would have.
Basically, it was fun, just fun. Any rare type of container made me chuckle. On the other hand, I wanted a little to copy the serious research workers, who write their numerous articles that often from some reason or another are concluded by stating that "further research is necessary in this or that field..." Perhaps this is how science started, by playing. Perhaps good old Aristotle as a toddler played on the beach and collected different sorts of mollusks and shells just for fun.
I also wanted to make a caricature of what I sometimes experience as far fetched conclusions from observations. And I wanted to entertain possible readers.
I do think that science is very important. But at the same time, I think and I know that life itself is greater than science, which is just one sector of human life. Science is what we believe we know, religion is what we know we believe. Then there is music, art and literature and the joy that is in life itself... Despite the great triumphs of science, which we rightly honor and on which our standard of living is dependent, we should never let it become an idol to replace all other valuable sides of human existence. A physician, for example, needs as much a good heart as a good brain.
Every serious and even this humorous study starts with an historical introduction. You may all have seen beautiful paintings with motives from the medieval and later periods of some learned doctor holding up a translucent bottle containing some yellow fluid. This act was called uroscopy (meaning looking at the urine) and played together with astrology and alchemy an important role in medieval medicine. There are numerous medieval treatises or tractates on uroscopy, like there are many publications on sophisticated laboratory methods of to-day. Strangely enough, urine was not one of the classical four body humours, which were blood or sanguis, phlegm, mainly from the brain, black gall from the spleen and yellow gall from the liver.
What did our learned medieval colleague look for during his uroscopy? Professor Gundolf Keil of Würzburg, Germany, could have told you a lot about this. For my part, I have to limit myself to mention the color and the possible sediment. Or, perhaps, may I guess that he also used his sense of smell or even his sense of taste?
Did you know that the ancient people of the Indian subcontinent would observe that ants were particularly attracted to the sweetness of the urine of some persons who passed larger quantities of urine than normal? To-day we apply other diagnostic means for diabetes mellitus.
The medieval and renaissance doctors of Europe looked at the urine sample itself, whilst we, to day, stare intensely at small strips of test paper that we dip into the precious yellow fluid. This is modern uroscopy and modern alchemy in happy combination! Only astrology is left out, at least in my practice.
When you look at the old paintings of uroscopy, you will see that the container usually is a beautiful glass jar with a wide opening, understandably enough. Probably, it was only the well to-do who could afford this. University trained doctors at that time were rare birds.
Now, in this study, we are interested in the containers, not in the content. The wrapping-up paper in this case is more interesting than the content.
What does the average patient do when he or she is asked to bring a urine sample? A frantic search will begin, in the cupboards of the kitchen, the bathroom and the sitting room. All the bottles registered in my study have contained either different categories of food and spices, medicines, perfumes and strong liquors. You take what you find, no matter what the size and label is. You cleanse it, boil it if possible, dry it and then there is a new challenge: How do you get the urine sample into the bottle if the opening is like the pin point opening of some perfume or liquor bottles? Well, I really don't know, but I am indeed impressed by the degree of precision that some persons seem to have exercised during the operation.
What a boring contrast the ready made, sterile, plastic containers of hospitals, institutions and even here and there in general practice are! There you need no imagination, no gift of precision, and the translucent wrapping-up container leaves no doubt as to the content. Imagine if we got all our birthday and seasons presents in translucent wrapping-up paper! I therefore deem it an important task from the point of view of medical history to register man's incredible gifts in this field, before the whole matter is wrapped up in the impenetrable container of oblivion.
From some reason or another, I always seem to have had an interest for apparently useless phenomena. Take for example my interest in Händel's Water Music, perhaps an early sign of my later interest...
No one would dispute the usefulness of finding a leak proof container of adequate size for their urine sample. Everyone might prove the uselessness of spending time and energy performing a study ending up in publishing an article on the phenomenon.
I kept the study going for twelve months, from May 1997, to May 1998. Finally, on my list there was a variety of 110 different types of containers, totalling 164 samples.
All containers produced specially for urine samples were excluded. I was rather pleasantly surprised never to find a falsely positive reaction for glucose in samples brought in containers having originally contained sweet drinks or foods. Formerly, I remember, stool samples were brought in anything from match boxes to far more voluminous jars.
What, if anything, does the type of container tell the doctor about the patient? In this field, temptations flourish! I don't deny that some conclusions may be drawn, but extreme caution is necessary. Facts to the right, imagination to the left!
