The Hot-Cold Theory of Disease PDF

The Hot-Cold Theory of Disease Implications for Treatment of Puerto Rican Patients Alan Harwood, PhD Many Puerto Ricans classify illnesses, medicines, and foods priests and...

The Hot-Cold Theory of Disease Implications for Treatment of Puerto Rican Patients Alan Harwood, PhD Many Puerto Ricans classify illnesses, medicines, and foods priests and others who provided Eu¬ according to an etiological and therapeutic system which derives ropean medical care to the indige¬ nous and mestizo populations. historically from Hippocratic humoral theories of disease. Adherence to this system influences the way in which patients comply not Through these channels of influence the humoral theory became an inte¬ only with therapeutic regimens for hypertension, arthritis, ulcers, gral part of Latin-American folk and rheumatic fever but also with instructions on infant feeding, and medical practice, where it persists antepartum and postpartum To achieve maximum therapeutic care. today. benefit for Puerto Rican patients who adhere to this system, According to the Hippocratic the physician is advised to work within its framework in prescribing theory, the bodily humors (blood, medicines and diet. phlegm, black bile, and yellow bile) vary in both temperature and moist- communicate effectively with this theory for understanding and Health is conceived in this sys¬ To ness. a patient about his illness or treating patients who subscribe to it tem as a state of balance among the treatment regimen, a physician have rarely been examined. (A num¬ four humors which manifests itself must know something about how the ber of works3 8 discuss in a general in a somewhat wet, warm body. Ill¬ patient conceives of disease, its eti¬ fashion the medical implications of ness, on the other hand, is believed ology, and therapeutics in general. the hot-cold theory for treatment of to result from a humoral imbalance When the patient comes from a dif¬ Mexican-Americans, but no such at¬ which causes the body to become ex¬ ferent sociocultural milieu than the tention has been accorded other cessively dry, cold, hot, wet, or a physician, the likelihood is great Latin-American groups in the Unit¬ combination of these states. Food, that the two will face each other ed States.) This communication de¬ herbs, and other medications, which with quite different views on these scribes the hot-cold etiological sys¬ are also classified as wet or dry, hot matters. For this reason, the physi¬ tem as it is found among many or cold, used therapeutically to are cian is unlikely to be able to antici¬ Puerto Ricans in New York City restore the body to its supposed nat¬ pate or understand questions and and discusses specific ways in which ural balance. Thus, according to the problems the patient has that may patients' commitment to this belief system, a "cold" disease, such as ultimately prevent him from carry¬ system affects their medical treat¬ arthritis, is cured by administering ing through a prescribed regimen. ment. "hot" foods or medications. In order to treat patients of a differ¬ When the Hippocratic theory was ent sociocultural background effec¬ Background: Understanding the incorporated into Latin American Hot-Cold Etiological System tively, the physician must therefore folk practice, the wet-dry dichotomy develop a special understanding of The hot-cold system stems from became insignificant as a basis for their medical beliefs and practices. Hippocratic humoral theories of dis¬ diagnostic and therapeutic deci¬ Although anthropologists have dis¬ ease which carried to the west¬ were sions, and the hot-cold (caliente- cussed the hot-cold theory of disease ern hemisphere by the Spanish and frío) dimension came to dominate etiology in many Latin American Portuguese in the 16th and 17th cen¬ the system. In the Puerto Rican cul¬ cultures,1,2 the direct implications of turies. Medical schools, established tural variant of the system, diseases in Mexico and Peru in this period, are grouped into hot and cold class¬ taught the system, and its tenets es, while medications and foods are From the Albert Einstein College of were also embodied in household trichotomized as hot, cold, or an in¬ Medicine, Bronx, NY. medical references which were used termediate category, "cool" (fres¬ Reprint requests to 3674 Third Ave, Bronx, NY 10456 (Dr. Harwood). throughout Spanish America by co).910 Cold-classified illnesses are Downloaded from jamanetwork.com by University of Calgary user on 12/10/2024  treated with hot medication and plunging the hands into cold water hot-cold framework. The following foods, while hot illnesses are treated after they have been immersed in sections consider these two issues. with cool substances. hot. Similarly an upset stomach may The data which will be discussed Table 1 lists the major illnesses, be attributed to eating too many