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MEDICAL ANTHROPOLOGY I Volume 10 I Number 4 207

Robert T. Trotter /IBernard Ortiz de Mantel/ana

Michael H. Logan

Introduction epidemiological profile of this syndrome amongSpanish speaking people in the American Southwest(e.g., frequency of occurrence, assumed etiologies,and modes of curing); and 3) does Western or cos-mopolitan medicine have a direct analog to caida demollera?

The Syndrome of Fallen Fontanelle

Ethnic diversity is highly evident in the AmericanSouthwest. This region, encompassing the borderstates and pans of Colorado, Utah and Nevada, is acultural mosaic, with peoples adhering to one ofthree principal cultural traditions: Amerindian, His-panic, and Euroamerican or "Anglo." Thoughthere has been admixture among these traditions,each remains distinctive with customs and behav-iors largely its own ranging from language and dietto the ways in which members of a tradition defineand treat sickness. Our concern in this paper iswithin the Hispanic tradition and one of its uniquetraits pertaining to disease theory. caida de molleraor fallen fontanelle.

Much of the scholarly reporting on Hispanic folk-medicine focuses on what is generally known as"culture-bound syndromes." These are illnessstates with associated etiologies and therapiesunique to members of a given group. In other wordsthey are culture-specific, not pan-cultural as in thecase of cosmopolitan or modem medicine. ]n com-parison to other syndromes reported on for Hispan-ics and Hispanicized Indians (e.g., susto or frightsickness [Rubel, O'Neil, and Collado Ardon ]984]and empacho or an obstructed stomach [Trotter andChavira 1981], caida de mollera has received rela-tively little research attention (also see Simons andHughes] 985). Our purpose here is to elevate cur-rent understanding on caida de mollera to a levelmore closely approximating what is known aboutthe other folk-bound syndromes. Specifically, wewill address three principal questions: ]) where didthe trait of fallen fontanelle originate: 2) what is the

In any society the very young are prone to misfor-tune. Injury, sickness, and death are common risks.Among Hispanics, one threat newborns and infantscommonly encounter is caida de mol/era. a condi-tion, at times fatal, attributed to physical trauma. Afall, accidentally being dropped, a severe spanking,suddenly withdrawing the nipple while nursing, orany form of rough handling can disrupt, it is be-lieved, the child's fontanelle, causing it to drop im-perceptibly or to collapse totally. (The anterior fon-tanelle, or mol/era. is a membranous interval ofincompletely ossified bone at the crown of theskull). The displacement of the fontanelle, whethervisually noticeable or not. marks the onset of caidade mol/era. and those so afflicted are indeed trulysick. There is excessive crying and a reduced de-sire, even ability. to feed. The eyes of the victimmay appear watery and withdrawn. Diarrhea, vom-iting, and restlessness are typically common. Theseand other symptoms may persist for days.

Therapy for fallen fontanelle is directed not somuch at eliminating its symptoms, but its ultimatecause. The fontanelle must be returned to its properposition. At times this can be accomplished bypushing upward on the roof of the victim's mouth,

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208 MEDICAL ANTHROPOLOGY I Volume 10 I Number 4

by holding the child upside down and shaking himrepeatedly, by patting the bottom of the victim'sfeet. or by sucking the mol/era or .'soft spot." Oc-casionally, medicinal teas or a compress will beused. Favorable results. though. are not always ob-tained. Caida de mol/era can be a severe, lingeringdisorder. At times it proves deadly. There is goodreason. then. why this syndrome is considered sig-nificant among those of Hispanic cultural tradition.Yet. the origins of caida de mol/era lie not withthe Spanish but with the Aztec of pre-ColumbianMexico.

A Question of Origin

In a now classic paper which has been widely cited,Foster (1953) suggests that many traits characteriz-ing contemporary Latin American folk-medicine areultimately of foreign origin, being brought to theNew World by the Spanish. Such traits included thenow widespread hot-cold theory of disease, as wellas the folk-bound syndromes of susto. mal de ojo.empacho and caida de mol/era. According to Fos-ter, aboriginal beliefs and practices had less effecton shaping the ethnomedical customs seen in LatinAmerica today than those held by the colonizingSpanish. Unquestionably the Spanish foreverchanged the face of the New World, but to arguethat contemporary Latin American folk-medicinederives mostly from Spanish influence is mislead-ing. In the case of fallen fontanelle, such an inter-pretation is wrong.

