Brown Ch 27 (Harwood)

Brown Ch 27 (Harwood) - 27 ' I i an Harwood " hot-cold...

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Unformatted text preview: 27 ' I i an Harwood " hot-cold theory (ff discase is probably the most wide- -d humoral concept in the world. As we saw in Foster’s ' .- ogy (selection 12), the hot—cold theory is an example of i naturalistic approach—diseases are either hot or cold, and ‘I their remedies involve selecting the medicines or foods that _.~=aounteract the natural character of the disease. The healthy 3mm body is at equilibrium between the different humors. hot—cold theory was brought to the New World by way 'Qf the Spanish conquest (Foster 1994), and the theory was simplified to drop the moist-dry distinction found in classi- _ 'ml Hippocratic (or Gallenic) humeral theory. Of course, the , hot-cold classifications do not refer to actual temperature ‘ but rather to the essential character of the thing (almost like I nouns that have gender in Romance languages). There is no : completely standardized system of hot-cold classification—- n for diseases or especially for foods or medicines. in parts ' of Latin America, a remedy may be categorized as hot in . one valley and cold in an adjacent valley (Logan 1977), On " 1 the other hand, the classifications do not Seem to be particu- larly arbitrary. Fevers are always hot, as are the symptoms that often accompany febrile illnesses (rashes, diarrhea). The symptom complex that North Americans call the common cold (nasal congestion, mucus, muscle aches) is always thought to be cold. This famous selection was written for practicing physi- cians and published in a well-known medical journal. Alan Hanuood, who studied the medical systems of Puerto Ricans in New York City (1977), had previously focused on espiritas and mental health, but he realized the practical importance of understanding the hot—cold theory of illness. in this selection, he offers practical advice on how physi- ' II clans can "work within ” the people’s ethnornedical system. . - 1,. - Notice that there is afimdamental logic to the hot-cold -. " ‘ ' theory, which probably accounts for its global popularity. lf P’flCiicing physicians ignore this underlying cultural logic, their credibility may be suspect. - e Hot—Cold Theory of Disease: Implications for the reatment of Puerto Rican Patients A French physician 1 know was once practicing medi- cine in a village in Bangladesh (where there is also the hot-cold distinction). He says that at the end of every doc- tor—patient interaction patients would ask him what to eat during therapy. At first, the physician said that it really didn't matter, that they should eat healthy food . People were not satisfied with such a silly answer. After learning about the basic categorization of hot and cold illnesses and foods, he was able to answer patients“ questions in culturally ac- ceptable ways. Consequently, his patients were much hap- pier. When he left the village afier a year, people told him that when he first came, they didn't think he knew anything, but then he became a good doctor. Thefirst two rules of Hippocrates are "First, do no harm" and second, "Know thy patient.” Knowing the pa- tient includes being aware of the patient’s cultural beliefs. As you read this selection, consider these questions:- I Why do Puerto Rican mothers think it sounds danger— ous to give an antibiotic to a child who has a rash and fever illness? I What methods does Hat-wood suggest to get around the cultural problem of the hotacold theory? I Do ethnomedical beliefis always present a problem to the practice of medicine? I The problem of compliance (adherence) to a complete course of antibiotics is commonplace (even college» educated people fiail to take the entire prescription). Why is this a problem? Does it seem wrong to blame cultural factors in this case, if hardly anyone is compliant? I To what extent is the degree of acculturation important in answering these questions? 