466 lines
26 KiB
XML
466 lines
26 KiB
XML
import Article from "@/components/Article";
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const ArticleTheTraumaOfBirth = () => {
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return (
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<Article title="The Trauma of Birth" author="Viola M Fryman, D.O.">
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<p>
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The newborn skull is designed to provide maximum accommodation to the
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forces of labor and minimum trauma to the developing brain. However,
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injury to the head during birth is more common than many people realize.
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</p>
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<p>
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In a study of 1,250 newborns I conducted a few years ago, it could be
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demonstrated that severe visible trauma was inflicted on the head–either
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before or during labor–in 10 percent of the infants. Membranous
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articular strains, which could be detected by the physician proficient
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in the diagnostic techniques of osteopathy in the cranial field, were
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present in another 78 percent. Thus, nearly nine of every 10 infants in
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the study had been affected. (1)
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</p>
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<p>
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How important are these membranous articular strains to the physician? I
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have found that common problems of the neonatal period–such as
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difficulty in sucking, vomiting, nervous tension, and irregular
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respiration–are frequently overcome just as soon as these strains are
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corrected. Similar strains are encountered in school children who have
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learning and behavior problems.
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</p>
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<p>
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In a study of 100 children between the ages of five and 14 who were
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having learning or behavioral difficulties, it was found that 79 had
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been born after a long or difficult labor and had one or more of the
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common symptoms of the neonatal period. Also, it is my impression that
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many cases of childhood allergy can be traced to musculoskeletal strains
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originating at the time of birth. (2) And vertebral scoliosis occurring
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in childhood and adolescence is, in many instances, the consequence of
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cranial scoliosis originating during birth. (3 ) Thus, recognition and
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treatment of dysfunction of the craniosacral mechanism in the immediate
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postnatal period represent one of the most, if not the most, important
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phases of preventive medicine in the practice of osteopathic medicine.
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</p>
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<p>
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To gain a clearer understanding of the origin and nature of these
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membranous articular strains, it will be helpful to review the anatomic
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features of the newborn skull and to note how they are affected by the
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forces of labor.
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</p>
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<h2>Labor</h2>
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<p>
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As was mentioned above, the newborn skull is designed to provide maximum
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accommodation to the forces of labor, minimum trauma to the infant’s
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brain, and complete restoration to free mobility of all its parts once
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the stress of labor is over.
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</p>
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<p>
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Just before birth, the infant in utero is positioned for delivery by
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presenting the smallest diameter of his head to the largest diameter of
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the mother’s pelvis; this is the position of full fetal flexion. As
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contractions continue, the infant is conducted by the inclination of the
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maternal pelvic floor into the midline for delivery around the pubic
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symphysis by a process of extension of the head.
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</p>
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<p>
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This descent in full flexion, progressing to birth by extension of the
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head, is of profound significance to the initiation of pulmonary
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respiration. The respiratory activity associated with the vigorous vocal
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activity of the newborn serves to expand the cranial mechanism and
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restore the bones and membranes to their anatomic relationships
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(permitting their free physiologic motion). Healthy sequential
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development of the central nervous system within can then continue.
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</p>
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<p>
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These ideal circumstances, however, seldom occur in our modern,
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civilized world. Owing to such factors as poor nutrition of the mother,
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structural inadequacies before and during pregnancy, drug abuse,
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inadequate preparations for labor, and, sometimes, the mechanical or
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artificial acceleration of labor by an impatient obstetrician, only a
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relatively few infants are born without undue skein or cranial trauma.
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</p>
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<p>
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Instead, structural inadequacies of the maternal pelvis may cause the
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fetus to assume a degree of extension (and lateral cervical flexion)
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greater than the ideal; the result will be a presentation of a portion
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of the head greater than the minimum occipitobregmatic diameter. This
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can range from a moderate extension to posterior occiput, to transverse
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arrest, to brow presentation, or even to a complete extension in which
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the face itself presents-a position in which vaginal delivery is
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impossible. In such a circumstance, cesarean section will be necessary
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if the baby is to survive.
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</p>
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<p>
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But the compressive forces will have already traumatized the head as the
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uterine contractions force it progressively towards the birth canal.
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Prominence of the base of an anterior maternal sacrum may obstruct
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descent of the head on one side, and such asynclitism can distort the
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cranial mechanism. The presence of large twins, both striving to present
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the head at the same time, may cause cranial stress to one or both even
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before active labor begins. These are only a few of the mechanical
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insults that may occur before birth.
