HUMAN URINE-BASED THERAPEUTICS IN SPAIN FROM THE EARLY 20 th CENTURY TO THE PRESENT : A HISTORICAL LITERATURE OVERVIEW AND A PRESENT-DAY CASE STUDY

* Departamento de Terapéutica Médico-Quirúrgica, Facultad de Medicina, Universidad de Extremadura, 06006 – Badajoz, Spain. ** Instituto de Investigaciones Antropológicas de Castilla y León, 37071 – Salamanca, Universidad de Salamanca, Spain. *** Grupo de Investigación de Recursos Etnobiológicos del Duero-Douro (GRIRED), Facultad de Biología, Universidad de Salamanca, 37071 Salamanca, Spain. Correspondence address: José Ramón Vallejo, Departamento de Terapéutica MédicoQuirúrgica, Facultad de Medicina, Universidad de Extremadura, 06006 – Badajoz, Spain. E-mail: joseramonvallejo@unex.es.


Introduction
The historical review shows that urine therapy emerged in the remote past as a means of healthcare, and that it is universal and timeless in character.Going back to the beginning of therapeutics, it can be seen how copropharmacies were available to the ancient civilizations, including animal and human urine [1][2][3], and in the Greco-Roman world urine-based remedies appear in the great classical works [3][4][5][6][7].However, it was not until the Hindu culture that human urine-based therapy achieved relevance.This practice -known as amaroli -is described in classical Sanskrit texts as the Hatha Yoga Pradipika.According to their ancient beliefs, drinking one's own urine brings the benefits of a long full life [8].
Urine is under investigation and consideration as a potential biomedical therapeutic resource [9,10].It also has a large number of advocates like Raso, an author of the "Alternative" Healthcare: A Comprehensive Guide [11], Christy, an author of Your Own Perfect Medicine [12], or Schaller and Razanamahay, who have recently published Urinothérapie [13].Moreover, urine therapy is found among the different types of complementary and alternative medicine (CAM) used by the patients with serious diseases, such as AIDS or cancer [14,15].However, from an anthropological point of view, we believe that it is not a single convention, with just a single symbolism associated with its practice.Depending on the culture, there have been and still exist different "software" that explain and give meaning and orientation among people of different traditions [16][17][18][19][20][21].Our interest arouses the knowledge that urine therapy is still currently operating in different parts of the world, in different cultures and societies, one of which is the Spanish culture.Therefore, the present study aims to gather Spanish ethnomedical knowledge about urine therapy, as an indicator of cultural identity, and determine their associated symbolisms.This type of knowledge has historically helped maintain collective cohesion of our society, within a common project framed in tradition.In general, many practices of the Spanish traditional medicine are falling into disuse due to the strength and influence of biomedicine, however, health care is determined by the sum of traditional contributions, complementary therapies and the healthcare system, according to the current needs and interests of individuals.Because of this, we also plan to add present life experiences.

