Ability to observe quickly and accurately is seldom more needed than it is by a woman who cares for children. No one expects babies to explain their troubles, but people forget that small children are unable to describe their physical sensations with any degree of accuracy, although discomfort or sickness may show itself in all degrees of ill temper and bad conduct. For these exhibitions many a suffering child has been punished, where an older and more articulate person would have received considerate attention.

Children, like babies, have a low resistance to disease. Moreover, they react quickly both to favorable and to unfavorable surroundings. Hence slight causes sometimes produce p.r.o.nounced or even violent symptoms in children without giving cause for great anxiety, although the same symptoms if exhibited by adults, might indicate critical illness. On the other hand the recuperative power of children is high, and their recoveries are sometimes surprisingly rapid. It is a mistake, when a child has completely recovered from an acute but brief illness, to coddle him for weeks afterward merely because a grown person in similar circ.u.mstances would have failed to regain his strength.

When a child is sick in bed, especial efforts should be made to insure adequate ventilation without chilling him. Children always lose heat rapidly because the body surface is proportionately large; when they are ill, therefore, it is especially necessary to keep them well covered, to see that their hands and feet are warm, and to avoid chilling them during their baths. But overheating must also be avoided, since all children, sick or well, who are too warmly dressed or who stay in rooms that are too warm, become weak and irritable and more susceptible than others to colds and other respiratory disorders. The child's skin should be kept clean and dry, but he should not be disturbed nor handled unnecessarily.

Sick children require very simple food at short intervals. Variety is not so necessary for a child as for an adult, unless the child has been allowed to form bad habits of eating. Sick children should not be indulged unnecessarily, either in regard to their food or in other ways.

However, attempts made during an illness to change the habits of a badly trained child are unwise because usually unsuccessful; parents who sow the wind by neglecting to train their children when they are in good health may as well make up their minds to reap a veritable whirlwind when the children are ill. Even when children are well trained it is difficult and sometimes impossible to prevent them from forming bad habits during sickness. Yet the labor of training a child reaps perhaps at no other time a richer reward than it does when the child is ill, and his recovery might be seriously impeded by unwillingness to accept necessary food, medicine, or treatment.

PHYSICAL DEFECTS are faults in the structure of the body; adenoid growths, imperfect eyes, abnormally curved spines, and defective teeth are examples. Most physical defects can be cured in childhood by treatment or by slight operations. If untreated they frequently lead to sickness or to serious impairment of the body, and if neglected until adult life their injurious consequences are generally beyond remedy, even when the defects themselves can be repaired.

Some indications of common physical defects are given below; they ought to be more generally known than they are. If a child exhibits one or more of the symptoms mentioned, he ought to be given a complete physical examination by a competent physician, and treatment, if needed, should begin without delay. The idea that children will outgrow these defects without treatment is erroneous. Better, however, than waiting until symptoms appear is the modern way of giving every child a physical examination at stated intervals, a practice already common in public schools where effective health work is carried on.

EYESTRAIN frequently comes from imperfections in the shape of the eye; these imperfections can almost always be corrected by gla.s.ses. When a child is suffering from eyestrain, the eyes themselves may show indications of trouble; they may be blood-shot, the lids may itch or be crusted or inflamed, or styes may appear. In other cases the symptoms of eyestrain have no apparent connection with the eyes; such symptoms are headache, nausea, vomiting, indigestion, fatigue, irritability, poor scholarship, and nervous exhaustion. If a child shows any of these symptoms, or if he rubs his eyes, frowns, squints, wrinkles his forehead, sits bent over his book, or develops round shoulders, there is sufficient reason for having his eyes examined by an oculist.

Examination by an optician should not be considered sufficient.

ENLARGED TONSILS AND ADENOIDS.--The tonsils are ma.s.ses of spongy tissue situated at the back of the mouth, on either side of the opening into the throat. If enlarged they may seriously interfere with breathing, and if diseased they frequently harbor the germs causing many acute infections, as well as germs of rheumatism and most of the heart disease originating in early life. Therefore the tonsils ought to be removed if they are diseased or greatly enlarged, but there is ordinarily no good reason for removing normal tonsils.

