Health Education - a handbook of suggestions (1956)

This pamphlet was an updated version of the Board of Education's Handbook of Suggestions in Health Education, first published in 1928 and revised in 1933 and 1939.

The complete document is shown in this single web page. You can scroll through it or use the following links to go to the various sections.

Part I The development and scope of health education

Introduction (page v)
1 Historical development (3)
2 Preventive medicine and the health services (13)
3 The biological basis of health education (23)
4 The child at home and at school (32)
5 Health education in the echool (37)
6 School and the future parent (51)
7 Health education and youth (62)
8 Health education and the adult; the parent as partner (67)
9 The training of teachers (74)

Part II The provision of health education

Introductory Note (83)
10 Cleanliness (84)
11 Movement and rest (97)
12 A chapter of accidents (103)
13 Drugs, alcohol and tobacco (111)
14 Nutrition and food (117)
15 Warmth and clothing (129)
16 Care of the body (132)
17 The prevention of communicable diseases (139)
18 Mental health (158)

Appendix

Normal development. Chapter III of the 1955 Underwood Report (166)

Index (176)

Notes

Square brackets were used twice in the original (on pages 87 and 93). Elsewhere in the pamphlet I have used square brackets to give metric equivalents for imperial measures.

See also the 1955 Underwood Report Maladjusted Children, which is referred to and quoted from in this pamphlet.

The text of Health Education - a handbook of suggestions was prepared by Derek Gillard and uploaded on 30 June 2022.

Health Education - a handbook of suggestions (1956)
Ministry of Education Pamphlet No. 31

London: Her Majesty's Stationery Office 1956
Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen's Printer for Scotland.


[cover]


[inside cover]




COVER DESIGN
The photograph on the cover of this pamphlet is of "The Family", a group in bronze by Henry Moore, and is reproduced by courtesy of the Trustees of the Tate Gallery.

QUOTATIONS
This pamphlet contains a number of quotations, the authors, titles and publishers of the works from which they come being recorded in the footnotes. The Ministry wishes to acknowledge the ready way in which publishers and others gave permission for the use of those quotations where copyright is involved.






[title page]

Health Education


A handbook of suggestions
for the consideration of teachers and others
concerned in the health and education
of children and young people


MINISTRY OF EDUCATION

PAMPHLET NO. 31







LONDON
HER MAJESTY'S STATIONERY OFFICE
1956 : Reprinted 1958


[page iii]

Contents

Introductionv

PART I

THE DEVELOPMENT AND SCOPE OF HEALTH EDUCATION

Chapter 1. Historical Development3
Chapter 2. Preventive Medicine and the Health Services13
Chapter 3. The Biological Basis of Health Education23
Chapter 4. The Child at Home and at School32
Chapter 5. Health Education in the School37
Chapter 6. School and the Future Parent51
Chapter 7. Health Education and Youth62
Chapter 8. Health Education and the Adult; the Parent as Partner67
Chapter 9. The Training of Teachers74

PART II

THE PROVISION OF HEALTH EDUCATION

Introductory Note83
Chapter 10. Cleanliness84
Chapter 11. Movement and Rest97
Chapter 12. A Chapter of Accidents103
Chapter 13. Drugs, Alcohol and Tobacco111
Chapter 14. Nutrition and Food117
Chapter 15. Warmth and Clothing129
Chapter 16. Care of the Body132
Chapter 17. The Prevention of Communicable Diseases139
Chapter 18. Mental Health158

APPENDIX

Normal Development. Chapter III of the Report of the Committee on Maladjusted Children, 1955166

Index
176


[page v]

Introduction

IN A MODERN COMMUNITY everybody needs to know and follow the rules of healthy living in order to keep well. This does not mean that we should become a race of hypochondriacs; there is no need to stop and think each time before opening a window, or eating a fresh apple, or washing before a meal; nor would anyone ever do so. Yet we all need a good stock of basic general knowledge in a form which can be easily applied at the right moment, and there are occasions when nearly everyone has reason to be concerned about health in both its private and its public aspect; in any case the general practice of the community reflects the level of public opinion, which needs to be well-informed and responsible.

Certainly it is the business of the whole community, and in particular of parents, to see that the rising generation gets the best possible general training in matters of health. But the parent cannot be expected to do everything single-handed; and a strong professional team, which includes doctors, teachers, health visitors and social welfare workers of every kind, is at work all the time to make sure that parents and children alike are living in as healthy an environment as possible and that help is available when needed. Within this team, the teacher's special relationship with young people at school provides him with a unique opportunity of giving them the training in matters of health which they need. The work of the biology teachers speaks for itself. But the work of every other teacher in a school is just as important, whatever subjects he may be teaching; his general point of view in matters of health, the standards he sets and the things he considers important, all these form the main source of the indirect education which every good school provides continuously for all its pupils. To this end the teacher must have at least a sound general knowledge of the main aspects of health education, including some understanding of its scientific basis. He need not be an expert but he should know more than he has to pass on. He must also be the kind of person whom his pupils will wish to follow. All this is much to expect, even though the community cannot ask for less. The main purpose of this pamphlet, as of its predecessors, is to help young men and women studying to become teachers to equip themselves for this arduous role. But perhaps it will also be of interest to a wider circle, including professional workers and parents.

The chapters which follow fall into two main sections. The first, Part I, reviews the general principles of health education. A brief historical survey leads to a summary of public health provision in the


[page vi]

United Kingdom from the point of view of preventive medicine; it is necessary to bear in mind the essential basis in biology of all education in this field, and the consequences for child, parent and teacher. Subsequent chapters then trace the course of health education from the point of view of the individual as he grows up. First comes the small child, already individual, but still very dependent on his parents; health education at this stage should be mainly a matter of good practice and good habits, induced not so much by forcing or drilling as by steady encouragement in an atmosphere of security and affection. When he goes to school, still as a small child, the health education which he is given there should be similar in spirit to what he has had at home; but, as time goes on, good practice will need to be confirmed and strengthened by increasing knowledge. One problem of particular importance for the older boy and girl is considered at some length: what should they be taught about sex? Further chapters consider health education in terms of the adolescent who has left school and of the adult; though they may have finished with formal education, both are still open to influence, and when young people marry and have children of their own, much can be done to help them, particularly if a real sense of partnership can be developed between professional worker and parent. The last chapter considers health education from the point of view of the young teacher in training; attitude, experience and knowledge, his own further education and his professional training, are all of the greatest possible importance.

The final chapter of Part I leads on to Part II, which is particularly concerned with the needs of prospective teachers. It surveys, briefly and selectively, the more specialised subject-matter of health education and current views about such topics as cleanliness, exercise, rest, warmth, clothing and the care of the body, nutrition, the prevention of communicable disease and the promotion of good mental health. Of course neither these chapters nor those in Part I which are relatively specialised can pretend to treat their subject-matter exhaustively; their purpose is rather to give a general impression of the way in which the constituent parts contribute towards the whole. Finally, both teachers and other readers, too, may be interested to consider, in the light of the Handbook as a whole, the chapter on "Normal Development" reproduced from the recently published Report of the Ministry of Education Committee on Maladjusted Children. (1)

All this covers much the same ground as previous editions of this pamphlet, but a good deal of revision has been necessary. This has been not merely a matter of bringing the pamphlet up to date. Today the level of general knowledge, public opinion and everyday practice is

(1) Ministry of Education Report of the Committee on Maladjusted Children, Chapter III. Her Majesty's Stationery Office, 1955, price 6s. 0d.


[page vii]

appreciably higher than even two decades ago. Thus, from the point of view of the student, there is perhaps not the same need today for such a pamphlet as this "to be regarded as a compendium" (1) or summary of suitable teaching material. A more selective and reflective approach seems needed in which the essential scientific basis of the whole subject can be considered, however simply. A good deal of attention, too, has been paid throughout to the historical background, since this can help the student to see his own changing times in a better perspective. Even so, no work of this kind can offer more than a framework of knowledge and a point of view. For anyone who wishes to go further there can be no short cut; the more specialised forms of study which follow carry their own disciplines and rewards with them.

One major question is implicit on every page. What is health? How far is it bodily, how far is it more than bodily? Is it just an unconscious state of well-being, or does it signify something more consciously recognisable? How far is health a mental or even a spiritual quality? Such questions are not less real or insistent for most of us because no agreed answer to them exists. Very often there is no acceptable language in which an answer could be given; such words as body, mind and spirit are the best we have, but they can be misleading if their use in particular contexts is allowed to break up what should be regarded as a whole. The dictionary derives the root meaning of the word "health" from "whole", "wholeness"; a harmony of body and mind is implied from the onset. Given this, the term can be properly used, as often in these pages, to denote bodily or physical health; but the wider and more profound meaning can never be very far out of mind. For it is not enough, as some dictators have done, to cultivate physical health as a means of developing physically fit young barbarians. Our task is rather to make sure that bodily health plays its proper part in the whole education of responsible citizens. To discharge it successfully we need a clear understanding of the nature of our civilisation and its principles. We must also have regard for realities which go beyond the merely physical. Our roots lie deep in the Christian background of our civilisation and the things of the spirit cannot be passed over.

It is for this reason that in theory and practice alike health education is often so curiously difficult to define. Too narrow a definition is likely to end up with a syllabus of hygiene which, though valuable in its way, is not enough; yet on a wider interpretation such as has just been suggested it is almost impossible to avoid working from the part towards the whole, so that what began as a consideration of health ends as a study of the good life. Let it therefore be clearly understood that health, however precious, is sought not just for its own sake but in order that we may have life more abundantly; health is a means not an end.

(1) Introduction to the 1933 edition.


[page viii]

So, too, health education exists in order to serve the whole education of which it forms part.

Throughout the study of health education the student's attitude to the whole question of progress is likely to be of great importance both for him and also, later on, for his pupils. This pamphlet has a tale of rapid advance and development to unfold. It may not be easy for us to realise how far we have advanced even in a few decades; but let anyone who is uncertain about the point compare modern photographs of children at work or at play with the corresponding photographs of fifty years ago; there is in today's children a liveliness and sense of radiance which in the old days were too often missing. The child of today is taller and heavier than his predecessors; he is probably better adjusted and his school and his family relations are likely to be happier and more natural than they used to be. None of this need make the modern reader complacent; we too shall be left behind. We can point to progress, but it is progress on a long slope which leads far beyond the present day.

Health education is concerned with a vast and varied field, touching many branches of science besides such subjects as history, geography and language; it involves every type of school, children of all kinds, parents, teachers, all of us. And its claim must be pursued not in the abstract realm of academic theory, but in the demanding context of a good general education that will meet the needs of the time. It is within this context that so great a variety comes together; the result should be a pattern of health education in which we never lose sight of our main objective, a serene people moving from strength to strength in body, mind and spirit.




[page 1]


Part I



The Development and Scope of Health Education






[page 3]

Chapter I

Historical Development

THE HISTORICAL BACKGROUND is important for any reader who wishes to go at all deeply into the relationship between education and health at the present day; apart from that, the story is exceptionally interesting and too little known. Ideas, institutions and human beings are all involved, though in a short chapter only a brief impression can be given.

A proper regard for the blessings of health is as old as human life itself, and education in health matters can be traced back to the dawn of history. The Mosaic law, as it is set out in the Old Testament, enshrines a traditional code much of which is directly concerned with maintaining practices conducive to personal and communal health. Ancient Greece saw the first beginnings both of what we understand today by scientific method and of systematic medicine; in the famous Hippocratic Oath, Health appears as an almost personified blessing. It was in Greece, too, that the State first showed a concern for schools and education: "at their best the educators of Greece and Rome aimed at wholeness, and held that the educated man combined moral, intellectual and physical excellence. At Athens an uneducated body was as much a disgrace as an untrained mind". (1) In the Roman Empire urban civilisation made rapid progress; one historian (2) writing only thirty years ago commented "I have no doubt that some or most modern Italian cities differ very little from their Roman ancestors. Almost all the cities of the Empire, especially in the Hellenistic East, had a good scientific system of drainage, an abundant water supply even in the upper storeys of the house ... good public conveniences, well paved streets and squares. ... As regards comfort, beauty and hygiene the cities of the Roman Empire, worthy successors of their Hellenistic parents, were not inferior to many a modern European town. ... Another large item in the budget of a city was the expense of public education and the

(1) Oxford Classical Dictionary, The Clarendon Press, Oxford, I949: Article on Education, III 5.

(2) M. Rostovtzeff, Social and Economic History of the Roman Empire, pp. 133, 135 and 139 (The Clarendon Press, Oxford, 1926). The picture given in this now classic work is not overdrawn and it should be remembered that many of the features mentioned here were anything but new in the Roman Empire. Thus, to take one example, the Minoan palace at Cnossos, which in the main is not likely to have been built later than 1600 B.C., was superbly equipped in respect of water supply, drainage, bathing and even internal closets designed to be flushed with water. (For a vivid and easily obtainable account see The Bull of Minos by Leonard Cottrell, Pan Books, 1955 edition.)


[page 4]

physical training of young and old, especially in the completely Hellenised cities of the East."

After Rome came the Dark Ages when much was lost and life was "nasty, brutish and short". For example, the ruins of Bath, where besides the hot springs there were hot air baths heated by means of coal during Roman times, came to be regarded by the Anglo-Saxons as the mysterious "work of giants". Yet, at least by the time of the later Middle Ages, life was by no means so crude or unhygienic as is often supposed. (1) The reader of Chaucer will find much that is still recognisable in England today, along with much that is alien to the modern mind; his Doctor of Physic appears to have considered his medical skill to be based on a thorough knowledge of the stars and their movements, but he was also most interested in diet. In the fifteenth and sixteenth centuries many schools were founded which still survive, and the age of chivalry passed on to the Renaissance the practice of knightly games which, later on, were to develop into the great outdoor games of today. That somewhat intellectual educationist John Milton was well aware of the importance of bodily exercise. Yet much still remained primitive, as a study of the Plague of 1665 will make only too clear. There was no central health authority and the local authorities of the time had few powers or responsibilities in respect of communal health. The nation was still for the most part a farming community, towns were relatively small, and the population was sparse and scattered. Thus the effects of epidemic disease were generally limited; where, for example, only a few families shared a well, there were only a few persons to be affected if the water should become contaminated. Even among educated people enlightened ideas about medicine were to be found side by side with superstitions having only age to commend them. The mental climate in which a seventeenth century doctor in Norwich had to work can be vividly seen from Sir Thomas Browne's penetrating study of "Vulgar Errors", first published in 1646, while it has been suggested only recently that the eighteenth century doctor knew but little more than the doctors of the ancient world: "The ancient physician was, perhaps, a little less confident than his eighteenth century successor, a little more cautious, a little more conscious of his helplessness". (2) Even in the mid-nineteenth century the medical arrangements provided in the Crimean War appear to have compared unfavourably with the provision made for a sick or wounded Roman legionary.

But reform was already in the air. In 1710, St. Bartholomew's and St. Thomas's had been the only hospitals in London; others now began

(1) For an interesting general account (which not all scholars would accept without reservation) see Lewis Mumford, The Culture of Cities (1938), Chapter I, "Protection and the Mediaeval Town".

(2) Oxford Classical Dictionary, The Clarendon Press, Oxford,1949: Article on Medicine, Section 23.


[page 5]

to be established by public benefactors, in the metropolis and elsewhere, for the benefit of the sick poor. At the same time there were advances in medicine itself; a number of physicians with enquiring minds were throwing off the dogma which had hampered progress hitherto and were studying the prevalent diseases with a fresh and critical eye. During the eighteenth century the nation's health, certainly seems to have improved and this was probably a factor in the striking increase in population which had set in by the end of the century; in the 40 years between 1791 and 1831 the population of England and Wales rose from 8 to 13 millions.

Meanwhile vast social and economic changes were taking place that altered the character of life in Britain and had sinister repercussions on the public health. From being an agricultural community the nation became an industrial one. With the development of machines, mines, foundries and factories were appearing all over the land, especially in the midlands and north, and bringing with them a great demand for labour. There was work, even in the mines, for quite young children (who today would still be in the primary school), so that whole families could be employed. At the same time the Enclosure Acts deprived many yeoman farmers of their land and livelihood and obliged them to look to the towns for employment. A mass migration from the countryside into the industrial areas was the natural result. But what was gained from the prosperity brought by better wages was offset by the bad living and working conditions. The very limited accommodation which the new industrial towns possessed had to support a grossly inflated population. New housing was insufficient; generally crowded together, and of poor quality; indeed, in the words of a distinguished social historian, "the worst period for sanitary conditions in the industrial regions was in the middle of the nineteenth century rather than the beginning, because so many of the new houses had then had time to become slums, since no one repaired or drained them as the years went by." (1) Nor were the greatest houses in the land any better; in 1884, 53 overflowing cesspits were found under Windsor Castle, while in 1849 the drainage system, such as it was, of Buckingham Palace was considered dangerous to health (and was still far from satisfactory even 30 years later). It is not surprising, then, that when cholera struck this country it spread with devastating effect.

Cholera is a disease caused by a micro-organism which invades the intestines and is transmitted, as a rule, by infected drinking water; it

(1) G. M. Trevelyan, English Social History, p. 476 (Longmans, Green & Co., 1942). An interesting parallel is mentioned by Lewis Mumford (The Culture of Cities, p. 171) in connection with New York, where because of bad housing and sanitation the infant mortality rate rose from between 120 and 145 per thousand live births in 1810 to 180 per thousand in 1850 and 240 in 1870. See also pp. 163-168 of the same book.


[page 6]

originated in India and at this time was rapidly spreading across Europe. The first case in Britain was diagnosed in Sunderland on 20th October, 1831, and during the next few months the disease extended widely across England and Scotland, resulting in a total of 31,000 deaths. Subsequent epidemics of the same disease in 1848 and 1849 and from 1863 to 1867 took a heavy toll of victims.

Yet, even before cholera became so menacing, many intelligent observers had been concerned about the insanitary conditions in which a large section of the population was living. One of the most active reformers was Edwin Chadwick, a Poor Law Commissioner, who, in 1842, published a disturbing report on "The Sanitary Condition of the Labouring Population of Great Britain". In this work he commented on the poor water supply, the lack of drainage, and the filthy condition of the towns, and he pressed the need of improvement. Such efforts and the continuing threat of further epidemics led, in 1843, to the setting up of a Royal Commission to enquire into the causes of disease amongst the inhabitants of towns. Out of forty towns investigated conditions were considered tolerable in only eight; Chadwick's findings were endorsed and the ultimate result was the Public Health Act, 1848, under which improvements in water supply and sanitation were made. Cholera outbreaks were abated and, before the end of the century, died away. (1)

But there were other infectious diseases which kept ravaging the population, notably typhus, typhoid, smallpox and scarlet fever: the last-mentioned in a much more virulent form than it is known today. The incidence of typhoid fever as well as that of cholera was reduced by the provision of a better water supply; for both these diseases were commonly spread through well-water contaminated by seepage from cesspits or defective sewers, and when the sewerage system and water supply were put in order the main channel of infection was eliminated. But it is not enough for the supply of water to be pure; there must also be enough of it. In a modern urban community, accustomed to a piped water supply and hot and cold running water in dwellings, the availability of water is taken for granted. But a century ago a proper water supply was enjoyed only in prosperous homes, while very many people, particularly in the towns, still had the greatest difficulty in keeping their clothes and their bodies clean. In such conditions lice will flourish, and lousiness was responsible for the prevalence of typhus fever at the time. The virus causing this disease is transmitted from one human being to another by way of the louse; with improving standards of cleanliness came a corresponding reduction in louse infestation, and this in turn had its effect on the incidence of typhus fever, which vanished towards the end of the century.

(1) The last major cholera epidemic in Great Britain was in 1866, though there were small localised outbreaks in 1872 and 1894.


[page 7]

Smallpox, which is nowadays occasionally introduced into this country from the East and may still cause alarming outbreaks, caused much trouble in the nineteenth century and epidemics due to it were widespread and severe. As long ago as 1796, Edward Jenner, a Gloucestershire physician, had demonstrated the truth of a popular local belief that persons who contracted cowpox were subsequently immune to smallpox. By deliberate inoculation of subjects with the virus of vaccinia, which is another name for the harmless cowpox, he had been able to protect them against the much graver disease of smallpox. This method of protection came to be widely adopted and the Vaccination Act of 1853 made it compulsory. At the end of the century, when the frequency of outbreaks had declined, an Amending Act with a conscience clause was passed; more recent legislation (the National Health Service Act, 1946) has made vaccination a completely voluntary procedure.

By the middle of the nineteenth century, much was known of the principal infectious diseases of the time, but what caused them was still a matter of conjecture. Their origin was attributed to filth, or to noxious exhalations. But physicians studying the epidemics of cholera, above all John Snow, (1) did begin to make significant deductions as to the nature of the causal agent of that disease. Snow put forward the theory in 1849 that cholera was caused by polluted water and his views were put to the test and proved in the epidemic of 1854-55; but it was not until later in the century that the existence of germs, or bacteria, was demonstrated and the foundations of bacteriology were laid by Louis Pasteur and Robert Koch, working respectively in France and Germany.

But progress was also retarded by the lack, during most of the century, of an efficient system of local and central government, capable of carrying out systematic reforms. Improvement was curiously uneven; thus with the passing of the first Factory Act in 1833 (after long agitation) hours of work were restricted for the first time and factories were subjected to State inspection, yet it was not until 1875 that the employment of children to sweep chimneys was forbidden by law. The

(1) See Proceedings of the Royal Society of Medicine, Vol. 48, No. 12 (Dec. 1955), p. 1008, "Snow - An Appreciation" by Dr. A. Bradford Hill, C.B.E., F.R.S., for a discussion of the celebrated story of Dr. Snow and the Broad Street Pump. Snow was able to show that many who drew water from this source died from cholera, whereas adjacent users of a newly installed supply of pure water from Thames Ditton remained almost immune; admittedly the case "rested almost entirely upon statistical observations and relationships", but in spite of the relative failure of the 1855 edition of his book On the Mode of Communication of Cholera his views gradually came to be accepted. In the story of the actual pump, fact must be distinguished from fiction; Dr. Snow did persuade the Vestrymen of St. James' to remove the handle (on September 7th, 1854; it was removed next day) but it is not strictly true that the epidemic then died down - in fact it was already nearly over. This remarkable man also achieved the distinction of administering chloroform to Queen Victoria at the birth of Prince Leopold in 1853, another landmark.


[page 8]

inspection of mines on a centralised basis commenced in 1850. The appointment by local authorities of medical officers of health had commenced before 1850 and was made compulsory in 1872. As early as 1835 the Municipal Reform Act had provided some of the larger towns with the beginnings of an adequate local government system; but the rest of the country (including Greater London) had to wait until the Local Government Act of 1888 authorised the setting up of County Councils; elective urban and rural district councils followed a few years later and the new system was beginning to work effectively by the end of the century. The development of the central authority was likewise gradual. In 1848 a General Board of Health was established to carry out the provisions of the Public Health Act of that year (which has already been mentioned) and this body was replaced in 1871 by the Local Government Board, which was to put into effect the important Public Health Act of 1875 consolidating previous enactments in the matter of housing, sanitation and water supply; the local Government Board itself eventually gave way in 1919 to the Ministry of Health. From about 1900 the personal aspect of the health services began to be markedly elaborated. Greater powers and duties were laid on local authorities in respect of the treatment of pulmonary tuberculosis and venereal disease, the maintenance of hospitals, and the care of women in childbirth. The legislation on environmental health was brought up to date by the Public Health Act, 1936, and two years later amplified by the Food and Drugs Act, 1938. The second world war pointed the need for reorganisation of the health services and a year after its close an Act was passed which substantially changed the pattern of their administration, at the same time conferring on the nation a universal and comprehensive health service. This was the National Health Service Act, 1946, which came into force on 5th July, 1948.

Meanwhile the course of education had been curiously similar; here too, after a period of stagnation, improvement began in the course of the eighteenth century and in the nineteenth century progress was rapid though uneven. Even before 1800 the industrial Sunday and voluntary school movements had begun to provide schools in which thought was necessarily directed to such matters as cleanliness, physical environment and hours of work. From the beginning of the century such domestic subjects as needlework, cookery, laundrywork and housewifery were in one form or another coming to be represented in the school curriculum and played an important part in the steady improvement of health and living conditions; at the same time various forms of natural and social science were making their way into schools, as the importance of science came to be more widely recognised. By 1846 we find physiology being taught in a London school. This was only seven years after the publication of "Nicholas Nickleby" in which Dickens' description of Dotheboys


[page 9]

Hall exaggerated by only a little the appalling conditions still prevailing in some schools, but in the better schools there was a genuine interest in health; the cult of fresh air and exercise began to spread fast. Most important of all, it was beginning to be realised that education could be the most powerful of all instruments of reform, in health as elsewhere. Thus Ruskin, in the preface to "Unto this Last" (1862), pleads for schools to be established "at Government cost", where a child should "imperatively be taught, with the best skill of teaching that the country could produce, the following three things:

(a) the laws of health, and the exercises enjoined by them;
(b) habits of gentleness and justice; and
(c) the calling by which he is to live."
By this time there was a very wide interest in the achievement and maintenance of good health which already went far beyond formal education. Even so, it was not until the Education Act of 1870 that systematic primary education was made possible and systematic secondary education had to wait until 1902.

In the decade between 1900 and 1910 the two main streams of public health and public education seem to have flowed together. (1) As the grosser defects in living conditions were corrected, and the big epidemics waned, a change came about in the orientation of preventive medicine. From a consideration of the purely environmental aspects of health, attention was turned to its more personal aspects. Probably because the general situation was becoming less black, specific deficiencies in the nation's health began to appear in sharper relief. For example, the infant mortality rate, which represents the number of infants dying within the first year out of every thousand born alive, stood at 154 in the year 1900 (as compared with 24.9 in 1955): that is to say, in 1900, 154 infants out of every 1,000 were living less than twelve months after birth. Such a wastage of infant life, which seemed all the more serious at a time of falling birth rate, aroused public concern. One consequence was the Notification of Births Act, 1908 , which enabled medical officers of health to receive prompt information about all births in their area. The first infant welfare clinic was opened in 1905, to be followed by others, at first run on a voluntary basis and later taken over by the local authorities. In the same decade the first health visitors were appointed for instructing mothers in the rearing of their children. There was a like concern with the well-being of older children. The Royal Commission on Physical Deterioration, set up when the Boer War revealed the appallingly low average physique of the nation, emphasised in its

(1) A fuller (though still brief) account of the main developments in the School Health Service between 1900 and 1950 will be found in Chapter VI of Education, 1900-1950. The Report of the Ministry of Education for 1950. Her Majesty's Stationery Office, price 7s. 6d.


[page 10]

Report of 1904 the importance of better food for the children of the very poor. In 1906 an Act of Parliament authorised public money to be spent on the provision of school meals for necessitous children; in 1907 the duty of medical inspection of school children was imposed on local education authorities and the School Medical Service was set up. In this way there began a system of supervision of school children which developed into the School Health Service as it is known today.

Great progress was also being made in the conception of hygiene as an important subject in education; before 1900 it was beginning to be taught in schools and it had been a prescribed subject in the syllabuses for men and women in the examination for Teachers' Certificates issued by the Education Department, Whitehall, in 1894. In 1904 the annual report of the Board of Education states (p. 16) "The Board have now made the study of Hygiene an essential part of the Syllabuses in the Theory of Education both for Students in Training Colleges and for Candidates for the Certificate Examination." As the newly trained teachers went out into the schools, they naturally took with them a new awareness of the need to encourage children to live healthily. They could see these children, too, as the parents of the future who could be given instruction and advice in school which would be valuable later on. In this decade the teaching of hygiene was, with good reason, particularly closely linked with the teaching of temperance; an outline scheme for the two together was issued in 1905, and a further syllabus in 1909. A number of specialised pamphlets (1) issued by the Board of Education culminated in the Handbook of Suggestions in Health Education, first published in 1928 and successively revised in 1933 and 1939.