251 _———_____ 252 Case Studies in Explanatory Models To communicate effectively with a patient about his illness or treatment regimen, a physician must know something about how the patient conceives of disease, its etiology, and therapeutics in general. When the pa- tient comes from a different sociocultural milieu than the physician, the likelihood is great that the two will face each other with quite different views on these matters. For this reason, the physician is unlikely to be able to anticipate or understand questions and prob- lems the patient-has that may ultimately prevent him from carrying through a prescribed regimen. In order to treat patients of a different sociocultural back— ground effectively, the physician must therefore det velop a special understanding of their medical beliefs and practices. Although anthropologists have discussed the hot- cold theory of disease etiology in many Latin Ameri- can cultures}2 the direct implications of this theory for understanding and treating patients who sub- scribe to it have rarely been examined. (A number of worksH“ discuss in a general fashion the medical implications of the hot—cold theory for treatment of Mexican-Americans, but no such attention has been accorded other Latin-American groups in the United States.) This communication describes the hot-cold etiological system as it is found among many Puerto Ricans in New York City and discusses specific ways in which patients' commitment to this belief system affects their medical treatment. BACKGROUND: UNDERSTANDING THE HOT-COLD ETIOLOGICAL SYSTEM The hot-cold system stems from Hippocratic humoral theories of disease which were carried to the western hemisphere by the Spanish and Portuguese in the 16th and 17th centuries. Medical schools, established in Mexico and Peru in this period, taught the system, and its tenets were also embodied in household medical references which were used throughout Spanish America by priests and others who provided European medical care to the indigenous and mestizo populations. Through these channels of influence the humoral theory became an integral part of Latin- American folk medical practice, where it persists today. According to the Hippocratic theory, the bodily humors (blood, phlegm, black bile, and yellow bile} vary in both temperature and moistness. Health is conceived in this system as a state of balance among the four humors which manifests itself in a somewhat wet, warm body. Illness, on the other hand, is believed to result from a humeral imbalance which causes the body to become excessively dry, cold, hot, wet, or a combination of these states. Food, herbs, and other medications, which are also classified as Wet or dry, hot or cold, are used therapeutically to restore the body to its supposed natural balance. Thus, according to the system, a "cold" disease, such as arthritis, is cured by administering "hot" foods or medications. When the Hippocratic theory was incorporated into Latin American folk practice, the Wet-dry di- chotomy became insignificant as a basis for diagnostic and therapeutic decisions, and the hot-cold (salient:- fii‘o} dimension came to dominate the system. In the Puerto Rican cultural variant of the system, diseases are grouped into hot and cold classes, while medica- I tions and foods are trichotomized as hot, cold, or an in- termediate category, “cool” (fresco).9‘1" Cold-classified illnesses are treated with hot medication and foods, while hot illnesses are treated with cool substances. Table 1 lists the major illnesses, foods, medicines, and herbs associated with the hot-cold system among Puerto Ricans in New York. The various herbs men- tioned in the table are available in herb shops (botani- cas), located in most sectors of the city with heavy concentrations of Latin American residents, or may be acquired from relatives who send them from the is- lands. The medicines, like magnesium carbonate and t mannitol, are available at neighborhood pharmacies. While there is general agreement about the assign- ment of foods and medicines to the categories listed in the table. the system allows for variation as well. In general, a person may categorize a food or medicine differently from the norm if it idiosyncratically pro- I. duces physical symptoms which are typically classi~ fied as hot or cold. For example, a person may note _- that pineapple causes him to have diarrhea or Some other hot reaction (eg, hives) and therefore considers it ‘ caiiente, even though it is not generally so considered. Pork is a food which is particularly subject to variant ' categorization. : Although the terminology of the hot-cold system suggests that it is based on temperature, the thermal state in which foods and herbal remedies are taken 15" ' not relevant to the classification. For example, lindet'h-tl- HGWer tea may be served straight off the fire and is still: . considered cool, while cold beer, because of its alcov holic content, is considered hot. Temperature does Fla '*-: a role, however, in ideas about the etiology of ' ' “'" in the system. Cold illnesscs are believed to be can by a chill, which may occur when a person moves W heated to unheated surroundings. For example. C_°l__ are commonly attributed to drafts, and arthritic pain " I :11! FRIo (Com) Arthritis Colds F rialdad dc! mémago‘ Menstrual period t Pain in the joints - Prisms“ .