If in fact the Spanish did introduce the trait offallen fontanelle to the Americas, then one wouldlogically expect to find three things: I) reference tothis syndrome in the medical texts available to theSpanish during the 16th century: 2) the presence ofcaida de mol/era. or even a survival or parallel of it,in the ethnomedical traditions of Spain today: and 3)a fairly even distribution of the trait throughout con-temporary Latin America. Though we must limitour discussion here, it is truly interesting to notethat none of three "areas of proof" can be substan-tiated.

In his 1953 paper (and in subsequent works),Foster gives no European counterpart to caida demol/era, nor does he cite any reference for its oc-currence anywhere in the Old World. We askedthree noted medical historians highly familiar withEuropean folk-medicine if they had ever encoun-tered reference to this trait in the materials they had

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TROTTER et al. I Fallen Fontenalle 209

or by "reading" grains of corn that had been castinto water. Accompanying such divination thehealer frequently employed an incantation: ". ..letus look here at the poor child, he whom his vener-able tonalli perhaps has abandoned. .." (Ruiz deAlarcon 1953:137). At times the tetonalmacanime.or in the words of Ponce de Leon (1965: 125)-"those who give tonalli to people"-would treatafflicted children by lifting the hair on their fon-tanelle then ask the sun to return their wanderingtonalli. A line was drawn on the patient's face fromnose to the middle of the skull with juice from to-bacco or tlacopatli (Aristolochia mexicanaJ, the lat-ter having a special power to attract tonalli (Her-nandez 1959, vol. 2:130-131; Lopez Austin 1980,vol. 1:240-241). This rite closed the openingthrough which this vital force had earlier escaped(Lopez Austin 1967:108).

Though Spanish chronicles of Aztec life and cul-ture unquestionably colored, to varying degrees, thecontent of Indian reporting on native ways, one can-not ignore the symbolic importance of the head,more specifically the hair, in the aboriginal worldview prior to contact. In literally thousands ofscenes-on pottery, on murals, on wood, on stone--there is a standard sign symbolizing defeat, or thetaking of an enemy-a captive being grasped by thehair. The tonalli of the vanquished was thus underanother's control. For the Aztec, hair was viewed asa protective layer that impeded the loss of this vitalforce. and. as noted by Lopez Austin (1967), shouldthe hair on one's coronilla (crown) be cut. the sub-ject would soon die. It seems, then, that tona/li.hair, and the fontanelle were symbolically inter-twined, both in the context of good fortune and bad.

Additional and persuasive evidence that caida demo/lera was a recognized illness category amongthe Aztec appears in Sahagun's Primeros memori-ales. one of the earliest works he collected in Nahu-atl. Here he describes the "teapahtiani." a healerspecializing in the treatment of fontanelle (LopezAustin 1980, vol. 1:250):

The TEAHPAHTIANI thus cures little chil-dren: she hangs him upside down. she shakeshis head from one side to the other and shepushes on his palate. Some of them attract (thespirit) with their breath.-and also push thechild"s palate with cotton which they stuff in.Some get well with this. others don't. Thisresembles the method in which they puncture(the palates) of little children. from which they

based on introduction. A recent article on Spanishsurvivals in the folk-medicine of Chile containsnothing on caida de mollera (Alvarez et aJ. 1983).Valdizan and Maldonado's (1922) extensive over-view of ethnomedicine in Peru has detailed materi-als on both evil-eye and fright-sickness, but nothingon caida demollera. The work of Hubi (1954) andothers confinns the same finding, fallen fontanelleis not a feature of popular health culture in the An-dean region. But it is precisely here, according toFoster (1953:215), that Spanish survivals in folk-medicine are most clearly seen. And if this is in factthe case, would not fallen fontanelle be more com-mon here than elsewhere in Latin America? Andwhy did Esteyneffer's teachings on caida de mol-lera fail to pass from Spaniard to Indian, when acopy of his works was housed at the University ofSan Pablo de Lima in the 1700s (Valdizan and Mal-donado 1922, vol 3:69)? And finally, why is thetrait of fallen fontanelle so evident in Mesoamerica.?The answer, of course, is that it was aboriginal toMexico.