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</p>
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<p>
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So much for the passage of the infant into the birth canal. Now let us
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consider the structure of the infant skull itself at the time of birth.
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</p>
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<h2>Anatomy</h2>
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<p>
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The vault of the newborn skull is a membranous structure. Plates of bone
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are enveloped in two layers of membrane, which are in apposition at the
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anterior and posterior fontanelles and sometimes at the pterion and
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asterion. These plates of membranous bone are designed to telescope into
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each other as the skull passes through the birth canal-the parietals
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overriding the frontal at the coronal suture, and the occiput at the
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lambdoid suture. The degree of this overriding is controlled and limited
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by the investing aural membranes.
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</p>
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<p>
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The bones of the base develop from the cartilaginous chondrocranium. At
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birth, development is still incomplete.(4) The occipital bone is in four
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parts, united by intraosseous articular cartilage. The spheroid is in
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three parts, the temporal in two, the maxilla in two, the frontal
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frequently in two.
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</p>
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<p>
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The cranial suture is designed for a very small but vital degree of
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motion.(5) How much greater is the potential motion of the bones of the
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developing newborn skull! At this time each part of each of these bones
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functions virtually as a separate bone, moving in relation to its other
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parts.
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</p>
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<p>
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Let us consider the occiput. It is most commonly the presenting part,
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and therefore the part that may take the brunt of the trauma of labor.
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The four developmental parts surround the foremen magnum. The base
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articulates anteriorly with the base of the spheroid. Posterolaterally,
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it articulates with the lateral masses. The hypoglossal nerve, which
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innervates the muscles of the tongue, passes out of the skull between
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the base and the lateral mass, through the intraosseous cartilage in the
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space that will become the condylar canal. The occipital condyle, which
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articulates with the atlas, spans the intraosseous cartilage; its
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anteromedial third is found on the base, the posterolateral two-thirds
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on the lateral mass.
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</p>
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<p>
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Immediately anterolateral to this condylar area is the jugular foremen,
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a space between the condylar part of the occiput and the petrous portion
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of the temporal. This foremen gives passage not only to the jugular vein
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but also to cranial nerves IX, X, and XI (glossopharyngeus, vague, and
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accessorius, respectively). The vagus nerve provides innervation to the
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gastrointestinal and cardiorespiratory systems.
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</p>
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<p>
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The supraocciput formed in cartilage fuses with the membranous
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interparietal bone to form the occipital squama. Compression transmitted
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through the squama to the condylar part on one side may disturb the
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function of the vagus and/or hypoglossal nerve, causing vomiting,
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irregular respiration, and difficulty in sucking. If this compression is
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transmitted further to the base, the relationship of the base of the
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occiput to the base of the spheroid may be distorted, causing a lateral
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strain of the sphenobasilar articulation and a parallelogram deformity
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of the cranium(5) (Figure 1).
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</p>
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<p>
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Figure 1. Lateral strain of the sphenobasilar articulation. Viewed from
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above, the sphenobasilar symphysis has been strained (displaced), with
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the basisphenoid moving to one side and the basiocciput to the other.
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Both bones side-bend about parallel vertical axes in the same direction.
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The lesion is named from the position of the basisphenoid: lateral
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strain with the spheroid to the right, etc. (From Magoun, H.{" "}
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<em>Osteopathy in the Cranial Field.)</em>
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</p>
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<p>
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Bilateral condylar compression may cause a buckling type of strain of
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the cranial base, producing a vertical strain between the occiput and
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the spheroid at the sphenobasilar articulation. This may be associated
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not only with vagal dysfunction but also with symptoms of tension,
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spasticity, opisthotonic spasms, sleeplessness, and excessive crying due
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to the irritation of the pyramidal tracts on the anterior and lateral
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aspects of the brain stem in the foremen magnum. This should be
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considered as a precursor of the spastic type of cerebral palsy.
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</p>
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<p>
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The spheroid bone is in three parts at birth; the central body bears the
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lesser wings, with the greater wings (from which the pterygoid process
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subtends) on either side. The greater wing-pterygoid unit articulates
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with the body by an intraosseous cartilage. This is situated immediately
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beneath the cavernous sinus, through which pass cranial nerves III, IV,
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and VI, innervating the extraocular muscles, and the ophthalmic division
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of V, which is sensory to the orbit, upper face and scalp. The body of
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the spheroid articulates with the base of the occiput posteriorly and is
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therefore distorted by the lateral or vertical strains resulting from
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condylar compression. Anteriorly the body carries the lesser wings,
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which enter into the formation of the orbit. The orbit is approximately
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pyramidal in shape; the apex is at the optic foremen-that is, the root
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of the lesser wing at the body. Its anatomic integrity is dependent on
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the relationship of the greater wing to the lesser wing, which is in
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fact the relationship of the greater wingpterygoid unit to the body.
