AN_EMIA OF SCHOOL CHILDREN Various unfavorable influences are at work in the development of school amemia. Vitiated air may cause a bad effect by acting on the nervous system and thus causing disgust in tender children; overheating is also a factor, especially if the heat is supplied from a central furnace; further, exertion, purely psychic causes, longing for the mother, ambition, anxiety; finally the lack of fresh air may well be of greater importance than the presence of bad air. Some children become affected in the first six months of their school work; others only in later years, as increased studies make greater demands upon them. The children of the poor are distinctly more affected in large cities than those of the rich. This is even more so in children of widows, which is explained not only by unfavorable surroundings, but also by unsuitable psychic influences on the part of the mother. Here, as in all forms of anaemia, hereditary tendency and especially nervous debility play a considerable role; ill ness or advanced age of the parents at the time of birth of the children, tendency to migraine and similar disturbances, favor the development of school anaemia and make its cure more difficult.
Symptoms.—The subjective complaints and nervous troubles are fatigue, heaviness in the legs, headaches which occur principally in school, vomiting at school which in severe cases may be repeated almost daily. Especially after bodily exertion, such as gymnastic exercises, there is pain in the sides and epigastric region. Parents notice the de pressed condition of the child, the decreased vitality, increased desire to sleep, and diminished inclination to take part in games. Sleep is restless and often disturbed by attacks of pavor nocturnus. There is less appetite (the lunch is brought back home), and the bowels are irregular.
The objective signs are: weakened constitution, pallor of the form erly fresh complexion and mucous membranes, decrease of the subcuta neous fat and a striking flabbiness of the muscles. Respiration and pulse are frequently accelerated, the pulse may be full, but soft. Examination of the blood shows a decrease of haunoglobin and of red blood corpus cles; sometimes the latter show differences of form, also a slight in crease in leucocytes; usually the changes are not very pronounced or they may be absent altogether in spite of severe clinical symptoms.
Cardiac dulness is sometimes slightly increased; the impulse may be widened and surprisingly strong. Heart murmurs are found, espe cially after slight exertions, and the first sound may be reduplicated or impure, or accompanied by a slight murmur. Over the cervical veins a venous 1111111 may be distinguished even in infants.
Many otherwise robust children, who are at once affected in their first school year by the mere change of conditions, or perhaps later owing to unfavorable exterior influences, recover rapidly after a short vacation; others, if once affected, may drag the trouble with them throughout their school life. These are usually weak children with an hereditary taint. In cases of this kind the prognosis is doubtful in view of the tendency of the debility to persist until a later period of life. These children are also apt to develop scrofula.
The diagnosis requires careful exclusion of other affections (scrof ulosis, tuberculosis, intestinal parasites).
necessity of removing the original cause would make it desirable to keep the children away from school for a time.
In serious cases this should always be done, as the injurious influences which act on both body and mind are thereby counteracted. In the first stages of the trouble a few weeks' rest is frequently sufficient, but in a case of long standing prolonged rest is required. After recovery has taken place, it is generally easy for the refreshed brain to make up for lost time. In obstinate cases where the school again and again causes the trouble to break out afresh, a cure should be attempted in spite of the child attending school. Well-to-do families may for a time have recourse to private lessons. For the poorer part of the population schools situated in the woods are excellent in this respect. It is important to correct mistakes of education at home, to tone down the ambition of the mother in wishing her child always to be the first, to omit the music lesson, etc. Among the poor too much house work (see the Care of Chil dren in Poor Families); or using children for business purposes such as delivering newspapers, are also great exertions and shorten the hours of sleep. The time out of school should be largely devoted to sleep, also during the day a few hours of sleep should be inserted, perhaps immedi ately after school or before dinner. Children should be in the fresh air as much as possible. The arrangements which permit children, includ ing the poor, to spend at least a few weeks of the year in really good air, are to be hailed with delight. Places of recreation, vacation colonies, sea resorts, summer colonies and rural sanitaria, or possibly a visit with relatives in the country, are desirable. Even if after return to town the body weight and percentage of liTmoglobin should fall again, in the majority of cases an improvement still remains as compared to the con dition before the commencement of the cure. The children of well-to-do parents are sent to rural sanitaria or summer resorts. The best places are those where the climate is warm and yet affords sufficient protection from excessive heat. In the country, heat is much more bearable than in the streets of great cities, where the gigantic piles of stone and mortar absorb the heat of the sun and do not easily become cool again. Ante mic children can bear heat better than and summer resorts in the flat country are very suitable, also watering places (there is no necessity for taking the baths), whereas many places in wooded districts have too many cold and wet days. The climate near the sea has an evil rep utation in regard to its effect upon antemic patients. Those endowed with a fairly good power of resistance may be sent to the seaside, hut care should be taken not to expose them to the hot. rays of the sun and not to allow them to bathe in the sea. With many young children the climate at high altitudes agrees well, v'hich in the opinion of very competent physicians may have a salutary effect in very obstinate cases. Very high altitudes, however, are not suitable for every child. High altitudes probably act less by the increase of red blood corpuscles, than by improved metabolism (Miescher, Loewy and Zuntz, Schumburg and Zuntz, Meissen and Schroeder, Gottstein). As to the use of chalybeate waters, which may also be used in the case of young children, more will be said in a subsequent paragraph.