In the world view of pre-contact Mesoamericanpeoples there was the belief that life-giving forcesresided in most everything both animate and inani-mate. Each and every person possessed several in-ner forces. Among the Aztec one of these forceswas known as tonalli (see Lopez Austin 1980). Thisinner force imparted warmth, vigor, and courage. Itwas tonalli, too, that favored children with growth.While found throughout one's body, the principalabode for tonalli was the head. Its loss, either byfright or physical violence (Molina 1970). wouldprovoke grave illness, even death, and childrenwere at great risk, not surprisingly, because theirfontanelles had not fully closed (Lopez Austin1980, vol. 1:224). Torquemada. writing shortly af-ter the conquest, states that the Aztec believed thatparents should not cut a child's "long hair at theback of the head" (1943, vol. 2:84), for this wouldbe equivalent to opening a dangerous door throughwhich the tonalli would escape (also see LopezAustin 1967). There are many other 16th centurysources that contain reference to Aztec therapiesdirected at the fontanelle, the hair, or the head gen-erally (Hernandez 1959, vol. 2:147; Ponce de Leon1965; Ruiz de Alarcon 1953:140-141).

The Aztec diagnosed the loss of tonalli by feelingthe patient's pulse and by observing the condition ofthe mollera (Ponce de Leon 1965:131). Diagnosiswas also established through divination, either bylooking at the child's reflection in a vessel of water

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210 MEDICAL ANTHROPOLOGY I Volume 10 I Number 4

soon die-or they I1Jb them with salt or theypress repeatedly (papachoa) the little childrenwith tomato. [Garibay 1943]

the fontanelle as a locus of disease. and how theafflicted could be cured. Hispanics in the AmericanSouthwest are the heirs of a long and interestingcultural history. one where caida de mol/era owesmuch to the aboriginal peoples of Mexico.The treatments appearing in this passage closely

parallel the pattern of therapy found today. Pushingup on the palate, for example. is the favorite remedyamong those we interviewed in Texas (N = 80).Many also treat the victim by holding him upside-down or by patting the soles of the feet. These andother contemporary practices in the treatment ofcaida de mollera can be traced back to the Aztec,but not to Esteyneffer who wrote the foll01wing:

An Epidemiological Profile

If the fontanelle of the child is fallen, themother should put breast milk in the fontanelleitself and she will see it visibly rise. Or put thechild's head into a vessel of lukewarm water tothe depth of the nose, but donI let water getinto the nose, and lift out suddenly repeating itseveral times with which the water will suckthe fontanelle out. After this treatment. put aplaster on the fontanelle made out of incensepowder. ..or from 'copal', made into a pastewith a good bit of beaten egg white and placedon a cloth. It should be applied lukewarm. [Es-teyneffer 1978, vol. 1:441]

Despite pronounced variation in acculturation to-wards an "Anglo" lifestyle (see Cuellar, Harris,and Jasso 1980), many Hispanics in the AmericanSouthwest recognize fallen fontanelle as a common,potentially serious threat to newborns and infants.Because this syndrome lies. at least in popular opin-ion, beyond the realm of modern medicine. parentsrarely report it to physicians or other health carepersonnel. To the contrary, diagnosis and treatmentoccur almost exclusively within the home. How-ever, a stricken child might be gravely ill, withdeath as a possible outcome. There is a very realdiscrepancy resulting from the syndrome's biophys-ical manifestations and its ethnomedical etiologyand cure that places many children at considerablerisk. Parents frequently postpone, or more com-monly never seek, biomedical consultation for achild with caida de mollera. Because of this there isa need to improve current understanding amonghealth professionals concerning the ubiquity of thissyndrome. and how it is perceived and treated in thecontext of the home. Similarly. parents must beencouraged to report cases of caida de mol/era tophysicians. The syndrome of fallen fontanelle isbiomedically real and too frequent for parents toignore physicians and vice versa.

Our data on the occurrence and treatment ofcaida de mol/era were collected from two samplepopulations. The first data set was generated byinterviewing Hispanic patients at 31 migrant and/orPublic Health clinics in Texas. New Mexico, andArizona. Informants were chosen at random duringa period of one week. Interviews were conducted bybilingual interviewers in the language preferred bythe informant. The survey instrument contained 18questions. seven demographic in nature (age. sex,household composition. occupation. etc.) and therest on folk medical concepts. These questions in-cluded. for example. whether or not anyone in thehousehold had been treated for caida de mol/era.and if so. by whom and when. There was also anopen ended question on knowledge of remedies forcaida de mollera. While the patients interviewed at

It should be stressed that the treatments noted byEsteyneffer are not the predominant treatments usedtoday in any region where caida de mollera isfound. Incense and copal poultices are not cited atall. Dipping the child's head in water was men-tioned, for example, by only 2% of our eighty in-fonDants and only 5% thought that an egg poulticewas an appropriate remedy. This is not what onewould expect if Esteyneffer were the sole or pri-mary source of infonnation shaping contemporaryMexican and Mexican-American folk medicine. Tothe contrary, most of the remedies people use todayfor treating fallen fontanelle also appear in Aztecethnohistoric literature.