Materials and Methods
We performed a double methodological approach: a systematic review of scientific literature to compile traditional remedies based on the use of urine, combined with a case study as a means of approximating actuality and as a direct analysis of symbolic systems.
The literature review was based on automatic searches in the databases of the information system of The Consejo Superior de Investigaciones Científicas (CSIC), the bibliographic web Dialnet, Google Scholar and the catalogue of the Bibliotecas Públicas del Estado (BPE).This survey focused on the period from the beginning of the last century to the present.We checked for the existence of international works on Spanish traditional urine therapy, consulting the Web of Science and Scopus database.
The case study was conducted through a field work focused on two groups of people: (a) local traditional and (b) local non-native, i.e. in the area of alternative or complementary medicines.To facilitate participant observation and respondents' exposure to the experience we chose the social context of one of the authors (Valladolid and Palencia).This direct observation technique was applied to eight people."Group A" is composed of a young woman (1a), another of mature age (2a), an elderly older man (3a) and an elderly young woman (4a)."Group B" consists of a young university student (1b), a man of mature age (2b), a woman of middle age (3b) and an older woman (4b).
Considering the authors of the different consulted references as "cultural interpreters", the information documented by them is assigned to different symbolisms, in our case: (1) naturalist symbolism, related to a local and traditional idea of nature as environment (climatic, spatial, mineral, vegetable, animal, human), "acting" with a utilitarian, practical and concrete purpose (naturally rebalancing), on mainly similar environments or parts thereof; (2) symbolism associated with traditional beliefs, related to a traditional idea, usually local, of the existence of "centers of power" (of different natures) associated with certain natural-sensory actions and/or independent of them, which are in any case able to intervene and influence on expressions of alteration and imbalance leading to results that rebalance and cure; and (3) mixed symbolism (naturalism plus other beliefs and traditions), related to varied ideas, from different backgrounds, more or less intermingled and associated (with capacity-power to influence) with the physical-sensory process or with a specific action carried out on the health problem to gain rebalancing curative results.
Finally, the conditions treated with the use of urine were classified according to the chapters of the International Statistical Classification of Diseases and Related Health Problems, ICD-10 (http://apps.who.int/classifications/icd10/browse/2010/en).

Results and Discussion
Urine therapy is widespread in Spanish traditional medicine, as evidenced by the obtained geographical data (Figure 1).Table 1 summarizes the ailments and diseases treated with human urine.Among the 204 collected remedies, those related to the treatment of diseases or skin conditions predominate (63%).Remedies have been reported for the treatment of the skin diseases such as eczema, chloasma, alopecia, etc, to treat or alleviate burns, chilblains, wounds or skin chapping, and as a treatment of venomous bites.
Regarding the chapters of the ICD-10, the chapter XIX (relating to "Injury, poisoning and certain other consequences of external causes") is the one with the highest number of therapeutic applications (34%) (Figure 2), followed, in order of importance, by the chapter XX ("External causes of morbidity and mortality") with 13% of indications, the chapter XII ("Diseases of the skin and subcutaneous tissue") with 12%, and the chapter I ("Certain infectious and parasitic diseases") with a 10% of use reports.As regards the route of administration, 133 of the recorded remedies are for the external use -i.e., 65% of the total-, 35 (17%) are administered orally, and twelve remedies (6%) are based on washing eyes with urine.Furthermore, five remedies based on gargling, four based on "vapors seat", and vaginal washings were recorded.These traditional uses of urine may be justified by the existence of biologically active substances in it, and there is an evidence pointing in that direction [10,92].

References [22-91]
Wounds (open wounds, flesh wounds, superficial cuts) Topical application, to clean wounds NAT Extremadura Domínguez Moreno, 1999 [38] The urine clean wounds and stop hemorrhage, if you are on an empty stomach NAT Fuenteheridos (Huelva) Garrido Palacios, 2001 [56] In Jarandilla, urine macerated along one night with tobacco leaves constitutes an excellent wound-healing product.However, in most villages urine without further elaboration is preferred, but people believe that the results vary according to certain characteristics.In Calamonte, it is current on the wound to apply urine soaked diapers, especially when the wound is located on lactating breasts.In Talaveruela, it easier and more rapid healing gotten if the urine comes from a young woman menstruating and she who pees directly on the wound.Requirement that the donor is a virgin.Human urine is an incredibly complex biofluid, it can contain 3,000 chemicals.It is rich in urea and uric acid, and presents proteins such as albumin and the Tamm-Horsfall glycoprotein.Calcium, phosphorus and creatinine are removed through the urine in values that vary with the age, sex and muscle mass of the individual.In addition, ordinary urine contains various electrolytes, ketones and urobilinogen, and may also contain crystals of calcium oxalate and phosphate.Besides, there are no significant amounts of antibodies, enzymes, hormones, glucose and water-soluble vitamins [93,94].

