Reference has already been made to certain accidents of embryology during the very early days or weeks of the formative period of the embryo. Common illustrations of such deforming developmental accidents are harelip, cleft palate, and club foot.

HARELIP AND CLEFT PALATE

In the case of a partial or complete failure of the two sides of the face to come together in the median line, a deformity results which is known as harelip—a partial or complete cleft of the upper lip. It may be a single or a double cleft, exposing the teeth, or the cleft may even extend up into the nose. This deformity may seriously interfere with nursing, making it necessary to resort to feeding with a medicine dropper and later a spoon. The success of the operation for the relief of harelip, which should usually be performed during the early months of life, is often very remarkable.

Should this failure to unite be in the deeper structures of the head, then cleft palate is the result. This, too, may be partial or complete: partial as seen in a cleft of the soft palate only; and complete, when the hard palate also is involved. In such an instance it is the floor of the nose that is defective; hence the nose and mouth are one cavity.

A specially devised apparatus which assists the child in nursing may be found on the market, for nursing is well-nigh impossible without the closure of the roof of the mouth. The operation for cleft palate is usually successful when performed at the proper time and by competent hands.

In tongue-tie the weblike membrane underneath is attached too far forward, so that the child is quite unable to protrude his tongue, and this condition greatly interferes with sucking. The operation for the relief of this condition is slight, and should be performed as soon as the defect is discovered.

DEFORMED HANDS AND FEET

Occasionally there is a webbing of one or more fingers of the hand, and there are sometimes seen too many fingers or a double thumb. It is needless to allow such a deformity to continue; the operation for relief is often remarkably successful and should be performed very early.

Clubfoot results when short tendons or contracted tendons pull the toes inward or outward with raising of the heel. Treatment must be instituted early; braces or splints are applied; and untiring efforts are put forth in massage and other lines to prevent a lifelong handicap of clubfoot.

An inward rotating of the legs presents the deformity of pigeon-toe. The normal foot naturally inclines toward "pointing in," and such a condition should not be discouraged. Many flat feet (broken arch) are due to shoe lasts which compel the toes to slant "out," and the bunions which so often follow such mistreatment may be exceedingly painful.

By all means place shoes on the pigeon-toed child that possess straight lasts with flexible arches, and which admit of the exercise of many muscles of the foot which otherwise remain inactive.

As the child grows older the toenails thicken, and often in their trimming they are cut so closely at the corners that sometimes a condition results known as ingrowing nails. Such are very painful and must receive special attention. First of all, the nail is cut squarely, and after scraping it thin the corner is lifted and cotton so placed under it that the nail's downward and inward growth is stopped.

SPINAL CURVATURE

Curvature of the spine is more common than is usually thought. The most frequent variety of it is the lateral curvature. One shoulder is lower than the other, and the hips are therefore uneven. Rickets, during infancy, is the most common cause of spinal curvature.

Improper sitting at school—sitting on the edge of the seat—or carrying heavy loads are often contributing factors to the production of lateral curvatures. Only the muscles and ligaments enter into this deformity, hence the treatment should be started early and should consist of:

1. Stretching exercises.
2. Hanging from the rounds of a ladder securely fastened to the wall.
3. Certain applications of hot fomentations to the spinal muscles for their relaxation.
4. Firm cushion placed under one or other of the hips to encourage the re-establishment of muscular poise.
5. Special supervision of the case.

POTT'S DISEASE

Pott's disease, or tuberculosis of the bone, often results in an angular spinal deformity. This curvature, unlike the lateral curvature, is a sequela of an actual disease of the bones. It is always very serious and demands early treatment from skilled hands. Early in the disease there is a peculiar stiff, tottering gait. The little child holds the spine rigidly, and in picking up objects from the floor bends the knees instead of the spine. If the trouble is in the upper spine, the shoulders are held high and the head is stiffly poised, it is never rotated; in looking about the entire body turns.

Medical aid should be secured early. The X ray not only locates the difficulty but also determines the extent of the process. If the spine be put to perfect rest, outdoor life begun, a diet rich in fats established, the results are often wonderfully successful.

Another tubercular condition is seen in the much dreaded hip-joint disease which parents should always be on the lookout for. The earliest symptoms are crying out in the night suddenly, unnatural standing on one leg (to relieve the strain on the diseased hip) and so-called "growing pains." Call in a physician very early and institute proper treatment. A posterior curvature of the spine is often associated with a bad case of rickets. It is of temporary duration, and usually clears up when the symptoms of rickets have been eradicated. It involves only the back muscles—not the vertebral bones.

The young mother is often very much concerned over the misshapen head of the child as a result of a prolonged labor; and it does seem quite miraculous to see a head, more nearly resembling an egg than anything else, become beautifully round and shapely by the end of two or three days.