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</p>
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<p>
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In the event of a lateral strain at the base due to unilateral condylar
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compression of the occiput, the orbit will be distorted by rotation of
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the base of the spheroid carrying the lesser wing anterior on one side
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and posterior on the other. In the parallelogram head due to lateral
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compression, the greater wing is compressed medially and carried forward
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on one side and posterior on the other. In either event, lateral muscle
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imbalance of the eyes is commonly found in varying degrees ranging from
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mild esophoria or exophoria to severe strabismus.
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</p>
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<p>
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The temporal bone is in two parts at the time of birth -the petromastoid
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portion, developed in cartilage that projects obliquely between the
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occiput and the greater wing of the spheroid to articulate at its apex
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with the body of the spheroid, and the squamous portion, developed in
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membrane the forms the greater part of the lower lateral wall of the
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skull. The tympanic portion is not yet a bony canal but resembles a
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horseshoe adherent to the inferior posterior aspect of the squama. These
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two parts, the squamous and tympanic, unite just before birth. The
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petromastoid portion contains the auditory and the vestibular apparatus.
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</p>
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<p>
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The auditory apparatus consists of the bony eustachian tube emerging
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between the petrous and squamous portions, from which the cartilaginous
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tube extends to the fossa of Rosenmuller. The eustachian tube is
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susceptible to distortion, which may impair hearing if lateral stress
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compresses the squamous portion. Laterally the eustachian tube opens
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into the middle ear, which, by the ossicular mechanism, transmits the
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auditory vibrations received from the tympanic membrane to the internal
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ear. The vestibular apparatus includes the semicircular canals,
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precisely related to each other and geometrically balanced with those of
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the opposite side. Distortion of the axis of the petrous portion may
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disturb this delicate mechanism of equilibrium.
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</p>
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<p>
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The maxilla develops in two parts-the premaxilla, which will give origin
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to the incisor teeth, and the body, which carries the canine and all the
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other upper teeth. Angulation between these two developmental parts of
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the maxilla gives rise to malalignment and malocclusion in later years.
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</p>
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<p>
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Thus far our consideration has been directed to certain structural
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changes that may sometimes be visible and are always palpable following
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various difficulties of labor. Radiologic techniques have been developed
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to substantiate many of these palpatory observations and confirm their
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persistence in childhood problems.(7)
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</p>
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<h2>Examination</h2>
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<p>
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The craniosacral mechanism of the newborn infant should be examined
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within the first few days of life. There is probably no field of
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osteopathic diagnosis where the injuction “if at first you don’t
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succeed, try, try again” applies more than in the examination of the
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newborn cranium. The mobility of the cranial mechanism is much greater
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at this age than it is in the adult skull, although the range of motion
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is of course much smaller. Dr. R. McFarlane Tilley used to speak of the
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amplification mechanism within the human hand and brain, which permits
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the perception of motion in the range of 0.0001 inch. It is this
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perceptive mechanism that must be developed in order to make a
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meaningful examination and to complete an adequate treatment program for
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these infants.
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</p>
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<p>
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Furthermore, one must learn to palpate motion within motion, for these
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infants rarely lie absolutely still for an examination. One should first
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consider the contours and articulations by passing the hands gently over
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the surface. Look for asymmetry, bossing of the frontals or parietals,
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grooves above the eyebrows, overlapping of one bone on the other at the
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coronal or lambdoid suture, prominence and compression of the sagittal
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or metopic suture, and depression of the pterion. Let the occiput rest
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in the palm of the hand, and note unusual prominence of the
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interparietal occiput or hard flattening of the supraocciput. Study the
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relative size and position of the eyes and nostrils and the inclination
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of the mouth. Examination for inherent motility will be facilitated if
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the baby is nursing or sleeping. Here is a check list that may be
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helpful:
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</p>
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<p>
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1. Place the hands gently on the vault, with the index fingers on the
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greater wing of the spheroid and the little fingers on the lateral
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angles of the occiput. The other fingers lie comfortably between them.
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Is your first palpatory impression that your two hands are symmetrical?