A respected, elderly gentleman of high standing in the community brought his first urine sample in a bottle labelled Bell's Old Scotch Whisky. His second appeared in a bottle of Koskenkorva Finnish Vodka. The eighteenth century Edinburgh doctor John Brown who believed in alcohol and opium for all diseases which he divided into two classes, sthenic and asthenic, would have rejoiced.
So did I, for these two valuable samples for my collection. Then the temptations appeared and I had to mobilize my religious and scientific training and scepticism. Was this honourable gentleman addicted to the bottle? Did he bring the bottles as a non-verbal cry for help? Or did he indirectly invite me for a drink on an occasion? Or did he insinuate that I, the doctor, might be addicted to the bottle? Did he hold shares in the companies producing the liquors? Or did he want to demonstrate defyingly against the paternalistic anti-alcohol warnings of the medical community and the ministry of health in Norway??
I don't know the answer, except I do think, with my knowledge of the gentleman, that he has a perfectly normal consumption of strong drinks. The bottles probably just happened to be available in his home. I did not examine the alcohol content of the urine samples, but still, the situation reminds me of a sign in in the gents' room of an English pub: you thought you bought it, but you just borrowed it...
The possibility of a non-verbal demonstration, I think, should be thought of when someone brings you samples in containers having been made for so called alternative medicine, like Ubiquinone Coenzyme Q, or for Purple Coneflower or for Nature Sunshine Matrem, which is advertised as "a well known herb for migraine and problems in joints and structures of bones".
On the other hand, does a urine sample brought in a bottle having contained antidepressant tablets communicate that the patient is in need for help and comfort? Again, facts to the right, imagination to the left!
One of the most astonishing solutions of the problem of finding an adequate container was, I think, represented by a Mum Roll On Deodorant. The ball had been taken away and the deodorant replaced by a malodorant. Some samples are brought in delicate plastic or cardboard containers. They usually are well wrapped up in large plastic bags from the local supermarket. Bottles for obsolete remedies are also brought, for example one labelled "Boric acid 2%, for external use until May, 1985".
An amusing episode comes to mind. The patient, a male, dark-eyed islander had just sat down opposite me, on the other side of my desk. "Do you happen to bring a urine sample?" I asked. No answer. But he leans slightly forwards towards me, looking at me steadily, intensely. The corners of his mouth pull downwards, his right hand slides smoothly into his left inner pocket of his coat. I am reminded of some good old western movie... Luckily for me, however, his right hand didn't produce a gun, but a bottle of Coke containing a familiar yellow fluid... The corners of his mouth elevate and retract into a smile! We both relax...
I live and practice in a western Norwegian province called Sunnhordland, in the community and island of Stord. By far the most frequently used container in my general practice was the jar of Stavland's tomato puree. Stavland is a producer on the neighbouring island of Bømlo.
Well, I wonder, why is Stavland's tomato puree jar the most frequently used container for urine samples in my practice? Does the tomato puree produce urinary infections or kidney diseases that necessitate a check of the urine? Or are the consumers of this product more health conscious than others? After deep, penetrating thinking, I came to the important conclusion that the explanation probably would be found in the widespread use of just Stavland's tomato puree in the households of our region. So is also the case with Stavland's Genuine Heather Honey, which was the third most frequently used container. In addition they have a wide opening and a lid that shuts well. There seems to have been a certain decline in the quality of urine sample containers during the last five hundred years!
As a conclusion, and with tears in my eyes, I have to admit that my present study is not a serious exercise for the promotion of science or for the author's career in any field, be it urology, psychiatry, folklore, marketing or medical history... It was just performed in a playing spirit, in full consciousness of the uselessness of such a useless study. Like most plays and games, this game was and remains utterly useless as far as any immediate results is concerned.
But we all know that games and plays can be useful in the long run. As you know, the British Empire was a result of the games on the playing fields of Eton... The apparently useless can indeed become useful in the long run. This is the case for scientific research as well as for children's games.
It may even be true for my little exercise, if for nothing else than to stimulate our smiling muscles... In my practice as a country practitioner, I sometimes find it important to whistle, that I may not weep...
But I owe you at least an attempt of a final serious conclusion. Indeed, I have to state that further research is necessary to survey possible geographic variations in the national or even international use of different types of containers for urine samples.
Thank you for your scholarly attention.