The evidence at hand clearly points to Mesoamer-ica as the locale from which caida de molleraemerged. Syncretism between Aztec and Spanishcultures was pronounced in the early colonial pe-riod, and no doubt the native view regarding tonallimeshed well with European illness categories basedon assumed displacement of body pans. Though theconcept of tonalli was most likely replaced by theChristian idea of soul, there has been remarkablecontinuity from Aztec times to the present re:garding

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TROTTER et al. I Fallen Fontenalle 211

son or daughter for caida de mollera. Holland(1978) found that 33% of his informants in Arizonahad treated a family member for fallen fontanelle,and 55% felt that this syndrome is a serious risk tochildren. In their study of curanderismo in TaosCounty, New Mexico, Scheper-Hughes and Stewart(1983) show that the most frequent complaint pre-sented to folk healers (curanderos) is caida de mol-tera. Martinez (1966) reports that 97% of the Mex-ican-American women he interviewed claimedknowledge of the concept of fallen fontanelle and33% cited precise remedies for its treatment. Fi-nally, other studies (e.g., Casillas 1978; Clark.1970; Hurtado Vega 1979; Knoke 1984) reveal thatfallen fontanelle is a fairly ubiquitous health prob-lem in Hispanic populations in general.

Unlike the cause of caida de mollera, a subjectupon which there is wide agreement among infor-mants, beliefs regarding the signs of fallen fontane-lle, and how best to treat this condition, are highlyvariable. However, certain patterns predominatewithin this variability. Our second research popula-tion, one consisting of 80 informants, was used togenerate data on symptoms and treatments of caidade moltera. Considerable variability was encoun-tered. For example, a total of 27 symptoms wereidentified by individuals in this population, asshown in Table 2. Certain symptoms, though, ap-pear to be idiosyncratic. Chills, constipation, in-flammation of gums, heavy perspiration. andweight loss were cited only once as signs of fallenfontanelle. These symptoms are unique, then, togiven individuals. At the other extreme are symp-toms that exhibit greater consensus among infor-mants. Rather than being idiosyncratic or unique,these symptoms are group or collective phenomena,thus reflecting the general or modal pattern fallenfontanelle usually takes. The symptom most fre-quently mentioned by our informants, and severalgave multiple responses. is diarrheal complaint(53.7%). This was followed by excessive crying(43.7%). fever (36.2%), loss of appetite (30.0%),restlessness or irritability (25.0%), and watery eyes(22.5%). Another 21 symptoms. ranging from in-ability to nurse and vomiting (20.0% and 17.5%,respectively) to a bloated stomach (2.5%) werementioned by informants. Most of those inter-viewed. however. described a cluster of symptomsfor caida de mattera, the largest being 8, the mode3, and a minimum cluster of two symptoms. Ap-proximately two-thirds of the informants presentedsymptom clusters (these will be discussed in the

these clinics may not be completely representativeof the total Hispanic population in the three states.our sample none the less conta-ins a wide cross-section of individuals in terms of age. family com-position, education, occupation, and degree of ac-culturation (see Trotter 1985a.b). Moreover. thesample is large (N = 1900) and thus provides a senseof confidence that these date approximate the be-liefs of low-income Spanish-speaking peoplethroughout the Southwestern United States.

The second data set was collected from a purpo-sive sample of 80 individuals. No attempt was madeto randomize the sample. In fact. only individualswho were known to have treated caida de mo/lerawere interviewed since the purpose was to explorethe overall parameters of the treatment of this syn-drome rather than its epidemiologic occurrence.These individuals all resided within the lower RioGrande Valley of Texas. They ranged in age from18 to 64; 92% are female; all are Mexican Ameri-can. The estimated socio-economic status of theseinformants ranged from very poor to upper middleclass with the preponderance of the informants com-ing from households headed by semi-skilled andskilled laborers. The data collected from this pur-posive sample. were used to identify major patternsin the symptomology and treatment of caida de mo[-[era.