ATB
However, these traditional remedies do not only have an interest in biological or therapeutic fields but also in other levels of the person that we classify here under the term "symbolisms".Most of the remedies compiled in our literature review (ca.72%) are associated with a naturalist symbolism based on local traditions that have been passed from empirical knowledge.The symbolisms associated with traditional beliefs constitute 26% of the total, and in five cases there is a mixed symbolism, which integrates naturalism with other beliefs and traditions (Table 1).
Thus, for example, we can highlight information with symbolisms based on belief in cases of ophthalmic problems and animal bites.There are arguments for using the urine of virgin twins on the eye to cure sties in some areas of Extremadura [31,44], or for administrating the child's urine [29,36,67].In the province of Cáceres, for a snakebite it is recommended to take three glasses of your own urine, or of the two children who have taken First Communion in the same year or who were born either on Good Friday or Christmas [83].This reference is loaded with symbolism even beyond the natural virtues of one's own urine as a curative.Beliefs are involved that correspond to associated information or software, which complete physical medicine, the remedy.In this sense, the practice of urinating on fire and rubbing the genitals with a toad bladder to help cure urinary incontinence, were noted in Torremenga, Cáceres [38].All these symbolisms, naturalists or relating to beliefs, complete both the visions of the problems and the treatments.In some places in Castile and León, a marital symbolism was added to the possible natural virtues of urine, so that "the parturient should drink the urine from her husband to facilitate childbirth" [29].Here is an interesting naturalist symbolism reference to nonspecific liver diseases in La Alberca, Salamanca: "In the morning before sunrise, the sick person went to the river and urinated in the water.Another person collected water downstream and gave it to her to drink" [55].In La Victoria (Tenerife) nervous system problems, such as alferecía, were treated by giving the patient the urine from her mother with added powder of coral [43].Again, more mixed symbolism: the urine has to be from a parent (the mother) and it has to be mixed with exotic natural elements.
Today, urine is a bodily waste associated with dirt and bad odor for most people, but for many people involved in the search or application of naturopathic treatments, it is an element with many healing properties, which also helps to keep the functional balance in healthy individuals.
Regarding the development of new medical techniques, note here the way of utilization of the patient's own urine, previously centrifuged and treated with ozone, developed by the clinic Clinalgia (Murcia) for treating and curing a series of chronic diseases such as allergies, asthma or psoriasis.Human urine remains aseptic and becomes a natural auto-vaccine being injected to the patient through an intradermal application carried out in the abdomen.This treatment achieves an efficiency of 87% and it has no contraindications or side effects [95].
As we analyze symbolic references or those mixed with symbolism, we do not intend to explain them.We will just describe them because of our interest in the anthropological concept of health.And so, in a "fact-status of communicable experience" [96] in which the discourse given by the sufferers and their explanatory models are those that can lead us to approach an understanding of the experienced problems [16].Understanding the symbolisms necessarily entails listening to the first hand experience stories of those who have lived through them.Thus, the following describes the symbolisms obtained through participant observation in the groups (A), informants 1a, 2a, 3a, 4a, and (B), informants 1b, 2b, 3b, 4b.
The first informant (1a), a professional of Valladolid and a mother, older than 35 years, presents an associated symbolism of a naturalist type.She says: "For nettle stings urine is great.In the village we put some beer stands on the banks of the river.Next to the stands were loads of nettles.All the kids got stung.We saw all the mothers having their children urinating on their own bare feet with immediate results.The redness, stings and swellings disappeared instantly.Amazing!I had seen it done before and I value it.I have no hesitation in using urine in other situations related to skin problems and to apply it to my husband or my son".
The following informant (2a) is a 49-year-old nurse, living in Guadalajara though originally from Palencia.She used urine therapy for months in various ways and emphasizes the use of urine as a "facial product", and says that it gave satisfactory results: a smoother skin which is more resistant to external aggressive agents.In the interview, she said: "I had written my experiences down but do not know where I left them.I can tell you that I took some and it worked.No problem.I am still using urine from time to time, especially for my face.I have recommended it to friends and they still use it.You ask me about the symbolism.I think that I am closer to the traditional naturalist meanings.I do not see it as a technical form but more as a natural medicine.The value for me is that urine therapy is something of oneself.It has your personal mark and therefore could help you.I have always heard the elders in my area that urine was very good for chapped, dry and sore hands.I can not find any inconvenience.It works well for me and I don't find it disgusting at all".
An 85-year-old man (informant 3a), a native of La Puebla de Valdavia (Palencia), who in his youth worked in the country, gives us a rural and traditional symbolism.He referred to remedy: "At the time of harvest I would get my feet and legs scratched with wheat straw.When urinating, I would pee on my legs and it helped".
A retired teacher from the El Cerrato area (Palencia) (informant 4a) told us that even knowing about the local tradition of using urine for certain troubles, and its good results, she could never make herself drink it.This informant also later learned about urine therapy from the advice of some naturopaths.This is a case where the rural symbolism is inhibited by disgust and a cultural reticence.