At this point we reach our own times. Over the first half of the century children's physique, so far from suffering as a result of two world wars, has shown a remarkable improvement. One instance may serve among many. Until well into the third decade of this century it was not unusual to see children suffering from rickets dragging their legs in iron splints; rickets in fact, used to be known on the Continent as "the English disease" because of its prevalence here. But with the discovery of Vitamin D there was a miraculous change, and a case of rickets is now rare. Development has been continuous in many fields such as parentcraft, hygiene, physical education (in which there have been remarkable changes), and in all branches of mental health. The interest which adults now take in nutrition, clothing, child-care and similar topics indicates the degree to which direct and indirect education have con-

(1) e.g., a "Memorandum on the Teaching of Infant Care and Management in Public Elementary Schools" (Circular 758), 1910; a very full syllabus of "Hygiene and Physical Training, 1912", issued in 1913; "Hygiene of Foods - a Syllabus of Lessons for use in Schools, and Notes for the assistance of teachers", 1920.


[page 11]

tributed to preventive medicine. There is still much to be done, but we can at least claim to be advancing at a good speed.

Out of the tale unfolded in this chapter certain generalisations emerge as particularly significant. First, if one wishes to assess progress or the lack of it in a particular age, it is necessary to take into account the whole climate of ideas prevailing at the time, and not merely some part of it. If, for example, one asks why Chaucer's doctor entertained such primitive notions or why his contemporary in real life, John Arderne, did not succeed in spreading very far his advanced views on cleanliness (1), it can only be answered that the fourteenth century attitude to medicine was very different from ours and was much affected by prevailing views about the universe, causation and the purpose of life. This is still the case today; the key to many of our present health problems may well be found in current modes of living and thinking which we normally take for granted. Specialist knowledge is essential for any programme of systematic health education, but to be effective it must be combined with wide general understanding.

Secondly, over the whole field, ideas and institutions interact. It is often difficult, looking back, to say which came first; in general, ideas are most likely to flourish when they have a chance of being put into practice, but that presupposes an administrative framework and institutions capable of making the practice effective. Throughout the latter part of this chapter the story of developing institutions has gone side by side with new discoveries and points of view. It is worth noting that in the nineteenth century there was a tendency for the initial reforms to come from enlightened individuals whose personal leadership eventually caused the government to take action. Very often in this country the original individual and voluntary effort has continued to exist side by side with official institutions; such a pattern is particularly evident in the school system and in social service, where the variety seems to correspond with something in the national temperament which is suspicious of any completely coordinated uniformity. The principle of voluntary effort is particularly valuable where the subject matter is new and contentious; thus education for marriage and smoke abatement have until now been mainly the concern of voluntary or semi-official bodies, although in the latter one can see at the present time (1956) the traditional pattern of private initiative leading by way of a government inquiry to State action.

Finally it should be noted that ultimate responsibility for the preservation of health has come to be spread over a steadily wider area. In 1665 it was enough for the heroic villagers of Eyam in Derbyshire to save the neighbourhood by voluntarily isolating themselves when plague broke out in their village; 260 out of 350 died. Today the increased speed of

(1) See Chapter 10, page 87.


[page 12]

transport and communications has brought us all so much closer together that the prevention of disease demands worldwide cooperation. But that is no longer enough. New problems arising out of reduced infant mortality rates, the longer expectation of life and the demands for improved nutrition, housing and recreation, which first became apparent in a few very highly developed countries, are now extending over the whole world. Here is a challenge on an international scale which will need thought, courage and practical application. It was to meet such problems that the World Health Organisation was set up by the United Nations; but an enlightened lead from member states, including our own, is more needed than ever. For as John Donne once put it in the seventeenth century, "No man is an island entire of itself ... any man's death diminishes me, because I am involved in Mankind." We can claim to have been pioneers for over a century and there is still much to do.





[page 13]

Chapter 2

Preventive Medicine and the Health Services

IN THE COURSE of these Suggestions many of the aims and activities of the National Health Service and the School Health Service will come to be considered in their own proper contexts. But the reader will also need, at the outset, a clear general picture of how these services are constituted and what they are trying to do; such is the theme of this chapter. It should be read in the light of the last chapter, for the health services as we have them today are the products of historical development, and they are still developing. It is particularly worth considering, from such a point of view, the legislation which controls the spending of public money, and which thereby determines the framework within which operate the various State services on which our society depends. Rigid as the framework may often seem, the more effective enactments have survived and become adapted to changing circumstances in very much the same way as the more efficient species or organs found in Nature. Legislation, such as that which culminated in the National Health Service Act of 1946 and the Education Act of 1944, provides neither a sudden transformation nor a fixed and final pattern of administrative effort, but rather a suitable framework for further development, such as is still going on. Within such a framework will be found incorporated much of what was best in earlier enactments, such as those providing for child welfare clinics, a health visiting service and a domiciliary midwife service. But with the steady and continuing rise in standards of health their orientation has been changing in the direction of prevention rather than cure. For adult and school child alike the main emphasis has come to be placed upon positive health and it is significant that we speak today not of the medical services but of the National Health Service and the School Health Service.

Some of the implications of the term "health" were touched on in the Introduction; in the pages which follow it will normally mean the smooth functioning of body and mind and a proper balance between the individual human being and his environment. The interaction between man and his surroundings is particularly important; one might indeed regard as the first and basic stage in preventive medicine the prevention of disease through such improvements in environment as better housing, a pure water supply and the thorough removal of refuse and sewage;


[page 14]

the aim of all such measures (to be considered from the point of view of environmental cleanliness in Chapter 10) is to eliminate obviously harmful influences. The next step is to protect the individual himself, beginning with help and advice on his upbringing as a child, especially in respect of nutrition, protecting him by inoculation against the infectious diseases to which he may be exposed, and watching over his growth and development so that any abnormality or defect which appears can be promptly dealt with. Yet preventive medicine has developed into something even more positive; it may yet be "preventive" in so far as its main aim remains the prevention of disease, as opposed to its cure (a conception which, as could be seen from the last chapter, is still relatively new); but there is a further stage, the pursuit of positive health, which goes far beyond the mere elimination of illness.

Such a conception will involve not only the health services but also the subtler and often slower influences associated with social welfare and education. For if people are to be fit and capable of making the most of their lives, it is hardly enough for them to be able to fulfil their elementary needs such as adequate accommodation, rest and a proper diet; they should also be able to work under reasonable conditions at jobs for which they are suited, and they will need leisure and opportunity for intellectual and emotional satisfactions. Where all or any of these conditions are withheld for a sufficiently long time, there will be frustration which may lead to real ill health. The close correlation between mind and body is well known and, as has already been observed, discontents of mind are recognised as having physical repercussions; it is a commonplace that anger makes the heart beat faster and raises the blood pressure, and there is a close connection between worry and duodenal ulcers. Preventive medicine has to recognise this affinity; in its broadest sense it is as much concerned that an individual should not become a square peg in a round hole, or that he should enjoy satisfying recreation, as that he should be adequately housed, nourished and immunised against all the customary diseases.

Clearly only a part of preventive medicine can come within the direct purview of doctors; they advise, but much of their advice, at least in the sphere of prevention, is left to others to carry out. Parents may receive guidance from doctors or nurses, but the upbringing of their children is of course in their own hands. Matters of first concern in environmental health, such as sewage and refuse disposal, are usually dealt with by the civil engineers of local authorities; likewise the heating, lighting and ventilation of buildings, features which are all of prime importance for health, are handled by architects. But many others are involved, including such unexpected allies as the statistician, whose figures illuminate progress and often help to indicate where further advance is most urgently needed; for those capable of reading figures with imagination


[page 15]

the history of health may be found in dramatic form in his impersonal tally of births, deaths and notification of infectious diseases and it is, to take one instance, worthy of note that the death rate for girls of 15 to 19 was recently halved within four years (1949-1953). To the general advance in the nation's health of which this is a token, health education, along with the other influences already mentioned, has made a profound contribution.

It is through the provision of services directed towards the personal health of the individual that recent legislation has made its main contribution to positive health, thereby aiming at a basic state of fitness. The National Health Service Act, 1946, came into force on 5th July, 1948. Local health authorities had been required to submit schemes of their proposals for various sections of the Act before the appointed day. Thus, by the time it became law, the procedure for carrying out the various requirements of the Act as to maternity and child welfare, home nursing, vaccination and immunisation, and mental health arrangements, to name some of the more important sections, had been worked out for each authority in detail. The different sections of the Act are wide and flexible in their provisions, and, as in the case of the Education Act, 1944, serve to some extent as an outline plan for action which has not yet been fully implemented. In this way it is possible for a local authority to amend its original proposals under the Act in order to bring them into harmony with changing circumstances.

The health services of the nation are gathered by the National Health Service Act, 1946, into three sections: a general practitioner service; a hospital service; and a local authority health service. The first of these provides a domiciliary medical service and is administered by 138 local executive councils, which are also responsible for the local dental, pharmaceutical, and eye services. The area covered by each executive council corresponds generally with that of a local health authority, but a few cover two authorities' areas. Doctors and the citizen alike are free to take part in, or make use of, the national health service arrangements or not, as they wish; having opted to join, the doctors are free to choose their patients and these in turn are free to choose their professional advisers. In fact about 95 per cent of the general practitioners who are in active practice and some 97 per cent of the lay population take part. The general practitioner plays a vital role in the national health service. The level of fitness in a community as judged by the absence of illness, particularly of a chronic sort, and the rate at which patients are restored to full health after illness, must to some extent depend on the ratio of doctors to patients in the area. The general practitioner is the chief guardian of personal health; he also acts as an essential link between the patient and the hospital and other services. The old ideal of the family doctor has not been lost sight of with the advent of the national health


[page 16]

service: whole families normally have their names on the same doctor's list, and for many the doctor is indeed a counsellor and friend. Since, with a free service, more people now consult their doctor than previously, the demands on the individual practitioner's time are greater and he has perhaps less opportunity for the preventive aspects of medicine than he would wish; but where time allows he is in a unique position to give health education, being persona grata and close to the very heart of the family. As the ratio of doctors to patients increases, it is to be expected that more such opportunities will occur.

Before the Act came into force, the hospitals in the United Kingdom could be divided into three main groups: a small number of teaching hospitals; the independent voluntary hospitals, supported largely by donations and contributory schemes; and the municipal or county hospitals, including general, mental, and fever hospitals and sanatoria, maintained out of local authorities' revenue and exchequer grants and containing about three-quarters of the total number of hospital beds. Apart from a small number of "disclaimed" hospitals, e.g. those run by religious organisations, all the hospitals in Britain have been in effect nationalised by the Act. For the purposes of administration England and Wales (1) have been divided into 14 hospital regions, each based on a city having a medical school. The hospitals in each of these regions are controlled by individual boards; and the regions are further subdivided into hospital groups, usually comprising the hospitals of a town or a group of small towns, whose day-to-day running is supervised by hospital management committees. The teaching hospitals are administered by separate boards of governors.

Whereas the activities of the general practitioner service and the hospital service are essentially curative, in that they deal for the most part with the treatment of persons who are sick, the intention of the local authorities' arrangements is, in the main, preventive. The two local authority administrative units for the purposes of the National Health Service Act are the county council and the county borough council, both of which are also responsible for the supervision of the health of school children under the provisions of the Education Act, 1944. There are 146 such authorities in England and Wales. Considerations of environmental health, covered by the Public Health Act, 1936, and the appropriate provisions in the Food and Drugs Act, 1955, including the enforcement of requirements relating to housing, sanitation, control of infectious disease, and cleanliness of food, are dealt with by the county borough councils and the councils of county districts. The services provided under the National Health Service Act, 1946, are not altogether new, since in many instances the relevant sections of the Act merely replace similar sections in earlier Acts which have been repealed, as was men-

(1) There are separate Acts on similar lines for Scotland and Northern Ireland.


[page 17]

tioned at the beginning of this chapter. These services include antenatal and child welfare clinics; a domiciliary midwifery service; a health visiting service; a home nursing service; arrangements for vaccination against smallpox and immunisation against diphtheria; an ambulance service; arrangements for the care and after-care of tuberculosis and for the prevention of this disease; (1) provision for convalescent treatment; a home help service to assist where there is illness, infirmity, or a confinement in the home; and a mental health service, including the provision of officers to deal with admission to hospital of patients under the Lunacy and Mental Treatment Acts and to carry out the supervision of mental defectives at home or on licence. All these services are provided free of charge, except for domestic help and convalescent treatment in respect of which local authorities are entitled to recover a proportion of the cost. A number of health departments have on their staff a special health education officer to plan and coordinate the many different aspects of health teaching, and in many others an officer engaged on other duties is delegated to attend to this increasingly important side of the work; the Central Council for Health Education also provides a central advisory service of which great use is made by local health authorities.

The local authorities responsible for administration of the National Health Service Act, 1946, are the same, as has been pointed out, as those concerned under the Education Act, 1944, with the working of the school health service. One of the main features of the school health service is the periodic medical inspection of school children, which generally takes place on first entering and before finally leaving school and also in the last year at the primary school or the first year in the secondary school. Provision is also made for the treatment of minor ailments; for ophthalmic examination and the provision of glasses; speech therapy; orthopædic care (including remedial exercises); ear, nose and throat examinations, with which may be combined the testing of hearing by means of an audiometer; and child guidance, for which the local education authority usually appoints an educational psychologist and arranges with the regional hospital board for the services of a psychiatrist at the child guidance clinic. Each local education authority provides a dental service for school children under the control of its principal school dental officer, with full facilities for treatment, including fillings, extractions, X-ray examinations, and orthodontic work, which corrects irregularities of the teeth and jaws. The school health service is especially concerned with the assessment and subsequent care of handicapped pupils, including blind, partially blind, deaf, partially deaf, educationally sub-normal, epileptic, physically handicapped, maladjusted, speech defective, and delicate children.

(1) Now including B.C.G. vaccination - see Chapter 17, page 150.


[page 18]

The school health service has changed to some extent in the fifty years since it came into being. At first its chief aim was to detect and alleviate the grosser defects which seriously hamper a child's education, such as severe eye defects, infections of the middle ear, rickets, malnutrition, infestation and vermin, and skin infections, especially ringworm. These troubles still exist, but some of them are now rare. The school health service has never aimed at providing a complete medical service; its purpose has been to see that a child should receive the treatment needed to get the best out of its schooling. In its earlier years the service did much to fill up some of the gaps in the medical services generally, at a time when these were less comprehensive than they are now; thus when ringworm was particularly rife (in 1920, for example, the incidence was 15 times as great as in 1950), school clinics run by the more enterprising authorities of the time were equipped with X-ray plant for the treatment of this condition. Now that a comprehensive and practically free medical service is within the reach of all, the curative work of the school health service has been very much reduced; today it is easier for school medical officers to promote or assess fitness and also to investigate the more obscure causes of ill health, so that, to take one example, the health visitor or school nurse who thirty years ago would have been busy following up cases of rickets will now have more time to bring to light the incipient neuroses. The school health service is today, more than ever before, an active force in the field of preventive medicine.

The officer administering the school health service is, with three exceptions only, the same person as the medical officer of health of the county or county borough. This is an important fact, since there are many points where the national health service and school health arrangements overlap or supplement each other; for example, the Education Act, 1944, imposes a duty upon local education authorities to provide for children from the age of two upwards who may need special educational treatment, and "for the purpose of fulfilling that duty" they may require the parent of any child over two to submit him for an examination by a medical officer of the authority. This is particularly important for blind or deaf children, whose early training and education in compensation for their deficient special sense must begin as soon as possible. Such cases may come to the authority's notice at a child welfare centre, or in the course of the health visitor's rounds of her district. If the medical officer of health and principal school medical officer are one and the same person, continuity of care is simplified; however, where the two offices are held by different persons, there is always close liaison. In most areas the post of health visitor is combined with that of school nurse, so that the health visitor will have followed a child from infancy, through home visits or his attendance at the welfare clinic, and should still be


[page 19]

able to supervise his welfare in her capacity of school nurse when he reaches school age. Moreover, her acquaintance with the family background, particularly where she has been able to study more than one generation, should often provide the health visitor or school nurse with a wealth of knowledge about the children in her district which can be of great help to teachers in dealing with pupils when there are particular social problems to solve. (1) But here also, when the two branches of the nursing service happen to be separate, there is normally a close interchange of information. Immunisation against diphtheria and vaccination against tuberculosis are both of interest to the principal school medical officer as well as to the medical officer of health; so also are the arrangements for the mass x-raying of teachers and school children as a measure in the early detection of tuberculosis.

The work of the principal school medical officer is in the same way often complementary to that of the teacher. Both are interested in the development of the child, the teacher perhaps with a bias towards the intellect and personality, the doctor with a predisposition towards traits connected with physique and emotion. Yet teachers are daily confronted with emotional or behaviour problems, while it falls within the sphere of the medical officer to advise on educational sub-normality. Teachers, as part of their duties, may conduct physical education, while doctors on their side are concerned with the child's ability to see sufficiently to read, or to hear well enough to be able to take part in lessons in an ordinary school: their respective interests in the child are dovetailed so that it is often difficult to discern the precise dividing line between health and education. This close relationship between teacher and school medical officer is an important feature of our educational system. There are many large organisations which in their own interests provide a health service, manned by their own doctors and nurses, as part of the arrangements for the welfare of their staff; if then, health supervision is necessary for adults engaged in their everyday work, how much more is it necessary where children are concerned. For apart from the problems inherent in growth and development, the school child tends to suffer from a variety of ailments and infections which he catches for the most part after mixing with other children of about the same age in the usual groups in schools, so that infections tend to spread more rapidly. There are also the special problems connected with the different categories of handicapped pupil already mentioned. The question of communicable

(1) The importance of the health visitor's work in the homes and the need for "a better coordinated approach to families and fuller use of the opportunities the Health Visitor has to do supportive work and gain relevant information in the course of her duties" are considered more fully in the report of a working party set up by the Ministers of Health and Education which reported in 1956: An enquiry into Health Visiting. Her Majesty's Stationery Office, 1956, price 6s. 6d. net.


[page 20]

disease will be dealt with in a later chapter; meanwhile it should be stressed that the relationship between the school health service and the individual school is comprehensive and practical. The school medical officer sees each child at the periodic medical examinations, and often on a number of occasions besides, so that he should be a frequent visitor to the school. The aim of the school dental officer is to inspect the teeth of each child annually, when there is adequate staff. The school nurse calls constantly at the school, as a rule weekly, either for a regular health inspection or in response to a particular request by the school doctor or by the head teacher. The school doctor, dentist, and nurse should be the teacher's allies in maintaining fitness in the school, and they should be almost as familiar to the children as the teachers themselves. In this way, moreover, children can be introduced to the doctor and dentist in a friendly, matter-of-fact way which will help both sides in later life. The closer the liaison between the school health service and the school, the better it will obviously be for the health of the school children. The principal school medical officer and his staff are as anxious to be informed of illness or infection in a school as the head teacher is to have advice about it; prompt information about infectious disease may enable an outbreak to be quickly traced to its source and dealt with. If a teacher brings to the notice of the school medical officer a child thought to be below par, the child can be followed up and referred to its own doctor; thus a condition whose neglect might have serious consequences may be given timely treatment. There may arise an urgent question of arranging for the care of a child injured or taken ill at school; or some less impelling but nevertheless important problem of school health may crop up: on such occasions a telephone call will generally put the resources of the school health service at the head teacher's disposal. Nor need the relation be one-sided; the school medical officer may have much to give to the teacher, but he also depends greatly on the teacher's good will and help in carrying out health projects in the school. Both doctor and teacher have closely related parts to play in the educational system, and both are concerned with the wider aspects of preventive medicine; both also share a common dependence on the understanding and support of the parent, whose important part is considered in Chapter 8.

One might well have expected that with the establishment of the national health service the voluntary welfare organisations would find themselves with nothing to do. On the contrary, many of these voluntary bodies became more active than before and, in particular, there hardly exists a disabling disease which does not have a thriving association devoted to the interests of its sufferers. Cerebral palsy, poliomyelitis, multiple sclerosis, diabetes, epilepsy, and hæmophilia, to name the more prominent conditions, all have their protagonists and the organisations


[page 21]

representing them (1) play a most important part in making needs known and filling the gaps in the local authorities' services. In a highly organised community such as ours it is inevitable and right that so much should be done for the individual; if he is to stand on his own feet, he may need all the help that can be given him from any source. Public and voluntary agencies are available to advise and perhaps succour him in moments of stress, whether he needs to satisfy essential needs such as food, clothing, and rent, or to find the solutions of such problems as getting legal aid, obtaining the burial of a relative for which he has not the means to pay, or securing care and accommodation for an aged person or a child: it is possible to help him in any of these matters, quite apart from everyday requirements such as those relating to his own health or that of his family, and the education of his children, which are already fully covered by the State. Inevitably there will be a risk, which must be guarded against, that the receiver will sit back and passively accept what is offered without playing his part in return; adult citizens and parents, no less than children at school, may need to be stimulated to think and act for themselves, and guidance should lead in the direction in which the individual's own efforts are likely to be most effective. Happily it is only a minority of persons who are content to play a purely passive role; most have sufficient pride and independence of spirit to want to do things for themselves. Thus in the organisations for the handicapped, mentioned above, the handicapped persons themselves or their relatives have been the prime movers, taking on the responsibility for conducting their own affairs.

Considered as a whole, the health services display a rich and diverse pattern. Health is seen to be by no means exclusively a medical matter; it is a communal responsibility. Efforts to attain it are focused on two principal objectives: first, to make the environment as good as the community can make it; and second, to see that the individual's own physical and mental well-being is watched over, with especial care during growth, and that at all times, both as child and adult, he receives the necessary health services provided by the national health service and the school health service. In such a context it is for health education to make sure that the principles of good health and preventive medicine are generally known and observed. Individual and community alike should in their own common interest understand the nature and scope of the health services, appreciating their aims, learning to use them reasonably, and remembering that every citizen, through his elected representatives, can help to influence further development. With this in mind, the reader will be ready to consider health education in greater

(1) More than 300 organisations concerned with social welfare are listed by the National Council of Social Service (Inc.) in their handbook Voluntary Social Services, 1951.


[page 22]

detail, first in respect of its scientific basis in biology and then observing the ways in which it can be made effective at different stages of life, above all in childhood; but he should still bear in mind the whole context of national aim and effort in which it occurs and the significance of both the Education Act, 1944, and the National Health Service Act, 1946, in establishing or consolidating an adequate framework for future development. How far preventive medicine and the health services may yet be developed will depend on many factors, including economic progress, but one thing is certain: health education has a major part to play in much that is still to come.





[page 23]

Chapter 3

The Biological Basis of Health Education

THROUGH A LONG PROCESS of gradual physical and mental development man has come to be differentiated in certain important respects from other animals. He has, for example, learned to stand erect and his forelimbs are unique in their freedom; his opposable thumb has greatly increased his powers of manipulation; above all, his power of speech enables man to formulate ideas and communicate far more effectively with his fellow men. But even greater differences have arisen out of man's spiritual nature, whether this is regarded as the latest great advance in the evolution of what has always been potentially there (and can be found in an incipient state in other forms of life) or whether it is considered peculiar to man and something outside the scope of biology; whatever its origin, the fact remains. It is his unique plasticity of mind and spirit which gives man his unique capacity for learning by experience.

More recent stages in the story of human development can be traced back through time with the help of history and geology or - though much is disappearing fast - observed in the present behaviour of primitive peoples with the help of the anthropologist. Primitive man is more often than not comparable with civilised man in his physical and mental potential; his ways of living can be most complex. Yet in other respects he is not so far removed from the position of animals in the wild state which for the most part seem to live healthily without apparent effort, moving into favourable and out of unfavourable environments with a sure instinct for finding the foods that suit them. Some of the most virile examples of mankind are to be found among untutored peoples and one thinks of the Red Indians or the Zulus as they were when first discovered by the white man. In the wild state both animals and men alike seem well equipped with a physical inheritance and with various preferences and tastes in food which are likely to determine many of their reactions in the direction of good health.

Yet even these reactions can be fallible; the moth flies into the flame and the child eats nightshade berries. Nor is mere survival necessarily the same thing as good health. On closer inspection both animals and men in the wild state are often found to be suffering from parasites of one kind or another (including micro-parasites such as microbes or viruses); neither animal nor man necessarily reaches the highest state


[page 24]

of well-being that might have been expected within the limits of constitution and environment. That most wild animals look reasonably healthy follows from the disappearance in the struggle for existence of all seriously affected individuals; only the robust survive and weaker animals, or those which have been pushed into less favourable environments, are in due course eliminated. The Darwinian theory of evolution would attribute to this process of elimination the adaptations which lead to healthy lives. Yet, to judge by the observable rates of change, any adaptation of this kind must come about very slowly; if changes in environment should take effect more rapidly than the process of adaptation, the species might very well become extinct. If adaptation does depend on the process of selection, there must be an expendable surplus upon which selection may operate and such a surplus is nearly always found. Once selection ceases to operate, there is evidence, to judge by the history of a line of cave bears whose remains were found in an Austrian cave and studied by Abel, that variations between individuals increase and the prospects of survival for the stock as a whole are diminished.

It was suggested in the last paragraph that a species may become eliminated as a result of being forced into an unfavourable environment. Is man such a species? Even before the beginning of civilisation man was living in an unusually wide range of environments. Today civilised man, usually because of lack of living space, has been compelled to accept an even greater variety; he has settled in cold areas or damp areas where it is necessary to live shut up in stuffy houses or sewn up in clothes; he has moved into areas infested with parasites and in the search for minerals he has even spent much of his time deep down in the earth. And this is not all; by limiting the number of his offspring and by enabling almost all to survive, Western man has interfered with the process of natural selection, since he has done away with the surplus on which selection must work to be effective. What is the price of all this?

But it is precisely here that one can see civilised man beginning to use his intelligence. Even comparatively primitive peoples, or tribes at the very beginning of civilised life, have developed a number of practices which are in the main such as to make for greater health both in the individual and ultimately in his stock. These practices are often handed down as traditions taken for granted; but one can also see an increasing ability to deal with situations as they arise, an ability unfortunately hampered by the kind of uninformed or faulty reasoning so often found, for example, in mediæval medicine. Then at the beginning of modern times there begin to appear the first indications of an entirely new development, first worked out in ancient Greece but not fully understood or utilised until two thousand years later. This involves not just the capacity to consider step by step what needs doing next, but the


[page 25]

harder task of analysing a situation systematically and then planning accordingly; such an analytic approach has been steadily developed in the past century with the help of new techniques of careful observation, accurate measurement, and the study of cause and effect, all culminating in controlled experiment. Such techniques and capacities have finally enabled man at least to attempt to keep pace with the changes in his environment, supplementing or modifying his inherited adaptive behaviour by conscious control. Whether he will succeed remains an open question.