Protruding ears may be encouraged to lie more flatly by the wearing of a specialized bonnet at night. When the babies are too young to turn themselves they should be turned first to one side and then the other, while care should always be exercised in properly straightening out a curled under ear or an overlapping ear.

RHEUMATISM

While we so often regard rheumatism an adult disease, nevertheless, children do suffer its aches and pains as well as the fever which so often attends the inflammatory type. The so-called "growing pains" are often of rheumatic origin.

Diseased tonsils not only are often—very often—the avenue of entry of infectious microorganisms that cause one type of rheumatism, but many forms of valvular heart disease are also directly traceable to these same diseased tonsils. The treatment consists in giving proper attention to the tonsils, even removal if necessary—and if the child is old enough. All other possible causes should be located and removed; the child should have absolute rest in bed with brisk cathartics and a liquid diet (no meat broths). The diet should consist more of alkalinizing foods as shown in the special table in the appendix. Medicinal alkalines are often given when the urine shows a very high acid reaction.

SCURVY

Scurvy, seen in children who subsist on "prepared foods," is manifested by tender legs and swollen gums which have a tendency to bleed easily. Pallor, loss of appetite, and insomnia accompany the condition. The treatment of scurvy is change of diet from "patent foods" to fresh cow's milk, with the addition of orange juice, daily. In older children the food must be very nutritious; out of door life, salt glows, friction baths (see appendix), and the taking of large amounts of fats are all essential to the cure.

ADENITIS—ENLARGED GLANDS

Enlarged glands, or what our grandmothers used to call "kernels" in the throat are often the result of inflammation in the mouth or throat, and occur in connection with many of the childhood diseases, notably diphtheria, scarlet fever, and scarlatina.

Glands appearing in the back of the neck may be occasioned by pediculli (lice), ring worm, or eczema, while those seen in the neck just back and below the ears may come from mastoiditis (inflammation of the middle ear) or adenoids.

Glands felt under the arm enlarge because of trouble or infection in the breast, hand, or arm; while glands in the groin are usually due to some infection of the feet, legs, or abdomen.

These glands usually disappear when the general health and well-being of the child is improved by:

1. Outdoor life.
2. Morning dry-friction rub to the skin.
3. Good liberal diet, including plenty of fats.
4. No feeding between meals.
5. The salt glow and general tonic treatment (see appendix).
6. The oil rub at night.

RICKETS

Rickets (a disease of the bones) often follows in the wake of faulty feeding and unhygienic surroundings. The bones lack a proper amount of lime salts and other elements. Development in general, especially that of the bones, is greatly interfered with.

Bowlegs, prominent square brow, enlarged perspiring head, weakness, and often tenderness of the flesh, are notable signs of the disease. The treatment varies little from that of scurvy, and will be provided in detail by the attending physician.

MALARIA

Children often suffer from malarial parasites. Sudden rise of fever on regular days (sometimes daily, every two days or every three days) should demand a careful medical examination including the examination of the blood where the offending organism is seen in the red blood cells. We recently saw a little girl who happened to have an earache and was about to be operated on for ear trouble, when examination of the blood revealed the fact that she was suffering from malaria.

TUBERCULOSIS

In the routine examination of adult patients, the X ray observations of the lungs often reveal deposits of lime salts which tell the story of a successful fight against tuberculosis (Fig. 16). And while it may seem surprising, we believe beyond a doubt that most of us have had some varying degree of tuberculosis while young—the unrecognized battle has been fought—and these small monuments of lime salts alone remain to tell the interesting story.

The pity of it is that whole armies of little folks fall in this struggle against disease, for it is one of the common and fatal diseases of childhood. Fresh-air schools, playgrounds, and free school lunches are saving hundreds of children from the ravages of this disease each year.

Tuberculosis is strictly a house disease, hence the little tubercular patient must seek outdoor life. All avoidable exposure to the disease must be denounced, and public sentiment must continue to be aroused to the hygienic betterment of the tenement districts and basement homes. The sanitary drinking cup and the bubble fountain must be encouraged, as must also the proper ventilation of all places where crowds assemble, be it the schoolroom, the theater, or the church.

While tuberculosis is known as the "great white plague," syphilis and gonorrhea constitute the "great black plague," which seen in the little folks is pitiable indeed, leading us to realize that surely "the children's teeth have been set on edge" because of the careless eating of sour grapes by the parents. Syphilitic parents who have not been properly treated, should think many times before they take upon themselves the awful responsibility of bringing into the world a tainted child. Proper mercurial treatment should be instituted at once not only for the child but also in the case of both parents.