- H or bodily -' ,_,. . tinns ‘2 19 t The Hot—Cold Classification Among Puerto Ricans The Hot-Cold Theory of Disease 253 Fresco (Cool) Calientc {Hot} Constipation Diarrhea Rashes Tenesmus (punt; Ulcers mung; and herbs Bicarbonate of soda Anise - Linden flowers mar dc tits) ASpimt Mannitol {mutt dc mantra) Castor oil Mastic bark (almridgn) Cinnamon MgCO3 {magnesia hobo) Cod liver oil Milk of magnesia Fe tablets Nightshade {yet-ha mom) Penicillin Orange-flower water Rue (rude) (agar! dc azaliar) Sage Vitamins I Foods Avocado Barley water Almholic beverages ; Bananas Bottled milk Chili peppers Coconut Chicken Chocolate Lima beans Fruits com-e Sugar cane Honey Corn meal White beans Raisins Evaporated milk Salt-cod {basaltic} Garlic Watercress Kidney beans Onions Peat.- Tobacco 'Faran explanation of these terms, 599 text. the hands is often said to come from plunging the hands into cold water after they have been itnnterscd in hot. Similarly an upset stomach may be attributed to eating too many cold-classed foods which are believed to chill the stomach, a condition known as frialdad del estémago (or frt‘o en el sstémago). The term pasmo is used to describe two different conditions, both related to the hot-cold theory. In one of its uses, prisms refers to tonic spasm of any voluntary muscle. This condition is usually attributed to a chill arising from exposure to cold air when the body is in an overheated state. in its other use, pasmo refers to a cough, stomach pain, or other cold-claSSified symptom Which has become chronic. Many people attribute such lingering symptoms to a chill or the eating of cold- classified foods. (In describing this situation, patients most often use the Verb pasnmrse rather than the noun Ffismo. For example, the statement, thndo tenth r011- ‘llit’m, tomé jugo dc china 3,: me pcsmf, best translates as "When I was hoarse with a cold, I drank orange juice 311d became chronically hoarse") New foods or medicines are incorporated into the hot-cold system according to the effect they have on the body. Thus penicillin, because it can cause hot- classified symptoms (a rash or diarrhea), is catego- rized with hot substances, while a drug which might cause muscular spasms would be considered cold. The Very fact that new items are still being incorpo- rated into the hot-cold classification attests to its vital» ity in Puerto Rican culture. The existence of a vital medical tradition such as this raises several important issues for those who prac- tice medicine with a Puerto Rican clientele. The first of these issues is how the system specifically influences patients’ behavior when they consult a physician, and the second is how the professional practitioner can work with patients who evaluate illness and therapeu- tics within the hot-cold framework. The following sec- tions consider these two issues. The data which will be discussed Were derived from three sourccs: (1) from observations in 64 Puerto Rican households, made over a period of one year as part of an ethnographic study of medical beliefs and practices within the target area of the Dr. Martin Luther King, Jr, Neighborhood Health Center in the south Bronx; (2} responses to a questionnaire concerning 254 Case Studies in Explanatory Models postpartum practices and infant care, which was ad- ministered to all Latin American women living in the Martin Luther King Health Center area who had given birth in November and December, 1967 (questionnaire was administered as a focuSed inter- view three months after the women had given birth [number interviewed—27]); and (3) anecdotal reports from medical personnel at the Martin Luther King, Jr. Neighborhood Health Center. THE HOT-COLD SYSTEM AND PATIENTS’ BEHAVIOR General Medical Care Treatment of Colds Common colds are seen as quite serious by many Puerto Ricans, since they are viewed as the start of a possible chain of illnesses, brought on by repeated chills and failure to effect a cure. Thus, an untreated or chronic cold is believed to lead to chronic shortness of breath or wheezing (fatiga), which in turn may develop into bronchitis or even tuberculosis. All conditions in this prodromal sequence are considered cold in nature and treatable by hot reme- dies. Patients with any of these illnesses may thus face a dilemma when the physician outlines a treat— ment regimen which includes cold or cool substances, since these violate the patient's conception of proper treatment. A common example of this situation is