In the course of this massive development many general principles have been gradually traced out, studied and expressed in scientific terms. Among them are the principles of good health and we can speak today of a basic science of health, biology; it is of cardinal importance not only for maintenance of good health in the immediate present but also for the survival of the human race in the circumstances outlined earlier in this chapter. Biology is more comprehensive in scope than is often realised. For the biologist, the individual human being must be considered not in terms of body, mind or spirit taken singly, but as a whole and in terms of his environment; this implies the study not merely of form and function but also of behaviour, and points in the direction of fields more often associated with the social sciences. It does not, of course, follow that in the modern age which is beginning scientific knowledge can claim to be sufficient in itself; certainly there remain other aspects of health, personal, æsthetic and spiritual, which are not less real because they cannot be measured. None the less it is clear that mankind must be in many respects considered as one among other forms of living organisms; as such, man like all the others is subject to the great generalisations, often called natural laws, which affect living organisms generally and govern their mutual relationships. Yet no other organism has his power of observing and reflecting upon the operation of these laws to control his environment or come to terms with it - for perhaps there are more ways than one of regarding the process. Here is man's chance to make sure that the good life is not hampered by the relentless workings of an environment which he has failed to take into account.

It is not for science to ignore any tenable explanation of the relationships which are found to exist between living organisms, including man; but of all possible explanations the concept of evolution has been accepted by the great majority of scientists as being the most convincing; no other can coordinate so wide a range of phenomena, which extend from questions of physics on a cosmic scale down to detailed observations of man's nature. Thus with the help of the evolutionary concept, a generalisation arising out of and combining all this evidence, we can see man's present state as traditional, a compromise between the adaptation of his human and prehuman ancestors to conditions which no


[page 26]

longer exist and his own present need to adapt himself to new conditions. His body itself represents a compromise, in which organs and physical powers which were in the main adapted to the circumstances of his ancestors have been inherited for use under new and very different conditions; for example, the skeletal and muscular structure of modern man can be recognised as an imperfect adaptation to the vertical posture of a structure originally adapted for going on all fours. Such a point of view should help us to allow for the weaknesses which are discovered in the human frame, and to make sure that in the new conditions of our machine age the body is not subjected to strains and stresses for which its structure is not suitable. It should help us, too, to understand what is natural and unnatural in the use and treatment of the body; because, for example, the erect posture is a relatively recent result of evolution, abdominal support seems clearly desirable in certain circumstances and should not necessarily be condemned as "unnatural". Many of our behaviour patterns appear to the biologist to represent a similar compromise between old and new; thus in considering the problems of boys and girls coming to maturity he will find it relevant and helpful to bear in mind that, for reasons deriving from an earlier stage in his development, man as compared with other animals tends to become sexually mature before he is physically mature and both physically and sexually mature before he is economically independent.

One of the greatest achievements of the biological sciences (for there may be more than one) has been the elucidation of the part played by heredity in relation to environment. Every living thing starts life with potentiality inherited from its parents and is able through reproduction to make its own contribution to the succeeding generation. Inherited potentialities may differ widely between the offspring of the same parents, and the nature of what is inherited can to some extent be varied by selective mating and, in certain plants and animals, even by chemical or physical means, a development which has attracted anxious attention in connection with atomic radiation. Thus the nature of man is shaped by a combination of heredity, all that he inherits from his ancestry of men and animals, with variation, all that causes him from the outset to depart from the parental pattern.

But no individual can be understood if he is considered merely in terms of his nature, however complex. Besides nature, the product of heredity and variation, there is also nurture, the impression made on man's inherited nature by all the factors and influences which affect him from outside and especially by what is normally called his environment; this will affect profoundly the realisation of his potentialities acting upon him in a number of ways which include the selection of variants. We tend to think of such an environment as something beyond individual control, and yet the environmental influence is the ability to make use


[page 27]

of the accumulated wisdom and experience of the race; these are being transmitted from generation to generation not through genetic inheritance but through education. The beginnings of this new process can be observed in animals and birds many of which, however strong their instincts, may also need parental instruction; some kittens seem to learn their mousing technique by something very like direct instruction from the mother. But the process of education goes much further in man; in the struggle for survival he has acquired many skills or habits which are being so effectively transmitted by education that we can begin to regard them as an entirely new form of inheritance. One view would be that man is capable of profiting from three distinct processes of inheritance - the genetic inheritance received in ovum and spermatozoon from his parents, the maternal inheritance received by the developing fœtus at a time when the mother's well-being (by which the fœtus is affected) is at least partly under human control, and an inheritance received through education. The term social inheritance should normally connote the second and third of these, bearing in mind that birth is but an incident in a continuous life begun some time previously.

The extent to which man can control his own development, and perhaps the genetic inheritance of posterity as well, is growing at an ever increasing rate; he now has powers far beyond anything which he has yet attempted to exercise. Undoubtedly new and vastly improved standards of physical and mental health are within reach, though both in education and in the field of mental health a certain humility is advisable; in both there are compromises between old and new which must be taken into account no less than when one is considering man's physical life. It must be recognised too that biological knowledge, to be fully utilised, must be disseminated much more widely. Most difficult of all will be the reaching of a measure of agreement on aims and policy; but we are living for high stakes, and the alternative might very well be extinction, the dying out of civilised man.

For the biologist can never forget that living organisms have reproductive powers which tend to outstep the available food supplies. Many populations wax and wane rhythmically; among many examples are the twice-yearly maximum in marine plankton and the periodic swarms of locusts and lemmings, in all of which the cycle turns out on investigation to be dependent on the relation between population and food supplies. Attention has often been drawn to a similar tendency on the part of human populations to outstrip their food supplies, and many civilisations have incorporated practices (such as ritual abstention or infanticide) which to some extent restore the balance; sometimes such practices include a measure of selection, whereby the fittest have survived. To the modern citizen of Western Europe individual human life is sacred; such a practice as infanticide, however common in classical times, seems


[page 28]

altogether wrong to us for reasons which we accept as basic and well grounded. Yet this very regard for human life, combined with our great advances in education, medicine, sanitation and health practice generally, has brought about a population problem of a serious and urgent kind. It is true that in Europe itself several factors have combined to keep the pressure of population within limits during recent decades, and the birth rate has been falling; there may ultimately be a similar development in other parts of the world too. Nevertheless this very reduction in the European birth rate has coincided with the application of new methods of agriculture over vast areas of the world in such a way as to divert our attention from the fact that the larger part of the world's population has hitherto been kept in check only by premature death from disease or starvation, Already in some European countries the demand for spaces for recreation as well as for food production cannot be met in full. It is true that world food production could be increased by the fuller use even of existing knowledge, and yet there can be no ultimate prospect of achieving a really high level of health for all peoples, unless a balance can be maintained between population, available land and supplies of food and raw material. (1)

With so much at stake the contribution of biology must be expressed not merely in terms of specialist knowledge but also, and even more important, in the development of a better general awareness among ordinary people; biology concerns us all. The effects of such a contribution may be far-reaching; certainly merely to see oneself in the context of the physical universe is in itself a profound experience, with implications for action as well as knowledge. As it is, we are moving very fast, though there is still a long way to go. Progress seems in the main to take the form not so much of revolutionary changes, though these can happen, as of gradual modifications in the body of custom which is transmitted from generation to generation by precept and practice, by formal and informal education. It is in this way that much of our knowledge about food, clothing, ventilation, cleanliness, rest and many other similar matters is gradually transmitted and transformed. Already many habits have by degrees been altered out of recognition, or even put into reverse: windows are opened when they used to be shut; babies are no longer swaddled, nor are children sewn into their garments at the beginning of winter; efficient refrigeration and advances in our knowledge of dietetics have revolutionised traditional habits of eating and drinking.

(1) One striking and much documented illustration of the problem could be found in the experience of Puerto Rico, where, as a result of improved health services, the population has been increasing at such a rate as to offset the expected rise in the standard of living. It is claimed that, hitherto, this increase has been absorbed without serious consequence as a result of increased industrialisation and more efficient methods of agriculture; but to the outside observer it must remain an open question whether such a process can be continued indefinitely.


[page 29]

The process continues today; often it is imperceptible, but that is not an excuse for ignoring the underlying principles. As with machines in a factory, so with the human body: the operator must have a reasonable knowledge of how the machine is constructed and how it works. Sometimes he may seem to be operating more by touch and instinct than by taking thought, but at other times custom is not enough; a new discovery such as that of vitamins or antibiotics may alter many things almost overnight, or a new problem may demand understanding as well as good habits. If, for example, a comprehensive national health service is to work effectively, we must as individuals know enough about health and disease to control the service intelligently and use it well. And here is our best hope for the future; notwithstanding the confusions which seem inevitable at a time of great change, there are some grounds for believing that a better understanding of the reproductive processes in man, of the nature of sex and sex behaviour, and of the basic facts about population, are already beginning to help many individuals to judge in their own life between what is true and what is false, and may eventually lead to a more rational conduct of sex life and family relations; in this way civilised man may yet be able to come to terms with his environment while there is time.

Perhaps we can come closer through biology than in any other way to the unbiased understanding of our position in the physical universe, which is so much needed, seeing ourselves, our needs and our environment in their mutual relation. Thus, when we are considering diet and the composition, purity and origin of the foods which are available, we must never forget how completely man depends on his surroundings for these foods. Biology is concerned with diet and food composition; it cannot ignore food production and other related issues. Again, to take another example, the study of animal life will illustrate at every point the importance to the growing child of fresh air and sunlight, food, exercise, warmth and rest. It is not enough to study such questions in terms of human behaviour patterns alone; too exclusive a concentration on the study of human bodily processes may produce a state of excessive introspection, whereas by linking the study of animal behaviour with the study of mankind biology can give us a better understanding of many human reactions and needs. A comparative approach of this kind is likely to be congenial to adults and children alike; most human beings are interested in the form and behaviour of other living things. The very small and the very large, the ferocious and the fleet of foot all have their appeal, and the study of human biology can in this way find its place in a much wider context; this very width should prevent too much introspection, and lead to a more balanced view of man's place in nature and a deeper understanding of natural processes.

The actual care of animals provides the best possible illustration of


[page 30]

what heredity and environment mean in practice for the maintenance of health in the individual and the race. The successful breeding of animals, whether for food, clothing or simply for show purposes, demands attention to the nature of the stock, to the food supplied and to living conditions; parallel lessons in human biology are easy to find. In well kept animals, as in man, the eye can observe such characteristics of good health as natural cleanliness, glossy skins and hair, poise, gracefulness, and in some animals the enjoyment of play. Here is also an opportunity for the development of a kindly, but not sentimental, point of view towards animals; when they are kept to supply us with food, clothing and other commodities, that is all the more reason why they should be kept healthy and as far as possible safeguarded against pain and distress.

The relation between plant and animal life is also of great importance; they have much in common, very different though they may appear in outer form. The simplest forms of animal and plant life are indistinguishable from one another and the basis of the structure of each is the cell. As higher forms develop, groups of cells become differentiated in form and function, and tissues peculiar to animals and plants respectively will be the result. Nevertheless many of the basic life processes are similar in both plants and animals. Both grow by obtaining food which they build into their own structures; both derive oxygen from the air, through leaves in the case of higher plants and through lungs in that of the higher animals. Because of these similarities, it is possible to carry out experiments on plants which will elucidate a number of life processes, particularly those concerned with growth and respiration - although the student must beware of applying conclusions drawn from plant life too uncritically to animal life, or, even worse, to man. The study of plants in their natural environment and in the laboratory is also relevant in view of the need for fresh food in a normal diet and the garden's importance as a source of supply; the student should not overlook the many uses made of plant material for clothing, fuel, drugs, and condiments, as well as the poisonous nature of certain plants.

Though animals and plants are essential to man, there are also many animal and plant forms which regard man as their prey. The ravages of the larger animals can be avoided or countered; but, so far, man has been less successful in dealing with the smaller forms; there is still much to be done here. The rat still consumes and fouls our food supplies and remains an ever-present potential transmitter of disease. Many types of fly, including the house fly, are a danger to human health. Improvements in food storage and in the control of flies have reduced the incidence of fly-borne diseases, so that epidemic diarrhœa amongst babies, once a frequent menace, is now much rarer. But here as in so much else any relaxation in standards would be disastrous, and it remains important that the facts should be well known. In many countries flies of various


[page 31]

kinds still play a major part in the spread of disease. Lice, fleas, bugs and mites are still widespread, even in Great Britain, and though, except in the case of the body louse, there is little evidence that they spread disease, the need to exterminate such pests is self-evident; this again demands a fairly general knowledge of their life histories. Over extensive areas of the world parasitic worms weaken large sections of the population and cause much suffering. In this country threadworms (Oxyuris) sometimes lead to fretfulness and restless sleep in young children, the cause of which is often not realised at the time. The tape worm (Tænia solium) has to a great extent been brought under control in Britain, but even so there was a recrudescence of tape worm infestation just after the war; we can never afford to relax our efforts. The smaller organisms, including fungi, protozoa, bacteria and viruses, cause diseases which vary in their effects from discomfort to death. The life cycles of some of these are simple and the organisms are transmitted from one person to another through the air which both breathe. Other cycles are more complex and one or more other animals may be needed for their completion and for the transmission to a new host; for example, the organisms responsible for malaria and yellow fever are transmitted by mosquitoes. In modern times this particular menace has been much reduced by the elimination of mosquitoes from wide tracts of the world; none the less, the increased ease and speed with which people, machines and goods are moved about the world provide opportunities for the more rapid and extensive dissemination of these and other disease-producing organisms and their carriers. Much progress has already been made in checking these pests and the diseases to which they give rise; further progress is likely to depend upon a more widely spread knowledge of the contribution of biology to health. For a disease to be checked, or a given pest to be brought under control, it is almost always necessary to start by studying the life history of the causative organism or organisms; in the same way the remedies, when discovered, usually presuppose some knowledge of the relevant life history if they are to be intelligently used.

In this chapter an attempt has been made to show the all-important part of biology in any effort to improve the general level of health through a programme of education. Man as one living organism among others is learning to control his environment; but lack of self-control threatens him with disaster. Biology can do much to help him to see himself in his context; he may then hope to consider. more effectively what to do next. But this involves at every stage much more than a knowledge of the facts or even the principles, necessary as both may be. Knowledge, attitude and behaviour are all interrelated, and to encourage a proper harmony between them must be our main concern through all the successive stages of education. In the chapters which follow an attempt is made to consider the stages of health education from such a point of view, passing from child to adult.


[page 32]

Chapter 4

The Child at Home and at School

EVERY CHILD is a single being; body and mind are both involved in all his progress and it is unfortunate that so many studies of the growth of children have tended to concentrate upon either the physical or the mental aspects of progress, instead of taking both into account. Happily most mothers know better, having always regarded their children as whole and complete individuals, and today we are beginning to appreciate more highly the mother's natural and unspecialised approach which does not sacrifice the feelings in the name of too rationalised an upbringing. Thus recent years have seen increased awareness of the importance for growing children of the feelings of stability, good will and enjoyment that accompany the satisfaction of their physical, emotional, spiritual, social and intellectual needs - for all are involved. In particular, the physical aspects of child care have come to be better understood in their wider context; so much essential pleasure comes from the satisfaction of physical needs, especially hunger. For the small infant at his mother's breast feeding is a supremely happy business and, as he grows, his meals should continue to give him pleasure. It is not enough to ask if he is getting the right amount of the right kind of food; does he also enjoy it? One might think that this would lead to a conflict between what is advisable in theory and what seems to satisfy a particular child, but in practice a reasonable balance is usually possible; in any case different children have very different needs, and recent years have seen some weakening in the previous emphasis on scientific formulas and time schedules. Of course such a point of view does not make exact scientific knowledge any less necessary; but it should be held in its proper context.

Pleasure is equally important for the satisfaction of intellectual and other spiritual needs. Children are by nature curious, venturesome and enterprising; from the earliest months they show a strong urge to learn. The satisfaction of this urge at every stage will produce not only a good foundation of knowledge and experience, but also delight, interest and other factors making for emotional stability. Intellectual development will be influenced by such factors as good personal relationships, sound physical development and plenty of scope for various forms of play. Here again it is necessary to satisfy the individual needs of a particular child, allowing for his ability and interests at different stages of growth


[page 33]

and meeting his need for experience without forgetting that he still depends on adults for help in many aspects of life. In a good setting the child will do his part; almost every child enjoys learning new skills and copying the adults round him,

"As if his whole vocation
Were endless imitation." (1)
But children can learn only at their own rate. Once interest begins to flag, it seldom does much good to nag or to enforce rules. Teaching and learning must take account of the stage which the individual child has reached; rigidity or vain repetition which ignores his feelings or emotional reactions will be worse than useless. Of course it may be necessary to pull up a child from time to time, yet this should happen but seldom and then in a civilised way with patience. The adults round a child should never forget that the environmental influence which influences him most powerfully is likely to be their own attitude and behaviour.

Growth cannot be hastened by imposed systems of habit training. It is true that there are many food habits and clothing habits (2) which quite young children take for granted; they represent settled practices and conventions which are the result of bodily adaptation to both natural and man-made circumstances. But the terms "habit training" and "habit formation" are often used more narrowly to denote strictly nervous responses. Human beings acquire many habits of this kind, often while young, by practice and repetition till a particular action becomes almost automatic, needing little effort or thought; such habits, when used for special purposes, are often called "acquired skills". Thus there has arisen the notion that the human brain functions in a similar way and can itself be trained, especially in the early stages, by mechanical repetition; at one time it was commonly accepted that the sooner children were trained to develop conditioned reflexes and automatic responses, the more rapid and permanent would be the result. But we have come to realise in considering such matters as feeding, sleep and elimination - all of the deepest significance for a child's all-round growth - that to demand behaviour and skills beyond a child's capacity will merely lead to failure and disappointment, and mental growth will suffer. We must not expect too much too soon; a child's inability to do this or that often reflects neither obstinacy nor bad teaching but merely insufficient development of the nervous system. Nobody expects a child to walk before he has crawled; in the same way, learning to control bladder and bowel is a gradual process and no amount of training to be "clean" or "regular" is likely to affect the

(1) Ode on Intimations of Immortality; W. Wordsworth.

(2) The basic meaning of the word "habit" is "bodily apparel or attire; dress" (Shorter Oxford English Dictionary).


[page 34]

child's ability to control his excretions before he is ready. So-called "cleanliness training" in the first year, merely takes advantage of certain convenient reflex actions and a normal physical rhythm; properly understood it has great value, but not when carried to excess. Perhaps we should think less in terms of habit training and more of children's development as involving the requirements of two parties, the child and society. There should never be any serious conflict between the two, but rather a gradual process of give and take. Inevitably the baby is almost entirely self-centred and his needs must be satisfied accordingly. As he grows, these must gradually come into line with the needs of the family and society, a process which requires an atmosphere of affection, security and satisfaction. Given this, most children should come to accept the larger community outside as an extension of the family; as a child fits into one, so he should fit into the other. Though lapses and anti-social characteristics may occur even among quite normal children, most boys and girls accept society and its conventions and are ready to conform for the sake of social acceptance.

The whole process of maturation, physical, intellectual and emotional, goes on throughout the formative years, though at different rates for different individuals and at a rate for any one child which can be accelerated or retarded by external factors. For all alike the main need is still for affection and security, in an environment capable of encouraging independent growth. School is another stage on the journey, but there is little difference in kind between the lessons learned at home and what is now to be learned in the larger group. During school hours the teacher is still in loco parentis, even though the family is now larger and the family relationship less intimate, more impersonal. A child's natural qualities do not desert him at school; his sense of growth, desire for understanding and encouragement, natural curiosity and urge to learn are all still there to be used and he will learn for much the same reasons and in much the same way as before. The expansive sense of being in a larger community should provide a new stimulus. But he is still the same child; the school and the community should not forget how immature he still is. Throughout school life there is a tendency, for which society as a whole is quite as much to blame as the schools themselves, to instil knowledge before a child is ready for it, although there is no longer the same insistence as in earlier decades that a particular lesson shall be learned at a particular stage regardless of the point which the pupil has reached.

Of all the stages of human life the time spent at school is the single most important period from the point of view of systematic health education. It is at this stage that children are at their most receptive, even though the limitations already considered must never be forgotten. At this stage, too, children are more accessible than at any other time


[page 35]

of life, since attendance at school is compulsory. Here and now, as at no other time or place, the pupil can learn at least something of what he should know and - not less important - he can develop the right attitude to what he learns. As reasoning powers begin to develop, most children will show an increasing sense of responsibility and be ready for the beginnings of explanation; even so, anything like adult scientific reasoning belongs to a much later stage which for perhaps most children is unlikely to be reached during their time at school. At best real education is a slow business; how much ground can be covered by any particular pupil must depend on his ability, his interest and the length of time that he stays at school. Certainly their schooldays should be able to introduce boys and girls to something of what health means in life and how it can be maintained; if the introduction has been enjoyed, the subject should still arouse interest and concern even after they have left school. Beyond that, school can offer a detailed and rationalised course of great value for all who have the ability to go far enough, but to attempt a compressed course of instruction for boys and girls of average ability who leave school at 15 or 16 would be useless. Will average boys and girls leave school with a rational attitude towards health; do they know enough to realise something of what they can do for themselves, and also when and how to get good advice? These are the main questions.

If the last paragraph conveys a moral, it is not that facts are unimportant, but rather that the learner must make them his own and understand them if they are to be of any use. In the more detailed chapters which follow an attempt has been made to indicate at any rate a few of the possibilities which arise in school. Some of these possibilities arise in the course of routine instruction, some are more closely associated with the school's corporate life from day to day. Many schools give a great deal without ever assigning a period on the time-table to a subject called health or hygiene; the incidental education which a good school provides may be as carefully thought out as more formal instruction and the right facts about health should leave quite as deep an impression if they occur in the form of general knowledge. Many schools are fortunate in that they can provide, particularly for older pupils, a combination of direct instruction (not necessarily formal), with good daily practice and example. There can never be any single approved mode of teaching or learning. But in all schools alike it is the continuing example and attitude, whether conscious or not, of each individual master or mistress with whom a pupil comes into contact that will usually be the principal factor in determining his ultimate attitude to questions of health. In a good school the Head and the whole staff, both individually and as a body, can irradiate the whole climate of school life. It is in such a school that any specialist teacher will have the best chance.


[page 36]

The life of a child should be spontaneous and lighthearted, with a capacity for joyful impulse. It would be tragically wrong to darken the gaiety with self-consciousness or morbid preoccupation with medical topics. Routine and habit provide a welcome safeguard here, though neither must be pushed to the point at which boredom waxes and initiative wanes. For older as for younger children routine and habit, within reason, can greatly increase efficiency by economising thought; children, like adults, have quite enough to think about without having unnecessary cares thrust upon them. It should be possible to preserve a mean between self-consciousness and boredom, between too little routine and too much. And where a minor misdemeanour is committed, the grace of tact and good humour is as precious in teaching as in other walks of life; there is seldom need to make heavy weather of the occasion. Any personal comment should be private between child and teacher, particularly if it bears on a child's home habits and ways of life - the public comparisons still occasionally heard are odious. Where home is involved; the parents' help will be needed; sometimes the parent is at fault, sometimes not, but in either event it should be remembered that the parents have to cope after school, sometimes in restricted surroundings, with the inevitable reactions of boys and girls who have gone through a school day of seven or eight periods. Apart from particular difficulties, most parents appreciate feeling that they are taken seriously by the school and in general they are more prepared to cooperate than is sometimes realised. The precise way in which such cooperation can best be achieved will depend on local circumstances; in some cases a parent-teacher association may offer the best prospects, in other cases there may be much to be said for some more informal arrangements for bringing parents together, or it may seem more profitable to concentrate on purely individual contacts. What matters most is that a school should be the kind of community in which the mainspring of behaviour is affection; parents soon sense this no less than their children, and react accordingly.

The growing child goes to and fro between home and school and brings to each what he learned from the other. When both influences pull the same way, health education is likely to be understood, remembered and applied. With both it depends for its ultimate quality on personal example and human relationships, involving heart as well as head. Much depends on the energy and spiritual quality of the leadership; in a school that is full of light the children are likely to grow strong and straight.



[page 37]

Chapter 5

Health Education in the School

THIS CHAPTER should be seen against the background of the last, being more particularly concerned with the successive stages of health education as children pass from one type of school to the next. A child may attend as many as three successive stages of primary school (nursery, infant and junior) and then the secondary school, making four kinds of school in all. A reasonable continuity between them is clearly essential; but, given such continuity, the actual change from one kind of school to the next represents for most children a real and welcome sign of advance. The reader will not find in this chapter any summary of the successive stages of childhood, though a good picture of these will be found in the Appendix on "Normal Development" at the end of these Suggestions. (1) The pages which follow are concerned mainly with the possibilities for health education which arise in different kinds of school, but the examples given are necessarily selective and much must be taken for granted. A number of points will be equally relevant for any kind of school. Thus, in all schools alike, the most careful and continuous use should be made of the records now kept to enable teachers to watch for the first signs of ill health, fatigue, strain or any other difficulty apparent in the individual child; in all schools there remains a continuing need for the close contact between teacher, parent and the school health services which should have begun in the nursery or infant school.

It was suggested in the last chapter that health education should be regarded as a continuing influence running right through a school's daily life and work; indeed it should include not only what is often called hygiene but also all those influences which can help a school to foster the physical, moral and spiritual well-being of its members. So wide a definition need not mean confusing health education with education as a whole; health education is normally taken to be concerned in the main with the more physical aspects of growth and development, though never exclusively so and never to the point at which the ultimate aim of education, the development of the whole human being, can be overlooked. Can health education so understood be regarded as in any normal sense of the term a school subject? Yes, in so far as it covers a definite and demanding field of subject matter; no, if by "subject" is

(1) Reprinted from the Report of the Committee on Maladjusted Children, Chapter III.


[page 38]

meant something necessarily appearing on every school time-table for one or more regular weekly periods. Too many time-tables are too full as it is; in any case health education, if it is going on all the time, may not invariably lend itself to concentration into one or two short weekly periods. Where regular periods of instruction in "hygiene" occur, they are meant to provide valuable points of concentration rather than the whole training. Yet to suggest that for much of the time health education at school will be mainly a matter of incidental training does not mean leaving everything to chance. Incidental education needs quite as much thought and planning as any other kind of education: how much knowledge should the pupils acquire and how rapidly? are the pupils capable of acting on the strength of what they know? how can the subject matter best be presented? For teachers who realise the possibilities and importance of the subject innumerable opportunities will suggest themselves in the course of teaching other subjects; a few of the possibilities are mentioned under subject headings towards the end of this chapter.

PRIMARY SCHOOLS

The Nursery School

The importance of the nursery school is out of all proportion to its numbers; probably no other kind of school has done so much to build up the health of the children coming to it, and much that has been worked out here has been subsequently put to good use in the infant and junior schools. At this age health education is almost entirely a matter of good growth in a good environment; it covers every aspect of the day, including work, play, rest and, of course, washing and eating. All through their waking hours children of nursery school age are discovering experiences of every kind, and much nursery practice follows from their need to combine different varieties of sensory impressions. The whole world of sight and touch is in a single toy. There are things to pull and things to push; objects and innumerable materials of many shapes and sizes, textures and colours, all appeal to eye and ear, to foot and hand and everything else which a lively child can bring to bear. All this is closely related with those aspects of play which lead more directly into imaginative experience; movement, music, story, pictures, all have their part to play and at this stage bodily and mental development are almost inseparable. At the same time such pleasures and occupations involve more than the mere individual; even at this stage a normal child is learning to take account of the other children and grown-ups round him, beginning already to realise that it is wise to take account of other people's wishes if he wishes to achieve his own. All this makes for a sense of security and achievement, the best possible foundation for further advance later on.