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</p>
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<p>
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2. Are the index finger and the little finger of one hand cephalad or
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superior to those of the other, as in a torsion strain. If so, the
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spheroid and occiput will have rotated around an anteroposterior axis in
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opposite directions, elevating the greater wing of the spheroid on one
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side and the lateral angle of the occiput on the other (Figure 2).
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</p>
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<p>
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Figure 2. Torsion strain. Torsion of the sphenobasilar symphysis occurs
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about an axis running from the nasion (anterosuperior) to opisthion
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(posteroinferior) at approximately right angles to the plane of the
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sphenobasilar symphysis. In bottom view, a left torsion lesion is
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diagrammed, with the greater wing and basisphenoid high on the left side
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and the basiocciput and squama lower on that same side. (From Magoun, H.{" "}
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<em>Osteopathy in the Cranial Field, </em>Second Edition. Kirksville,
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Mo.: Journal Printing Company, 1966).
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</p>
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<p>
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3. Are the index finger and little finger of one hand caudad or inferior
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to those of the other hand, with a sense of fullness in the palm of the
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inferior hand, as in a side-bending rotation strain. In this instance,
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the spheroid and occiput have side-bent in opposite directions around
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parallel vertical axes and rotated inferiorly into the convexity thus
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created.
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</p>
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<p>
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4. Is there a sensation that the index fingers on the greater wings are
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directed towards one side, while the little fingers on the occiput are
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carried to the other side? This is lateral strain (Figure 1). Owing to a
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lateral force, the spheroid and the occiput have rotated in the same
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direction around parallel vertical axes, causing a shearing strain at
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the symphysis between them.
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</p>
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<p>
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5. Are the two index fingers on the greater wings forward and downward
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(caudad) as compared with the little fingers on the lateral angles?
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Conversely, the index fingers may be superior (cephalad). These are
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vertical strains (Figure 3 ). Both superior and inferior strains are
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shown in the diagrams (superior on the left). The spheroid and the
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occiput have rotated in the same direction around parallel transverse
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axes, producing a vertical shearing strain at the sphenobasilar
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articulation.
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</p>
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<p>
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Figure 3. Vertical strains of the sphenobasilar symphysis. Viewed from
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the side, the sphenobasilar symphysis has been strained or displaced
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before ossification, with the basisphenoid moving cephalad (flexion) and
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the basiocciput moving caudad (extension), or vice versa. Both bones
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rotate about parallel transverse axes in the same direction. (From
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Magoun, H. <em>Osteopathy in the Cranial Field </em>Second Edition.
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Kirksville, Mo.: Journal Printing Company, 1966.
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</p>
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<p>
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6. Is there a sense of hardness and tension under your hands, resembling
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wood? This suggests a compression strain.
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</p>
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<p>
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These palpatory observations of asymmetry are clues to the dysfunction
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of this mechanism: But it is the nature of the inherent cranial rhythmic
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impulse-its symmetry, rate, amplitude, and constancy of pattern- that is
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important. If the inherent motion is distorted, impeded, limited, or
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retarded, there are certainly membranous strains that need attention.
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</p>
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<p>
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It is not possible to develop the necessary tactile skills in a few days
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or during a brief course of instruction. But with assiduous application,
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the sensitivity will be developed, and you will be able to make these
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vital diagnoses at the age when they are most susceptible to correction.
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</p>
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<p>
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7. With your index finger on the greater wing of the spheroid and your
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little finger on the lateral angle of the occiput, be still and permit
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the mechanism to convey its movement through your fingers and hands. Is
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there rhythmic, symmetric expansion and contraction of{" "}
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<strong>external and internal rotation </strong>of the bilateral vault
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bones that accommodates the <strong>flexion and extension </strong>of
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the spheroid and occiput? (This is transmitted to the index fingers as a
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rhythmic downward and forward and then upward and backward cyclic
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motion, while the little fingers also move downward and backward, then
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upward and forward. ) Is the direction of motion that of the torsion,
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side-bending rotation, vertical or lateral strains?
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</p>
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<p>
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8. Cradle the occiput in the hands, and place the tip of the index
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fingers on the mastoid process of the temporal bone bilaterally. (While
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there is no bony mastoid process at birth, the attachment of the
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sternomastoid muscle provides the palpatory landmark.) Is the sensation
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that of symmetry, or does one fingertip seem posteromedial to the other?