when a physician recommends fruit juices for a cold. Since most fruits are fresco, this regimen is unacceptable. The culturally preferred remedy for this condition is gin- ger tea, which is hot and usually taken instead of the recommended juice. As the patient nears recovery from a cold, a cathartic hot substance, usually anise or castor oil, is also routinely administered to clean the system of accumulated phlegm. In the above example patients solve their dilemma concerning an unacceptable treatment regimen in a manner which does not impair therapy. This is not al- ways true, however, and complications can arise. The regimen prescribed with diuretics provides a good ex- ample. Use of Diuretics When prescribing a diuretic, routine medical practice is to encourage the patient to eat bananas, oranges, raisins, or other dried fruit in order to maintain the potassium balance in the system. With patients who adhere to the hot-cold theory, however, this advice may have untoward consequences, since all these foods are considered either cold or cool. As a result, when the patient contracts a common cold or other cold-classified illness, he will stop eating these potas- sium sources because they are contraindicated for his immediate condition. Women particularly run into difficulty with this type of regimen, since many of them are careful to avoid both cold foods and acidic cool fruits during their menses. This practice therefore eliminates all potassium sources usually suggested to them. A way out of this dilemma might be for the physician to prescribe potassium in solution as a “vita— min” (and therefore hot) to be taken during menstrua- tion or whenever. the patient has a cold or to suggest hot foods rich in potassium (like coffee, cocoa, peas, etc), in addition to the usual cold foods, so that pa- tients have enough options to make choices within the hot-cold system themselves. Prophylactic Use of Penicillin Another difficulty which arises in treating people who follow hot-cold medical practices results from the pro- phylactic use of penicillin for former rheumatic fever patients. Since rheumatic fever involves joint pains, it is considered a cold illness, and hot penicillin is there— fore readily accepted as treatment. However, should a patient experience temporary diarrhea or constipation while participating in a maintenance program, he will usually stop taking his medication bemuse in all likeli- hood he will attribute his symptoms to the hot peni— cillin. A way of dealing with this eventuality would be to encourage patients to take their penicillin with fruit juice or some other cool substance, since ingestion of something cool in conjunction with something hot is believed to neutralize any adverse effects of the hot substance. This important principle of "neutralization" is one which we shall return to a number of times in the ensuing discussion, since it is an effective method of working with patients within the hot-cold system. when this approach seems indicated. (The term neu- tralization is one which I have chosen to describe the activity involved and is not one which SparLiSh‘ speakers would use. They refer to the activity as "rg‘rescando el estémago" "refreshing" or "cooling" the stomach.) The Reinforcing Value of Hot-Cold Beliefs The hot—cold classification should not be viewed as _ producing only problems for the medical professional- _ I. ‘many instances it comports with and may therefore " used to reinforce standard treatment regimens. We . already noted that the use of penicillin for treat- " ' -., tof rheumatic fever fits the logic of the system. In ditton, bland diets recommended for ulcer patients ""hibit most of the foods which are considered hot ,__ ,. would therefore be avoided as a matter of course - the folk system. Similarly, the use of aspirin for _: 3' 'f of colds or arthritic pain accords with both thera- ' wtic systems. Indeed, although the hot-cold and hodem therapeutic systems differ in their basic -p1.'emises, the behavior they imply is probably more 'similar than antipathetic. One may even conjecture 5 that the viability of the hot—Cold system is founded to I-some extent on this fundamental agreement in the health behavior implied by the two systems. Pediatric Care t Infant Feeding Perhaps the most important implica- tion of the hot-cold classification for pediatric care concerns the feeding of infants. As noted in Table 1, evaporated milk, the formula base usually recom- mended to mothers on leaving the hospital, is consid- ered hot, and whole milk is considered cool. Since infants tend to develop rashes, and rashes are