[page 39]

A special feature in the nursery school should be open-air life, since out of doors the stimulating effect of good surroundings seems to take on a still keener edge; when the weather allows, the children should be free for much of the time to run in and out as they wish and to play with sand and water and outdoor properties. There are insects to watch, leaves to sweep up, bonfires to make and admire, and planks, boxes and builders' bricks offer infinite possibilities; all this should be considered as so much basic provision, supplementing what is provided indoors. Thus many nursery school teachers should be spending a considerable amount of time in the open air. The right clothing is very important, and should be light, loose and airy, but none the less warm, for teachers and children alike if they are to make the most of the opportunities for going outside, particularly in winter; summer should bring many possibilities of playing in the sun, though proper protection should always be provided. For outdoor play in all weathers leather shoes have the advantage of being flexible yet protective; rubber boots are unventilated and unhealthy when worn for too long at a time, even though (like clogs) they can be most useful on occasion. Some fortunate schools have paddling pools or little swimming pools in which the children can play or bathe when the weather is good.

At this early age the children should enjoy their meals and eat heartily and well, just as they would at home. If attractive food is served, there should usually be no trouble about most children eating it; but, particularly at this age, some allowance must be made for individual likes and dislikes. The children in nursery schools should be trained to wash or go to the lavatory regularly and sensibly; the fitments are generally designed with great care to meet their needs. Rigid habit-formation is of course neither possible nor desirable, but within reasonable limits an element of habit and routine is necessary in the interests of child and school alike. Many children will need and enjoy an opportunity of resting, usually in the afternoon, though individual needs vary as much in this as in appetite and a rigid rest period is best avoided. If the children can be kept warm enough and protected from rain or too much sun, they should be able to sleep out of doors. Yet it must be confessed that nobody has yet discovered the ideal verandah which would give protection without either interfering with the light and ventilation of the playroom or using up too much of the garden space. In some schools the children can lie down on camp beds in the open air; it is important that the beds should be as well spaced as if they were indoors.

The Infant School

For most children the first real experience of school life will be what they are given when they join the infant school. They are by now very


[page 40]

distinct personalities, with a considerable amount of experience behind them, yet still in most respects like nursery school children; the principles and practice of a good nursery school should be continued without a break into the infant school. Initiative in both body and mind is developing fast and should be encouraged; children should be finding things out for themselves. At this stage of education, as earlier, the open-air periods are particularly important and should not be confined to the morning and afternoon breaks; the time-table should be sufficiently elastic to allow teachers to take advantage of good weather for out-of-door activities. To this end the infant school should wherever possible be provided with suitable garden playgrounds, with opportunities for enjoying sun and shade, for playing on grass or on dry paths, and for shelter from wind and rain; the possibilities include digging, sowing, and, of course, gathering flowers and whatever else has been grown; proper garden equipment should be provided. To encourage a variety of free movements, there should be scope for exploring and climbing, for such operations as pitching a tent or sawing wood, and for games with bats and balls, hoops and ropes. Active pursuits of this kind take up time and are in no sense frills, to be regarded as in some sense less essential than the beginning of reading, writing or number; both kinds of occupation are equally important, closely related and to be pursued with equal gusto; where there is insufficient space or time for play, general progress is soon affected.

All through the school day there should be a proper balance between rest and activity. A pleasant environment and a leisurely atmosphere are particularly necessary when children take their milk and when they stay to midday dinner, which should be one of the most educationally valuable events in the school day. Wherever possible, infant school children should take their dinner at their own school, where they can eat without hurry and without having to sit with a large number of older children. It has long been recognised (1) that teachers in infant schools ought to be given adequate outside assistance in the task of supervising the children during and after the service of their meals. After dinner some of the children of this age ought to rest; space and sufficient beds will be needed. Every member of the staff should set and expect high but reasonable standards of hygiene; this presupposes a reasonable allocation of time and a common understanding of how much to expect. Each child should have his own comb, towel, handkerchief, and, whenever conditions in the school permit, a tooth-brush and house shoes; children who have been in nursery schools will have had all these things before, and should by now be more aware of the need. Many parents will be prepared to provide them when the children first come to school; here is one of the points at which school and home meet, and there is

(1) See Ministry of Education Circular No. 97. April, 1946.


[page 41]

much to be said for regarding such things as personal property, in which a child can take an owner's pride; where this is not possible, it will mean much if the school can unobtrusively provide them. The right clothing and footwear remain as important as in the nursery school, and should be similar in kind. Some supervision of personal habits will still be necessary; in modern buildings with good washing facilities housed in the main block this should not be too difficult, but in badly planned premises with inadequate facilities the teacher may very well need someone else to help her in this work. Portable basins in the classrooms may sometimes help out; but where the washbasins or water closets are out of date, nothing short of complete modernisation will ever be really satisfactory. It is not always easy in an old-fashioned and perhaps dingy school to encourage children to take a pride in being clean and healthy; a child's day at school should be passed in clean, cheerful and attractive rooms, equipped with light, movable furniture which will permit plenty of movement with frequent changes of posture.

Naturally, any training in health matters at this age will be almost entirely incidental and based on good example and the good daily practice which has just been described. Formal lessons could only do harm, but there is no occupation which cannot contribute opportunities for the kind of questions, conversation or discussion in which the children can begin to find out for themselves some of the essential facts which in any case are interesting in themselves. To begin with, most of the children will take a pride in keeping their room clean and tidy, perhaps on a weekly rota. There are flowers to renew, vases to wash, plants to water, the floor to sweep, the windows to open, and much more besides; numbers have to be recorded for milk and meals, account has often to be taken of the weather, and there may be animals to look after. Children of this age can for the first time really begin to accept some responsibility for the care of their pets, learning a great deal in the process. Of course any pets must be well housed under the careful supervision of a teacher who understands their needs. In such an atmosphere the children will certainly ask many questions involving the reason for this or that rule of health; the answers must be positive and truthful.

The Junior School

The transition from infant school to junior school ought not to be abrupt. The day-to-day training and the practice in good habits that began at an earlier stage should continue, and so should the informal personal atmosphere and the scope for learning through experience. But the junior school, in carrying on good practice, will naturally take account of the children's increased knowledge, self-reliance and sense of being in a community. There should be a syllabus of health teaching;


[page 42]

all the teachers ought to know its contents and importance, and records should be kept to show how much ground has been covered. But specific health lessons are still not very often found; as a rule, it remains more important at this stage to encourage good habits, discussing any appropriate point that seems to arise, than to inculcate a set quota of information in formal lessons. The time-table as a whole should still maintain a proper balance between relaxation and activity, so that children can satisfy to the full their natural desire for frequent movement without ever being subjected to prolonged mental or physical strain.

There will still be no lack of valuable training in the general school life of the community, with buildings to look after, books, pictures, toys and cups and plates to keep tidy and use effectively, rubbish and salvage to be properly disposed of, and safety precautions to remember both at school and on the roads. Children's training at this stage should be essentially practical and worked out in terms of things to do. It should make definite demands on them, through the group as well as through the individual; thus the class as a whole can be encouraged to take a pride in the fact that its members all wash their hands effectively at certain stated times. By now the children should be encouraged to ask questions which include why as. well as how; answers should be frank and as full as the children can follow. As in the infant school, many good starting points are likely to occur spontaneously in such regular features as shoe inspection or the drying of damp clothes on wet days. Or some more general topic may suggest itself such as the value of warm clothing and exercise in cold weather; when colds are about, there may be an opportunity of discussing such points as the sources of infection, the use of handkerchiefs, and the importance of ventilation and room temperature. Physical education, too, will touch on such points as the reasons for changing shoes and clothes, the relation between sweating and cooling, the use of handkerchiefs for keeping the nasal airway clear and so promoting good breathing, the advantages of healthy habits and a sound body. Everyone all through the school day should take a pride in good posture, whether walking, running or sitting in class - always provided that the seating arrangements are such as to make good posture possible, a matter too often neglected. A word on the use of the cloakrooms may help to focus interest on the proper care of personal belongings and the need for cleanliness; the visit of the school dentist often leads to a discussion of teeth and how to look after them. Some elementary ideas about the structure of the body and about bacteria and antiseptics will occur naturally when there are small accidents or cuts to deal with. (1) Many points will arise in the course of class teaching; in arithmetic there are obvious possibilities in height and weight records, while some of the possible topics for discussion which have already

(1) See also Chapter 6, especially page 55, for questions involving sex.


[page 43]

been suggested should fit naturally into the work in language. As in the infant school, the care of animals (as an element in nature study) should be particularly rewarding and by this time can include some consideration of their structure and vital functions; it is relevant that children of this age are usually prepared to consider animals not only as pets but also as sources of food and clothing.

Lastly, it should not be forgotten that whether or not (as is often claimed) the normal junior school child is passing through a period of relative stability, the junior school itself appears to be in a period of transition; new ideas have been coming in from every quarter, There are many good junior schools whose ideas vary widely among themselves; some follow newer trends, others prefer older traditions. Not every school is likely to react in the same way to detailed suggestions; but, if the teachers care for and understand children and if the atmosphere is calm and friendly, the children's health education should be in good hands.

SECONDARY SCHOOLS

The transition from a primary to a secondary school usually comes a little before the profound changes associated with puberty; but it can no longer be assumed that in every case the problems of adolescence will be delayed until the secondary school is reached since it has now been established that over a number of years the age of puberty, and with it the age of sexual maturity, has been falling. This is particularly important for girls, and it is necessary to take their maturity into account when planning their school work.

The physical changes at the time of adolescence would alone be sufficient to upset the relative stability of the primary school period; but there are also mental changes, closely related with the physical, which cannot easily be explained in terms of bodily or sexual development alone. Most children become more aware of themselves, more reflective, and often more self-conscious; the old equilibrium is upset, leaving a rather unstable creature who will have to work out a new balance. At this time boys and girls become much more conscious of the differences between them; they mature at different rates and their interests diverge along markedly different lines. Even so, adolescence - though a time of uncertainty - is neither an illness nor an abnormality; it brings with it a sense of growth and increasing power which are sometimes forgotten by older observers, and most of us look back with an approving eye to the days when we ourselves were young.

The concern of health education with the physical and emotional changes of adolescence will be self-evident; it can make a profound contribution to boys' and girls' success and happiness later on. In


[page 44]

grammar schools much of the health education is given in the course of such subjects as science (particularly biology), housecraft and physical education; in secondary modern and unreorganised schools, where the science courses are not usually so far developed, housecraft and physical education often carry a correspondingly greater part of the load. (1) Often a course of lessons on hygiene is given at some stage and can be most valuable, where properly linked with other aspects of the work. Other more informal kinds of instruction will be considered later in this chapter. Meanwhile in all secondary schools the single most immediate problem to be considered from the point of view of health education is normally concerned with the development of sex. Schools vary greatly in their approach to this topic, some approaching it naturally in the course of a comprehensive scheme, while others ignore it altogether. Others, again, separate health education from sex instruction, confining the latter to a short course at what is thought to be the appropriate time - though this may be unduly deferred, and to cut off sex instruction from other aspects of health education may mean surrounding it with not very desirable mystery. Whatever is done will call for sympathy, knowledge and continuing cooperation with the home; the whole question is considered further in the next chapter.

In the secondary school there will still be as much need as ever for continued attention to the strengthening of good habits and, as before, children should be encouraged to find out as much as possible for themselves. But by now there is likely to be a perceptible alteration of emphasis; it is no longer enough to encourage good habits without also giving an insight into the reasons why they should be observed. Some boys and girls can reason more ably than others, but at least a slight degree of understanding is really essential for good adult practice and within the power of nearly everyone. And with increasing powers of reason the individual is becoming more aware of his position in the community. The experience in earlier years of belonging to a group can now be developed with greater understanding; children on good terms with their neighbours are better equipped to face the problems of adolescence. By the end of their time at school they should be on the threshold of adult life, with a good start behind them and a modest confidence in themselves, the result of sound habits fortified by some acquaintance with underlying principle. Meanwhile, discerning adult influence can help the individual to make proper use of the new forces which are at work in him. Many boys and girls begin to join voluntary associations; both in and out of school, which often give scope to the individual's interests within the framework of a congenial group; often too they help him to discover what it means to serve the community.

(1) Of course this list is not exhaustive; such subjects as history or geography are very important for any kind of secondary school (see page 45).


[page 45]

Many children are inspired by the desire to prove their quality in sport or swimming or mountaineering; to this end they submit to disciplines of training and practice which will serve them well later on. The developing consciousness of personal appearance is a powerful and generally beneficial factor in making individual boys or girls more aware of themselves and their neighbours; with a little encouragement it can give new point to many considerations of diet, clothing, cleanliness and personal hygiene. Even such manifestations as the use of "make-up" have their possibilities; many schoolgirls begin at this stage to experiment in the use of cosmetics out of school, and a little adult help can show them how to use such aids with discrimination and without harm to the skin.

Environmental studies are important. They may begin with the school grounds and buildings, which in many secondary schools are very attractive; from here the pupil's interest can often be drawn to a study of the home and so to all the arrangements made at home, at school and in civilised communities generally to safeguard health. Urban and rural areas do not always have the same problems, and may call for a different approach. Even within the same school it may be necessary to differentiate between boys and girls, though it is often urged that they should not be separated at any stage of their health education; theory varies, but in practice individual schools, teachers and children have very varying problems, and what is attempted must depend upon local circumstances.

Subjects in Secondary Schools (see page 37)

Most of the work in a secondary school takes the form of instruction in specific subjects because, as the pupils become capable of more advanced study, they must respect the increasing differentiation between various fields of learning; in the grammar school the number of subjects taken by older pupils becomes progressively reduced as specialisation develops. In all kinds of secondary school health education is likely to cut across the main subject boundaries and it must make the fullest possible use of the possibilities which arise in the course of teaching other subjects; this may also benefit the subject concerned, which can often be illuminated from a new and interesting angle particularly, though not only, in advanced studies. It is from some such point of view that the following notes, which are anything but exhaustive, deal with five main teaching subjects. The key subject of physical education is, however, not touched here, since it will be briefly discussed in Chapter 11 (Part II).

Science

The whole of his scientific studies are relevant for the student of health education, for they exist to give him not only essential knowledge


[page 46]

but also a grasp of scientific method. Innumerable examples suggest themselves. The special contribution of biology was considered in Chapter 3 and need not be further discussed here; whether or not specific lessons in hygiene are provided, the biology course in itself, if it includes a study of the structure and working of the human body, should be able to offer many opportunities for encouraging the growth of a responsible attitude towards health and social problems; biology also includes various forms of ecology, the study of living things in terms of their environment, and natural history which, for a number of children, provides a welcome hobby. Many aspects of physical science are involved, such as the transference of heat, the principle of levers, ventilation, breathing, electricity, all have their contributions to make in varying degrees. The human body cannot be understood without some knowledge of the process of combustion, while many chemical processes are involved, particularly in breathing and digestion. Finally the profound implications for health of various forms of radioactivity claim consideration and the use already being made of radioactive isotopes in medicine should be of great interest.

Housecraft

Few girls of eleven or twelve are likely to be interested in hygiene for its own sake, yet, from the moment of entering the housecraft room, health education should be an essential element in all that they do. In the early stages of instruction the work will be mainly concerned with personal cleanliness and the care of personal possessions, but later it should extend to the planning, preparation and serving of meals and the management of the home. Clean hands and aprons and a trim appearance are essential preliminaries to the day's work and in recent years there has rightly been an ever increasing insistence on cleanliness in the preparation, handling and storage of food. The specifically hygienic aspects of such a training are important, but housecraft can also foster skill and discrimination in home affairs; such qualities should add to the quality and pleasure of family life in later years. This is traditionally a subject for girls; yet boys too could benefit from some preliminary training in the domestic skills which a wife may now reasonably expect of her husband; efficiency, cleanliness (particularly in handling food), and proper standards of taste in domestic matters are as important for boys as girls. To provide boys with housecraft periods may not be easy, but much of what is needed can be acquired in other craft lessons, gardening and science; for the rest, a short concentrated housecraft course (whether almost continuous over a short period or requiring a lesser number of hours per week spread over a longer period) would seem to offer one


[page 47]

very practical possibility. For both boys and girls the school meals should provide an interesting and practical introduction to problems of diet.

History

(See also Chapter I, which, however, is not concerned with questions involving history teaching in schools.)
The teacher of social history today has become very generally aware of the important part played by hygiene in determining the life of peoples in different ages and civilisations; without taking account of this, we should find it difficult to understand their ways of life or to make useful comparisons with our own. The pupils' attention may be drawn to the ideas which have prevailed in a given period about sanitation, housing, cleanliness, water supply, food supply and habits of eating and drinking, disposal of refuse, treatment of disease and similar topics. Many questions rise up in the mind when one starts thinking: what exactly was the great plague at Athens in the year 430 B.C. which Thucydides describes so vividly? what really were the economic consequences of The Black Death? how did the medieval monks manage through the long cold winters in such cold abbeys with so few fires, and does that help to explain the large size of their infirmaries? did people get enough to eat under the feudal system? How was it that both in the Middle Ages and much later too, when popular notions about health, disease and living habits seem to us to have been so crude and misguided, there was so often a physical robustness and calm confidence of mind which must be set against the prevalence of disease and the high mortality rates in assessing the real quality of life in such periods? Whatever the answers to such questions, their asking should bring us to a juster appreciation of the past, so that the picture is neither too rosy nor too dark; past practice and present knowledge illuminate each other and no period of history should be studied without reference to this essential aspect of its life.

Geography

The teacher of geography can point to major environmental factors, such as climate, which influence the health of the individual and the community. Some parts of the world, such as Switzerland, California and New Zealand, have become famous as health resorts; others are notoriously unhealthy; others again, such as the Panama zone, have been converted from unhealthy into healthy regions and the number of these is growing. In some areas humanity is still exposed to deadly diseases such as cholera, malaria, plague, sleeping sickness and yellow fever, and also to more lingering infections, such as hook-worm or leprosy. All these diseases owe their origin to parasitic organisms and their transmission


[page 48]

usually involves climatic conditions and animal pests. Some races succumb more easily than others, particularly when they migrate. But parasitic organisms and pests are not solely to blame. Human beings themselves are also responsible for much of what is bad for their health. In many undeveloped countries magic superstition and tribal customs militate against healthy living, although the social habits of primitive peoples should not be condemned out of hand; often they are the result of centuries of adaptation to a primitive environment, combining sound instinct and much traditional good sense with what seems to us out of date and harmful. We should try to see the achievement as well as the defects, bearing in mind that we ourselves have by no means solved all our own problems. (1) It is possible, for example, to admire what civilisation has done to increase the world's food supply, arranging for its transport with the help of refrigeration and other means of preservation, and so making possible a more varied dietary and improved health, without feeling that the life of modern man in cities represents the last word; have not we ourselves still far to go? Such topics and questions as these should make a real contribution both to geography and to the study of health in its relation to the life of the community. It would certainly be relevant in the course of such studies to refer to the work of such international bodies as UNESCO, the World Health Organisation (WHO), the Food and Agriculture Organisation (FAO), the United Nations Children's Fund (UNICEF), and the Red Cross.

English

English offers obvious possibilities which illuminate language and literature alike, so long as pupils are not forced to deal with them as extraneous questions, as Robert Browning indignantly put it:

"Who fished the murex up?
What porridge had John Keats?"
But nobody can read Chaucer, Shakespeare or Dickens without realising vividly how people lived in other times; the study of Shakespeare's views on sickness and health (which take full account of mind as well as body, and are particularly concerned with the significance of order) is a long story in itself Nor is it possible to read Keats, the Brontës or R. L. Stevenson, or in our own century Katherine Mansfield, D. H. Lawrence, or George Orwell, without thinking of their tragically premature deaths, all from tuberculosis; would not most if not all of these writers have enjoyed longer lives today, and would they have written differently with better health? But beyond the individual example there is a deeper connection between literature and health. Young people are still forming

(1) For two interesting and readable anthropological studies on these lines see Growing up in New Guinea and Coming of Age in Samoa, both by Margaret Mead (Pelican Series).


[page 49]

their standards of value, and their attitude to sex and the other physical aspects of life will be profoundly influenced by their immediate surroundings, including contemporary books, films, broadcasting and the press. In the hands of a sympathetic teacher the study of literature can help, without preaching, to introduce them to standards going beyond their immediate environment and representing the human race at its finest. This is in any case likely to be the most important task that the teaching of English can offer, but the student should find many more points of contact with health questions as he works at the right ordering of language; he will be dealing not only with literary but also with non-literary material, including argument and discussion, précis and notemaking, deductions or assessments to be made from words, graphs or other data, and, of course, the intelligent reading of a newspaper. Similarly in current affairs, local studies, and other aspects of education for citizenship, the opportunities should be evident. But the general principle is the same for all; here as in history any reference should be natural and unforced; for the great dead did not live merely

"To point a moral or adorn a tale".
Other special opportunities for health education may also occur in the course of a term. They include occasional or regular talks, whether by teachers or by outside speakers, films, study-projects, essays and short talks by the pupils themselves, and such ventures as the concentrated short course, perhaps at a time when for some reason normal work is not going on. The informality of these occasions should make them all the more effective. Some particularly interesting school broadcasts (in sound) have been provided by the B.B.C. at regular intervals; (1) television should ultimately offer new and valuable opportunities.

CONCLUSION

Perhaps this chapter should end by reasserting the continuity between the secondary school and all that has gone before and will come after. All through the secondary school the fullest possible advantage should continue to be taken of the School Health Service; as before, school medical staffs, teachers and other social workers should work closely together and their collaboration should not end in the school; it is as important now as earlier to win and hold the parents. But into this

(1) For example, one year in a two-year cycle on Science and the Community (for boys and girls of 13 and I4 in secondary modern and unreorganised schools) has been regularly assigned to a sequence of broadcasts on many aspects of health; the programme planned for 1956-57 includes a term of broadcasts, covering various aspects of The Fight against Germs, a second term on Science and the Doctor, and a third on Health at Home and at Work, which includes an introduction to the National Health Service. Another programme (intended for slightly younger children in secondary schools, but also followed by a number of primary schools) provides a concentrated sequence of programmes during a single Health Week in December.


[page 50]

familiar pattern there should be entering a new element, the conscious contribution of the pupils themselves. Long ago, while they were still primary school children, they should have learned to approach doctor and dentist without fear or reluctance; by now they should be able in their own right to make an intelligent use of the health services. And they should by now be aware of their own personal responsibility to enter upon adult life with body and mind in a state of health which is something more than the mere absence of disease. Then, as boy and girl grow up, they will still be developing their own lives along a pattern which school helped them to establish and confirm. For school is only a beginning.





[page 51]

Chapter 6

School and the Future Parent

THE DESIRE OF MEN and women to marry, make a home and have children is deep and urgent; nothing can be more satisfying than a good home in which parents and children share the interests, pleasures, anxieties and common duties that make up family life. But to achieve a good home calls for many virtues: sacrifice, understanding and good humour, not to mention effort, knowledge and skill. At best this is much to ask and many families fall short even of reasonable success. Far too many married couples expect too much for too little; often they have drifted into marriage as a kind of happy ending, such as can be seen any night on the screen, without realising that it is only a beginning; they have little knowledge of how to start and manage a joint household, and little idea of the economic, practical and personal problems involved. Not that marriage is an impossibly complicated business, demanding an unreasonably elaborate preparation; on the contrary, there are not very many problems that cannot be solved by give and take and willingness to learn, and after an unpromising start many couples have settled down together without coining to any serious harm. Yet all the evidence suggests that there are many strained and broken homes which might have been saved with a little forethought; mainly for this reason there has come to be a persistent and growing demand that boys and girls, while still at school and under instruction, should be prepared for the time when they may become parents themselves.

The case for such a preparation is appealing; but opinions differ greatly concerning its scope, the age at which it should be given, and the qualifications and experience most desirable for teachers who deal with the subject. Some observers consider that such signs of failure as uncleanliness, faulty diet and bad housekeeping are all due to the kind of incompetence which might with a little of the right instruction have been put right at the outset. A good deal of the instruction which such observers have in mind is in fact being given at school; for many years it has been a common practice to include instruction in mothercraft in the curriculum for girls who leave school at the age of fifteen (or, until comparatively recently, fourteen). It is argued that the last year at school will for many girls be the last chance of such preparation that will ever present itself, and this is a reasonable point of view if the intention is merely to introduce girls in their last year at school (who will often be interested in small children anyhow) to the beginnings of child care, so


[page 52]

as to provide a first glimpse of what will claim many of them later on. But the teaching has too often gone beyond this, to include elaborate practice in bathing the baby or doll, preparing feeds, making and washing clothes; sometimes it has even included detailed baby care and precise feeding schedules. Yet much of this at the age of 14 or so could hardly help being mere doll play and the feeding schedules have often been obsolete by the time there was occasion to remember them - if indeed they could be remembered years afterwards. In any case our whole approach to the rearing of small children has gradually altered and the present tendency is to rely somewhat less than before on rigidly prescribed rules, quantities or schedules; prematurely elaborate teaching of this kind would be even less useful than formerly.

Many attempts have been made to introduce schoolgirls to the care of small children in a more practical fashion; they are often, for example, taken to visit nurseries and nursery schools and such a visit can be an attractive experience. But there still remains a certain risk of introducing the girls to detailed work for which they are not ready; in any case, for such a visit to be profitable, they need a guide who will be quite free to show them carefully round and few nurseries can spare one of their staff as a guide for any length of time. The young children, too, are often disturbed by the intrusion of so many strangers. Perhaps less formal contacts will often be happier; sometimes, for instance, a group of girls may prepare a party for a nursery class, keeping in subsequent touch with the children by making or mending toys, preparing special treats for dinner or tea, or making clothes for a particular friend or relation in the class. On a wider scale any general cookery course should provide all who take it with a simple background of good general knowledge covering the right kinds of food for everyone in the family, including small children, and the preparation and serving of a few simple dishes for special occasions or when mother or some other member of the family is ill. But elaborate lessons on "meals for young children" are of less value, even if remembered; young children need not so much an elaborate diet of their own as simple family food, well chosen, prepared and served.

One reason sometimes advanced for introducing schoolgirls to more elaborate forms of child care is that they often have small brothers and sisters to look after at home. Certainly it is all to the good if a girl brings home some of the new ideas learned at school. Yet within the family there remains a certain risk of the new learning clashing with mother's ideas; technique is not the only thing that matters and it is not good at such a stage for girls to become involved in any conflict which may confuse their trust in their mother's judgment. In any case girls with small brothers and sisters often have more than enough to do at home looking after them and it is doubtful if they should be encouraged to


[page 53]

spend still more time at school on the subject; what time there is may be needed for the pursuit of new interests which will help them to develop their own latent capacities.

Yet a great deal can be done to give both girls and boys the kind of preliminary instruction which really will be of value later on. It is not always realised how much time and thought is in fact given to parentcraft in any good secondary school, though not necessarily under this name. By raising the general level of intellectual attainment, school is helping its pupils to lay a better foundation for all that they may do later on, including the bringing-up of children; by touching their imagination with what is best in history and literature (see Chapter 5, page 48) it can give them at least the sight of greatness and an introduction to values that are not tawdry or ephemeral; it can provide them with a good practical grounding in essential knowledge. And through the introduction of crafts and leisure interests which can be followed at home, school can help to associate recreation with something more than the passive reception of organised entertainment outside the family. Yet in training of this kind the responsibility of the home must never be forgotten; a child's natural love and regard for parents and home needs to be reinforced, not challenged or sapped. Where an element of conflict between the standards of school and home is unavoidable, it is up to the school to show tact.