Adenoids are situated at the back of the nose, and like the tonsils are composed of spongy tissue. Adenoids sometimes become so enlarged that they interfere with the pa.s.sage of air through the nose, thus predisposing to catarrh, colds, and other respiratory diseases, to high palate with irregular teeth, to inflammation of the middle ear leading to deafness, to diminished mental activity, and to general poor health.

If a child breathes through his mouth, if he snores at night, keeps his mouth open and has a dull, apathetic expression, his nose and throat should be examined, and if advisable his tonsils and adenoids should be removed.

DEFECTIVE HEARING.--Permanent deafness among children in the great majority of cases comes from trouble in the throat or nose; hence the most effective measure to prevent deafness is to make sure that every child's nose, throat, and mouth are in a normal condition. Sensitive or timid children try to hide infirmities of any kind, but deaf children seem peculiarly unable to explain their difficulties. "No one," says Cornell, "has ever recorded that a small child complained of inability to hear." A child's ears should be examined if he breathes through his mouth, if he stoops habitually, if he is persistently inattentive, or if he is vague or stupid in carrying out directions. A child who appears normal at times and inattentive or stupid at other times should also be examined, since he may be deaf in one ear.

Temporary deafness may come from acc.u.mulated wax in the ear. The wax should be removed by a doctor; inexpert attempts are likely to cause serious injury to the ear drum. Intermittent deafness may be caused by enlarged tonsils and adenoids. Children thus affected are not infrequently punished for seeming disobedience. Such children are especially liable to street accidents.

DEFECTIVE TEETH have been considered on page 44.

POSTURE.--In childhood the bones are soft and yield with comparative ease to continued strains; hence they often become deformed by bad positions a.s.sumed in sitting, standing, or in using the body in other ways. The postures habitually a.s.sumed by a child should be noticed and good postures should be insisted upon. But it is not enough to admonish him. The various causes tending to encourage bad positions should be corrected; among them are insufficient illumination of books and work, defective eyesight or hearing, obstructions in breathing, muscular weakness, and low general vitality. Children should have their chairs and tables suited to their size for their work both at home and in school.

[Ill.u.s.tration: FIG. 28.--INCORRECT SITTING POSTURES. (_From Cornell, "Health and Medical Inspection of School Children." F. A. Davis Co., Philadelphia._)]

[Ill.u.s.tration: FIG. 29.--INCORRECT SITTING POSTURES. (_From Cornell, "Health and Medical Inspection of School Children." F. A. Davis Co., Philadelphia._)]

[Ill.u.s.tration: FIG. 30.--INCORRECT SITTING POSTURES. (_From Cornell, "Health and Medical Inspection of School Children." F. A. Davis Co., Philadelphia._)]

[Ill.u.s.tration: FIG. 31.--INCORRECT AND CORRECT STANDING POSTURES. (_From Cornell, "Health and Medical Inspection of School Children," F. A. Davis Co., Philadelphia._)]

The adjustable chairs and desks now used in schools are a marked improvement upon the school furniture which has caused so many deformities in the past.

[Ill.u.s.tration: FIG. 32.--ROUND SHOULDERS. (_Goldthwait, from Pyle's "Personal Hygiene."_)]

One of the serious deformities caused by habitual faulty posture is curvature of the spine. A curvature not only injures a child's appearance and thus handicaps him in later life, but it brings strains and pressure upon the organs of the chest and abdomen which may seriously impair his health. As curvatures often pa.s.s unnoticed in their early stages, every child should be inspected occasionally when all his clothing has been removed, to see whether the weight is borne evenly on both feet, whether the development of the two sides is uniform, and whether the head and shoulders are properly carried. It should be noticed when the child stands, whether one shoulder is higher than the other, whether one shoulder blade projects more than the other, whether one hip is higher than the other, and whether one hand is lower than the other when the arms are hanging at the sides. The child should walk both toward and away from the observer, who should notice whether the child uses the two sides of his body in the same way, and whether he drags or shuffles his feet or has other abnormalities of gait.