believed to come from hot foods, mothers prefer to feed their infants cool foods instead of the hot evaporated milk formula. in the sample of 2'7 Puerto Rican mothers de scribed more fully above, 41% almost immediately on return home from the hospital curtailed their babies’ intake of hot formula. Two strategies were used for doing this. FiVe mothers (19%) simply discontinued the evaporated milk formula after a few weeks and fed their babies only whole milk. Since it is believed dangerous to switch an infant too rapidly from hot to cool foods, mothers commonly feed their babies weak tea and mannitol (both cool substances) for 24 hours before starting the whole milk. (The fact that whole milk, besides being cool, is also considered more pres- , tigious and easier to prepare by some mothers un- . 1' doubtedly also contributes to its adoption.) *, .r Rather than switching milks, six mothers who - .. were interviewed in the same study (22%) used the I neutralization principle in resolving the contradiction ' betwaen their beliefs about infant feeding and the - ' medically recommended procedure. These mothers ei- .l ther added a cool substance to the evaporated milk i formula or fed something cool to the baby as a supple- i ' merit. The cool substances used were barley water, 1 magnesium carbonate, and mannitol. The latter two are a cathartic and diuretic, respectively, and were The Hot-Cold Theory of Disease 255 administered to the babies in sufficient quantity to cause diarrhea. This finding suggests a source of diar- rhea in the Puerto Rican infant population which should be investigated in a more rigorous fashion. In the meantime, however, the pediatrician working with a mother who believes in the importance of the hot— cold classification might well reinforce the use of bar- ley water as a neutralizer in preference to the two, possibly harmful substances. Oral Medication for Children The concept of neutralization is commonly employed by mothers when administering vitamins or other hot medications, such as aspirin or cod liver oil, to chil- dren. The cool substances most often used for this pur- pose are fruit juice, milk of magnesia, or mannitol. It is therefore advisable for the physician to find out which of these substances the mother is using, in order to avoid any which might have a detrimental effect on the child. Childhood Diseases As might be expected, measles, chickenpox, and other childhood diseases involving rashes are classified as hot in this nosology. Cool medications are therefore used in the home for these illnesses. For measles or chickenpox, raisins soaked in warm milk or water are commonly fed to children “to bring out the rash,” ie, to "cool" the internal organs sufficiently so that the “heat” comes to the surface in the form of the rash. Cool herb teas are also mod for this purpose. Obstetric and Gynecologic Care—Anteparturn Care During pregnancy a woman is careful to avoid hot foods or medication to prevent her baby from being born with an “irritation” (a rash or red skin}. To fur— ther guarantee this, many women “refresh” them- selves repeatedly with either milk of magnesia (l to 3 tablespoons a day) or commercial anti-acids (one to four closes a day), especially during the first and sec- ond trimesters. Since many abortifacients are consid- ered hot, a woman who has used them unsuccesshilly will be particularly diligent to prevant further irrita- tion to the foetus by taking cool preparations. An important consequence of the avoidance of hot substances during pregnancy is that many women will not take hot iron supplements or vitamins. These 256 Case Studies in Explanatory Models patients might be encouraged to take these pres— criptions with fruit juice or an herb tea to "neutralize" them. Postpartum Practices After delivery women traditionally underwent a pe- riod of seclusion for 40 days (the cum-criteria), during which time Several practices associated with the hot- cold system were observed. Many of these are still fol- lowed, even though the full ctmrentena rarely is. Many women avoid eating cool foods after deliVery on the ground that they impede the flow of blood and there- fore prevent complete emptying of the uterus and birth canal. Should the lochia flow toward the head, it is believed to cause nervousness or even insanity (pulga def part0, literally the “purge of parturition"). To help prevent this, certain tonics are drunk which con— tain mostly hot foods. One, for example, is made of chocolate, garlic, cinnamon, rue (rude, an herb), mint, and pieces of cheese. Similar beliefs attach to the menses. Cool foods are