The Trauma of Birth - Examination
he craniosacral mechanism of the newborn infant should be examined within the first few days of life. There is probably no field of osteopathic diagnosis where the injuction "if at first you don't succeed, try, try again" applies more than in the examination of the newborn cranium. The mobility of the cranial mechanism is much greater at this age than it is in the adult skull, although the range of motion is of course much smaller. Dr. R. McFarlane Tilley used to speak of the amplification mechanism within the human hand and brain, which permits the perception of motion in the range of 0.0001 inch. It is this perceptive mechanism that must be developed in order to make a meaningful examination and to complete an adequate treatment program for these infants.
Furthermore, one must learn to palpate motion within motion, for these infants rarely lie absolutely still for an examination. One should first consider the contours and articulations by passing the hands gently over the surface. Look for asymmetry, bossing of the frontals or parietals, grooves above the eyebrows, overlapping of one bone on the other at the coronal or lambdoid suture, prominence and compression of the sagittal or metopic suture, and depression of the pterion. Let the occiput rest in the palm of the hand, and note unusual prominence of the interparietal occiput or hard flattening of the supraocciput. Study the relative size and position of the eyes and nostrils and the inclination of the mouth. Examination for inherent motility will be facilitated if the baby is nursing or sleeping. Here is a check list that may be helpful:
1. Place the hands gently on the vault, with the index fingers on the greater wing of the spheroid and the little fingers on the lateral angles of the occiput. The other fingers lie comfortably between them. Is your first palpatory impression that your two hands are symmetrical?
2. Are the index finger and the little finger of one hand cephalad or superior to those of the other, as in a torsion strain. If so, the spheroid and occiput will have rotated around an anteroposterior axis in opposite directions, elevating the greater wing of the spheroid on one side and the lateral angle of the occiput on the other (Figure 2).
Figure 2. Torsion strain. Torsion of the sphenobasilar symphysis occurs about an axis running from the nasion (anterosuperior) to opisthion (posteroinferior) at approximately right angles to the plane of the sphenobasilar symphysis. In bottom view, a left torsion lesion is diagrammed, with the greater wing and basisphenoid high on the left side and the basiocciput and squama lower on that same side. (From Magoun, H. Osteopathy in the Cranial Field, Second Edition. Kirksville, Mo.: Journal Printing Company, 1966).
3. Are the index finger and little finger of one hand caudad or inferior to those of the other hand, with a sense of fullness in the palm of the inferior hand, as in a side-bending rotation strain. In this instance, the spheroid and occiput have side-bent in opposite directions around parallel vertical axes and rotated inferiorly into the convexity thus created.
4. Is there a sensation that the index fingers on the greater wings are directed towards one side, while the little fingers on the occiput are carried to the other side? This is lateral strain (Figure 1). Owing to a lateral force, the spheroid and the occiput have rotated in the same direction around parallel vertical axes, causing a shearing strain at the symphysis between them.
5. Are the two index fingers on the greater wings forward and downward (caudad) as compared with the little fingers on the lateral angles? Conversely, the index fingers may be superior (cephalad). These are vertical strains (Figure 3 ). Both superior and inferior strains are shown in the diagrams (superior on the left). The spheroid and the occiput have rotated in the same direction around parallel transverse axes, producing a vertical shearing strain at the sphenobasilar articulation.
Figure 3. Vertical strains of the sphenobasilar symphysis. Viewed from the side, the sphenobasilar symphysis has been strained or displaced before ossification, with the basisphenoid moving cephalad (flexion) and the basiocciput moving caudad (extension), or vice versa. Both bones rotate about parallel transverse axes in the same direction. (From Magoun, H. Osteopathy in the Cranial Field Second Edition. Kirksville, Mo.: Journal Printing Company, 1966.
6. Is there a sense of hardness and tension under your hands, resembling wood? This suggests a compression strain.
These palpatory observations of asymmetry are clues to the dysfunction of this mechanism: But it is the nature of the inherent cranial rhythmic impulse-its symmetry, rate, amplitude, and constancy of pattern- that is important. If the inherent motion is distorted, impeded, limited, or retarded, there are certainly membranous strains that need attention.
It is not possible to develop the necessary tactile skills in a few days or during a brief course of instruction. But with assiduous application, the sensitivity will be developed, and you will be able to make these vital diagnoses at the age when they are most susceptible to correction.
7. With your index finger on the greater wing of the spheroid and your little finger on the lateral angle of the occiput, be still and permit the mechanism to convey its movement through your fingers and hands. Is there rhythmic, symmetric expansion and contraction of external and internal rotation of the bilateral vault bones that accommodates the flexion and extension of the spheroid and occiput? (This is transmitted to the index fingers as a rhythmic downward and forward and then upward and backward cyclic motion, while the little fingers also move downward and backward, then upward and forward. ) Is the direction of motion that of the torsion, side-bending rotation, vertical or lateral strains?
8. Cradle the occiput in the hands, and place the tip of the index fingers on the mastoid process of the temporal bone bilaterally. (While there is no bony mastoid process at birth, the attachment of the sternomastoid muscle provides the palpatory landmark.) Is the sensation that of symmetry, or does one fingertip seem posteromedial to the other? If the tip of the mastoid is posteromedial (i.e., less prominent) the temporal bone is externally rotated. If it is anterolateral (more prominent), the temporal bone is internally rotated. This asymmetry of the mastoid process is indicative of the position of the occiput, with the internally rotated temporal bone or the prominent mastoid process being associated with the elevated lateral angle of the occiput. Is one temporal bone more anterior than the other without the medial or lateral motion? This suggests a lateral strain of the sphenobasilar articulation that has carried the head into a parallelogram distortion. Again, be still, and observe the relative mobility of the two temporal bones.
9. Steadying the head with the two fingers gently on the frontal bone, slip the other hand down and around the curve of the prominence of the occiput. Two fingers are usually adequate. Note the tension of the suboccipital muscles, and compare the two sides of the midline. Does one of the two palpating fingers come in contact with the arch of the atlas before the other? If it does, this is probably the side of condylar compression, for the occiput will have rotated anteriorly on this side. Be still, and observe the motility. Impaired motion on one side or both will suggest, respectively, unilateral or bilateral condylar compression.
10. By now the baby may have finished nursing and may even be asleep. Now change your position, and sit at the infant's right side, at the level of his lower limbs. Steady the pelvis with the left hand while placing two fingers of the right hand under the sacrum. Are the two sides of the body symmetrical? Does the sacrum project into the hand at the coccyx? Be still; observe the motion of the sacrum in relation to the ilia. Is the motion symmetrical, around a transverse axis? Or do you find a rotating motion superiorly on one side, around an anteroposterior axis?
11. Place the hands under the lumbar spine, and note the presence of lateral flexion producing a concavity to one side. Relate this to lateral motion of the pelvis.
The treatment of the craniosacral mechanism cannot be learned solely from the written word. The palpatory skills must be developed and evaluated with supervised experience. But the treatment, in summary, consists of finding the point of balanced membranous tension of the mechanism, holding it, and permitting the inherent therapeutic force within to normalize the body.
"The osteopath reasons that order and health are inseparable," said Dr. Andrew Taylor Still, "and that when order in all parts is found, disease cannot prevail." And as Dr. W. G. Sutherland reminded his students, as the twig is bent, so the tree is inclined.
Give attention to those little bent twigs, so that they may grow into handsome, healthy, happy generations for the future.
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