[Ill.u.s.tration: FIG. 33.--LATERAL CURVATURE. (_From Bancroft's "Posture of School Children." The Macmillan Co., New York._)]

[Ill.u.s.tration: FIG. 34.--"WING SHOULDER BLADES IN FORWARD SHOULDERS.

(_From Bancroft's "Posture of School Children." The Macmillan Co., New York._)]

If abnormalities are found, a physician should be consulted. Often corrective exercises are all that is needed, and no one should put braces of any kind upon a child unless they have been prescribed by a physician. No attempt should be made to correct the common tendency of children to toe in or "walk pigeon-toed." Toeing-in is a natural manner of walking during the formative period and tends to strengthen the arch of the foot, while toeing-out tends to weaken the arch and to cause flat foot or broken arches.

PREDISPOSITION TO NERVOUSNESS.--Heredity plays an important role in the predisposition to nervousness, so that children of nervous parents are particularly likely to show nervous instability. It is, however, difficult to say in a given case how much of his nervousness a child inherits and how much he acquires by imitating the irritability, the out-breaks of temper, and the other evidences of imperfect emotional control displayed by his nervously disposed parents. On the other hand, even children of nervous predisposition sometimes overcome their defects to some extent by imitating parents who have acquired self-control.

Children predisposed to nervousness should be watched with special care, but they should not be allowed to realize that they are the objects of unusual solicitude. They need the most favorable surroundings that can be obtained, and their general health should be maintained at the highest possible level. Any condition that lowers vitality tends to increase their troubles; nervousness may be caused among children of good inheritance, and increased among others, by poor nutrition, lack of exercise and play out-of-doors, fatigue, loss of sleep, eyestrain, adenoid growths, and the poisons of infectious diseases.

It is characteristic of many nervous children that they are too easily stimulated; they may be excitable, restless, unnaturally quick in moving, over-sensitive to pain and discomfort, easily fatigued, irritable in temper, and unable to control the emotions. They frequently make involuntary motions like grimacing and winking the eyes. Children of low nervous tone, however, are not necessarily excitable. A nervous child may be muscularly weak, awkward in gait, listless, dull, clumsy, forgetful, and inattentive. Such children often suffer from cold hands and feet and from profuse perspiration.

Much can be done for these unfortunate children by removing the cause of their troubles if possible, by giving them simple and wholesome surroundings, by suiting their occupations to their strength, by eliminating mental strain, particularly during the adolescent period, and by training them to control their minds as well as their bodies.

"In addition to the hardening of the body, the education of the child should include measures which increase the resistance of the child against pain and discomforts of various sorts. Every child, therefore, should undergo a gradual process of 'psychic hardening' and be taught to bear with equanimity the pain and discomfort to which everyone sooner or later cannot help but be exposed. What I have said about clothing, cold baths, walking in all weather and at all temperatures, play and exercise in the open air, has a bearing on this point, for a child who has formed good habits in these various directions will have learned many lessons in the steeling of his mind to bear pain and to ignore small discomforts."--(Barker: "Principles of Mental Hygiene Applied to the Management of Children Predisposed to Nervousness.")

CONVALESCENT PATIENTS

After serious or prolonged illness the vitality is generally low and all bodily processes are likely to be depressed. During convalescence, therefore, the digestion is feeble, the muscles are weak so that fatigue follows slight exertion, and the sluggish condition of the circulation renders the patient especially sensitive to cold. Since the nervous system also becomes depressed and irritable, a convalescent patient is easily excited, easily discouraged, and quickly fatigued by mental effort. He finds the simplest decisions hard to make, and his emotions difficult to control; indeed, many a patient who has borne acute pain with unflinching courage becomes peevish at this stage, weeps easily, and expects more expression of sympathy than is good for him. Some persons naturally make quick recoveries, while others recuperate slowly. A long and tedious convalescence, it should be remembered, is the patient's misfortune rather than his fault.