The general health education and housecraft teaching given by the secondary school should make an excellent foundation for family responsibilities. Boys and girls who appreciate the importance of good health and have some knowledge of how to achieve and maintain it will later on want their own children to be well fed, housed, clothed and cared for. In the same way girls will have learned not merely how to cook, clean and sew, but also how to organise and time their work, with a respect for method and some awareness of where to look, in books and elsewhere, for essential information. With or without actual lessons in parentcraft, every child who leaves school should have some understanding of the health and welfare services and how these can help family life. Instruction of this kind will probably be most effective towards the end of the school course; it is sometimes based on a series of visits and on talks from actual practitioners in various services, and boys and girls are often encouraged to do some useful piece of work in connection with local nurseries, children's hospitals or old people's homes, so that they may think of their own families and other people in terms not merely of physical surroundings but of human needs and service. Of great importance in all that is said or done is the personal relationship between adult and child, both at school and at home; boys and girls will show how they were influenced by their parents and teachers when they come to have children of their own.


[page 54]

Probably the most debatable issue in the whole of this field is concerned with the nature and scope of instruction in sex relationships. Sex is often either exaggerated or passed over. Lack of sensible guidance on sex can lead to unhappiness and broken marriages, though unsatisfactory sex relations are by no means the only cause of domestic failure. Ought instruction in sex to be given at school? Opinion is divided. Some feel strongly that anything of the kind is more often than not unwise; many married people have succeeded without such instruction and surely boys and girls of good character will of their own accord develop satisfactorily towards adult life and marriage, finding out what they need to know from reputable sources. Yet the demand for some more definite form of instruction does seem to reflect a real need. Children brought up in the smaller families of today cannot compare with children of earlier generations or even with children living today in many parts of the world for direct experience of birth and death, and in many families they still remain far too long ignorant of vital facts. In this the main responsibility clearly rests with the parents; but often parents feel embarrassed about discussing such matters with their children; they may lack the right words or they are conscious of emotional difficulties which make discussion awkward. Certainly the evidence suggests that many parents are grateful when the school is willing to take part of this responsibility.

In everything which concerns sex education, the child's basic need is for knowledge and this is best given individually; any other approach may often lead to embarrassment and misunderstanding. It is better to think in terms of gradually informing the individual child as he grows up than of any programme of set lessons or talks, however carefully planned. In any case the gradual approach is more likely to satisfy the child's needs. Every child gropes for understanding of the wonders of creation and will be curious from an early age about the parts of the body; quite early on many children begin to ask questions and these should be answered simply, naturally, and as fully as a child is capable of understanding at the stage which he has reached. The initial responsibility for answering questions lies with the parents but, as we have seen, the school is likely to be involved too, if only because the children are apt to ask questions at school as well as at home. One question can lead to another and some of them can be unexpected and searching. But however disconcerting such questions may be at times, they should be answered truthfully and at once, within the limits of the teacher's own capacity. For there will always be a risk that attempts to evade the question may cause a child to lose confidence in his teacher or, even worse, in himself, so that the ultimate result may even be serious maladjustment; in any case many children will try to find the answers elsewhere, often from immature or undesirable sources. It is also important not to give the impression in dealing with a question that it should not have been asked;


[page 55]

this again could harm the relationship between teacher and child. There is no need to answer more than the question asked or to provoke further curiosity; if the teacher answers swiftly and honestly as he would on any other point, embarrassment is unlikely. As a rule the questioner will soon be satisfied with the answer given and at that point the questions cease, though younger children may forget what they have been told and ask again, perhaps more than once, later on.

Children whose questions have been consistently answered in this way should not need set instruction in the physiology of sex. But their understanding will be all the better grounded if it includes some first-hand acquaintance with living things. It was suggested in the last chapter that quite small children should, where possible, be encouraged to keep pets at school. This will introduce them quite naturally to the biological ideas of internal fertilisation and viviparity (live-bearing) at a comparatively early age, when they are likely to take both for granted, and the questions which arise should be much easier in such a context. Both reproductive processes can be seen among insects, crabs, fish, amphibia and reptiles, as well as in the warm-blooded mammals; small mammals and live tropical fish can be particularly useful when kept at school under the right conditions.

Older children, particularly around puberty, often ask more searching and profound questions; these too should be answered by giving information within the limits of a boy's or girl's maturity and comprehension, just as with questions on any other subject. Questions involving human sex and reproduction are particularly liable to arise incidentally, during lessons in other subjects such as religious instruction, English literature, history, geography and science, and teachers of these subjects should be ready for them; sometimes related social and ethical issues will come up for discussion in this way much more easily than if one were to deal with them specially. All this means that the simpler questions of sex may fall to be dealt with by almost every teacher in a school and not merely by one or two specialists. This need not embarrass the individual teacher; an initial slight diffidence when first confronted with such questions is probably not uncommon, but it should not last long. Many men and women are grateful to the teachers who dealt with such questions as they arose. It is, of course, entirely for the individual teacher to decide how far to answer them; but anyone who stands in loco parentis to a group of children will not lightly consider leaving to others all responsibility for this aspect of their well-being. Where a teacher feels real hesitation about trying to answer a particular question, the pupil should be referred to someone else, whether the Head or some other colleague, the school nurse, or the school medical officer; in schools which have a biologist on the staff he will often be in a position to give advice or information. Whoever is concerned should bear in mind that,


[page 56]

through films, television and much else, the boys and girls may be in closer contact with the outside world than we often realise. This means that direct unemotional answers, of a kind that will fit in with what they know from the world outside, should have the best chance of being accepted with conviction, and also that much will depend on the general values which (over a long period and with the help of the parents) a good school can help its pupils to build up for themselves. Some of the questions asked are likely to reflect as much hesitation or anxiety about the values and tendencies of the world round them as about a particular issue concerned with sex - and should be dealt with accordingly.

In many secondary schools the work of teaching young children about the ways of living creatures can be taken a stage further, developing by degrees in the direction of more advanced biological studies; for many children this is likely to be their first introduction to the subject. In biology boys and girls can be helped to find out about the physiology of sex in unemotional fashion, particularly if such work can be begun before there is any risk of its being associated with individual emotional difficulties due to puberty; they can learn to consider reproduction objectively along with other forms of activity on the part of living things, instead of singling it out as something exceptional. It should also be possible to help them to see the reproductive processes as adaptations, making in the long run for the better survival of the individual and the race. There may sometimes be children in need of further elucidation and help; this is best given individually and privately after the class is over. Of course not all schools provide biology as an optional subject, whether under its own name or within the wider field of general science, and not all the pupils take it where the option exists. In some girls' schools instruction in the main facts of sex is linked with housecraft. Sometimes it is felt that objectivity without embarrassment is most easily achieved when information is given directly but impersonally to a large group by a visiting specialist, who may later be available for private interviews; sometimes a series of lectures is given. Many schools have found such an arrangement helpful; nevertheless certain drawbacks attach to it. The special lecture or course tends to invest the subject with undue importance; it is less common than formerly for children to be specially withdrawn from such occasions; but where this happens the children so withdrawn will in all probability find out from their friends afterwards, while the mere possibility of withdrawal tends to cut off the occasion from normal life. More serious still, any one class of this kind will probably contain children at very different stages of physical and sexual development, so that what may help one child may not be right for another. Contact with parents is important at all times. Sometimes the headmaster or headmistress arranges for parents' meetings before the children enter the school, in order to explain what


[page 57]

the school is trying to do; sometimes the parents' cooperation is sought through individual approach.

The foregoing paragraphs have been concerned mainly with the imparting of information; no two boys or girls are the same and their questions cannot be solved in the mass by rule-of-thumb answers. So too in questions of conduct society is rightly concerned with a number of general principles, but this does not necessarily mean that the best way to help young people to apply these principles in their own lives is to proffer too much general good advice. It is often said that young people should be advised to exercise restraint and self-control in matters of sex. The point is important for society as well as for the young people themselves, since, as an earlier chapter pointed out, civilised man tends to reach sexual maturity before he is fully adult and it may be longer still before he becomes economically secure. Nevertheless, while general advice of this kind is not necessarily harmful, it can involve real risks and in any case does not always produce the result intended. To focus attention on the ways of sex may merely serve to provoke them; it may also be only too easy to give the impression, however unintentionally, that a normal physiological development is somehow strange or harmful; too much advice is no more welcome during one's youth than at any other stage of life. In the long run the force of example, or what is learned in other fields of education, may prove more successful than direct advice in helping the individual to exercise self-control. In any case the emotional changes involved in adolescence are even more important than the physical. Many children at this stage become reticent and anxious, being emotionally troubled, and an understanding teacher who sees this can help the individual boy or girl very greatly by being a good listener, gently encouraging any questions that seem to be causing anxiety, and by giving reassurance, as well as essential advice. Where, with good general guidance, emotional development is proceeding normally and happily, the sex urges will be more easily sublimated, coming to be taken for granted as a natural and not too troublesome phenomenon which is part of growing up. Apart from this, boys and girls are not altogether helpless; it is often possible to perceive in them a natural modesty or fastidiousness which varies in intensity with the individual and his background. This quality, which is not the same as prudery, should be respected. It helps to protect young people from undesirable actions which are often more surely avoided by instinct than by knowledge or experience.

Some of the problems that do trouble boys and girls, while seldom very novel or beyond the range of effective advice and help, are anything but easy for the young people themselves to bear or tackle unaided. Often these difficulties do not arise from ignorance or lack or principle; rather, the boy or girl has "gone off the lines somehow", knows it, and


[page 58]

is distressed. Here it is not knowledge which is needed, but help. The parents are often not in a position to help - even if asked, which is often not the case - and it can mean a great deal if there is someone on the staff to whom the boy or girl can turn. Of course privacy, discretion, and above all mutual confidence are essential; sometimes a child's own teacher is the best counsellor, and in boarding schools and some day schools the housemaster or house tutor is often in a special position to help. Some children may anyhow find it easier to confide in a counsellor outside the school; they should be encouraged to do so, the teacher remaining observant in the background. There is, again, no ready-made answer; each individual problem is unique and its solution must be individual.

Certain special difficulties need special attention. The onset of menstruation in adolescent girls can cause emotional shock, particularly if it comes without warning. An observant teacher will note the first signs of approaching adolescence and this is the moment at which to ask the parents whether their child has been told what may come next. If nothing has been said, and the parents are reluctant to explain, then it is for the teacher to make sure that the girl is emotionally prepared, explaining that menstruation is a normal physiological process and necessary for reproduction. It may also be necessary to emphasise that bathing at such a time is not harmful. Sanitary towels should be changed frequently and clean towels (1) should be available in all schools with older girls, so that a girl can attend to herself in school with proper privacy. Receptacles are needed for soiled towels and it should be understood that these are not to be put into the water closets.

At certain stages of adolescence boys incline to dislike girls, particularly in schools containing both; the girls often reciprocate in kind. On the other hand, particularly in schools containing children of one sex only, strong friendships may develop between boy and boy or girl and girl. Sometimes a boy or girl develops a keen admiration for a teacher or older pupil of the same sex; thus it is not uncommon for girls to admire a mistress to a degree that can be embarrassing. Most emotional reactions of this kind are natural, passing and harmless; hero worship is often a valuable incentive. But the teacher should be prepared for such phenomena, knowing when to ignore and when to comment or act in a friendly and matter-of-fact way; conversely, ignorance, tactlessness or lack of balance on the teacher's side could do harm to the pupil. Such matters usually need not so much specialised knowledge as good will and common sense for their solution. Older boys and girls, particularly

(1) For a fuller note, see the Report of the Chief Medical Officer of the Ministry of Education for 1950 and 1951, p. 17; (Her Majesty's Stationery Office, price 5s. 0d.) The situation has improved in the intervening years, but still falls short of what might be hoped.


[page 59]

in the sixth form, will of course usually have passed from this stage to friendship with the opposite sex. This, too, is likely to involve both in difficult moments, which are not made easier by the frequency with which traditional standards of behaviour are challenged in modern life. Many of the boys and girls concerned are less mature, at least to outward seeming, than their contemporaries who have already left school; but they probably have more opportunities of the kind which arise naturally in the course of the day's occupations to realise for themselves that sex relationships involve more than the individuals concerned. School can gradually help them to realise that in our kind of society individual happiness and social stability alike depend on marriage and the family.

If little but preliminary instruction in parentcraft can be given at school, it is inevitable that many boys and girls will leave school with only the sketchiest preparation for what lies ahead; even when further education is developed, there will still be a limit to what can be taught in the time. But whatever can or cannot be done to help young people later on, it is useless to cram them prematurely while they are still at school; the best preparation in youth for parenthood is a good general education. The time for really detailed help will come later, with courtship, marriage and the birth of children; this is when the preparation undertaken at school will prove its value.

The preceding paragraphs should give a general idea of the range and scope of the responsibilities in this field of the individual teacher. Much of course depends on the school as well as on the teacher; there is seldom a single way of doing things, and practice varies greatly in different schools. Headmasters and headmistresses are responsible for policy in this as in other matters, and they should choose as their helpers those members of staff who are constitutionally suited to deal with the more delicate problems of sex education; those who feel an emotional urge to do this work are not necessarily the most suitable. Thus, while the young teacher should be prepared for the kind of question about sex that may arise at any time in ordinary school work, he need not expect at the outset of his teaching career to have to deal with all the questions raised in this chapter; some of them require considerable maturity and experience. While the questions that trouble pupils should always be dealt with quietly and without emotion, that does not of course mean that the teacher should be indifferent or off-hand. The boys and girls themselves will soon recognise, and appreciate, good will and good sense; even quite young masters or mistresses who have won their pupil's trust will often be in a position to help them when need arises.

In the short pamphlet (1) on Sex Education issued by the Board of

(1) Board of Education, Educational Pamphlet No. 119, Sex Education in Schools and Youth Organisations. Her Majesty's Stationery Office (out of print).


[page 60]

Education under the stress of war in 1943, the first paragraph concerned with training colleges ran as follows (Section 39):

"In the absence of adequate sex instruction in early childhood by their parents, and subsequently in the schools, many students enter teachers' training colleges and departments ill-informed on all aspects of sex. Some attempt is made during training college courses to help the students to develop a balanced attitude towards sex and the problems with which it presents them, as well as to give them accurate knowledge about the physiology of sex. In addition some training colleges try to give their students guidance in regard to the sex instruction which they may later be called on to give as teachers. But the general position in the colleges on the whole matter of sex is, understandably enough, marked by vagueness, hesitation and uncertainty."
It was added (Section 41) that "the difficulties involved are aggravated by the wide variations in the extent and the accuracy of the knowledge which students already possess, and by the anxiety of the more ignorant among them to conceal their ignorance." To the reader who considers all that has happened during the last decade and a half, particularly in the training colleges themselves, these words will probably indicate the very real progress made during this time. There still remains some hesitation and uncertainty; but the responsibility for equipping students at training colleges with a reasonable knowledge of sex instruction is now generally accepted.

The level of information which the students possess on arrival is almost certainly higher than it was, and many will have weathered their own adolescence without difficulty. Yet many students still come to college very poorly informed in all aspects of sex and some may still be in the throes of emotional disturbance or immaturity; all these will need help which should be given individually. Students should be made to feel welcome if they bring their problems to a member of the staff. Often the college matron is in a position to help greatly. On the other hand a student may feel embarrassed at approaching any member of the staff; if so, an interview in confidence with his general medical practitioner may be valuable, or the college medical officer or principal school medical officer in the area can be approached. But whatever the difficulty, and whoever is consulted, the main thing is to know that sensible and knowledgeable people are there to help if they are wanted.

The whole problem was defined in the 1943 pamphlet in words which could still hardly be bettered (Sections 41 and 42):

"The really important point is not where the problem is treated but by whom. In each case the most suitable persons

[page 61]

available should be entrusted with this difficult and delicate task. It should always be remembered that, while accurate and adequate knowledge of sexual physiology, as the mechanism of reproduction, is essential, the most important aspects of sex from the point of view of young people are the emotional and psychological aspects". And "Finally, it should perhaps be said that sex instruction in training colleges should be mainly directed to the personal effect on the students themselves. The students are, indeed, too immature to tackle fully at this stage the problem of how to instruct children in sex matters."
By the end of their training the students should be as fully informed as possible about the normal physical and emotional development of children, and they should have been guided and helped to overcome or manage any problems of their own. With the necessary knowledge and a balanced point of view, the young teacher will be in a position to deal first with the natural questions which can arise at any time in any subject and later, perhaps, with some of the more difficult problems; only he must never forget that the solution for any of these will always be individual and unique.




[page 62]

Chapter 7

Health Education and Youth

ADOLESCENCE is a mixed state, in which childhood and adult life overlap, not always with ease. Many of the problems are much the same whether a boy or girl has left school or not: and in many respects the wage-earning adolescent is just like the school boy or school girl of like age; the needs of mind and spirit are the same, and the processes of learning are not essentially different. But for the young wage-earner school is over for ever; he is earning his living in a wider and insecure world, and this tends to give him an air of apparent maturity which his friends at school have still to achieve. He is also understandably suspicious of anything that smacks too obviously of his own childish past, however happy this may have been. Two of the symptoms of growing up met by every youth leader are the desire to smoke and the desire to have a drink in imitation of those who are already grown up. Young people must be helped to realise the dangers inherent in these desires, and the example of youth leaders and in fact of all adults is of the greatest importance. These topics are considered in more detail in Chapter 13.

With the new physical powers come many changes of mind and mood. Some of the changes are attractive; the body rejoices in its strength; boy and girl discover each other, and each wishes to be and look his best for the other's sake; some are conscious of new-found vocations. But adolescence is also the time of breaking voice, pimples and puppy fat; self-consciousness, insecurity, hesitation and loneliness are all at their worst over this period, and the instincts of sex are difficult to cope with. Young people at this stage meet a variety of standards of behaviour and thought, some of which are markedly different from anything which they have met so far. Rules which they have observed for years may be endangered; for example, new excitements or the claims of work or study are apt to encroach upon the time available for sleep, with irregular meals come irregular habits of elimination, and the new working conditions may make bodily cleanliness harder to maintain. At such a time the need for unobtrusive guidance becomes not less but greater if the transition to adult life is to be reasonably smooth. And yet, though most adolescent boys and girls realise their own insecurity and are very susceptible to the standards of those around them, it is often curiously difficult at this stage to turn to home for help, for home itself may seem a little cramped and lacking in privacy; apart from that,


[page 63]

many parents find it hard to accept that their children are growing up. Increasing independence, curiosity and a taste for adventure inevitably tend to prejudice young people against any kind of restraint or advice which seems to them based on a timorous regard for the conventions. They would father find out for themselves, and anyone who would help must respect this independence.

The opportunities for health education among young people seem to fall into three main groups, according to their sources. First comes everything which a young worker learns in the course of his employment that may have a bearing on his general education in matters of health. Under the Factory Acts careful provision is made for his welfare and many firms supplement the legal minimum in their own way; the actual job and the training needed for it may also be of real value from the point of view of accident prevention, hygiene or general physical development. But the knowledge and practice which are disseminated in this way are in practice very unevenly distributed; many of those who need help most do not get it.

Next comes all that can be provided through the young worker's further education. This will be a spare-time affair for most young workers, in so far as they are in full-time employment to begin with. It is true that an increasing number of employers are now setting aside some part of each working week for continued part-time day education, and, when Sections 43-46 of the 1944 Education Act come to be put into force, all boys and girls who have left school and are still below the age of 18 will eventually have to spend one day in each week or its equivalent in part-time day education at County Colleges. (1) These will provide systematic courses in education, with a proper balance between vocational and general studies; when the county college opens its doors, the opportunities for further education in health should be transformed out of recognition. Meanwhile, the existing day continuation classes are usually of only limited value for purposes of health education; attendance is voluntary, time is limited and, although the number of nonvocational courses is increasing, the vocational element inevitably predominates. Here and there individual courses in subjects such as biology or public administration may be provided, but are seldom on a large scale. Some day continuation schools are also encouraging their students to take part in camping and other similar ventures; the informal education and guidance so given are of good omen for the future.

Many more young people at the present time are able to take courses in their spare time at evening institutes. Here too the courses tend to be vocational, and therefore not very relevant from the point of view of health education. Yet the number of non-vocational courses is increasing,

(1) See Youth's Opportunity, Ministry of Education Pamphlet No.3. Her Majesty's Stationery Office, price 2s. 0d.


[page 64]

and many institutes have been successful in developing an informal and recreational side to their activities; these can be of great value to the limited number of students who make really systematic use of them. But too many adolescent boys and girls never join such institutes at all, or, after joining, fall away after a few weeks or months; often they are the young people who need help most. In short, evening classes are doing work of great value from many points of view; but they are not at the present time rendering large-scale services in the field of health education, for which they were never designed.

The third main group of activities is contributed by voluntary associations and local authorities; these organise youth clubs and other similar groups in which boys and girls of roughly the same age and interests can meet and take up various spare-time pursuits together. The churches are often in a position to help their adolescent members and can offer direct advice, which the receiver is likely to respect, through the friendly association of adults and young people in recreation and fellowship. The valuable work of evening institutes and day continuation schools in fostering leisure-time activities ought really to be included in this general category. Other bodies provide social training through more specialised activities, some of which (such as home nursing and first aid, home making and camping) have a very direct bearing on health education. Others again concentrate on a wide choice of recreational activities; most open youth clubs are of this kind. Nearly all these bodies regard social training as a main aim; their members are helped to develop as persons through learning to use their leisure enjoyably and through successful experience within their own particular group. If one takes account of all that is going on, the result is a varied and lively pattern of informal education which has excited much interest in other countries.

At the present time the contribution of this third group to health education is the greatest of the three. The work of the voluntary agencies, in particular, need not be less significant because they seldom provide set courses in biology or health education, or even single talks. For one thing many of their members will have taken some such course, however simple, at school and should have at least an elementary knowledge of bodily functions; to run over the same ground again might often be a waste of time. But instructional courses of this kind are anyhow not in line with the activities which youth groups and similar bodies are really organised to provide; the real contribution of voluntary clubs to health education is made in helping the individual to see himself in relation to the surrounding community, discovering for himself both what he can give and what there is to receive within a congenial group. In this way a high code of behaviour can be set, without priggishness and in a way which young people can accept as being in line with their own ways of


[page 65]

living and thinking. Such a code may be little discussed, but its workings can be seen in the respect with which members of the opposite sex are regarded, the attitude towards caretakers and cleaners, the courtesy shown to visitors, the consideration shown for people living in the immediate neighbourhood, the care that is taken of the club premises.

Unfortunately these premises are often old and less cheerful than they should be. If the members are encouraged to help with such things as planning, furnishing and decorations, so much the better; even old buildings can often be improved. Standards of taste and cleanliness should be held as high as is possible; any canteen or snack-bar should be clean and cheerful, with good service; any shower baths should be used to the full after exercise, and lavatories, wash basins and cloakrooms must be kept clean and fresh. Of course all this will depend mainly on the leaders and members themselves; however much they need financial aid from outside, the condition of the club will still in the long run be an index of their own efforts.

Leisure occupations for young people tend to be considered too exclusively in terms of indoor occupations, particularly in winter; all too often, except for a few field games, little serious attempt is made to develop the possibilities of the open air. Yet our climate is remarkable for the number of days when one can go out, even in winter; when the days lengthen, the possibilities out of doors are infinite. It should be possible to allow for seasonal variation, encouraging such occupations as ballroom dancing, table tennis, gymnastics or acting in winter time and more outdoor pursuits in spring or summer, including games of every kind, swimming, rambling, hiking and camping; of course the two categories overlap and should not be thought of as opposites. Camping is particularly valuable; it involves the art of living neatly and comfortably in a confined space, the technique of open-air life sanitation, cooking and much else, and there can be few finer opportunities for responding to other people's needs. The change from the routines of the rest of the year is valuable in itself, but that does not mean anarchy; the need for a few simple rules is probably more apparent in camp than at any other time. Even the misadventures which so often occur may have a value of their own; it is when the tent leaks or the cooking goes wrong that one really can learn fortitude and cheerfulness under trying circumstances.

As boys and girls become older and more interested in each other, they often become conscious of needing more information and advice in questions of etiquette, ethics, and general behaviour, particularly with members of the other sex, in general fitness and personal poise, in sexual problems and the problems involved in becoming a parent; one need only read the weekly column of advice in any journal much read by young women to see how greatly these questions agitate and often


[page 66]

confuse the next generation. Boys are perhaps more reticent, but both sexes turn eagerly to all apparently reasonable sources of help. Some turn to their parents, some to a minister or priest, some to the doctor; often the circumstances of the moment may provide a potential counsellor. Yet many find it difficult to confide in those who are set in authority over them; young people have always tended to react against the good intentions of an older generation and sometimes natural independence drives them to very dubious sources of advice. All those are fortunate who know an older and more experienced friend, who is still young enough to speak the same language, does not offer too much advice, and is none the less there when needed. Sometimes a young lecturer or tutor, sometimes a friend of the family, or a senior member of the youth group or some similar society, is in a position to give this kind of help. The contribution made by the best youth leaders is outstanding.

The picture set out in this chapter is manifold and promising - but still uneven; much has been achieved, but need continues to outrun performance. Many young people are left to chance; that most of them remain reasonable and normal is true and too elaborate provision would be a mistake anyhow. But is enough being done? There remains a definite anti-social minority, whose customs attract considerable attention, and there is a larger group, of whom one hears less, who may not have come to any great harm yet still need more help than they are getting in questions of health and social relations; failure here can generally be expressed in terms of incompletely realised potential. The setting up of county colleges, when they come, will make a great difference, particularly over the all-important years between 15 and 18. But even county colleges will never provide a complete solution at any stage; a great variety of provision and a strong voluntary element will always be needed. Already we have the foundations of good practice and experience on which to build.




[page 67]

Chapter 8

Health Education and the Adult;
the Parent as Partner

THE VARIOUS FORMS of further education available for adults, though valuable in themselves, are in the main of somewhat restricted significance for health education; in any case they appeal directly only to a small fraction of the adult population. Certain voluntary bodies, both in town and country, provide useful informal education which includes many features or activities bearing directly on some aspect of health or social welfare. There are also innumerable forms of publicity, whose effect may be none the less educational because often they do not derive from education at all as the term is usually understood. Such "mass media" of communication (as they are often called) as books, magazines, newspapers, films, sound or television broadcasting and various forms of advertisement all help to reach many who could not have been reached in any other way and to raise the general level of public opinion and practice; specific publicity campaigns such as that which taught that "Coughs and Sneezes Spread Diseases" have also been very successful.

But neither education nor mass media (however intelligently used) will ever be sufficient in themselves to give to adults the continuing health education which they still need. That is provided in a much greater degree by the local health authorities as part of the national health service, which, as was explained in Chapter 2, is as far as possible orientated in the direction of preventive medicine. Adults are concerned in this quite as much as young people, since "In a complete system of health education there is no point of special application. The family passes through its cycle of a generation and at every point in the cycle there is some special need." (1) All effective education ultimately depends on the personal link between giver and receiver and much of the educational work carried out by the health services is of this personal kind, including the work carried on by housing officers, almoners, doctors, health visitors and many different social workers; it includes not only all that is done to help the family, but also such advisory services as the different forms of after-care provision being developed by local health authorities and by hospitals, the work of deafness clinics

(1) Ministry of Health Annual Report of the Chief Medical Officer for 1953, p. 166. Her Majesty's Stationery Office, price 8s. 0d.


[page 68]

and, with the increase in the number of old people, the efforts now being made at geriatric clinics and in other ways to help these to keep active and physically fit for their age.