were derived from three sources: foods, medicines, and herbs associ¬ cold-classed foods which are be¬ (1) from observations in 64 Puerto ated with the hot-cold system among lieved to chill the stomach, a condi¬ Rican households, made over a pe¬ Puerto Ricans in New York. The tion known as frialdad del estómago riod of one year as part of an ethno¬ various herbs mentioned in the ta¬ (or frío en el estómago.) graphic study of medical beliefs and ble are available in herb shops (bo- The term pasmo is used to de¬ practices within the target area of tánicas), located in most sectors of scribe two different conditions, both the Dr. Martin Luther King, Jr., the city with heavy concentrations related to the hot-cold theory. In one Neighborhood Health Center in the of Latin American residents, or may of its uses, pasmo refers to tonic south Bronx; (2) responses to a be acquired from relatives who send spasm of any voluntary muscle. This questionnaire concerning postpar- them from the islands. The medi¬ condition is usually attributed to a tum practices and infant care, which cines, like magnesium carbonate and chill arising from exposure to cold was administered to all Latin Ameri¬ mannitol, are available at neighbor¬ air when the body is in an overheat¬ can women living in the Martin Lu¬ hood pharmacies. ed state. In its other use, pasmo re¬ ther King Health Center area who While there is general agreement fers to a cough, stomach pain, or had given birth in November and about the assignment of foods and other cold-classified symptom which December, 1967 (questionnaire was medicines to the categories listed in has become chronic. Many people administered as a focused interview the table, the system allows for vari¬ attribute such lingering symptoms three months after the women had ation as well. In general, a person to a chill or the eating of cold-classi¬ given birth [number interviewed— may categorize a food or medicine fied foods. (In describing this situ¬ 27] ) ; and (3) anecdotal reports differently from the norm if it ation, patients most often use the from medical personnel at the Mar¬ idiosyncratically produces physical verb pasmarse rather than the noun tin Luther King, Jr. Neighborhood symptoms which are typically clas¬ pasmo. For example, the statement, Health Center. sified as hot or cold. For example, a Cuando tenía ronquera, tomé jugo The Hot-Cold System and person may note that pineapple de china y me pasmé, best translates Patients' Behavior causes him to have diarrhea or some as "When I was hoarse with a cold, other hot reaction (eg, hives) and I drank orange juice and became General Medical Care.—Treat¬ therefore considers it caliente, even chronically hoarse.") ment of Colds.—Common colds are though it is not generally so con¬ New foods or medicines are incor¬ seen as quite serious by many Puerto sidered. Pork is a food which is par¬ porated into the hot-cold system ac¬ Ricans, since they are viewed as the ticularly subject to variant categori¬ cording to the effect they have on start of a possible chain of illnesses, zation. the body. Thus penicillin, because brought on by repeated chills and Although the terminology of the it can cause hot-classified symptoms failure to effect a cure. Thus, an un¬ hot-cold system suggests that it is (a rash or diarrhea), is categorized treated or chronic cold is believed to based on temperature, the thermal with hot substances, while a drug lead to chronic shortness of breath state in which foods and herbal which might cause muscular spasms or wheezing (fatiga), which in turn remedies are taken is not relevant would be considered cold. Trie very may develop into bronchitis or even to the classification. For example, fact that new items are still being tuberculosis. linden-flower tea may be served incorporated into the hot-cold clas¬ All conditions in this prodromal straight off the fire and is still con¬ sification attests to its vitality in sequence are considered cold in na¬ sidered cool, while cold beer, be¬ Puerto Rican culture. ture and treatable by hot remedies. cause of its alcoholic content, is con¬ The existence of a vital medical Patients with any of these illnesses sidered hot. Temperature does play tradition such as this raises several may thus face a dilemma when the a role, however, in ideas about the important issues for those who prac¬ physician outlines a treatment regi¬ etiology of disease in the system. tice medicine with a Puerto Rican men which includes cold or cool Cold illnesses are believed to be clientele. The first of these issues is substances, since these violate the caused by a chill, which may occur how the system specifically influ¬ patient's conception of proper treat¬ when a person moves from heated to ences patients' behavior when they ment. unheated surroundings. For exam¬ consult a physician, and the second A common example of this situa¬ ple, colds are commonly attributed is how the professional practitioner tion is when a physician recom¬ to drafts, and arthritic pain in the can work with patients who evaluate mends fruit juices for a cold. Since hands is often said to come from illness and therapeutics within the most fruits are fresco, this regimen Downloaded from jamanetwork.com by University of Calgary user on 12/10/2024  Table 1.