The informant 1b is a 21 year old university student who presents an initial motivation to use a utilitarian urine therapy, technical and based on the influence of complementary medicines.He states, that given his advanced alopecia he searched for information on natural treatments, eventually opting for urine therapy.It was a hereditary alopecia (grandfathers, maternal and paternal uncles had all lost their hair at a young age).Our informant conducted during several months a plan consisting of rubbing in circles, at least twice a day, the scalp with pure urine and urine diluted with a 50% of water.After this time, he observed that hair loss was slower; even some new fine hair appeared on the forehead.He also drank his own diluted urine.He reported no adverse effects from drinking it, but neither noted significant improvement in hair growth nor an increase in his general welfare.After a while he became bored and stopped."Laziness", he explains.The small improvement in his hair growth did not encourage him to continue the treatment.He ended up not caring about having less hair than other people his age.When asked about the personal symbolism associated with the use of urine, he could not find one.He says, he believes in the natural value of this compound even though it does not always work.
The second informant group B (2b) is the person who provides us the most data and experience information.He practices a technical urine therapy with a naturalistic symbolism that associates the idea of equivalence between the natural and the innocuous.Referring to homeopathy, he states: "Similia similibus curantur, as Hahnemann said.Urine is something of our own, carrying the «print» of what we are.Thus it may serve as a remedy in cases and situations that occur in our body, and in which other remedies can't do much.It works as an auto-isotherapy".He has used his own urine instilled into his nose in cases of colds and rhinitis, always with satisfactory results."What does this satisfaction consist of?", we asked him.He replied: "In having positive and rapid effects.Positive, in the sense of stopping a cold or ending rhinitis, and rapid, because it happens in a couple of days.It is rather commonplace that I use it as soon as I notice my first symptoms.Adverse effects: None.Moreover, my nose had chronic dryness, but since I have used urine therapy, end of problem".He has used urine by gargling 1-2 times a day for pharyngitis.In these cases the results were not as quick, but the pain has decreased since the first moment.He drank his urine diluted with a 50% of water as an experiment for the maintenance of wellness and kept a diary during nearly a month recording the immediate effects and significant perceptions.He indicated a feeling of euphoria and having more energy from the third day.Also, he noted the disappearance of the "euphoria" after a week and the normalization of his life.He does not express having suffered any adverse effects."Nothing negative was found in a blood test", he adds.He abandoned the continuous use of urine considering it unnecessary outside certain concrete situations of alteration.He also uses urine directly or diluted in water, such as aftershave lotion."Urine leaves my face perfect, that usually gets irritated and has pimples after shaving.It is excellent.Urine instantly calms my skin".He relates: "When I drank the urine daily, my skin took on a nice summer color.It also happens when I use it as an after shave lotion.If my foot hurts, or a sprain it while participating in sports, I apply a bandage soaked in urine.The discomfort and swelling disappear in less than 24 hours.From time to time I wash my eyes with diluted urine, for example when I have worked a lot with the computer.My vision recovers and normalizes.I used gargling when I had fungus on the tongue and throat as a side effect of the flu.It also went away.I did not have to take any chemical fungicides or plant remedies.For other problems, I have not used it but I'm willing to, if necessary".
An English teacher (informant 3b) also practiced urine therapy to improve her general condition and as a protection from the aggressive winter cold, damp, germs, etc.Unlike informant 4a, she explains that the symbolism -in this case naturalist-causes an initial motivation for the practice of a technical and utilitarian urine therapy, but eventually repugnance inhibits the use of this treatment.She was taking her own diluted urine for about two weeks, but she emphasizes that disgust made her abandon the treatment.She had no negative effects whatsoever, but she is also not able to specify whether any benefit was obtained.
Our last informant (4b) is a teacher of Religion in Public Education.Affected by a long-term rhinitis in which she had lost some of her sense of smell, she began treatment with auto-urine therapy applying to her nostrils several drops of her own urine twice daily.She combined this approach with phytotherapy.The first thing that recovered completely was the sense of smell.The nasal problem (mucosal swelling) also disappeared in about two weeks.She said it was not unpleasant, and valued the urine therapy as an effective and cheap remedy.She did not mention any associated symbolism.She saw the urine as a remedy more affordable, than, for example, isotonic saline serum, "but better" (in her own words).
In addition to the symbolic aspects, we wish to emphasize the complex structure of the health-welfare problems we consider and also the complexity of the remedies, correction proposals, therapies and treatments related to urine therapy.In reality, it is the expression of a set of social, psychological, biological, ecological and cultural dimensions.
Regarding the validity of urine therapy in the Spanish traditional medicine, Barandarián and Manterola [23] state that it was used in different parts of the Basque Country and Navarra in the past.These same authors note that in Murchante (Navarra) "... the urine was used frequently up until the seventies, especially if the affected person was a farm worker".However, in ca.90% of the studies published so far in the 21st century, the authors describe the remedies collected in their field studies in the present tense (as something actual) [25,46,56,65].Moreover, direct data obtained in this study allow us to affirm that the use of urine is still today a current therapeutic resource, and that there is an interaction between the traditional and the technical urine therapy.
The case study leads us to believe that the data compiled is not culturally "aseptic" information, even in those cases in which references are focused solely on a therapeutic use.Nor in the theoretically "naturalist" situations of urine therapy, have professionals and researchers trained in science whom we know and who have also given us their impressions (both from experience and from observation), added to their narrations associated information of a cultural nature.