In restoring a convalescent patient to normal living it is imperative to proceed slowly. Food should be increased gradually both in variety and in amount; but the patient's appet.i.te is not always a safe guide, and it may need to be encouraged or to be restrained. Both mental and physical exertion should begin only under careful supervision, and should increase by slow degrees. The patient should sleep as much as possible, should take long intervals of rest, and should continue no occupation to the point of fatigue. A patient who has been ill in a hospital or who has had at home the exclusive services of a nurse or an attendant, often finds the period following his return or following the nurse's departure an exceedingly difficult transition. The family should not expect or allow him to resume too many duties at a time when the mere acts of bathing and dressing may demand all the strength he has. Many convalescents are obliged, or think they are obliged, to take up regular work again before their strength is fully restored. There is generally no economy in so doing; indeed, time is saved in the end by waiting until recovery is complete before undertaking full work.

Important as it is to build up the patient's physical strength, it is hardly less important to direct his thoughts away from himself and his sickness, and to help him renew his interest in normal living. During his illness he has of necessity relied upon the judgment and support of other persons, and his pain and discomfort have forced him to think constantly of himself and his many needs. The habit of sickness is readily broken by some persons, particularly by those whose nervous exhaustion has not been great and whose interests outside themselves are naturally keen. But the sick point of view has remarkable tenacity, and other patients, unless circ.u.mstances or deliberate efforts redirect their thoughts, will look upon themselves as invalids to the end of time.

Hopefulness promotes health, while discouragement, apprehension, and unhappiness lower the tone of the whole system. Hence set backs, failures, delays, and relapses should not be dwelt upon, but signs of progress should be mentioned; judiciously however, since overdone attempts to cheer a patient seldom fail to have the opposite effect. If objects or situations that suggest undesirable thoughts are eliminated, the less often those thoughts tend to recur. Therefore, in order to break the habit of sickness, old thoughts must be gradually banished and new ones must be subst.i.tuted. Sick-room appliances should be put out of sight as soon as they are no longer needed, and the patient may profit by moving into a different bed room. A few days spent away from home as soon as his strength permits often prove effective in breaking up sickness a.s.sociations; the patient is generally encouraged when he finds that he can sleep in a different bed, endure some fatigue, and exist without daily visits from the doctor. Even a day spent at a different house in the same town sometimes directs the patient's thoughts into fresh channels. Gradually, but as quickly as safety allows, he should take his place in the normal family life and cease to be treated as an exception.

Merely eliminating a.s.sociations with sickness, however, is not enough; and exhorting a patient to forget himself and to become interested in something seldom accomplishes anything, especially if he is so depleted by illness that the thought of everyday activities suggests only weariness and pain. A person so weak that he is thoroughly fatigued by dressing himself should not be expected to view with enthusiasm the prospect of a full day's work. Much, however, may be accomplished by providing something that the patient really likes to do, and deliberate efforts must be made to stimulate his interest in some occupation, however simple it may be.

Occupations for invalids are more than a means to pa.s.s away the time; they are also of distinct curative value. The patient's interest is not always easy to arouse, and some ingenuity may be needed in the beginning; sometimes interest is best aroused by working at some handicraft in his presence, and finally offering, as a favor, to teach him to do it also. His interest in any occupation is invariably increased if a well person not only directs but shares in the work.

Care should be taken to select occupations suited to the patient's physical condition, to his age, tastes, and mental development. Two or three occupations are better than one, so that he may change from one to another before any one becomes tedious. Work requiring fine motions, close attention, or concentrated thought should be used for short periods, only, and no work should be continued to the point of fatigue.

The patient should not be allowed to feel that he must finish a certain amount in a certain time. Even poor work is better than none, and a patient should always be encouraged by judicious praise.

Games and puzzles are useful to some extent, but an aimless occupation is not so beneficial as one which has a tangible product, particularly a product that is useful as well as beautiful. Occupations frequently possible for invalids and convalescents include knitting, crocheting, many kinds of needle work, clay modeling, basketry, stenciling, weaving, book-binding, metal work, and photography. Manuals are now available giving directions for these and many other handicrafts. Sick children often enjoy collecting stamps, post marks, and other objects, making sc.r.a.p books, sewing, weaving, knitting, paper folding, and various other kindergarten occupations.