But there will always be certain points at which the educational process can be brought to bear with particular effect. For the adult perhaps the most important period of all begins when the young man and the young woman marry and in due course renew the family cycle with children of their own. The need for help at this stage is greater than at any other, if only because, as we have seen, there are such manifest limits to what can be done long beforehand at school; the time to learn in detail how to rear a family is when the family is actually beginning. It is because the family is so important, not only for the individuals concerned but also for the community as a whole, that so much provision is made out of the community's not unlimited resources for helping young parents.

The family should be considered against the normal background of marriage. Jane Austen expressed it with truth and elegance at the end of "Northanger Abbey" (written in 1797 and 1798 and published in 1818):

"Henry and Catherine were married, the bells rang and everybody smiled. ... To begin perfect happiness at the respective ages of twenty-six and eighteen, is to do pretty well."
The relative importance of the many social factors which have influenced the age of marriage has varied much with time, place and social group. This is particularly true of the three states of maturity mentioned on page 26 as well as of the degree of social maturity, all of which may be reached at different ages in the one person. Since "Northanger Abbey" was written there has been a general tendency to defer the age of marriage, although since the second world war this tendency appears to have been reversed. Generalisation is difficult if only because the different educational, regional and social groups may follow different patterns. In recent years the growth of hire purchase facilities and the economic independence of women have probably contributed to earlier economic maturity and to earlier marriage.

In any case most men and women marry young: in recent years more women have married at 21 than at any other age and more than half have married before the age of 24; the comparable figures for men are 23 and 26. But whatever the age, any preparation or guidance for marriage must be personal and private. Some turn to their parents for information and advice, others consult the doctor, a clergyman or a trusted friend; voluntary bodies such as the organisations for marriage guidance have done much to improve the general level of advice and information available. In any case, information, however


[page 69]

important in its own right, is not enough in itself; most important of all will always be the personal devotion of husband and wife to each other. Before the children begin to come, husband and wife should as a rule have gone some way to work out between them that ultimate relationship which means so much for the new family, however much the children themselves may in time deepen their parents' understanding of each other.

It is against this background that the health services concerned with parents and young children are so particularly rewarding; at no other time is the adult so open to suggestion and help, since the parents have undertaken a formidable commitment and are likely to be glad of all the help that can be given. It is thanks in great measure to doctor, health visitor and midwife, to clinic and maternity ward, and to all the sources of help available during a child's infancy that the parents today can hope to build up their family without losing sight of each other in the process, and that the mother, in particular, can hope to perform her heavy task without any longer becoming worn out before her time. Nor is there any real risk that the new agencies provided to help the parents may between them reduce the sense of parental responsibility. Some parents take their duties too lightly, just as others make a burden of them; both kinds will be known to welfare workers and teachers. But most parents take their responsibilities seriously, though not to the point of priggishness; those people who have themselves wrestled with the day to day task of bringing up children are seldom under any illusion that outside agencies can take the parents' place. As for the experts, the whole trend of current thinking is in any case to emphasise and build up the family unit within the larger framework of society, not to replace it. Where a family is not functioning properly, it needs to be helped to do better and rehabilitation is often possible; institutions may be needed in case of complete breakdown, but they cannot take the family's place.

"From its earliest inception the maternity and child welfare service has been educational and preventive in character; ... its main concern throughout its long history has been the preservation of the health of mother and child. ... Valuable and essential as are the services of the family physician, the hospital medical officer and the consultant, the need for the maternity and child welfare centre with its emphasis on health education remains undiminished ... despite the fact that women are now more knowledgeable in their approach to the tasks and responsibilities of motherhood than were those of earlier generations, there can be no relaxation of educational effort if this advance in the understanding of mothercraft is to be maintained and furthered." These passages, also from the Report for 1953 of the Chief Medical Officer of the Ministry of Health (p. 167), are worth remembering. It is through the maternity and child welfare. services that the mother can at every stage be given


[page 70]

that detailed help in respect of child care which would have been premature at school, though any help and instruction given now will be all the better if based on a good school education. (1) It is still not always recognised how much the work of these services is adult education of the highest order, in which the learner can find out for herself under guidance what she needs to know and then be helped to put it into practice. For a mother's own instincts and personal stock of knowledge, however valuable, cannot tell her all that she ought to know about the child's feeding, washing, exercising, rest, growth, mental development and general health, quite apart from her own welfare. And, as in other forms of education, a mother can be helped in developing her own general health sense in all that pertains to her family, so that she can deal intelligently with daily routine and also judge when outside advice is needed.

Apart from any visits to the mother's home by the health visitor, which will necessarily be limited in number, personal contact between the welfare services and the mother is maintained through the antenatal clinic and the child welfare centre, both of which often provide, besides routine weighing and medical examination and advisory talks, group discussion (probably even more useful than talks) and a variety of materials for visual education, particularly posters. As the same mothers meet each other week by week, a friendly atmosphere is likely to develop; sewing classes for mothers are held in some centres and a number of health authorities have gone one further, to establish mothers' clubs in connection with their maternity and child welfare schemes. These usually meet in the evening for educational and social activities, the mothers themselves being largely responsible for their organisation with the help and advice of medical officers and health visitors; sometimes a special subject for study and discussion will be taken throughout a year, and in some cases father too (if free from "baby-sitting" at home) can come, either regularly or on special occasions. Such clubs and classes make "an invaluable contribution to parental education", which deserves to be more widely known and developed throughout the country. Other work is done in mother and baby homes of various kinds, training courses in women's prisons, hostels for evicted and homeless families, women's institutes and the like, quite apart from more preliminary forms of work in schools and youth clubs. As for the future, "that depends upon the continued application of the principle upon which it was envisaged and founded by the social humanitarians of the early twentieth century-that much of the answer to the problem of the then high levels of infant and child mortality and morbidity lay in the teaching of mothercraft". (2) We have been making good progress, but

(1) See Chapter 6.

(2) Ministry of Health, Annual Report of the Chief Medical Officer for 1953, p. 169.


[page 71]

the infant mortality rate for England and Wales, though but a third of what it was in 1921-25 and only a half even of what it was in 1941-5, is still a little higher than in Sweden, New Zealand, The Netherlands and Australia. There is still plenty of scope for advance and, in certain fields such as, for example, mental health, welfare services are still in process of breaking quite new ground.

All the educational work just described has greatly increased the confidence of the parents in the health services generally, with the result that they are becoming more ready to cooperate not only with the welfare services while the children are still small, but also with the school health service later on; many of these parents were themselves at school not so long ago and retain memories of the work of the school medical officer and his colleagues which are pleasant and not at all intimidating. At this stage too, much can be done not only for child but also for parent, given cooperation. At certain times the parents' presence and interest can make all the difference, particularly at medical inspections in school; children being examined for the first time are usually accompanied by a parent, but the number of parents attending subsequent inspections seems often to be much less, either because many older children prefer not to have their parents with them or because travelling distances to the secondary school are often greater. Yet the inspection misses a good deal of its value if the parent is not present to tell the doctor about her child and also, if necessary, to be advised by him; often the school nurse can help to link parent and doctor when the parent is not present, but she cannot convey everything.

It is becoming increasingly recognised that the school health service and the schools need the cooperation of the parents if the best is to be done for handicapped children. Parents often need advice on the proper handling of their children; sometimes too they are in doubt concerning their mental or physical development and should then seek medical advice without delay. This is particularly important if they suspect that the youngster is not hearing as well as he should, or if he is backward in walking or talking. So too with a maladjusted child or a child who is not making satisfactory progress in school; the teachers and the workers in the school health service, whose partnership has already been considered in Chapter 2, can do much more between them if they know something of his home life and have secured the support of the parents; the difficulty may be due to such a simple and frequent cause as going to bed too late, or it may reflect something deeper such as overcrowding, irresponsible parents, or an unhappy or broken home. The aim should always be a three-cornered partnership between the school health service, the teacher and the parent. The parents' cooperation is essential in dealing with such essentially family problems as vermin infestation, and what can be done when all three parties work together can be seen from one


[page 72]

example: in 1954 in one large city where the percentage of verminous or very dirty children was just under 16 per cent (as compared with 20 per cent three years earlier) there was a school in which the head teacher had succeeded in getting the parents to realise the importance of sending their children clean to school and gave vigorous support to the school health visitor in dealing with any who were not clean; here the number of children found dirty or infested was only 7 out of 400 (or 1.75 per cent).

Perhaps more could be done to secure the active participation of parents in what is needed; their importance is universally conceded, but it is at times assumed in practice that the parent is there only to be directed by the expert. Perhaps parents themselves are often to blame, because they approach professional people not so much with a proper respect as with a timidity which may go back to experiences remembered from their own childhood; over a period of time doctors, dentists, teachers and nurses can help them to develop their own confidence and initiative. For the parent has no reason to feel inferior; however much professional people may know about children from their own special points of view, the mother knows her child uniquely as a whole individual who for her is always in the right. She is seldom objective about her own children; though she may criticise them herself, let someone else try to add to the criticism in front of her! This maternal instinct, however disconcerting at times, has come to be accepted as one of the most powerful of all biological forces; the mother's readiness to take her children's part on all occasions is in itself a valuable safeguard for them. Modern psychology tends to confirm that what the mother has done instinctively and naturally is often right, and modern methods of infant feeding are based on this assumption. If, therefore, there are difficulties between school and home, the whole blame may not invariably lie with the mother; she may well be making matters worse, but some part of the difficulties can be at least partially due to the school, though the mother may not realise this and is often left feeling wholly to blame. It is admittedly not always easy to appreciate a mother's capabilities at their true worth; she can be difficult as well as often wrong. Yet all this is so much the more reason for approaching her with the kind of underlying regard which is likely to make help more acceptable.

The expert's knowledge is unique and valuable, and so is the mother's; both are needed and the relation between the two should be one of mutual appreciation. Here (as in other fields of adult education) the relationship of monologue or unrelieved question and answer is not enough; so much, for example, can be discovered or settled at school or in the clinic, at medical inspections or on other occasions when the partners meet, if only the expert, whether health worker or teacher, knows how to elicit what the parents have to give. Only where father is


[page 73]

feckless or mother wholly ineffective may it be necessary to speak straight out to the parents, though never in front of their children. Even then it is worth remembering that the mother may be worn down through malnutrition; where things go wrong she tends to be the first victim and a number of the mothers in the two lowest of the five social groups into which the Registrar General divides the population are undoubtedly suffering from nutritional anæmia, sometimes aggravated by lack of rest and continuing exhaustion. In the face of such difficulties some mothers do fail and need understanding as well as help. But far more parents deserve respect or admiration for what they have achieved; given respect, even routine contacts can often inspire that sense of active partnership which makes education come alive.

Before long, the new generation of children will grow up too, and the cycle of health education will have revolved once again. But for a long time yet the school children are likely to remain dependent on their parents, with whom indeed they normally spend a greater part of their time than at school. All this time the joint efforts of parents, teachers, and health workers must continue, not being relaxed just because the children are older; the parents too may still need to be helped in their own right, perhaps even after the children have grown up and left them. The subsequent years of maturity and old age, which will bring their own problems with them, lie beyond the scope of this pamphlet; but probably they will not involve anything new in kind. Health education should last as long as life itself; only then will it be complete. To sum up, many of the ways in which the health education of adults can best be furthered are not less valuable because they lie outside "education proper"; taken as a whole, available opportunities and sources of help come to much more than is often realised, and the remarkable progress of recent years reflects not only all the research and discovery that has been going on but also the good sense and willingness to learn of ordinary men and women.




[page 74]

Chapter 9

The Training of Teachers

ANY SERIOUS STUDY of health education involves the training of teachers; these Suggestions are in any case particularly concerned with students in training colleges. What should the student learn and why? What part has health education to play at this very important point in the whole cycle? Of course, all that can be attempted in one short chapter is a brief general stocktaking. No special reference will be made to graduate students in university training departments; their needs in respect of health education are seldom different in kind.

The pattern of training reflects, yet differs from, the general pattern of health education in the schools; this, as we have seen, is not so much a conventional teaching subject as a form of education, pervading the whole life and work of the school and involving headmaster, headmistress and all their staffs. Every teacher has a contribution to make and must be properly briefed. First he must know the essential facts about health, including such topics as are considered in Part II of these Suggestions. Equally important, he must understand the children whom he is teaching, how they grow, how their minds work,. what health means for them and how they can be introduced to it in such a way that they will still practise what they were taught even after leaving school. Finally he will to a great extent be teaching by personal example; to carry conviction in matters of health, he must himself practise what he is preaching. Knowledge, understanding of children and a good example, all are necessary and the college will be concerned with all three.

At college, unlike school, health education must clearly be treated as a distinct and definite subject, to be taken by all. Yet it will still be closely related with several other subjects, particularly education, biology, housecraft, physical education and social studies, both as part of the continuing personal education of the students and also as part of their training for teaching in schools. The student should be helped to consider all that he learns about health in relation to the needs and natures of growing children. There is occasionally a tendency to assume in practice that teachers of younger pupils should know mainly about children, while teachers of older pupils need to concentrate more on exact knowledge; this is a fallacy to be guarded against during training, since at no stage can either exact knowledge or the understanding of children be neglected. And lastly there must be the closest possible link between the rest of the students' studies in health and all that is done by


[page 75]

the college to promote their own personal health; this involves the whole of daily life, including work, play, meals and rest, and the general physical and spiritual development of every student.

Most students attend one or two weekly lectures on the subject throughout their training. The lectures are generally given to large groups, though sometimes the subdivision into infant, junior and secondary groups, which is so often adopted for Education lectures, has been found useful here too. Since a diet containing too many lectures may make the students unduly passive, some colleges follow up the lectures with tutorials in small groups at which the students can discuss as well as listen, bringing with them their school experiences and any personal problems which may lend themselves for discussion; such a combination of lecture and tutorial is of great value. Within any one college the general responsibility for the health course usually lies with one of the lecturers in education, science or physical education. But some colleges have in recent years formed a special committee of lecturers in contributory subjects, the individual members of the committee sharing the work between them; such an arrangement is likely to make for closer working between the various departments involved. In certain colleges a qualified medical practitioner has lectured on health education with great success and several doctors have chosen this as a full-time occupation. A striking deficiency, of which the colleges have been very conscious, has been the lack of suitable specialist qualifications for lecturers in health; for a long time, apart from the certificate of the Royal Society for the Promotion of Health (formerly the Royal Sanitary Institute) introduced in 1919 and renewed after a lapse in 1952, there was no such qualification, but one Institute of Education has recently established a one-year course for experienced workers in this field who wish to pursue advanced studies in health education, and others may follow suit.

The actual content of the courses naturally varies from college to college. Originally most health courses were mainly concerned with what might be termed the mechanics of hygiene, which included human anatomy and physiology and the safeguarding of the community through, for example, efficient ventilation systems, water supply and sanitary systems. The straightforward course in anatomy or physiology is still often found, particularly in colleges of physical education where it serves a special purpose. But in recent years many courses have been developed in fields of study where the precedents are fewer; such courses are naturally all concerned with physical health, but many have also come to include references to mental and also spiritual health, regarding some study of these as essential even for the proper understanding of physical health. Such an approach involves the consideration of man as a social animal living in communities, and an ever increasing number of courses are


[page 76]

reaching out into what is often called "social biology". The effect of this development may in the long run be very far-reaching and will be worth watching. Most syllabuses today include some study of the public health services and of national insurance, and in many prominence is given to the family as a social unit; sometimes family studies have evolved from instruction in sex, (1) helping students in the process to see this in a more natural perspective, and at one college the entire syllabus has been built up around "the family". Visits to hospitals, clinics and schools for special educational treatment are included in most courses; particular attention is often given to this last, both for its own sake and for the light which it can shed on normal standards of health and on any deviations from these.

The assessment of the students' work in the subject is normally through examination. While the Board (now Ministry) of Education was responsible for the certification of teachers, all students had to pass an examination in health education. Today the responsibility for supervising and assessing the students' work in this, as in other subjects, has passed to the Area Training Organisations established between 1946 and 1951, and procedure varies in different areas. Health education continues, with hardly an exception, to be taught as a separate subject, but in some colleges separate examination papers have been replaced by a paper or group of questions included in the papers set on Education courses. Examinations and assessments are supervised by the Health Education Board of Studies which functions in most area training organisations as a sub-committee of the Academic or Professional Board; it includes specialist representatives from every constituent college in the area.

Apart from the normal courses, many colleges arrange for some of their students to make a special study of some health matter, usually during vacation. Studies of this kind are frequently concerned with the organisation of public health departments and institutions, town planning, or with some particular aspect of their work. Visits and personal investigation should be encouraged, though the student should remember that the time of the people whom he meets is precious and not to be wasted. The conclusions are as a rule recorded in an essay, which should provide a valuable discipline and much useful background knowledge; facts must be well ordered, and the reasoning lucid and properly illustrated. A few colleges provided advanced courses, which until now have been taken mainly by students preparing to teach small children. This is understandable, since health considerations are seen at their most immediate in the nursery and infant schools; even so, there is a growing tendency to consider such courses suitable for other teachers, too,

(1) The problems of instruction in sex at the training college are more fully considered, in Chapter 6, in connection with similar problems in the school.


[page 77]

though they are hardly likely to become frequent until the college course as a whole is extended from two to three years.

In their studies of health, whether in lectures or tutorials in other subjects or in observation or practice in schools, the students should lose no opportunity of seeing their subject through the eyes of the children whom they will soon be teaching. As in number or in language, so in health; to thrust adult conceptions on a child before he is ready will only confuse him. It is so tempting to seek too much too quickly, particularly where the instruction may be mainly incidental, the time available short and irregular, and the children themselves not nearly so aware of the laws of health as adults expect; most people who see much of children have had occasion to wish that they were more innately sensible in what and when they eat, less messy, less fond of sitting on damp ground and so on. Yet there is no short cut; one can move only at a child's own pace and it is essential to have some idea of what health may mean to him as opposed to an adult; then and then only is it possible to judge what to expect of him. All this, of course, is closely related with what the student will be learning in the course of his other college studies. Yet for him too all this will be only a beginning; students, too, can absorb only so much and will make their best progress if they concentrate on understanding as far as they can go, rather than on going further still.

The student should also be learning to see how the individual child is shaping generally; it has often been the teacher's eye that first noted something wrong while there was still time to put it right. His power of observation will be particularly useful where there are children who in various ways and degrees are handicapped, bearing in mind that, while severely handicapped children will always need specialised schools, many others with a little help should be able to follow the standard educational course and will be all the better for working with their completely normal fellows. Such children have their own difficulties; they tend, for example, to be more man usually vulnerable to any infectious disease that may be about; in other ways, too, they can occasionally be tiresome to their neighbours; and yet a very little extra help and training within the school will often make all the difference in enabling them to stand on their own feet. In such work - and indeed at many other points in the school day - the young teacher may not find it easy to deal effectively with the problem of pupils whose intelligence is in some cases low compared with his own or to plan a health course that will make sense to them. For this his own knowledge, which will have been based quite rightly on an understanding of the basic sciences, needs to be transposed into something much more direct and personal; such a task demands more experience than students normally possess, but at least a good beginning in this direction can be made while still at college.


[page 78]

A human problem of some difficulty often arises for the young teacher who has succeeded in establishing good relations with parents. Once these have learned to value his advice in connection with their children, they will often bring him their own troubles for solution. Colleges can do a good deal to prepare their students beforehand for such a situation when it arises, warning them of the need to consult with headmaster or headmistress in matters raised by parents; even so, this is a field in which every teacher needs all the tact and knowledge at his command, and also some understanding of the ideas and prejudices commonly held by adults, particularly where their own past education has been limited. It may on such occasions help most of all to know where to look for help; to be effective each member of the health team should know of the work of the other members of the team, besides having some knowledge of the statutory and other resources available. Every student should be given a clear idea of the school health service, what it tries to do, what fields it covers, and how, to be successful, it must work in close association with teachers. To this end students should be aware of, and be encouraged to read, such documents as the reports of Principal School Medical Officers and of the Chief Medical Officer of the Ministry of Education on "The Health of the School Child".

Finally there is the personal health of college students. Day-to-day supervision of this is carefully carried out by the matron, usually a State Registered Nurse, and the college medical officer; their work is particularly valuable when carried out in close touch with the academic staff who are seeing the individual students continuously and can judge of their progress. The students' own development is helped by the physical education and games which are taken by all, irrespective of their future work; their general course in health and the work in other subjects should also have brought out the need for personal fitness both now and later. Now is the time to learn the habits of work that will be needed later on, remembering to allow for reasonable spare-time occupations, including exercise, and personal interests.

Life at college should be very congenial to any reasonable individual; it is a well-balanced life, occupied with absorbing work in which there is always a strong human interest, not to mention the satisfaction of feeling that one's own development is going ahead; there is the satisfaction of working and playing on equal terms with an intelligent group of contemporaries in an atmosphere free enough to allow young men and women to discover their own capacities and limitations yet not so haphazard that there is nobody to turn to when need arises. But it is always a strenuous life, as is the subsequent vocation of teaching; indeed at the time of writing (1956) the present normal course of two years may often seem too short when there is so much essential ground to cover, and there is sometimes a sense of strain which, however


[page 79]

characteristic of modern life in general, is not good for the student. If the standard course comes to be extended to three years, it may become easier to do justice to the possibilities without any sense of strain.

The importance of individual example in the school has already been discussed; this will also be the single most powerful educative force in any kind of college. Its continuous impact includes more than the sum of the individual contributions of the lecturers and tutors; each college derives from its staff and students a distinct and unique corporate personality. Two institutions may have almost the same time-table and the same load of work, yet one will give the impression of intermittent wear and tear while the other retains a serenity based on forbearance and personal understanding. But that is not all. Sometimes one is also conscious of an exceptional warmth of human relationship, lighting up every transaction of the day's business; the avoidance of friction then becomes less important, since there is a harmony in which everyone can get on with the job in hand and friction is hardly conceivable. Everyone knows what is meant by a "happy ship"; leadership has much to do with it at every level, beginning with the Principal and ending with the students. The fortunate students of such colleges will have discovered for themselves at the outset of their career just what can be achieved and should be sought.

Nevertheless, this ultimate form of health is much to ask for. The difficulty lies not so much in the feeling (already expressed in these chapters) that ultimate health can never be defined merely in physical terms as in the feeling of many sincere people that such aims are too high for real life. Yet the conception of corporate health outlined in the last paragraph has often been achieved by groups of quite ordinary individuals; in any case the ideals with which a college may try to inspire its students are not less valid because no single person or college can live up to them the whole time. If the student is to teach health or any other subject effectively, he must set an example; the vocation of teaching, which few people understand who have not tried it, will not ultimately admit of less. The point was magnificently put by Milton in words which are as relevant for health as for language: "And long it was not after then I was confirmed in this opinion that he who would not be frustrate of his hope to write well hereafter in laudable things, ought himself to be a true poem; that is a composition and pattern of the best and honourablest things; not presuming to sing praises of heroic men or famous cities unless he have in himself the experience and practice of all that which is praiseworthy". (1) Health is at once a personal and a corporate quality; it is at college that the would-be teacher should begin to realise something of what example means for achievement.

(1) John Milton: Apology for Smectymnuus, translated from the Latin, Bohn, iii, 117-118.


[page 80]

Finally, however much he may have learned at college, the young teacher at the outset of his career will still have much to learn both in practical experience and in theory. In health education he will only just have begun; experience, more advanced forms of study, reading, short courses and conferences, and practical work, all can further his own education. Apart from that, our knowledge of health is not likely to stand still in coming years. The whole question of further study needs more attention than it has so far received; many opportunities are there for those who will take them.






[page 81]


Part II



The Provision of Health Education






[page 83]

Introductory Note

IN THESE CHAPTERS, the content of current health teaching is reviewed, however selectively, from the point of view of teachers and students in training. This involves an approach from several angles; some pages are concerned with what the student - or for that matter any other young adult - should know for his own good as a person, others with what he should know if he is to play his part in maintaining good standards of health among his pupils, and yet others with what should be taught to children. Yet in practice it is not easy to press such distinctions too nicely; one can seldom say with certainty in advance which facts will be needed by a teacher for his own use and which for passing on. In any case the teacher's point of view in health matters should not be so remote from that of parents and other thoughtful citizens; these chapters are offered to all who care for children.





[page 84]

Chapter 10

Cleanliness

INTRODUCTION

MODERN CIVILISED LIFE requires high standards of cleanliness; the whole subject is of great interest and relevance and its many aspects are too seldom considered together. Two questions stand out; how in a modern community can high standards of personal cleanliness be achieved and maintained, and how can the whole environment in which each individual finds himself be kept clean and healthy? Both issues are of course interconnected; personal cleanliness is more easily maintained in clean surroundings, but the environment itself is controlled and modified by public agencies which themselves depend on the general level of public opinion, and this is the responsibility of each individual citizen. In this chapter the approach to environmental cleanliness is inevitably selective: some consideration of the historical background is essential for the understanding of our own times, while contemporary aspects considered include water supply, refuse and sewage disposal, air and air pollution and sunlight. Town and country planning receives only brief mention; it is certainly relevant as a subject, but nearly all the issues involved would go far beyond the immediate theme. Air pollution, on the other hand, is considered in relative detail; apart from its intrinsic interest, the subject has comparatively recently come to arouse a degree of public concern which is now leading to action.

PERSONAL CLEANLINESS

Children are not particularly clean by nature and few of them see any particular virtue in cleanliness. In most families the initial training in cleanliness is largely a matter of habit formation, but there is a limit to what small children can be expected to learn; at no age is the mere inculcation (meaning literally "grinding in with the heel") of cleanly habits likely to be effective. But neither will undiluted sweet reasonableness be successful at any age, particularly before a child is ready for reasoning. Of course training in cleanliness can never be rapid; it involves home and, later, school at every stage, and the prime movers are habit, good example, praise - and the occasional critical comment. Explanations and instruction also have a part to play which may begin quite early but is sometimes overdone. Encouragement begins at home and most children should make considerable progress in acquiring good


[page 85]

habits, so long as too much is not expected of them; first mother and then teacher can encourage a child to take pride in washing, tidying up and other similar activities. Older children too should take a pride in keeping themselves clean and fresh; they should learn to appreciate their school and its surroundings and to have eyes for the pleasure and beauty of the countryside. It will then be easier for them to realise the havoc that is caused by litter and rubbish and to play their part in preventing both from disfiguring the landscape; as it is, the current standards of public taste in such matters reflect little credit on either our general feeling for hygiene or the quality of our visual education. At the same time it should never be forgotten that any normal child is likely to want to go out and play and get dirty at frequent intervals, in back-yard or garden, in the nearest countryside, or in whatever open space he can find. This is as it should be; children gain particular satisfaction from sand, earth and mud, and all this has nothing to do with habitual uncleanliness. So, too, with camping, particularly among older boys and girls - but in few places are the advantages of cleanliness and order so conspicuous as in a good camp. Indeed the child who has always been able to play freely and go on expeditions or perhaps go camping with his friends is not so likely to react against civilisation in the manner once described by Mark Twain, "Soap and education are not as sudden as a massacre but they are more deadly in the long run".