Several important findings emerge from thesetwo data sets. First. caida de mo/lera is fairly com-mon among Hispanics in the Southwest. As can beseen from the data in Table 1, 28.3'10 of the 1,900patients interviewed had treated someone in theirhousehold for caida de mo/lera at some time in thepast. The percent treated varies by geographic lo-cation. as would be expected. Under-reporting-areluctance to admit to interviewers that a familymember had been treated-probably accounts formuch of the variation from clinic to clinic as well asfor any unusually low rates. Differential accultura-tion is another possibility for such variation. Therange is from a low of 2.7% in Presidio. Texas to ahigh of 69.6% in Tucson. Arizona. Perhaps moresignificantly. 15 of the 31 clinics had patient poolswith a treatment range (for fallen fontanelle) be-tween 25% and 50%. Except for a few locations (EIPaso and Presidio). the occurrence of this illnessappears fairly common across our sample. Thesefindings are basically in line with what other re-searchers have reported. Granger (1976) notes that95% of his informants in Dallas had either. as achild, suffered from or, as a parent. had treated a

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212 MEDICAL ANTHROPOLOGY / Volume 10/ Number 4

Table 2.Symptoms Accompanying Caida De Mollera

Table I.Percent of Sample Treating Caida De Mollera inThree States

Number ofInformants

MentioningSymptoms

(N = 80)

.~ Number% Treating of Patients

Caida de Mollera InterviewedLocation

Arizona1. Tucson2. Somerton

Combined

New Me.\"ico

3. Portales4. Albuquerque5. San Miguel6. Sunland Park7. Anthony

CombinedTe.\"as

8. Bracketville9. Eagle Pass

10. HerefordII. Aoydada12. Crosby ton13. Plainview14. Goldwaite15. Gonzales16. EI Paso17. Muleshoe18. Dimmitt19. De Leon20. San Saba21. Levelland22. San Angelo23. Laredo24. Ollon25. Odessa26. Littlefield27. Crystal City28. Cotulla29. Presidio30. San Antonio31. Harlingen

CombinedTotal Sample

Symptoms %

69.616.342.1

464995

43352924201816141097

777543

53.7543.7536.2530.025.022.520.017.512.511.258.78.78.78.76.255.03.75

29.024.619.415.211.821.1

3112632

3734

260

24.427.033.046.745.925.321.731.33.1

35.737.518.419.044.661.219.328.664.039.011.716.22.7

44.139.628.628.3

41

79133741

9948

4896

43

46

40

28101

50

215

29

50

45

99103

3998

57

1.545

1.900

32222I

I

I

II

3.752.52.52.52.51.251.251.251.251.25

1. diarrhea2. excessive crying3. fever4. loss of appetite5. restlessness/irritability6. mucousy, watery eyes7. inability to grip nipple8. vomiting9. change in sound of nursing

10. sunken eyesII. bump on palate12. listlessness13. insomnia14. pale15. stomach pains or cramps16. weakness17. no pulse or movement

in fontanelle18. dehydrated19. excessive saliva20. runny nose21. bloated, rigid stomach22. loose jaw23. chills24. constipation25. inflammation of gums26. heavy perspiration27. weight loss

next section). Interestingly, an abnonnal appear-ance of the child's fontanelle was mentioned as asymptom by only 3 of the 80 infonnants. Appar-ently the fontanelle can be displaced without visibleevidence. Positive diagnosis, therefore, is basedprimarily on the presence of other symptoms andthe re-calling of recent, trauamtic events affectingthe child.

The etiology of fallen fontanelle invariably in-volves some type of physical trauma. As such, itsurely fits into Foster's (1976) notion of diseaseresulting from naturalistic forces. Fourteen different

.,

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TROTTER et al. I Fallen Fontenalle 213

Table 3.Causes of Caida De Mollera

Table 4.Treatments for Caida De Mollera

5940

5328

1414

17.517.5

24

96

52

11.257.56.252.5

24

10

2 2.5

I. push up on palate2. rub soap into, or fill

fontanelle withsoap. let dry

3. hold baby upsidedown by legs, tapon baby's feet

4. hold baby upsidedown by legs, shakeup and down

5. suck on fontanelle,usually with waterin mouth while

sucking6. fill fontanelle with

egg. let dry7. give baby a tea8. pull up on hair on

fontanelle9. hold upside down,

dip head in water10. put a plaster over

fontanelleII. lay baby down, pat

bottom of feet12. take to doctor13. rub fontanelle with

boiled egg14. rub fontanelle

92 2.5

87

10.08.7

2 2.5

2

22.52.5 5 6.25

2

I. fall to floor2. pulling nipple out

too fast while nurs-

ing baby3. jolting baby4. throwing baby in air

and catching it5. a hit on head6. dehydration7. poor nutrition8. traveling on bumpy