avoided at these times, since it is considered particu- larly important for the discharge from the womb to be complete. There is also an association, maintained mostly by older women, between strength and hot foods. Thus, a "weak" womb (malt-i2 débil) is believed to "jump" about in the body cavity in search of some— thing hot to fortify it. Rue, mixed with black coffee, rum, or cocoa, is taken as a remedy for this condition. TABLE 2 Table 2 summarizes the major points of the above dis- cussion by indicating patients’ reactions to particular symptoms and therapeutic regimens. COMMUNICATION WITH PATIENTS INVOLVING HOT-COOL BELIEFS In contemporary medical practice, commonication with Spanish-speaking patients most frequently oc» curs in one of three contexts: (I) the physician speak- ing (usually in English) directly to his patient or, in a family practice, to various members of the family as well, (2) the physician speaking through a translator or health worker from the Hispanic community who filters the communication through his own set of med- ical standards or accommodations between the profes» sional and folk therapeutic systems, and (3) health professionals informing the Spanish-speaking public through mass media or printed brochures. Each of these contexts obviously offers different opportuni- ties for sharing information and for mutual accom— modation between communicators. In the following discussion we shall be concerned only with the first two contexts, in which the physician or Hispanic health worker and patient have considerable latitude in accommodating to one another’s definition of an ill- ness or therapeutic course. Expectable Behavior of Patients Who Adhere to the Hot-Cold Theory‘ Patient’s Condition Expectable Behavior Common cold, arthritis, joint pains Patient will not take cold-classified foods or medications. but will accept those classed as hot Diarrhea, rash, ulcers Patient will not take hot-classified medications and uses cool substitutes as therapy _________________________________________. Requires a diuretic as part of a treatment regimen and has been told to supplement his potassium intake by eating bananas, oranges. raisins, or dried fruit Patient will not eat these cold-classified foods while he has a Cold or other cold~classified condition (For female patients this includes the menses) W Requires penicillin or any other hot medication, particularly on an ongoing basis Patient will stop taking hot medicine when he suffers any hot-classified symptom (cg. diarrhea, constipation. rash) W infant requires formula, which contains hot-classified evaporated milk Mother will put baby on cold-classified whole milk or will, after feaiing formula, "refresh" the baby’s stomach with various coo} substances, so”? of which are diuretic W Pregnant Avoids hot medicine and hot foods and takes cool medicine heal-‘de Postpartum and during menstruation Avoids cool foods and medicines, particularly those which are acidic W _ "See text for discussion of ways of treating such patients appropriately. l' '. For optimum therapeutic success, there are clearly . we important pieces of information which must be -m{erchanged between patient and physrcian in order no deal with any divergent views which may exist be- .'. een them conccrning the illness or treatment regi— ; a. :4 : (1) the physician must determine if the patient's views undermine the treatment regimen, and {2) if - 490, a mod us operandi must be reached whereby pa- . afient and physician agree on an appropriate treatment __ regimen- ‘- Determining a Patient’s Commitment to the : Hot-Cold Theory in identifying patients who are likely to adhere to the hot-cold system and the behavior it implies, degree of acculturation is, of course, a significant indicator: For, between different generations and among people of different educational backgrounds, the culture pattern takes different forms or may even be abandoned alto- gether. The elderly and recent adult migrants who . never completed high school are most likely to es— - pause the hot-cold system openly and consciously to weigh therapeutic decisions within its framework. Among 64 Puerto Rican families in the ethnographic study, 23 (36%) had adults who fell into this category. People who have been born in the States, on the other hand, or who have received most of their primary and secondary education here are not likely to express agreement with the hot-cold system openly. They may, however, defend those parts of it which agree with standard medical practice (eg, the association between I. I_ ulcers and hot foods) and almost certainly follow at f, 7 least some of the practices entailed by the system at ' - home. Even among the second generation American- born, the culture pattern may still survive in attenu- ated form. Remedies which stem from the hot-cold theory are remembered from childhood and may occa- Sionally be used, even though an awareness of the un- derlying hot-cold system is completely lost. in short, the process of acculturation through the generations creates subtle variations in the way hot- cold beliefs manifest themselves in the behavior of ‘ Puerto Rican patients. If the physician suspects that .