The main rules of personal cleanliness are not complicated. The skin requires frequent cleansing in order to remove not only visible dirt but also dried sweat, salt and grease which are produced by the activity of the skin glands and would, if left alone, provide a breeding ground for innumerable germs. Where there is a continuing state of dirt, unclean skin cannot function properly and skin disease may be produced or aggravated; a slight scratch, cut or blister is more liable to become inflamed and suppurate and the healing of wounds and abrasions will be delayed. Dirty hands and nails may convey germs to the mouth and to food. When the skin is cleansed, the germs are attacked at their source; similarly the itch mite which causes scabies will not find it easy to gain a hold on a well-washed skin and lice will have no chance to lay their eggs, the so-called nits, in a well cared for head of hair. There should be regular and frequent washing and bathing, especially after games, and everyone needs his own wash-cloth and towel. To be clean in one's own person is also desirable from the point of view of the community; it is a social as well as a personal obligation to keep hands and fingers clean, particularly after visiting the lavatory, when about to handle food, and before meals. Hair should be well brushed and combed daily and regularly washed, with brushes and combs kept clean. Some of these recommendations might appear superfluous, and yet the most recent figures hardly suggest any relaxation of effort. Though the number


[page 86]

of scabies cases in England and Wales fell rapidly from the figure of 11,428 in 1949, it still stood at 3,295 in 1953, and 3,034 in 1954, while the number of impetigo cases remained more nearly constant at 33,843 in 1955 as compared with 34,635 in 1953 and 38,281 in 1949; infestation of the body has become very rare, yet in 1955 there were still 267,681 cases of school children suffering from some form of infestation, usually of the head, as compared with 316,854 cases in 1953 and 443,016 in 1949.

The individual man or woman, boy or girl, cannot hope to stay clean for long unless his immediate personal surroundings are also clean; this involves, in the first instance, his clothes and his home, for we live on such close terms with both that they seem almost an extension of our own selves, and their cleanliness is essential to our own. It is particularly important that underclothing should be washed frequently, in order to remove the sweat and grease which accumulate from the skin. Clothing or bedding which has been used by a child suffering from infectious disease should be disinfected. In normal circumstances, blankets are seldom washed more than once a year, but bedding and blankets should be frequently aired and exposed to the sun. The water closet must be kept clean and fresh; children should be taught how to use it without soiling the seat or the floor and they will learn better if the adults set a good example. Here again children take time to acquire the necessary skill; to force training at too early an age may only do harm, and any action or word that might make a child ashamed should be inconceivable.

ENVIRONMENTAL CLEANLINESS

Progress in history

The social as opposed to the purely personal aspects of cleanliness stand out in particularly sharp relief against an historical background; history provides many illuminating examples of man learning to come to terms with his environment, in this as in other matters. For civilised life began with the coming together of hitherto scattered groups of people to form the first cities; before long, problems which had given little trouble before became much more serious. A nomadic people can leave its dirt behind and go somewhere else, but with rapidly increasing urban populations dirt and refuse began to accumulate in alarming fashion. The mounds which still show in many parts of the Middle East where ancient cities once existed contain not only broken down walls and collapsed buildings but also a great deal of household refuse which must have been most insanitary. In the ancient world as in mediæval Europe rats, lice and typhus all came together; water supplies were continually being polluted. (1) Yet there was real progress; in spite of

(1) See Rats, lice, and history ... the life-history of Typhus Fever, by Hans Zinsser, Routledge, London, 1935.


[page 87]

plagues and other setbacks, living in cities proved successful, their number increased and the quality of the cities in the ancient world at their best has already been mentioned.

There exists a good deal of particularly interesting evidence about the state of affairs in mediæval London. Great importance was attached to both personal and civil cleanliness, though the standards of the times were not ours. Among many indications of the value attached to personal cleanliness, one of the most interesting is to be found in a Latin treatise written in 1376 by an English doctor, John Arderne, and translated into English early in the fifteenth century: "Haue the leche [i.e. surgeon] also clene handes and wele shapen nailez and clensed fro all blaknes and filthe". (1) Nor was there any lack of concern for civic cleanliness; E.L. Sabine has shown in Speculum that, in the late fourteenth and early fifteenth centuries, "city cleaning was being carried on persistently and, on the whole, effectively", (2) in spite of an understandable decline a little earlier, just after the Black Death. "It is abundantly clear that the people of mediæval London and England were much more conscious of the danger of contamination and filth than has been commonly supposed." (3) Similarly in sanitation, though nothing resembling modern practice (4) was possible before the development of the trapped drain in the middle of the nineteenth century, there was a strenuous and persisting effort: "if citizens are to be judged by the time and money expended in their efforts to make their latrines comfortable, clean and sanitary, then many citizens of mediæval London must have deserved whole-hearted praise and respect." (5)

But over a long period, progress, as usual, has probably been spasmodic rather than continuous, and there is evidence of a decline in standards of personal cleanliness and sanitation between, say, 1400 and 1600, due partly to the continuing increase of population; thus the medieval custom of communal bathing fell out of fashion in the late Middle Ages. (6) Queen Elizabeth I took a bath once every three months. (7)

(1) Treatises of Fistula in Ano, Hæmorrhoids and Clysters, edited by D'Arcy Power, F.R.C.S., p. 6, line 32. Early English Text Society, Original Series No. 139, London, 1910.

(2) Cleaning in Mediæval LondonCity , Speculum, Vol. XII (1937), p. 19 ff.

(3) Butchering in Mediæval London, Speculum, Vol. VIII (1933), p. 335 ff.

(4) See Oxford Junior Encyclopaedia, 1955, Vol. III, p. 393, Article on "Sanitation, History of." In this article the original water-closet invented in the reign of Queen Elizabeth I by Sir John Harrington and the valve water-closet patented in 1778 are both illustrated and described. For many reasons development lagged behind invention.

(5) Latrines and Cesspools in Mediæval London, Speculum, Vol. IX (1934), p. 303. See also L. Thorndike, Sanitation, Baths and Street Cleaning, Speculum, Vol. III.

(6) See Lewis Mumford, The Culture of Cities, 1938, pp. 42-51 and 119-122, also p. 192 ff.

(7) See Oxford Junior Encyclopaedia, 1955, Vol. III, p. 354, article on "Personal Hygiene, History of." This volume contains a number of articles on various aspects of cleanliness, hygiene, the home and human biology which should be of interest not only to older boys and girls but also to adult readers.


[page 88]

Late in the seventeenth century that tireless and independent traveller, Celia Fiennes, vividly described her adventures in the hot baths at Bath in which she wore garments of a fine yellow canvas ("the water fills it up so that its borne off that your shape is not seen") and in the icy waters of St. Mungo's Well, Harrogate, which cleared up a persistent pain in her head; (1) but apart from spas, or "Spaws" as they were called, there was little bathing of any kind. Celia Fiennes also described a bath installed at Chatsworth House by the Duke of Devonshire in 1694 which must have been one of the first baths to be equipped with running hot and cold water; but it was to be two hundred years before such baths came to be common. That the great Duke of Wellington took a daily bath was considered remarkable. Progress was equally slow and uneven in other aspects of cleanliness; the new towns of the Industrial Revolution were probably worse at first than their predecessors, as for example in London where, in 1844, 300 sewers emptied into the River Thames above the lowest intake used by the water companies - but the story of London's drains and cholera has already been touched on. (2) All this may seem past history today; but, as a study of air pollution (page 91) will make clear, we still have a long way to go. Nothing can be taken for granted if the physical conditions of modern community life are to be kept from contamination; subsequent paragraphs will give some idea of the variety of effort involved.

Town and Country Planning

The contribution of good planning to cleanliness can be only mentioned, not described. Much dirt can be prevented at the outset through good planning, just as many of our present difficulties reflect the lack of planning in the past. Such planning includes the location of industrial and housing areas, green belts, decentralisation, new towns and so on; to be effective, it needs the support of enlightened public opinion as well as expert advice. But we are still feeling our way; the encroachment upon agricultural land is a serious matter and such issues as housing density or the balance between blocks of flats and small self-contained houses are still far from any generally agreed solutions. Such subjects are well worth discussing in school, though discussion, to be effective, must rest on a background of serious knowledge; the schools have their part to play in developing a public opinion which is informed and enlightened. In such matters economic, æsthetic and sanitary considera-

(1) The Journeys of Celia Fiennes, edited by C. Morris, pp. 17-20 and 79-83. London, Cresset Press, 1949.

(2) Part I, Chapter I. For a picture of the changing attitude towards the use of baths, see W. M. Thackeray's The History of Pendennis (1848-1850), Chapter XXIX, where the new point of view which identifies "The Great Unwashed" with the past is contrasted with the views of Mr. Grump who "had done without water very well".


[page 89]

tions often meet and mingle; it is essential, though not always easy in practice, to take all three considerations fairly into account.

Water Supply

An adequate supply of pure water for drinking, cleansing, and industrial processes of every kind is the single most important need of a modern community. In most of the larger towns in Great Britain the average supply of water per head is 30 to 40 gallons a day [136-182 litres], though this figure (which includes water used for personal, municipal and industrial purposes) may rise to as much as 80 to 100 gallons [364-455 litres] because of the number or nature of local industries. In many areas it is not easy to ensure adequate water supplies, particularly where industrial use or the population is rising; the avoidance of waste has already become a matter of great importance, and careful use begins with the individual. The sources are usually wells, springs, rivers or lakes. Water taken from shallow wells or rivers must undergo a systematic process of purification in view of possible pollution by sewage, animals, factory effluents and sometimes house refuse; the pollution of wells through cesspools, manure-heaps, or decomposing animal matter reflects personal inadvertence, and each individual citizen shares the responsibility for preventing such nuisances from developing at the outset. Where there is pollution, disease germs such as those of typhoid fever may gain access to water derived from a well or river near to some source of pollution. If (perhaps in emergency) the purity of a particular water supply is suspect, any water intended for drinking should be boiled first. But water supplied through the public mains has normally been purified at the outset; filtration and chlorination are the basis of water purification all over the world. In this country the water supply of towns is rarely a danger to health, as elaborate precautions are taken to prevent its contamination at the source, during transit or in any other way. Another major source of pollution may be the presence of chemicals, such as lead in solution; lead is sometimes found in very soft water, as a result of acids in the water attacking unlined lead pipes, and boiling is no protection against such a danger.

Refuse and Sewage Disposal

Arrangements for the disposal of refuse and other waste matter vary widely in different areas. While in scattered rural districts the householder is still often responsible, in urban areas, and increasingly in rural areas too, the work of collection is financed out of the local rates and carried out by the sanitary authority. House, trade and street refuse, excreta (the waste products of the body) and waste water, all have to be disposed of. Refuse is usually burned, dumped or sorted for salvage; sewage is either removed by the water carriage system, usually for


[page 90]

treatment in a sewage works, or else, particularly in rural districts, it is disposed of locally in various ways. Where cesspools or septic tanks are used, they have to be emptied at intervals; the untreated sludge cannot be used as a fertiliser without serious risk of infection. Where sewage or factory effluent is discharged into rivers or the sea, the pollution is often a serious matter, particularly along thickly populated coastlines. The householder is responsible for his own sanitary fittings and house drains and for proper storage of his household refuse until it can be collected; dustbins, which are sometimes a serious nuisance, must have proper lids and be kept clean and free of flies.

The air

Health is more likely to be affected by the physical properties of air, its cooling effect, humidity and rate of movement, than by any slight variations in its chemical composition. Even in ill-ventilated rooms the chimneys and casual chinks and crevices which are to be found around doors, closed windows and between floorboards are normally sufficient to provide enough oxygen and prevent a lethal concentration of carbon dioxide from forming; in the stuffiest room the oxygen content of the air is seldom reduced from the normal 21 per cent to even 20 per cent, while life can be sustained quite comfortably on 16 per cent or even less. When 123 out of I46 men and women originally confined in the Black Hole of Calcutta died, this was due not to luck of oxygen but to heat stroke, due partly to a rise in the air temperature caused by the heat of the victims' bodies and partly to an increase in the humidity of the stagnant air as a result of the moisture given off in the breath and from their skin. If the skin is to function properly, it must be kept cool, but this is not possible in an unventilated atmosphere. Good ventilation presupposes sufficient cubic space for each individual and an ample supply of fresh air, of a suitable temperature and humidity, so that any possible ill-effects from dust or germs may be minimised. Most rooms can be adequately ventilated without draughts; with a circulation of fresh air in any kind of room the risk of infection will be much reduced. Natural ventilation is most effectively caused through inequality of temperature, and so indoor heating and ventilation are always related. Heated air expands, becomes less dense and rises, cool air flowing in to replace it. But, in rooms which are kept very hot, effective ventilation becomes harder to maintain, since ventilation will naturally lower the room temperature and the air tends to come in as a cold draught. Over-heated classrooms slow up pupils' work and lower their resistance to colds and other respiratory infections; but under-heating is probably more common, particularly in old-fashioned schools where in cold weather open fires or inefficient low-temperature combustion stoves may fail to raise the temperature of the rooms by more than a few degrees above freezing


[page 91]

point. The temperature now prescribed (1) in this country is 62° [16.7C] for common rooms, staff rooms, teaching rooms and nursery playrooms, as compared with figures in some countries of 68°-72° [20-22C]; other appropriate temperatures are laid down for rooms with more specialised functions. These temperatures are to be maintained with a rate of ventilation which is defined in terms of a supply of fresh air varying with the cubic space available per person, or amounting to six air changes per hour, whichever is the less. In practice, however, it appears that even in new schools the actual ventilation rate generally falls far short of six air changes an hour; apparently full use is not being made of the available facilities.

Children should be encouraged to work or play out of doors as much as possible; outdoor activities are essential in themselves and will help to reduce the harmful effects of poor ventilation indoors. Fresh moving air has a stimulating effect on the body, the appetite is improved and a general sense of well-being results; the nasal air passages will be kept clearer and any risk of infection is likely to be reduced. But of course the virtues of the open air include not only its freshness but also the fact that we tend to breathe so much more effectively out of doors. Indeed breathing and air supply should always be considered together; to be effective good breathing requires good air, while the fresh moving air will not do its work properly if the breathing is wrong. Breathing should be deep; the involuntary deep breathing induced by vigorous out-of-doors exercise is excellent. It is worth noting that, whilst older children can be encouraged to take two or three deep breaths at intervals, many children of nursery and infant age are too young to be taught how to breathe deeply and the only way in which they are likely to do this is in vigorous exercise. Through deep breathing the whole of the lungs can be properly expanded and the air sacs in the most remote part of the lungs distended; tuberculosis and other infections are less likely to secure a hold in any part of the lung which is adequately ventilated. Finally, proper breathing depends on a good habitual posture; children who bend over their work, or loll about and carry themselves badly, will not exercise their lungs so well as children who hold themselves erect and are generally alert and vigorous.

Air Pollution

The air can be polluted in a number of ways which include not only smoke but also acid fumes due to certain industrial processes, dust found in the neighbourhood of some cement works, electric power

(1) The Standards for School Premises Regulations, 1954, Section 52. The evidence about the shortcomings of ventilation in actual practice is taken from Ministry of Education Building Bulletin No. 13 (July, 1955), Sections 22, 65 and 69. Her Majesty's Stationery Office, price 2s. 0d.


[page 92]

stations and factories, and the exhaust fumes from motor traffic. Little is yet known with any certainty about the effect of these, but under still air conditions, and particularly during fog or in the streets of large towns with taU buildings on each side, the fumes can become highly concentrated. In normal conditions the concentration of carbon dioxide is never enough to be troublesome, but tests made in Regent Street, London, suggest that it may reach levels which are dangerous for some elderly and susceptible people. Some of the other substances contained in exhaust fumes may prove in the light of further investigations to be even more dangerous.

But the most widespread and offensive of all the forms of air pollution is that caused by smoke and particularly by the smoke of burning coal. It has a long and interesting history which goes back to the early middle ages when, for example, in 1257 "Queen Eleanor was driven from Nottingham Castle by the unpleasant fumes of the sea-coal used in the busy town below". (1) Until the increasing use of domestic chimneys in the sixteenth century made it possible to burn coal in a domestic fire, coal was used mainly for industrial processes of various kinds; thus in 1307 its use in lime-burning (just outside the City boundary, near Ludgate, in an alley known as Sea Coal Lane as early as 1138) had to be banned in London. Sir John Falstaff was said by Mistress Quickly to have proposed to her "by a sea-coal fire upon Wednesday in Wheesonweek" (Henry IV, Pt. II, Act II, Sc. 1); it must have been a remarkable occasion. There was a rapid increase in the use of coal during the seventeenth and still more the eighteenth century; by 1800 the full horror of the new industrial towns was developing fast and their inhabitants lived under a pall of smoke which seldom really cleared. Coal runs through every aspect of the nineteenth century; prosperity, poverty and poetry were alike haunted by it,

"As some rich woman, on a winter's morn,
Eyes through her silken curtains the poor drudge,
Who with numb blackened fingers makes her fire - ". (2)
For cheap coal, the increase in the size of cities, and the invention of the modern type of open fire-place (by the remarkable Sir Benjamin Thompson, Count von Rumford, 1753-1814) had together led to a great increase in the use and number of domestic fires, which all added their contribution to
"The yellow fog that rubs its back upon the window panes." (3)
(1) L. F. Salzmann, English Industries of the Middle Ages, p. 6. Constable & Co., London, 1913. Also: "The earliest definite reference to mineral coal is in a Bruges record where among exports from England to Flanders in the year 1200 there is mention of charbon de roche." A. L. Poole, From Domesday Book to Magna Carta, p. 81 (and footnote). The Clarendon Press, Oxford, 1951.

(2) Matthew Arnold, Sohrab and Rustum, lines 302-4 (1853).

(3) T. S. Eliot, Collected Poems 1909-1935 (Love Song of J. Alfred Prufrock), Faber and Faber Ltd.


[page 93]

Britain's prosperity was based upon coal, but a price had to be paid; the health of children and adults was insidiously but often seriously affected, cities became bad places to grow up in and those who were able escaped into the new suburbs. Apart from physical harm, "The pall of smoke and smuts in itself was enough to discourage any effort after beauty or joy in the visible aspect of life". (4)

Sustained efforts have been made in recent years to popularise the use of smokeless fuels and to ensure that industrial furnaces shall consume their fuel as completely as possible; the emission of excessive smoke by factory chimneys led to court action under local by-laws, but the main problems have until now remained unsolved. In recent years there has been a much greater general awareness of the problem, and particular attention has been given to statistics. Thus, to take one instance, there seems a close connection between the air pollution and the deaths due to bronchitis and other respiratory infections. It is significant that, for example, in 1952 11.7 per cent of all male deaths in the heavily polluted district of Central Clydeside were due to bronchitis as compared with 7.5 per cent for the rest of Scotland, the corresponding figures for women being 9.6 per cent and 5.6 per cent. If we compare the figures for England and Wales with those for some neighbouring countries, the result is even more striking; in 1951 the bronchitis death rate in England and Wales was 107.9 per 100,000 of the population for men and 62.7 for women, as compared with 5.0 for men and 4.0 for women in Sweden and only 2.2 for men and 1.9 for women in Denmark. Bronchitis was also at this time responsible for more absence from work than any other form of illness. Of course, such figures as these are probably affected by other factors, such as housing and climatic conditions, as well as by air pollution; it may therefore be worth turning to more immediate evidence. The "Great Smog" of December, 1952, was directly responsible for about 4,000 deaths in the Greater London area, while it is now known that the foggy period between January 3 and January 6, 1956, was sufficient to cause almost 1,000 deaths in the same area. The comment of the Chief Medical Statistician of the General Register Office is of interest: "Three recently reported fog incidents have led to an increase in mortality in the London Area ... " [in 1948, 1952 and 1956]. "In the face of the apparent infrequency of such incidents throughout much of the nineteenth and the first half of the twentieth century, the fact that three incidents have occurred during the past eight winters is disquieting. It suggests the possibility either that the atmospheric pollution associated with London fogs has recently become more toxic, particularly to the very young, the infirm, and the elderly, or that there has been an increase in the number of persons who are specially vulnerable to its effects. The 4,000 deaths in December,

(4) G. M. Trevelyan, English Social History, pp. 578-9.


[page 94]

1952, made a deep impression on the public imagination. These further 1,000 deaths last January are a stern reminder that this major public health problem has not yet been solved." (1)

The report of the Committee on Air Pollution set up with Sir Hugh Beaver as Chairman after the Great Smog of 1952 was published in 1954; the conclusion was drawn that air pollution represents "a social and economic evil which can no longer be tolerated" and which should be combated with the same conviction and energy as were applied 100 years ago in securing pure water. The recommendations of this committee have led to the Clean Air Act of 1956, which for the first time gives a prospect of concerted action on a large scale. Meanwhile there have been some really promising developments such as the establishing of the first smokeless zones at Manchester in 1952 (subsequently extended) and in the City of London in 1955. What can be done may appear from the achievement of Pittsburgh, Pennsylvania, which was once one of the worst smog centres in the world and now enjoys clean air. Perhaps in two or three decades from now it will seem as remarkable that the airman of 1950 could detect London from far off by the darkening of the heavens above as it seems remarkable to us that less than two hundred years ago the stench of London was borne by the wind far out into the surrounding countryside.

Smoke carries poisonous sulphur compounds, tars and carbon monoxide; the sulphur compounds turn into sulphuric acid which attacks buildings, plants and lungs indiscriminately. But chemical corrosion is not the only effect. In large towns the smoke may cut off up to three-quarters of the sun's rays, as compared with a normal loss, as they come through the atmosphere, of one-half at the sea-side and one-quarter on a mountain top. In cold still weather the lowest layers of the atmosphere may never be reached by the sun at all, so that they remain cold and unstirred by any convection currents and we are conscious of the fog becoming gradually thicker and more choking. Even where the smoke can be specially treated, as in some factories and power stations, the grit still tends to sprinkle the surrounding area, while attempts to wash the gases may even increase their moisture content and density, thus causing them to fall more readily towards ground level. But smoke is only the half; soot is also falling in quantities which, over a year, may in some large industrial towns reach as much as 500 or even 700 tons per square mile, choking leaves and lungs, and depositing on all it touches not only black dust but a layer of tar as well. The smoke and soot are generally caused by domestic fires and industrial users in about equal proportion. Perhaps even yet the effects of air pollution and the improvements which would follow from its elimination are not sufficiently

(1) "Mortality from Fog in London, January, 1956," by W. P. D. Logan, M.D. Ph.D., D.P.H., British Medical Journal, March 31st, 1956, p. 722.


[page 95]

realised, though the shortage and high cost of coal is at least causing it to be more carefully used. Atomic energy may before long help to provide clean heat and power, though there will then be new forms of pollution to guard against; meanwhile education has its part to play. It will be a great day when large towns are once more clean and London looks again as it did to Wordsworth on July 31st, 1802, standing in the morning sun on Westminster Bridge:

"Ships, towers, domes, theatres and temples lie
Open unto the fields and to the sky;
All bright and glittering in the smokeless air."
Sunlight

Sunlight gives health and vigour to the body and destroys disease germs; it acts on the skin and causes the formation of Vitamin D in the tissues, and in this way the effect upon bone and tooth formation of any deficiency of this vitamin in the diet can be reduced. The more children play in sunlight the better; even without direct sunlight, the sky-shine can exert a good effect on the skin. Much of the good effect of sunlight upon health is due to invisible rays. When a beam of sunlight is passed through either a prism or the drops of a rain-shower and broken up into its constituent parts, we see the seven visible colours of which sunlight is composed, as in the rainbow; these range from red at one end to violet at the other, and beyond the violet rays are the ultra-violet rays which we cannot see. Their effect upon the body (except for the eyes, which may need protection) is beneficial; but unfortunately they are filtered out when sunlight passes through ordinary window glass, and this is one of the reasons why to be indoors is not so healthy as being out of doors. Ultra-violet rays, like other rays from the sun, are weakened by air pollution. It is wise to start all children, but especially fair-skinned ones, with short exposures to the sun's rays; otherwise unacclimatised skin is in danger of receiving superficial burns, which are often made worse by salt water or sweat. The shoulders and upper portion of the back, which so often receive the full force of the sun's energy while a child is busily engaged in play, should be protected from too long an exposure until a fair degree of pigmentation has been produced. People differ in their reaction to exposure to sunlight and for some, and especially for children, protection of the head and neck is important.

CONCLUSION

However great our progress in recent years, few of us would care to claim that our lives and surroundings are as cleanly as we should wish, and the importance for health of still higher standards of cleanliness is even yet not always sufficiently recognised in daily life. The ground


[page 96]

covered in this chapter should concern every thoughtful adult; much of it is likely to be of interest to older children. But school, again, is only a beginning; the value of the training in cleanliness that is given to children at school will not be fully apparent until they too are adult citizens.






[page 97]

Chapter 11

Movement and Rest

Movement

MOVEMENT is a sign of life. The joy of movement begins early, with a baby's cry or a wriggle, and soon the small child is discovering how to control a previously wobbling head, how to raise head and shoulders when lying prone, to sit up, stand and even, at last, to walk. For the mother's eye the punctual appearance of each new achievement is an indication that all is well with her child. The children themselves take an evident pleasure in their own gradually increasing powers as they begin to explore their surroundings and - with developing skill - to manipulate materials and handle toys; but from an early age they also appreciate movement in its own right and not merely for the skill which comes with it. The pattern of a child's activity may change as he grows up; but, if he is to live abundantly, he still needs ample opportunities for movement so that his natural powers may develop and have full play. Unfortunately the circumstances of modern life too often prevent boys and girls from making the fullest possible use of their own powers. Congested housing, small rooms and highly organised transport offer little inducement or opportunity for active exercise in fresh air and sunlight; the natural zest for movement is stifled so that neither the muscles (including those of the heart) nor the lungs function fully; appetite, digestion and excretion all suffer and life is never lived to the full. It is particularly noticeable that in adolescence the earlier delight in movement seems too often overlaid with an awkward self-consciousness at the time when it might have helped the boy and girl to gain much-needed poise and control.

Physical Education

Many developments can be traced in physical education since its early days; they include the improving of bodily control, the cultivation of individual initiative and prowess through games, the strengthening of particular muscles by the right exercises, good breathing habits; posture and so on. Such aims are still important, even if methods have sometimes changed, but in recent years physical education has come to be more widely defined. In the contemporary school it seeks to counteract at least some of the restrictions which a mainly urban civilisation has imposed on children's natural freedom of movement and growth. To give to each child something at least of the real experience of


[page 98]

physical activity and movement will be of great value for his general education, nourishing his vitality and confidence and helping to develop him as a unified individual, with body, mind and spirit in tune with each other. Thus a generous and well-considered programme of physical education is likely to include not only training in the old sense but also the widest possible variety of experience, including gymnastics, dancing and games, swimming, boxing and fencing, camping, canoeing, hiking and mountaineering and much more besides. Such forms of activity can make a profound appeal and it is sometimes hard to tell where the physical ends and the intellectual or æsthetic begins; often they all seem to go together, and in dancing and drama, for example, the art of movement can reach æsthetic expression of a high order. Nor are these various forms of activity concerned merely with the development of individual powers; they satisfy a number of human longings, social as well as individual, and should add to the individual's sense of belonging to his community. Physical education claims a central place in the general education of today.

Remedial Work

For some children the ordinary programme of physical education is not enough, and they need the individual help and corrective treatment which can be given through remedial classes. Such classes are often arranged in schools, but some children need the special treatment which can only be given at an orthopædic clinic. It is important that teachers should be on the lookout for defects of posture such as slight curvature of the spine, flat foot, round shoulders or a poking head; such defects may be due to bad habits of standing or sitting, to unsuitable school furniture, to fatigue and debility or to actual disease. Provided that these conditions are not due to inadequate rest and sleep, corrective exercises directed by an expert provide the most effective treatment.