road9. rocking baby too

fast10. picking baby up

suddenlyII. allow baby to suck

empty bottle12. fright13. don't carry or hold

baby properly14. leave baby's head

unwrapped and takeout into a fog

2 2.5 2.5

2 2.5

1.251.25Icauses for caida de mollera were noted by the 80

informants, as shown in Table 3. By far the mostcommon cause is "a fall to the floor," being men-tioned by 50 informants (73.7% of those inter-viewed). Next came "pulling the nipple too quicklyor forcefully from the infant's mouth.' (50.0%),"jolting the baby" (e.g., knocking him over[17.5%]), and "throwing the baby in the air andcatching him" (17.5%). Other causes were citedless frequently, for example, a hit on the head(11.2%), dehydration (7.5%), leaving the infant'shead unwrapped (2.5%), or allowing him to suck anempty bottle (2.5%). We have no evidence that ne-glect or abuse is involved. Many of these eventsoccur accidentally during the normal course of child

rearing.

I 1.25

As shown repeatedly by medical anthropologists(and others as well), therapy for an illness is manytimes an accurate mirror of the illness' assumedetiology (see Foster 1976). This is surely the casefor caida de mollera. Because this illness resultsfrom physical displacement of the fontanelle(\II"hether seen or not), most treatments, therefore,attempt to restore the fontanelle to its proper posi-tion by physical means. The range of cures seenamong our 80 informants surely reflects this point,as shown in Table 4. Of the 14 different treatments

-

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214 MEDICAL ANTHROPOLOGY I Volume 10 I Number 4

ancy between the ineffectiveness of folk remediesand the biomedical realities of caida de mollera(diarrhea. crying. fever. etc). This discrepancy ob-viously jeopardizes the well-being of many victims.Therefore. the following question must be asked: isthere an analog in Western medica) nosology thatcan account for the symptoms typically associatedwith fallen fontanelle? It is to this question that wenow turn.

Western Diagnosis or Fallen Fontanelle

mentioned, all but two are purely mechanical innature, the exceptions being use of a medicinal tea(only 8 informants prescribed this) and taking thestricken child to a doctor (only 1 informant out of 80said this would be appropriate). The most commontreatment, one employed by 53 of the 80 informants(66.2%), is to push the child's palate upward withone's fingers. Rubbing wet soap over the child'sfontanelle, then allowing the soap to dry (thus pull-ing up the fontanelle), is also quite common(35.0%). The next most frequently mentioned strat-egy is to hold the child upside down by the legs andthen either tap repeatedly on the feet or shake thepatient up and down (68% of the informants citedthese as effective cures). Other treatments, though,enjoy less currency: sucking on the fontanelle(12.5%); allowing a cracked egg to dry on the fon-tanelle (11.2%); pulling the hair that covers the fon-tanelle (8.7%); and dipping the child's heat intowater, something prescribed by Esteyneffer (6%).The remaining strategies to cure caida de molleraare idiosyncratic variations of the more commontherapeutic procedures cited above. Interestingly,most of the remedies cited by our informants areones that appear in various Aztec sources. Again, itappears that Esteyneffer had little impact on con-temporary treatment patterns for fallen fontanelle.

The most significant finding about how patients(or curanderos) attempt to cure a child of caida demollera is that virtually all of the procedures aremechanical in nature (save for medicinal teas andtaking the afflicted to a doctor), thus the highlyevident biophysical complaints associated with thissyndrome pass, in effect, untreated, as do the syn-drome's actual underlying causes. In short. then,folk therapy in this case is overwhelmingly ineffec-tive, a situation that undoubtedly gives rise to theknown seriousness of caida de mollera.