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If the tip of the mastoid is posteromedial (i.e., less prominent) the
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temporal bone is externally rotated. If it is anterolateral (more
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prominent), the temporal bone is internally rotated. This asymmetry of
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the mastoid process is indicative of the position of the occiput, with
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the internally rotated temporal bone or the prominent mastoid process
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being associated with the elevated lateral angle of the occiput. Is one
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temporal bone more anterior than the other without the medial or lateral
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motion? This suggests a lateral strain of the sphenobasilar articulation
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that has carried the head into a parallelogram distortion. Again, be
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still, and observe the relative mobility of the two temporal bones.
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</p>
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<p>
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9. Steadying the head with the two fingers gently on the frontal bone,
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slip the other hand down and around the curve of the prominence of the
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occiput. Two fingers are usually adequate. Note the tension of the
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suboccipital muscles, and compare the two sides of the midline. Does one
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of the two palpating fingers come in contact with the arch of the atlas
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before the other? If it does, this is probably the side of condylar
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compression, for the occiput will have rotated anteriorly on this side.
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Be still, and observe the motility. Impaired motion on one side or both
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will suggest, respectively, unilateral or bilateral condylar
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compression.
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</p>
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<p>
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10. By now the baby may have finished nursing and may even be asleep.
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Now change your position, and sit at the infant’s right side, at the
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level of his lower limbs. Steady the pelvis with the left hand while
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placing two fingers of the right hand under the sacrum. Are the two
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sides of the body symmetrical? Does the sacrum project into the hand at
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the coccyx? Be still; observe the motion of the sacrum in relation to
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the ilia. Is the motion symmetrical, around a transverse axis? Or do you
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find a rotating motion superiorly on one side, around an anteroposterior
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axis?
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</p>
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<p>
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11. Place the hands under the lumbar spine, and note the presence of
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lateral flexion producing a concavity to one side. Relate this to
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lateral motion of the pelvis.
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</p>
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<p>
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The treatment of the craniosacral mechanism cannot be learned solely
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from the written word. The palpatory skills must be developed and
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evaluated with supervised experience. But the treatment, in summary,
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consists of finding the point of balanced membranous tension of the
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||
mechanism, holding it, and permitting the inherent therapeutic force
|
||
within to normalize the body.
|
||
</p>
|
||
<p>
|
||
“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.
|
||
</p>
|
||
<p>
|
||
Give attention to those little bent twigs, so that they may grow into
|
||
handsome, healthy, happy generations for the future.
|
||
</p>
|
||
<h2>References</h2>
|
||
<p>
|
||
1. Frymann, V. M. Relation of disturbances of craniosacral mechanism to
|
||
symptomatology of the newborn: Study of 1,250 infants.{" "}
|
||
<em>J.A.O.A. 65 </em>(1966), 1059-1075.
|
||
</p>
|
||
<p>
|
||
2. Frymann, V. M. The osteopathic approach to the allergic patient.{" "}
|
||
<em>D.O. 10:7 </em>(1970), 159-164.
|
||
</p>
|
||
<p>
|
||
3. Cathie, A. Growth and nutrition of the body with special reference to
|
||
the head. <em>Yearbook of the Academy of Applied Osteopathy, </em>
|
||
1962,pp.149-153.
|
||
</p>
|
||
<p>
|
||
4. Crelin, E. S. <em>Anatomy of the Newborn: An Atlas. </em>
|
||
Philadelphia: Lea & Febiger, 1969.
|
||
</p>
|
||
<p>
|
||
5. Pritchard, J. J., Scott, J. H., and Girgis, F. G. The structure and
|
||
development of cranial and facial sutures. <em>J. Anat. 90 </em>
|
||
(1956), 73-86.
|
||
</p>
|
||
<p>
|
||
6. Magoun, H. I. <em>Osteopathy in the Cranial Field, </em>Second
|
||
Edition. Kirksville, Mo.: Journal Printing Company, 1966, p. 133.
|
||
</p>
|
||
<p>
|
||
7. Greenman, P. E. Roentgen findings in the craniosacral mechanism.{" "}
|
||
<em>J.A. O.A. 70 </em>(1970), 60-71.
|
||
</p>
|
||
<p>
|
||
8. Still., A. T. <em>Philosophy of Osteopathy. </em>Ann Arbor, Mich.:
|
||
Edwards Brothers 1899
|
||
</p>
|
||
</Article>
|
||
);
|
||
};
|
||
|
||
export default ArticleTheTraumaOfBirth;
|