Stories

Remote diagnosis from wee to the Web

Flasks of urine delivered by post were a central part of remote medicine in the 16th century, when a letter of diagnosis would be the response. Today, apps and video links have supplanted the postal service, but relying too much on screen-based consultations could be a mistake.

Words by Christine Ro and photography by Steven Pocock

  • Essay
Photograph of the left hand side of a watercolour painting from 1826, depicting a physician examining a urine specimen in which a faint figure of a baby is visible, a female patient is crying and being shouted at by her angry mother, indicating that she is pregnant. To the left of the watercolour is a glass specimen bottle containing a yellow liquid. The bottle has a cork stopper inserted and 2 further cork stoppers are beside the bottle. The whole scene has been photographed against a bright solid yellow background.

Harrison Nkemjika’s stammer has been an issue since he was a child living in Nigeria. He explains, “My stammer was so strong that I [couldn’t] even say a full sentence without pausing or trying to hit myself. It was so difficult for me, even answering phone calls.”

Nkemjika is now a nurse in south-east London, where his stammer has meant that it can take him some time to finish speaking with patients. He began stammering therapy, through the Airedale Stammering Therapy Project, on the insistence of his wife. Delivered from Yorkshire, this pilot study involved multiple sessions of speech therapy via video link.

He appreciated the convenience of the arrangement, as he could participate from his home or at work. He says that the therapy has helped him a great deal in controlling his speech. Experiences like Nkemjika’s suggest that health and wellbeing treatments don’t need to be delivered in person to be effective. In fact, there’s a long history of distance healthcare in Europe, well before the current craze for telemedicine (generally, clinical services provided using communications technology) or telehealth (a broader set of health services).

Photograph of 2 specimen bottles containing yellow liquid, 2 enveloped sealed with a red wax seal of a tree and is roots, a silver spoon and a wooden handled stamp. The whole scene has been photographed against a bright solid yellow background.
Diagnosis by post, Steven Pocock. Source: Wellcome Collection. CC BY.

Diagnosis by post

Epistolary consultation, or medicine by letter, was once widespread in Europe, peaking in the 18th century. Particularly used for chronic conditions, correspondence dealt with problems as varied as sexually transmitted diseases and epilepsy. 

Letters were a comfortable alternative to in-person visits, sparing doctors and patients long journeys. They were also psychologically comfortable for some patients, who appreciated the anonymity of receiving medical advice by post when dealing with embarrassing ailments like venereal diseases. Medicine by post was also cost-effective.

More: How people dealt with pests and parasites in the medieval period.

The age of uroscopy

One aspect of epistolary consultations that hasn’t aged well is the use of a certain diagnostic fluid. While urine samples are still useful for drug testing, for instance, in early modern Europe urine was seen as a treasure trove of information about all sorts of conditions. As medical historian Michael Stolberg has described it, “Uroscopy was ubiquitous in early modern medical culture. It was the central diagnostic method, and it was perfectly self-evident for patients and their relatives that they could rely on it.”

While uroscopy was part and parcel of doctors’ visits, flasks of urine often accompanied letters from patients to doctors. Uroscopists would describe factors such as the clarity, consistency, viscosity and colour of patients’ urine. There was some logic to this. Today, the colour and smell of urine are used to quickly assess hydration level, and contemporary urine-colour charts are (rather more prosaic) versions of the richly illustrated urinalysis charts of the 1500s.

Uroscopists would describe factors such as the clarity, consistency, viscosity and colour of patients’ urine. There was some logic to this.

Back then the procedure sometimes extended to tasting it. A skilled uroscopist would use these factors to diagnose a patient’s disease and its cause, select an appropriate medicine, and even learn basic information about a patient such as age and sex.

Uroscopy was initially particularly fashionable among the upper classes; its popularity started declining from 1600, when medical authors increasingly questioned the accuracy of the practice. In-person relationships between doctors and patients grew in favour, and, much later, tools like stethoscopes, thermometers and x-rays were seen to be more reliable.

Photograph of a yellow rotary dial telephone surrounded in a circle by 8 specimen bottle containing a yellow liquid which get lighter in hue as you travel clockwise around the circle. The whole scene has been photographed against a bright solid yellow background.
Diagnosis by phone, Steven Pocock. Source: Wellcome Collection. CC BY.

From urinalysis to modern telehealth

One reason that uroscopy and epistolary consulting remain more than quaint medical curiosities today is their relevance to contemporary remote care. There are clear links between the centuries-old practice of consulting by letter and today’s telehealth, which uses webcams and other communications technologies to bridge the physical distance between doctors and patients. As in early modern Europe, face-to-face physical examination isn’t seen as strictly necessary

There have been other stops along the way from letter to online consulting including phone calls and text messages. A key advantage of all these forms of telecommunications is that consultation and diagnosis can happen in real time, unlike mail-based advice. Video links have the added advantage of allowing healthcare providers to see into patients’ environments, and patients are generally more relaxed in their own homes. 

Remote care is helpful for populations that can be hard to reach, such as prison inmates, those serving in the military, or people with mobility issues. It’s also more convenient for patients who feel they simply don’t have the time to wait to see a doctor, as in Japan, although it’s concerning if health is being depersonalised. Telehealth has proven useful in diagnosing psychiatric disorders among refugees, retinopathy in premature babies, and many other conditions. 

In previous centuries, medical consultations by post were largely the preserve of the well-off, who were advocates for their own health, and could pay to receive opinions from multiple professionals. And today the unintentionally exclusionary nature of remote medicine should sound familiar – and worrying.

Photograph of 1 specimen bottle containing yellow liquid, 1 plastic specimen tube, 1 plastic syringe, a web cam ring light on a flexible arm and a web,. The whole scene has been photographed against a bright solid yellow background.
Diagnosis by webcam, Steven Pocock. Source: Wellcome Collection. CC BY.

Winners and losers

The users of some elective online health services, like many moneyed letter-writers in the 1700s, aren’t forced to use remote care. This is one in a menu of options for them, unlike the prison inmates, rural dwellers, and others for whom telemedicine is increasingly displacing person-to-person care. And with evidence that telemedicine benefits finances, but not necessarily quality of life, it’s important to ask who benefits and who loses.

There’s also the question of effects on the health system as a whole. Telediagnosis is especially useful in places without sufficient local capacity. But as with doctors writing letters from large cities in the heyday of uroscopy, an over-reliance today on distant specialists may keep healthcare systems from investing in local experts who have the cultural knowledge that is so crucial to health. 

Though Nkemjika is grateful for the therapy and the techniques he continues to use, he still would have preferred in-person therapy. He points out that it’s hard to capture the full range of body language over a video link. After all, a big chunk of spoken communication isn’t about words.

Clearly, telehealth can be a lifeline in some cases. But it would be short-sighted to automatically turn to this as a replacement for more personal forms of healthcare.

About the contributors

Photograph of Christine Ro

Christine Ro

Author

Christine Ro is a writer and editor whose work is collected at www.christinero.com.

Photograph of Steven Pocock

Steven Pocock

Photographer

Steven is a photographer at Wellcome. In the studio he captures the fragility of 150 year old manuscripts. At home he is captivated by the fragility of a 150 year old house.