It seems relevant here to briefly re-state threepoints about the data we have presented thus far.First, the syndrome is not a rare or unusual traitamong Hispanics. Rather, this illness is relativelycommon, perhaps affecting more than a third of alllow-income Spanish-speaking families at one timeor another. The estimate of one-third is based on themean of our reported cases. Second. pronouncedvariability characterizes popular opinion regardingthe symptoms of, and the appropriate means forcuring, fallen fontanelle. Yet the etiology and ther-apeutic procedures associated with this syndromereflect a single theme, physical displacement-phys-ical restoration. Third, there is a significant discrep-

As noted previously, victims of caida de molleratypically exhibit several symptoms simultaneously.While the total range of symptoms associated withthis condition is large, certain symptom clustersclearly predominate. The most common of these,judging from our sample of 80 informants, is onethat encompasses diarrheal complaint, excessivecrying. fever. and loss of appetite. Some informantspresented a modified or expanded version of thiscluster, making reference to the child's inability tonurse or bottle-feed, his irritability, and watery orsunken eyes.

It seems, then, that a majority of victims of fallenfontanelle display a recurrent set of symptoms,where both biological signs (i.e., diarrhea, fever,occasional vomiting, etc.) and behavioral changes(i.e., abnormal feeding habits. poor composure)collectively spell the need for therapeutic action.The label of "caida de mollera," we should add, isascribed to these and related symptoms if, and onlyif, some physically traumatic event involving thepatient had occurred prior to the onset of sickness.When trauma is absent, the same symptoms wouldbe glossed with another illness term, for example,colic. What is so important to remember, however,is that unlike the remedies for most other illnesscategories. those prescribed for fallen fontanelle arevirtually all mechanical in nature, as in the case ofpushing upwards on the palate. Such procedures,while viewed appropriate in folk medical theory,are totally ineffective in dealing with the organiccauses responsible for the highly apparent symp-toms of fallen fontanelle.

In an attempt to gain at least a preliminary un-derstanding of the probable organic causes of caidade mollera. we asked two area physicians (Edin-burg. Texas) to make "blind" diagnoses of threehypothetical patients with differing symptom pro-files. profiles based on the symptom frequency data

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TROTTER et al. I Fallen Fontenalle 215

acidosis. Loss of appetite. irritability. and frequentor prolonged crying are behaviors consistent withgastroenteritis and its related effects. The symptomsfor patient C also suggest gastroenteritis. Sunkeneyes is a sign of possible dehydration.

The picture that emerges, though it is surely pre-liminary in nature. is one where gastroenteritis, attimes coupled with upper respiratory complaint,may lie. in a majority of cases, at the base of thisfolk-bound syndrome. The relatively common oc-currence of fallen fontanelle in low-income His-panic households may simply, but quite impor-tantly, reflect the high prevalence of these disordersamong infants and young children. Here, risk is dueto substandard hygienic conditions. This is particu-larly true if an infant can crawl, is being bottle-fed,or has been placed on a solid diet. Much in theinfants' environment favors gastroenteritis.

Parents are highly.aware. too, of the potentialseriousness of fallen fontanelle. Fifty-eight percentof our informants. for example. reported that caidade mol/era, if left unchecked. can prove fatal (only22% considered it non-fatal). This awareness of thesyndrome's potential severity results from twothings. First. virtually all of the folk remedies forfallen fontanelle are ineffective in combating or-ganic disease. Second, dehydration is probably acritical feature of caida de mollera. It would surelybe the most likely suspected cause of death in ter-minal cases. It seems. then. that gastroenteritis is alikely source for many of the symptoms, biologicaland behavioral. categorized as fallen fontanelle.While other disorders, obviously, cannot be ruledout. the evidence at hand points to gastroenteritisand its related complications as the primary factor.

If we are correct. then several important issuescome to light. Most significant among these is thatcaida de mollera represents a serious threat to thewell-being of the very young. Furthermore, sincetreatment of this disorder is confined almost entirelyto home remedies. ones generally incapable of ben-eficial impact. any underlying causes. notably gas-troenteritis. dehydration. and upper respiratorycomplaint. are allowed to run their natural course. Itis also important to stress that very few in the His-panic community feel that physicians can help incases of caida de mollera. In fact. only one ofeighty informants considered physicians a viable re-source in treating fallen fontanelle. and then onlyafter repeated use of home remedies had failed.Time and again informants gave antecdotal materi-als to illustrate that physicians not only misunder-

gained from our sample. Unlike customary practice,the physicians had no knowledge of the patient'sfamily, no opportunity to consult or question par-ents, no understanding of home conditions, nochance to employ diagnostic tests. They were sim-ply asked, "if an infant displayed these symptoms,what would your diagnosis be?"