CHRONIC PATIENTS

The whole field of caring for the sick offers nowhere greater opportunity for fine and finished work than it offers in the case of chronic invalids. It is an achievement of which an artist might be proud to make a chronic patient comfortable in body, happy in mind, and agreeable to others. Moreover, since success can never be attained by one who wearies in well doing, the care given to a chronic invalid tests not only the attendant's skill but also her moral and spiritual quality.

Care of a chronic patient has for its aims maintaining the patient's health, rendering him as happy and comfortable in mind and body as it is possible for him to be, and providing whatever special treatment and attention his case requires. In order to maintain his health constant attention must be given to diet, to hygiene of the sick room, and indeed to all his surroundings. In many chronic illnesses, such as rheumatism and kidney disease, the diet is prescribed by the doctor; in every case care should be taken that the patient is not overfed or underfed, that the food is suited to his digestive powers, that foods causing flatulence are eliminated, particularly if the patient's trouble is heart disease, and not the least important requirement, that he derive as much pleasure from his food as possible.

The regular daily care of the patient and of his room, already described in this book, should be scrupulously carried out, and no less scrupulously during the tenth year than it was during the tenth day.

Cleanliness in every detail is absolutely essential to the patient's welfare; no one is more unpleasant either to himself or to others than a chronic patient who is neglected. Patients who are constantly in bed, it should be remembered, and paralyzed patients in particular, are peculiarly susceptible to pressure sores. If a patient is able, it is extremely important for him to sit up in a chair part of the day.

Sitting up should never be omitted because it involves the expenditure of time and trouble for the attendant.

It is often said that for most people some personal experience of sickness is beneficial; it can safely be said, however, that no one benefits from spending any considerable portion of his life in a state of helplessness and suffering. Behavior and character itself are determined by influences constantly coming into the mind from daily surroundings and a.s.sociations with other people: one who recalls this fact needs only a moment's reflection to realize how ill adapted to healthy development of mind and character are the limited lives of the sick. Especially unfortunate is the situation of chronic invalids, shut off as they are from the objective interests and activities of normal life, deprived of all practice in making the salutary small adjustments and sacrifices required in every day living with other people, and self-centered as they necessarily tend to become from the inevitable focusing of attention upon their own discomforts and pain.

On the whole, a surprisingly large number of invalids successfully resist the disintegrating effects of sickness upon character. But it is nevertheless true, as Dr. Weir Mitch.e.l.l says, that "Sickness enn.o.bles a few but debases many." A selfish invalid has more than once destroyed the happiness of an entire family, or spoiled the life of one member of it by monopolizing her whole time and attention. Families should remember that their injudicious sacrifices seldom bring enduring happiness or contentment to the patient himself; indeed, in the long run such sacrifices generally injure him even more than they injure his victims. Clearly much must and should be sacrificed by members of a family to the needs of an invalid; but in general it may be said that a sacrifice is injudicious if it relieves the patient of activity or responsibility that he can support without injury, if it makes him more dependent in mind or body, if it results in restricting his attention to himself and his affairs, or if it increases his tendency to make demands on others.

Purposeful activity of some sort and the necessity for contributing to the welfare of others are essential parts of a wholesome life. If these essentials are entirely eliminated from the life of an invalid, the patient's greatest needs are probably left unsatisfied, even though the physical care he receives may be perfect in every detail. All that was said in regard to occupations for invalids applies with particular force to occupations for chronic patients, since however valuable manual occupations may be as a means to bring about recovery, they are still more valuable in furnishing interest and purpose in a life whose only prospect is a succession of weary, useless years. Handicapped patients sometimes learn occupations that yield a financial return, and ability to earn even a little stimulates self respect and mental health, whether the money is needed or not. The important point, however, is that the finished product should have a recognized use.

In addition to enabling the patient to make things with his hands, a way should be found if possible by which he may contribute to the group of people with whom he lives. If a way can be discovered for him to do so, the opportunity should not be denied him nor should his service fail to be noted and appreciated, even if it is nothing more than telling a story to a restless child.