—The Hot-Cold Classification Among Puerto Ricans FRIO (Cold) Fresco (Cool) Caliente (Hot) Illnesses Arthritis Constipation or Colds Diarrhea bodily conditions Frialdad del estómago* Rashes Menstrual period Tenesmus (pujo) Pain in the joints Ulcers Pasmo* Medicines Bicarbonate of soda Anise and Linden flowers (flor de tilo) Aspirin herbs Mannitol (maná de manito) Castor oil Mastic bark (almacigo) Cinnamon MgCOa (magnesia boba) Cod liver oil Milk of magnesia Fe tablets Nightshade (yerba mora) Penicillin Orange-flower water Rue (ruda) (agua de azahar) Sage Vitamins Foods Avocado Barley water Alcoholic beverages Bananas Bottled milk Chili peppers Coconut Chicken Chocolate Lima beans Fruits Coffee Sugar cane Honey Corn Meal White beans Raisins Evaporated milk Salt-cod (bacalao) Garlic Watercress Kidney beans Onions Peas Tobacco 'For an explanation of these terms, see text. Table 2.—Expectable Behavior of Patients Who Adhere to the Hot-Cold Theory* Patient's Condition Expectable Behavior Common cold, arthritis, joint Patient will not take cold-classified foods or medications, but pains will accept those classed as hot Diarrhea, rash, ulcers Patient will not take hot-classified medications and uses cool substances as therapy Requires a diuretic as part of a histreatment regimen and Patient will not eat these cold-classified foods while he has a has been told to supplement potassium intake by cold or other cold-classified condition (For female patients eating bananas, oranges, raisins, or dried fruit this includes the menses) Requires penicillin or any other hot medication, Patient will stop taking hot medicine when he suffers any hot- particularly on an ongoing basis classified symptom (eg, diarrhea, constipation, rash) Infant requires formula, which contains hot- Mother will put baby on cold-classified whole milk or will, after classified evaporated milk feeding formula, "refresh" the baby's stomach with various cool substances, some of which are diuretic Pregnant Avoids hot medicine and hot foods and takes cool medicine frequently Postpartum and during Avoids cool foods and medicines, particularly those menstruation which are acidic 'See text for discussion of ways of treating such patients appropriately. is unacceptable. The culturally pre¬ tics provides a good example. contraindicated for his immediate ferred remedy for this condition is Use of Diuretics.—When pre¬ condition. Women particularly run ginger tea, which is hot and usually scribing a diuretic, routine medical into difficulty with this type of regi¬ taken instead of the recommended practice is to encourage the patient men, since many of them are careful juice. As the patient nears recovery to eat bananas, oranges, raisins, or to avoid both cold foods and acidic from a cold, a cathartic hot sub¬ other dried fruit in order to main¬ cool fruits during their menses. This stance, usually anise or castor oil, is tain the potassium balance in the practice therefore eliminates all po¬ also routinely administered to clean system. With patients who adhere to tassium sources usually suggested to the system of accumulated phlegm. the hot-cold theory, however, this them. A way out of this dilemma In the above example patients advice may have untoward consequ¬ might be for the physician to pre¬ solve their dilemma concerning an ences, since all these foods are con¬ scribe potassium in solution as a unacceptable treatment regimen in a sidered either cold or cool. As a re¬ "vitamin" (and therefore hot) to be manner which does not impair ther¬ sult, when the patient contracts a taken during menstruation or when¬ apy. This is not always true, how¬ common cold or other cold-classified ever the patient has a cold or to sug¬ ever, and complications can arise. illness, he will stop eating these gest hot foods rich in potassium The regimen prescribed with diure- potassium sources because they are (like coffee, cocoa, peas, etc), in ad- Downloaded from jamanetwork.com by University of Calgary user on 12/10/2024  dition to the usual cold foods, so that the foods which are considered hot ization principle in resolving the patients have enough options to and would therefore be avoided as a contradiction between their beliefs make choices within the hot-cold matter of course within the folk sys¬ about infant feeding and the medi¬ system themselves. tem. Similarly, the use of aspirin for cally recommended procedure. Prophylactic Use of Penicillin relief of colds or arthritic pain ac¬ These