The profiles to be diagnosed were constructedwith two points in mind. First, they should reflectactual data from our sample. That is, the symptomsselected for the three patients (again, all infants)should be those of relatively high occurrence. Sec-ond, the symptoms should exhibit "compatibility."Our analysis of the symptom frequency data re-vealed, is noted earlier, certain sets of clusters. If,for example, an informant mentioned diarrhealcomplaint and vomiting, it was very likely that fe-ver and excessive crying would be mentioned aswell. Similarly, when inability to nurse was cited,so, too, was a changed sound in nursing. Theseprofiles, then, are consistent with our data in termsof the prevalence of symptoms and the clustering ofsymptoms. Moreover, they represent variationswithin what appears to be the typical or model pat-tern for fallen fontanelle.

Each physician was given a written statement de-scribing the symptom profiles they were to diag-nose:

Patient A-diarrhea, loss of appetite, fever, rest-less/irritable, excessive crying, occasional vomiting

Patient B-mucousy or watery eyes, inability togrip nipple, changed sound of nursing, excessivecrying, restless/irritable;

Patient C-sunken eyes, diarrhea, inability tonurse, changed sound of nursing.

The physicians stressed, understandably, thattheir diagnostic opinions should be viewed asguarded, not conclusive. Nonetheless, they wereunanimous in what they thought was wrong witheach of the patients. Both remarked, as well, thatpatient B was the most difficult to assess. Thisaside, each felt that the symptoms present for pa-tient B would suggest a general systemic infection,perhaps coupled by an allergy. Obviously some-thing was affecting the infants breathing, which be-came particularly difficult when feeding. Neitherphysician could go beyond this.

Their opinions regarding patients A and C, how-ever, were more precise. And again the physicianswere in agreement. For patient A, the symptomsstrongly suggest gastroenteritis (evidenced by diar-rhea and fever), possibly leading to dehydration and

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216 MEDICAL ANTHROPOLOGY / Volume 10/ Number 4

tion as a folk-bound syndrome. and to explore itsprobable underlying organic causes. Though muchin this article is preliminary. it should serve as a callfor additional research. There is a strong need forgreater data on the actual outcomes of cases involv-ing fallen fontanelle. Similarly. an improved clari-fication of the syndrome' s organic parameters is an-other important need. While anthropologists canwork effectively within the Hispanic community.encouraging it~ members to seek medical help whentreating caida de mol/era. we can anticipate lesssuccess when addressing the medical community.Headway here will be closely measured by thedepth and rigor of future studies of illness categorieslying beyond the Western medical model. Caida demol/era is truly a case in point. one showing theneed to improve cross-cultural understanding in set-tings such as the American southwest.

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stood the true nature of caida de mol/era. they vir-tually deny its existence. But this syndrome doesinvolve organic disease and most every case goesuntreated biomedically. The issue. then. is how bestto sensitize parents. as well as physicians. about thereal need to have victims of fallen fontanelle diag-nosed and treated by a medical doctor. The task ofaccomplishing this. however. will prove difficult.

Perhaps the best place to begin is with improvedcommunication about the realities of caida de mol-lera. To reach members of the Hispanic commu-nity, various state. civil, and private organizations(e.g.. schools. churches, public clinics. communityaction groups) should be informed through mailedinformation and guest speakers about the potentialrisks associated with this folk-bound syndrome. Inturn, these organizations. through counseling, lec-tures, handouts, and other means (cf.. Takeshita1966), could inform Spanish-speaking parentsabout the probable biological parameters and poten-tial outcome of fallen fontanelle. as well as the needto seek medical attention.

Those in the health care profession, of course.must also become more fully informed about thissyndrome, its relatively common occurrence. its bi-ological features, its near exclusive treatment in thehome. Avenues to disseminate information includeprofessional journals. meetings of professional as-sociations, local newspapers. flyers mailed to pub-lic clinics and emergency units. etc. The point hereis to encourage physicians to talk openly with par-ents about this and other folk bound syndromes. sothat when a case does occur parents will be morelikely to seek clinical aid. To date. though, verylittle on caida de mollera has reached the medicalcommunity. There is one report (Guarnaschelli,Lee, and Pitts 1972) that has linked subdural he-matomas to folk treatments of fallen fontanelle.Other than this. little is known about its probableorganic dimensions. its prevalence. or its potentialseverity. With improved communication. however.this problem can be effectively reduced.

Conclusion

Like many regions worldwide the American south-west exhibits a diverse array of cultural traditions.The disease concept examined in this paper isunique to the Mexican-American subculture. Ourpurpose here has been to clarify the historical ori-gins of caida de mollera. to discuss its categoriza-

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