Conclusions
Medical anthropology, theoretical or applied, recognizes the diversity of ways of understanding and addressing health-wellness across the globe.Urine therapy is one example, and in general (based on the results) we can say that the corrector and rebalancing use of urine is not a priori an action of a superstitious nature as one might think from a strictly positivist perspective and position.
The use of human urine in Spanish traditional medicine is still in force as a result of the interaction of two types of practices: (i) a local, traditional, popular, and rural urine therapy with a utilitarian purpose, which was widespread until the decade of the seventies and still continues to be practiced today.The associated symbolisms observed range from naturalistic to belief symbolisms; (ii) a urine therapy we would call technical, currently growing and confined to natural health care contexts, primarily urban, and also with specific and utilitarian purposes.In some cases we have not found associated symbolisms, or they have been of a naturalist type.

Figure 1 :
Figure 1: Geographical distribution in Spain of the traditional medical use of human urine.The black dots represent the localities and counties directly cited.In gray, provinces and Autonomous Communities mentioned.

Figure 2 :
Figure 2: Relative importance of the diseases treated through the use of human urine in the Spanish ethnomedicine, ordered in accordance to the chapters established in the international classification ICD-10 (Table1).

Table 1 :
Spanish traditional remedies based on the use of human urine.Symbolisms: NAT = naturalist symbolism, ATB = symbolism associated with traditional beliefs; MIX = mixed symbolism.

Treated diseas- es or disorders Preparation and administration Sym bo- lisms Geographical location References [22-91]
XI. Diseases of the digestive systemXII.Diseases of the skin and subcutaneous tissue