mothers either added a cool Another difficulty which arises in cords with both therapeutic systems. substance to the evaporated milk — treating people who follow hot-cold Indeed, although the hot-cold and formula or fed something cool to the medical practices results from the modern therapeutic systems differ baby as a supplement. The cool sub¬ prophylactic use of penicillin for in their basic premises, the behavior stances used were barley water, former rheumatic fever patients. they imply is probably more similar magnesium carbonate, and mannitol. Since rheumatic fever involves joint than antipathetic. One may even The latter two are a cathartic and pains, it is considered a cold illness, conjecture that the viability of the diuretic, respectively, and were ad¬ and hot penicillin is therefore read¬ hot-cold system is founded to some ministered to the babies in sufficient ily accepted as treatment. However, extent on this fundamental agree¬ quantity to cause diarrhea. This should a patient experience tempor¬ ment in the health behavior implied finding suggests a source of diarrhea ary diarrhea or constipation while by the two systems. in the Puerto Rican infant popula¬ participating in a maintenance pro¬ Pédiatrie Care.—Infant Feeding. tion which should be investigated in gram, he will usually stop taking his —Perhaps the most important impli¬ a more rigorous fashion. In the medication because in all likelihood cation of the hot-cold classification meantime, however, the pediatrician he will attribute his symptoms to the for pédiatrie care concerns the feed¬ working with a mother who believes hot penicillin. A way of dealing with ing of infants. As noted in Table 1, in the importance of the hot-cold this eventuality would be to encour¬ evaporated milk, the formula base classification might well reinforce age patients to take their penicillin usually recommended to mothers on the use of barley water as a neutral- with fruit juice or some other cool leaving the hospital, is considered izer in preference to the two, possi¬ substance, since ingestion of some¬ hot, and whole milk is considered bly harmful substances. thing cool in conjunction with some¬ cool. Since infants tend to develop Oral Medication for Children.— thing hot is believed to neutralize rashes, and rashes are believed to The concept of neutralization is com¬ any adverse effects of the hot sub¬ come from hot foods, mothers prefer monly employed by mothers when stance. This important principle of to feed their infants cool foods in¬ administering vitamins or other hot "neutralization"* is one which we stead of the hot evaporated milk medications, such as aspirin or cod shall return to a number of times in formula. liver oil, to children. The cool sub¬ the ensuing discussion, since it is an In the sample of 27 Puerto Rican stances most often used for this pur¬ effective method of working with pa¬ mothers described more fully above, pose are fruit juice, milk of mag¬ tients within the hot-cold system, 41% almost immediately on return nesia, or mannitol. It is therefore when this approach seems indicated. home from the hospital curtailed advisable for the physician to find (The term neutralization is one their babies' intake of hot formula. out which of these substances the which I have chosen to describe the Two strategies were used for doing mother is using, in order to avoid activity involved and is not one this. Five mothers (19%) simply any which might have a detrimental which Spanish-speakers would use. discontinued the evaporated milk effect on the child. They refer to the activity as "re¬ formula after a few weeks and fed Childhood Diseases.—As might be frescando el estómago" "refreshing" their babies only whole milk. Since expected, measles, chickenpox, and or "cooling" the stomach). it is believed dangerous to switch an other childhood diseases involving The Reinforcing Value of Hot- infant too rapidly from hot to cool rashes are classified as hot in this Cold Beliefs.—The hot-cold classi¬ foods, mothers commonly feed their nosology. Cool medications are fication should not be viewed as babies weak tea and mannitol (both therefore used in the home for these producing only problems for the cool substances) for 24 hours before illnesses. For measles or chickenpox, medical professional. In many in¬ starting the whole milk. (The fact raisins soaked in warm milk or water stances it comports with and may that whole milk, besides being cool, are commonly fed to children "to therefore be used to reinforce stan¬ is also considered more prestigious bring out the rash", ie, to "cool" the dard treatment regimens. We have and easier to prepare by some internal organs sufficiently so that already noted that the use of peni¬ mothers undoubtedly also contri¬ the "heat" comes to the surface in cillin for treatment of rheumatic fe¬ butes to its adoption.) the form of the rash. Cool herb teas ver fits the logic of the system. In Rather than switching milks, six are also used for this purpose. addition, bland diets recommended mothers who were interviewed in the Obstetric and Gynecologic Care. for ulcer patients prohibit most of same study (22%) used the neutral- —Antepartum Care.