- . hot-cold theories have a bearing on the treatment regi- ; ' men he is prescribing, it is therefore in the interests of . -' 800d therapy to probe his patients' commitment to .' . 7 these beliefs. This is best done by indicating to the pa- tient an awareness of the belief system but without im— .:a ,: plying judgment of it. An appropriate probe might be, I .f "Some of my patients say that a particular medication :1 z. ' or food pertinent to the proposed regimen is caliente or The Hot-Cold Theory of Disease 257 fi'csco. Do you think so?" Similar questions might also be posed to the person who prepares meals in the pa- tient’s family or who takes charge of his treatment. In medical delivery systems where Spanish- speaking staff translate for physicians or work closely with families, their training should include an aware- ness of thosc illnesses in which the hot-cold classifica- tion might pose therapeutic problems so that they can discuss them at length with families. Arriving at an Appropriate Regimen Once the medical practitioner has determined that the hot-cold classification is relevant to his patient's treat- ment, the age and degree of acculturation of the pa- tient should influence how he handles the situation. At this point, too, the physician’s own attitude and temperament will play an important role in communi- cation. Some physicians may by temperament wish to use their authority to establish a modus operandi with the patient over the regimen; some may take the view that if the patient is "educated" to understand the logic of the regimen, he will abandon old habits and follow it; others may opt to work within the hot- cold system to achieve the desired therapeutic goal. From the standpoint of behavioral science, the most effective of these approaches—particularly with elderly or less acculturated patients—would be to work within the system, using notions like neutraliza- tion or other features of the classification discussed above to achieve the therapeutic goal. The probability of changing an individual patient’s conception of dis- ease etiology in a few encounters is small indeed— particularly with the hot—cold theory, which not only orders a great deal of health behavior but is also sup- ported by prestige, developed through generations of USE, as well as, in many instances, by empirical valida— tion. Respect for the paiient's tradition and an ability to work with the therapeutic choices inherent in it al- lows for development of a treatment regimen with the patient which does not contravene his deeply held ideas about illness and will therefore stand a much better chance of success. REFERENCES 1. Foster GM: Relationships between Spanish and Span- ish-American folk medicine. lAmer Folklore 66:201—17, 1953. 2. Adams RN, Rubel A]: Sickness and social relations: in Wauchope R (ed): Handbook qur‘ddl'e American frictions. Austin, University of Texas Press, 1967. 258 3. 4. 5. 6. Case Studies in Explanatory Models Saunders L; Cultural Dyj‘erences and Medical Care. New York, Russell Sage Foundation, 1954. Saunders L, Samora j: A medical care program in a Col- orado county, in Paul BD (ed): Health. Culture and Com- munity. New York, Russell Sage Foundation. 1955. Clark M: Health in Mexican-American Culture Berkeley, University of California Press, 1959. Samora J: Conceptions of health and disease among Spanish Americans. Amer Catholic Social Rev 22314—23, 1961. 10. Martinez C, Martin HW: Folk diseases among Mexican- Americans: etiology, symptoms, treatment. IMA 196: 161—4. 1966. Weaver T: Use of hypothetical situations in a study of Spanish American illness referral systems. Human Orga- nization 29 2140—154, 1970. Steward J'H {ed}: People of Puerto Rico: :1 Study in Social Anthropology. Urbana, University of Illinois Press, 1956. Padilla E: Upfrom Puerto Rico. New York, Columbia Uni- versity Press, 1958. ...
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Brown Ch 27 (Harwood) - 27 ' I i an Harwood " hot-cold...

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