—During preg- Downloaded from jamanetwork.com by University of Calgary user on 12/10/2024  nancy a woman is careful to avoid Thus, a "weak" womb (matriz andi must be reached whereby pa¬ hot foods or medication to prevent débil) is believed to "jump" about tient and physician agree on an ap¬ her baby from being born with an in the body cavity in search of some¬ propriate treatment regimen. "irritation" (a rash or red skin). To thing hot to fortify it. Rue, mixed Determining a Patient's Commit¬ further guarantee this, many women with black coffee, rum, or cocoa, is ment to the Hot-Cold Theory.—la "refresh" themselves repeatedly taken as a remedy for this condition. identifying patients who are likely with either milk of magnesia (1 to 3 Table 2 summarizes the major to adhere to the hot-cold system and tablespoons a day) or commercial points of the above discussion by in¬ the behavior it implies, degree of ac¬ anti-acids (one to four doses a day), dicating patients' reactions to parti¬ culturation is, of course, a significant especially during the first and sec¬ cular symptoms and therapeutic indicator. For, between different ond trimesters. Since many aborti- regimens. generations and among people of facients are considered hot, a woman different educational backgrounds, who has used them unsuccessfully Communication with Patients the culture pattern takes differ¬ will be particularly diligent to pre¬ Involving Hot-Cool Beliefs ent forms or may even be aban¬ vent further irritation to the foetus In contemporary medical practice, doned altogether. The elderly and by taking cool preparations. communication with Spanish-speak¬ recent adult migrants who never An important consequence of the ing patients most frequently occurs completed high school are most like¬ avoidence of hot substances during in one of three contexts: (1) the ly to espouse the hot-cold system pregnancy is that many women will physician speaking (usually in Eng¬ openly and consciously to weigh not take hot iron supplements or lish) directly to his patient or, in a therapeutic decisions within its vitamins. These patients might be family practice, to various members framework. Among 64 Puerto Rican encouraged to take these prescrip¬ of the family as well, (2) the physi¬ families in the ethnographic study, tions with fruit juice or an herb tea cian speaking through a translator 23 (36%) had adults who fell into to "neutralize" them. or health worker from the Hispanic this category. People who have been Postpartum Practices.—After de¬ community who filters the communi¬ born in the States, on the other hand, livery women traditionally under¬ cation through his own set of medi¬ or who have received most of their went a period of seclusion for 40 cal standards or accommodations be¬ primary and secondary education days (the cuarentena), during which tween the professional and folk here are not likely to express agree¬ time several practices associated therapeutic systems, and (3) health ment with the hot-cold system open¬ with the hot-cold system were ob¬ professionals informing the Spanish- ly. They may, however, defend those served. Many of these are still fol¬ speaking public through mass media parts of it which agree with standard lowed, even though the full cuaren¬ or printed brochures. Each of these medical practice (eg, the association tena rarely is. Many women avoid contexts obviously offers different between ulcers and hot foods) and eating cool foods after delivery on opportunities for sharing informa¬ almost certainly follow at least some the ground that they impede the flow tion and for mutual accommodation of the practices entailed by the sys¬ of blood and therefore prevent com¬ between communicators. In the fol¬ tem at home. Even among the sec¬ plete emptying of the uterus and lowing discussion we shall be con¬ ond generation American-born, the birth canal. Should the lochia flow cerned only with the first two con¬ culture pattern may still survive in toward the head, it is believed to texts, in which the physician or attenuated form. Remedies which cause nervousness or even insanity Hispanic health worker and patient stem from the hot-cold theory are (pulga del parto, literally the "purge have considerable latitude in ac¬ remembered from childhood and of parturition"). To help prevent commodating to one another's defini¬ may occasionally be used, even this, certain tonics are drunk which tion of an illness or therapeutic though an awareness of the under¬ contain mostly hot foods. One, for course. lying hot-cold system is completely example, is made of chocolate, gar¬ For optimum therapeutic success, lost. lic, cinnamon, rue (ruda, an herb), there are clearly two important In short, the process of accultura¬ mint, and pieces of cheese. pieces of information which must be tion through the generations creates Similar beliefs attach to the interchanged between patient and subtle variations in the way hot-cold menses. Cool foods are avoided at physician in order to deal with any beliefs manifest themselves in the these times, since it is considered divergent views which may exist be¬ behavior of Puerto Rican patients. particularly important for the dis¬ tween them concerning the illness or If the physician suspects that hot- charge from the womb to be com¬ treatment regimen: (1) the physi¬ cold theories have a bearing on the plete. There is also an association, cian must determine if the patient's treatment regimen he is prescribing, maintained mostly by older women, views undermine the treatment regi¬ it is therefore in the interests of good between strength and hot foods. men, and (2) if so, a modus oper- therapy to probe his patients' com- Downloaded from jamanetwork.com by University of Calgary user on 12/10/2024  mitment to these beliefs. This is larly with the hot-cold theory, which best done by indicating to the pa¬ great deal of health not only orders a tient an awareness of the belief sys¬ behavior but is also supported by tem but without implying judgment prestige, developed through genera¬ of it. An appropriate probe might be, tions of use, well as, in many in¬ as "Some of my patients say that a stances, by empirical validation. Re¬ particular medication or food perti¬ spect for the patient's tradition and nent to the proposed regimen is an ability to work with the therapeu¬ caliente or fresco. Do you think so?" tic choices inherent in it allows for Similar questions might also be development of a treatment regimen posed to the person who prepares with the patient which does not con¬ meals in the patient's family or who travene his deeply held ideas about takes charge of his treatment. illness and will therefore stand a In medical delivery systems where much better chance of success. Spanish-speaking staff translate for References physicians or work closely with 1. Foster GM: Relationships between families, their training should in¬ Spanish and Spanish-American folk medi- clude an awareness of those illnesses cine. J Amer Folklore 66:201-17, 1953. in which the hot-cold classification 2. Adams RN, Rubel AJ: Sickness and social relations: In Wauchope R (ed): might pose therapeutic problems so Handbook of Middle American Indians. that they can discuss them at length Austin, University of Texas Press, 1967. with families. 3. Saunders L: Cultural Differences and Medical Care. New York, Russell Sage Arriving atAppropriate Regi¬ an Foundation, 1954. men.—Once the medical practitioner 4. Saunders L, Samora J: A medical care program in a Colorado county, in has determined that the hot-cold Paul BD (ed): Health, Culture and Com- classification is relevant to his pa¬ munity. New York, Russell Sage Founda- tient's treatment, the age and degree tion, 1955. 5. Clark M: Health in Mexican-Ameri- of acculturation of the patient can Culture. Berkeley, University of Cali- should influence how he handles the fornia Press, 1959. situation. At this point, too, the 6. Samora J: Conceptions of health and disease among Spanish Americans. Amer physician's own attitude and temp¬ Catholic Sociol Rev 22:314-23, 1961. erament will play an important role 7. Martinez C, Martin HW: Folk dis- eases among Mexican-Americans: in communication. Some physicians etiology, symptoms, treatment. JAMA 196:161-4, may by temperament wish to use 1966. their authority to establish a modus 8. Weaver T: Use of hypothetical situa- tions in a study of Spanish American ill- operandi with the patient over the ness referral systems. Human Organization regimen; some may take the view 29 2:140-154, 1970. that if the patient is "educated" to 9. Steward JH (ed): People of Puerto Rico: a Study in Social Anthropology. understand the logic of the regimen, Urbana, University of Illinois Press, 1956. he will abandon old habits and fol¬ 10. Padilla E: Up from Puerto Rico. low it; others may opt to work within New York, Columbia University Press, 1958. the hot-cold system to achieve the desired therapeutic goal. From the standpoint of behavioral science, the most effective of these approaches—particularly with elder¬ ly or less acculturated patients- would be to work within the system, using notions like neutralization or other features of the classification discussed above to achieve the therapeutic goal. The probability of changing an individual patient's con¬ ception of disease etiology in a few encounters is small indeed—particu- Downloaded from jamanetwork.com by University of Calgary user on 12/10/2024