Rest

But movement is only half the story. The main rhythm of life is not between one kind of movement and another so much as between movement and stillness, exercise and rest. At all stages rest is necessary, in order that muscles may recover from the tiredness produced by muscular activity; it is also needed for the replacement of wear and tear in other parts of the body, such as the brain and digestive organs. On other grounds, too, a life of incessant activity would be inconceivable; the mind and the spirit also need their periods of calm. Children need rest even more than adults do. Their periods of rest should be frequent, but rest does not necessarily mean complete inactivity; a change of occupation or some reduction in the intensity of what is going on may provide all that is needed. The balance between rest and activity will


[page 99]

vary with different children; some need more rest than others. When a child is recovering from an illness which has kept him for some time in bed, his muscle tone may be poor, and the muscles are more easily fatigued; until he has fully recovered he will need more frequent and longer periods of rest, and so do malnourished, debilitated, and anæmic children. Some children may need more activity than others, but also more mental and emotional rest.

Sleep

The most satisfying and universal of all forms of rest is sleep, which is essential to human life; waking and sleeping are as day and night. For complete and speedy recovery from muscular activity, physical, mental and emotional repose are all necessary, and it is in sleep that they are best found. The voluntary muscles and eyes are rested, circulation and respiration are slowed and the activity of all other tissues and organs is lowered, so that tissue breakdown is reduced to a minimum. In this way more energy becomes available for growth, and it is for this reason that children need much more sleep than adults. For children and adults alike the quality of sleep is as important as its quantity; the value of sleep that is restless and disturbed is very much reduced. There are many conditions that help to bring about sound sleep. A child should have a bed of his own and, whenever possible, a room of his own, although during a period of emotional stress he may occasionally need the companionship of another member of the family in the same room. A mind disturbed, whether by fear, worry, guilt, disappointment or excitement, may prevent sound sleep, as Macbeth and Lady Macbeth discovered to their cost.

Bedtime, especially for younger children, is often a time for unburdening fears or worries; it is as though children sense that they will sleep more restfully afterwards. Disturbed sleep has often been reported after seeing too exciting a film at the cinema, or after too exciting a programme on sound radio or television, particularly if normal bedtime has been postponed. Sleep will be all the sounder if windows are kept open and sometimes the door as well, for the sake of cross-ventilation. The bed should be comfortable, with light but warm bedclothes, Some children are afraid of the dark after the light is turned out; these will often be helped by the judicious use of a nightlight. If a child complains of cold feet, bedsocks may be necessary, or a hot water bottle. Many young children like to cuddle a hot water bottle or a pet toy, or else they may associate sleep with the use of a certain blanket, or a particular pillow. Hungry children do not sleep well; but children vary in what they can eat towards bedtime without interfering with sleep; parents should be guided by past experience when a child says what he wants.


[page 100]

Of course, reasonable quiet and absence of unnecessary disturbance in the house are essential; how can we expect the children to go to sleep if the wireless is blaring?

Children vary considerably in the amount of sleep they need; factors which influence this include the rate at which a child is growing and the intensity of his activities during the day. More sleep is needed after a busy, active day; but over-activity may produce the kind of fatigue that interferes with sleep. A child who goes to sleep quickly, wakes up of his own accord, enjoys his breakfast, and is active and ready for work and play throughout the day, will almost certainly be getting sufficient sleep. But if he takes a long time to fall asleep at night, has to be shaken and roused in the morning, trifles with his breakfast and is irritable and lacking in energy throughout the day, these are all signs that he is not getting enough sleep of the right kind. During periods of rapid growth, such as adolescence, extra sleep is needed; but it is often at such times that a boy or girl resents parental advice and likes to assert independence by staying up late. Bearing in mind that individual variations will be many, the following table may be taken as a very rough guide for the average child, assuming that he rises at 7 o'clock each day:

AgeTo BedHours of Sleep
4 years7.00 p.m.12
6 years7.30 p.m.11½
8 years8.00 p.m.11
10 years8.30 p.m.10½
12 years9.00 p.m.10
14 years9.30 p.m.
16 years10.00 p.m.9
18 years10.30 p.m.

Insistence on routine daytime sleep has undoubtedly been overdone in recent years. After the age of 2½, the afternoon sleep can normally be dispensed with for those children who sleep sufficiently well at night. In nurseries it is found that at about the age of eighteen months some children take 15 to 30 minutes to fall asleep in the afternoon, while children who are between 3 and 5 may take up to an hour and some will not sleep at all. To attempt to force afternoon sleep on these young children without regard for individual needs can easily result in emotional strain. Far more important is the cultivation of the right attitude towards sleep; it should be one of pleasant, casual acceptance, which should follow readily enough when a child has been allowed to enjoy a full and satisfying day.


[page 101]

And it goes without saying that children should be given fair warning of approaching bedtime so that they are not suddenly torn away from any particularly absorbing item of work or play.

"Till the little ones, weary,
No more can be merry;
The sun does descend,
And our sports have an end.
Round the laps of their mothers
Many sisters and brothers,
Like birds in their nest,
Are ready for rest,
And sport no more seen
On the darkening Green." (1)
Fatigue

Fatigue may result from too much activity, too little rest or inadequate sleep; it is often aggravated by lack of food, and something to eat (particularly sugar, which is easily assimilated) or a nourishing drink will often avert fatigue altogether or at least reduce its severity. Any period of over-activity may soon produce a condition of acute fatigue which can become chronic if there is a continuous or too frequently repeated excess of activity over rest. Chronic fatigue frequently follows illness, or results from the intoxication of some chronic infection; it may, for example, be the only indication of a tuberculous infection in childhood persisting until adequate resistance against the tubercle bacillus has been built up; or a child may be similarly affected following rheumatic infection. Sometimes the cause of fatigue is emotional strain, arising perhaps from anxiety or fear connected with school life, or from the uncertainty of conditions at home. Many people find the increasing general noise of traffic and other mechanical devices most exhausting, and here is a field for further study.

Because of the energy required for growth, fatigue is likely to be felt more quickly by children than by adults. It is usually most pronounced during rapid growth, or at a time which, for one reason or another, is more strenuous than usual. Teachers and parents, for example, frequently notice signs of fatigue in children when they start school; this may reflect their uncertainty in a new environment, or the increased demands on mental and physical energy, or, for many children, the confusion of mind which arises from first mingling with a crowd. The signs of fatigue vary in different children. Loss of appetite is common, occasionally with nausea and vomiting; resistance to infection is lowered. Children who are over-tired often persist in fighting against

(1) From the "Echoing Green" in Songs of Innocence, by William Blake. See also the "Nurse's Song", also in Songs of Innocence, for an eighteenth century picture of playtime and bedtime on a summer evening.


[page 102]

sleep and stay awake too long. An over-tired child will readily cry or whine, being touchy and irritable; he may look pale, with dark circles or puffings under the eyes, and sometimes he suffers from headaches. Some become restless, excitable and over-active, others listless and apathetic; concentration is poor, initiative suffers and there is little pleasure at such a time to be gained from all the many class or school activities. Tired and jaded children are all too common and their teachers should be on the lookout for them. Often it is the parents' fault and a talk with them will help; but it is also conceivable that the school itself is providing too stimulating a programme for some at least of its pupils, with insufficient opportunity for rest or relaxation. This fault, where it exists, is not peculiar to schools; it is a feature of modern civilisation:

"What is this life if, full of care,
We have no time to stand and stare?"
We seem to have forgotten in practice that the word "school" once (in Greek) meant "leisure". For there is so much worth doing; the day is too short for all that has to be done and relaxation seems out of the question. Not that occasional overload is necessarily harmful, particularly for older children; but heavy persistent overloading is a serious matter at any age. There is the infant school child who comes home hollow and fractious at 4 o'clock after an over-organised day without a break; there is the child of, say, 8, who comes home from a well-meant sports festival of anything up to four hours' duration; there are older brothers and sisters who settle down listlessly to an unnecessarily large assignment of homework after another bolted tea. Every school, whatever the ages of its pupils, should keep in mind the general risk of overstimulation; a happy mean does not imply idleness.

It is worth watching out for the individual child who for one reason or another finds it hard to stand up to the normal school day. This may be only a temporary phase, such as may come after measles or a bad sore throat; too often at such times a child is pressed to make up lost ground just when his stock of energy is lowest. Or there may be some more deep-seated cause; any serious or doubtful case should be referred to the school doctor. The first essential for such children is usually a prolonged period of rest, after which they can gradually be introduced to short periods of activity, alternating with long periods of rest. Exercise is necessary to maintain and improve the muscle tone, but should not be started until recovery is definitely under way; good food and fresh air are, of course, important too. But for every serious case of this kind there are probably many more in which fatigue is not necessarily obvious; in a school where children can sometimes relax, fatigue is less likely to be a serious problem. Parents and teachers both have their responsibilities and in this should work together.


[page 103]

Chapter 12

A Chapter of Accidents

WITH THE INCREASING COMPLEXITY and pace of modern life, accidents have become responsible for an increasing proportion of the losses sustained by the community in sickness and death. How far can the educational process help to reduce the accident rate, beginning with the home, the school and the streets? And what can be done with children? Accidents of all kinds are now running almost level with all the infections and respiratory diseases put together as a main cause of death among school children and they cause permanent deformity to many more: thus in 1953 accidents were responsible for almost one out of 4 deaths among young people; 37 per cent of all deaths among boys aged between 5 and 14 were due to accidents, and no less than 42 per cent between 15 and 19; the corresponding figures for girls were lower at 21 per cent and 11 per cent. The schools are playing their part in a continuous effort to cut down such figures; in this way they are helping both the children themselves, the adults so often involved in accidents caused by children and in their long-term consequences, and also, in due course, the next generation when today's children grow up and take with them something of what they have learned. But we have not yet reached the limit of what can be done; those who have done most to cut down accidents will be the most aware of all that still needs doing, in the schools and elsewhere.

Most accidents involve an element of bad luck. Occasionally this seems quite unavoidable, as when insurance companies speak of an "Act of God"; in this category one would place accidents caused by earthquake or tornado, though even here carefulness may have its place. There are accidents which happen almost entirely through understandable failure of the human element, as when two children run into each other while playing. But as a rule each accident seems to involve first human carelessness and second some unfortunate circumstance which often seems pure bad luck: thus, to take some examples, the driver "took a chance" but he did not know that the road was blocked, the mother should never have left either her young child alone in the kitchen or the milk on too high a gas, but it was bad luck that the milk boiled over when it did; the door should not have been left open, but the gust that made it slam was quite unexpected. In most cases of this kind the human agent has taken far too great a risk; he might have known it at the back of his mind, like many a driver, or he


[page 104]

might not, because of settled habit - which is the ultimate cause of many accidents in the home. Most of these accidents need never have happened; it was not possible to control circumstance (the road over the hill, the precise moment that the milk boiled over, the unexpected gust of wind) but in each case the human being could with a little common sense have coped properly with his side of the matter; in each case momentary human weakness usually turns out to be the consequence of long-standing habits.

It is here that the educational process can make its greatest contribution, in helping boys and girls or men and women to be responsible and careful to begin with. Admittedly, it also has an important contribution to make in respect of knowledge and technique: an expert swimmer has a better chance of reaching safety, whatever the cause of his being in danger, and good driving technique has saved many a driver from a dangerous situation of his own making. But more important still, education can do much to make the individual more responsible and careful at the outset; such a task is certainly concerned with techniques, but it goes far beyond them and must also take into account the whole approach and attitude of a person. The time to begin it is in childhood, while habits of mind are still forming; both home and school must play their part.

Accidents at Home

"The average individual has not only to learn how to prevent accidents in his home; he must first be convinced that the various dangers exist." (1) It is seldom realised that more deaths are caused by accidents at home than by accidents on the roads; between 1940 and 1950 the ratio between them was roughly 5 to 4. Most of the victims of accidents at home are children and old people, more than a quarter of them being under 15 and more than a half over 50. In 1946, out of a population of 13,000 in a congested Birmingham area, 9 per cent of children under 10 and 3 per cent of all adults were treated at the Birmingham Accidents Hospitals; the rate for the whole population of the area was 4 per cent. Some of the local figures show remarkable variations; why, for example, should the death rate for all domestic accidents in 1952-3 be nearly twice as high for children under 4 living in conurbations (i.e. large built-up urban areas) other than London as for children in Greater London itself? By far the greatest number of accidental deaths in the home are caused by falls (58 per cent in 1951), which are followed by burns and scalds (13 per cent), suffocation (12 per cent), and coal gas poisoning (8 per cent). About 90 per cent

(1) Accidents in the Home: Report of the Standing Interdepartmental Committee on Accidents in the Home, p. 4. Her Majesty's Stationery Office, 1953. A number of the details which follow are taken from this report.


[page 105]

of the falls, over half the burns and scalds, and nearly two-thirds of the coal gas poisonings involve old people over 65; at least 80 per cent of the cases of suffocation (often due to babies turning over on a down pillow) and 20 per cent of the burns and scalds happen to children under 5. The commonest causes of death through accidents at home to children under 15 are burning and scalding, suffocation and falls. In one recent investigation of 1,639 cases of burning, 70 per cent of the victims were children under 15 and more than 80 per cent of the deaths were due to injuries caused by ignited clothing; most of the non-fatal cases required long periods of hospital treatment. Burns and scalds could be greatly reduced if fireguards were universally used, if inflammable materials were not used in clothing, and if children could be protected from electric fires, kettles, irons and teapots. Falls would be fewer if householders were more on their guard against trailing flexes, frayed or torn carpets and poor lighting on staircases and landings; the figures here vary seasonally in a way which suggests that many staircases are not properly lit by artificial light.

When accidents happen, our first instinct is to blame their immediate instrument, the unprotected wire, the rickety ladder, the offending saucepan. That is in keeping with primitive instinct; throughout the middle ages and indeed until 1846 personal chattels which were the immediate occasion of death were legally "deodand", that is to say, they were forfeited to the Crown and any money obtained for them was applied to pious uses. But, of course, the chattel is not really to blame; it has no mind and is at the mercy of unpredictable outward circumstances. What can be controlled is the mind of the human agent, as we have seen. Carefulness begins at home; it is for the householder to make quite sure that his home and all its equipment is properly kept and used. This involves a proper regard for individual items of equipment and a proper carefulness on the part of the user. School can help towards both; there should be many opportunities at school for specific instruction on such danger points in the home. In their housecraft courses girls should learn to cook safely, to look after electrical equipment, to keep the house clean and in good repair, and to keep poisons, disinfectants and drugs in their proper places; particular attention is given in housecraft colleges to the students' training in such matters. Boys, too, should be given equivalent safety training in any domestic work that they may do at school, in woodwork, metalwork, electricity or in other practical studies. But the underlying aim of all such instruction in technique goes beyond the immediate exercise; it should be to encourage the pupil to become more careful in himself.

Accidents at School

The number of accidents at school is also higher than is often


[page 106]

realised. Thus in Buckinghamshire, during 1952 and 1953, 1.2 per cent of all boys and 0.7 per cent of all girls had an accident in school each year. In Bristol schools, during 1952, there were 175 falls, 81 fractures and 82 cuts and dislocations; sprains, cuts, squeezed fingers, collisions, burns and miscellaneous accidents brought up the total to 448 accidents among just over 60,000 children, or 0.75 per cent. Only a minority of all these accidents occurred during physical education lessons, and climbing apparatus accounted for only three accidents, two of which happened during the dinner-hour when the children were climbing unsupervised, against orders. As a rule, children are very carefully supervised while at school, not least in the playground; but for this the figures would certainly have been much higher. Yet accidents continue to happen which could be avoided and every effort must be made to keep down the accident rate in schools. It is true children are naturally high-spirited, and boys, in particular, tend to play games which involve a slight but definite degree of risk; a policy of eliminating every conceivable possibility of accident would involve so strict a regime as to defeat its own ends by weakening the pupils' sense of personal responsibility. Some accidents to children there will always be, but with vigilance and intelligent discipline it should be possible to keep the accident rate within reasonable limits. And all teachers should have had at the very least such training as will help them to render first aid in any accident that does happen in school.

Accidents on the Roads

The community is by now thoroughly aroused by the problem of accidents on the roads; the scale of the problem, particularly as it affects children, is frightening, though the figures suggest that the hard work put into teaching children the elements of road safety has had a real effect. It is true that nearly half of all the children who die from road accidents are aged 5 or less, and therefore unlikely to have received much direct instruction at school; even so, the influence of school upon these children too must be considerable, though it comes at one remove through parents and older children. By the age of 6 the direct influence of school should have become evident, with good habits beginning to form. But carelessness in crossing the road, playing in the street, and the often all too careless use of scooters, toy cycles, bicycles and ultimately motorcycles all take heavy toll, quite apart from accidents for which the motorist is mainly to blame. For boys, road accidents represent the single most frequent cause of death between the ages of 5 and 19; the figures in 1954 were 16 per cent of all deaths between 5 and 14 and 22 per cent between 15 and 19, the corresponding figures for girls being 11 per cent and 8 per cent; girls became safer as they grew older, while the boys' risks increased. The vast majority of


[page 107]

accidents happen to pedestrians, cyclists and motorcyclists; in 1955 the total casualty figures reached a daily average of 15 persons killed and 720 injured; 764 children were killed in 1955, a rise of 15½ per cent over the year before; almost 48,000 were injured. More than a quarter of the accidents happened to child cyclists with whom the increase was as high as 17½ per cent. The number of children under 6 killed in road accidents has been steadily falling, but the number of children under 6 who have been injured is rising; similarly, over the 6 years 1949-55, there has been a reduction of 21 per cent in the number of deaths on the road of all children under 15, but an increase of 21 per cent in injuries, many of them serious. Over 133 children under 15 in Great Britain were killed or injured on the roads every day in 1955. Not that such figures are easy to assess; there were, for example, fewer children under 6 in 1955 than in 1949, but more children who had recently reached cycling age, and the rise in the number of injuries may reflect better reporting of accidents and better follow-up. But even after allowing for statistical adjustment, the accident rate remains a grave challenge to every citizen, teacher and parent.

Any real reduction in road accidents must involve a number of factors, some of which, such as traffic density, weather conditions or the ability of the highway system to cope with the traffic, have little direct reference to education. But there are also very many accidents that education can help to reduce. Some factors such as the driving technique and general carefulness of the average driver are amenable to the forms of educational work that can be applied to adults; the new Highway Code, like its predecessor, represents a major effort in this field. There remains all that the schools can do in conjunction with parents to train boys and girls in good road habits and also in indefinable "road sense". Admittedly this cannot come at once and its strength varies with different children. Yet much can be done to develop it throughout school life. Thus children should be taught kerb drill as soon as they come to school, and there are many games to help them. Police officers will sometimes be willing to give periodical talks in schools and assist in the inspection of bicycles used by children cycling to and from school, bearing in mind that the number of child cyclists killed or injured is rising; in such ways children can also discover for themselves that the policeman is a friend. Local authorities now appoint school crossing patrols to look after the children at the beginning and end of school hours, where traffic conditions make this necessary; both the local authorities and the voluntary societies concerned with the prevention of accidents will always help with advice and sometimes with direct assistance, as in arranging tests of cycling skill. But nothing is so likely to be effective as the patient daily effort of the school; the rest can add to the value of the school's own work but never take its place.


[page 108]

Here again the ultimate aim should be a positive carefulness which combines good technique with the right attitude of mind.

In the schools' work for road safety, as in other branches of accident prevention, help from outside in the form of lectures or demonstrations may be really valuable, yet it cannot take the place of what goes on from day to day or month to month at school. Serious as all the child casualty figures are, they would be much worse but for the devoted attention which teachers have already given to prevention. A continuing contribution from the schools, supplemented by occasional contributions from outside, will have great effect over a period of years. It does not matter if some of the detail learned at school is forgotten later; here, too, carefulness and consideration for others have a better chance if they begin early. And the work of the schools probably does more than is realised in keeping down the number of those people who appear to be so particularly accident-prone that even their choice of jobs has sometimes to be limited; too often such people never learned to be careful at the beginning.

Carefulness

Much has been said about carefulness in this chapter. As a virtue, carefulness is sometimes taken more lightly than it deserves. Yet it is anything but a negative virtue; for example, as any old soldier will agree, carefulness is not an enemy of courage but rather an invaluable ally. At no point does real carefulness ever consist of merely "taking care"; it embraces consideration for others such as is shown by mountaineers roped together on a difficult pitch or, less dramatic but also important, the considerateness with which a responsible person will avoid leaving bottles or empty tins lying about where they might hurt other people (to say nothing of spoiling the landscape). It also involves good technique and craftsmanship; one need only watch a really good driver or an expert craftsman to realise that first rate technique includes and embodies the finest safety training of all. Every cyclist should realise that to ride safely and skilfully on the roads is as much a craft as mountaineering or riding on horseback. And every school should give its pupils at least something of the craftsman's understanding of the material in which he is working and his regard for the tools which he uses. Girls should take pride in carrying out their domestic tasks quickly and with the right technique, so that they never become flustered or careless. Boys should learn to use tools skilfully and carefully, cleaning them and putting them away properly after use. A cyclist should look after his bicycle with as much loving attention as a cricketer of any quality gives to his bat, or a mountaineer to the rope on which his life may depend. In the practical science lessons every pupil should be taught as a matter of course to take care with bunsen flames, to look out for such things as


[page 109]

the danger from invisible steam, and to handle chemicals, apparatus and electrical equipment cleanly and competently. So too, later on in technical colleges or in other similar places the need for safe and helpful methods of working will still need bringing out at every stage. The carefulness and good craftmanship which they have learned will serve all these pupils well at school or college, at home, on the roads, and later on in their work; if they enter industry they will realise more quickly the close connection between skill and safe working. (1) However many regulations and protective devices there may be in a factory to safeguard the individual, he will still be responsible for his own safety and that of others. Throughout life, carefulness, consideration for others and good craftsmanship represent different aspects of the same virtue. To cultivate them at home and at school should be not merely the best form of accident prevention, but also part of a good general education.

First Aid and Life-saving

When, for whatever reason, accidents do happen, a knowledge of elementary first aid may make the difference between life and death. Certain simple forms of first aid should be within the grasp of every boy and girl of secondary school age. But in considering what to include in a first aid course there are always two questions to ask; does the staff include anyone with real knowledge and experience of the subject? And is there a risk of inadequate first aid doing more harm than good? Children should not be trained to undertake responsibilities in advance of their years; they must realise that first aid has two main aims:

(1) to recognise whether a particular injury calls for expert attention;
(2) to render such immediate help as will prevent further injury.
In both there are limits, which must be recognised, beyond which elementary first aid cannot go. Of course school is not the only place in which children can learn first aid; many children while still at school become interested as members of voluntary organisations, and those who come to join a Civil Defence organisation will find it vital. One particularly important form of first aid is life-saving from drowning. As many older boys and girls as possible should be instructed in life saving; it has been practised with great success by innumerable schools and provides a valuable link with more theoretical work in biology. Here, too, faulty technique can be dangerous for both victim and rescuer; if life-saving is taught, it must be taught effectively and only when the

(1) See also Industrial Accident Prevention, a Report of the Industrial Safety Sub-Committee of the National Joint Advisory Council (Her Majesty's Stationery Office, 1956), especially Chapter 1, which gives figures showing the number of industrial accidents affecting young people under 18 each year, and Chapter 7 on "Schools, Colleges and Universities, and Education in Industrial Safety".


[page 110]

essential proficiency in swimming has been reached. A sound training in swimming comes first.

The Teacher's Part

The teacher's part in helping children to avoid accidents will be clear from what has been said already. It includes an intelligent understanding of how accidents happen and can be prevented, particularly at home, at school, and on the street; it also presupposes a wide understanding both of how children learn in general terms and of what is really meant by responsibility. It includes a sense of craftsmanship and here, as in all else, teacher and student will not forget that children learn from personal example. Finally, as has already been suggested, every teacher should have a good working knowledge of simple first aid.





[page 111]

Chapter 13

Drugs, Alcohol and Tobacco

VARIOUS LEGENDS attach to the first beginnings of tea and coffee; it is said, for example, that coffee berries were chewed by Arabian mystics wishing to keep awake in contemplation. These represent only two of the plants which have been used, sometimes by quite primitive peoples, to give immediate satisfactions going beyond the mere appeasement of hunger. Some, such as tea and coffee themselves, are now in use all over the civilised world; the use of them has spread rapidly since John Evelyn commented on the coming in 1636 to his College of "one Nathaniel Conopios, out of Greece. ... He was the first I ever saw drink coffee" - while tea was first imported into Europe a few years later, about 1655. They are almost entirely harmless, providing a mild degree of stimulation with, for most people, no unpleasant after-effects. But some of the substances used to provide stimulation create new appetites which sometimes become cravings; these too have probably become more widespread as the strains of modern civilised life have increased the demand for whatever could give a sense of temporary escape or relief, at whatever ultimate cost. For this reason, and because many of these substances are in some degree poisonous, the community has found it necessary to control their use.

Opinions have varied about the nature of such a control or the choice of substances to be controlled. A century ago such drugs as opium (or laudanum, as its various preparations were often called) were a serious menace from which Coleridge and De Quincey suffered great harm; even towards the close of the nineteenth century it was still possible for Sherlock Holmes to take cocaine, though Dr. Watson did not approve. But today all such drugs are controlled nationally and internationally, and their use is permitted only in exceptional circumstances and in accordance with medical advice. Thus there is no serious drug problem of this kind in the United Kingdom today, and teachers in this country are hardly likely to be concerned with it.

There is, however, another form of drug taking which costs not only the individual but also the community a great deal of money. This consists of the consumption of pills, tablets and every conceivable kind of medicine out of a bottle, largely in order to satisfy the instinctive desire for some kind of magic remedy. Since all dangerous drugs normally require a doctor's prescription, most of the medicines concerned are harmless enough, though the indiscriminate use of laxatives


[page 112]

and aperients may be harmful to health and in general they are better avoided except on medical advice. We have outgrown such primitive remedies as ground up Egyptian mummies, spiders and so on; it is to be hoped that before long we shall equally have outgrown our faith in remedies which often have only faith to commend them. Over a period teachers can help their pupils to realise that the rules of good health are for the most part not too difficult to follow, and are anyhow cheaper and more effective than most pills and medicines.

Both tobacco and alcoholic drinks are subject to limited control by law. They may not be sold to, or used by, children, and both are heavily taxed. As children seldom like the taste of alcoholic drinks, these are no temptation to them. Trouble usually begins with young people who wish to appear grown up, and here the advice and general point of view of the teacher or youth leader may be of great value. He can help to dispel the illusion - not uncommon among young people - that in the world outside school abstinence is somehow unmanly, while indulgence is a sign of maturity and independence. In this matter, as in others prejudicial to sound health, children should be led to understand the need for good sense and self-control. Athletes when training for racing, boxing, football, mountaineering and other sports usually avoid alcohol for they know that its effect on strength and endurance may be harmful; moreover, alcohol may lower the resistance of the body to disease, and to take so much as to lose command of one's senses is disgusting and degrading.

Before leaving school children should understand that nobody who takes too much alcoholic drink can hope to do a good day's work or be fit for responsibility, and that the effect of alcohol, particularly on anyone who is young and still unused to it, can lead to serious consequences for others besides the individual himself. The loosening of control which may follow from excessive drinking can lead to sexual misconduct and is often associated with other common offences, such as wanton damage to property, hooliganism, assault, cruelty to animals and cruelty to children. When the driver of a car or motor cycle is the worse for drink, a smash is often the result and others besides the driver himself may be hurt, maimed for life or killed. It should also be realised that alcoholic drinks are expensive and that to spend too much on them may mean cutting down the amount of money available for the necessities of life or for other luxuries of more abiding value, so that individual and family standards of life and enjoyment may suffer.

When older people give advice, they should remember how impatient of restrictions they too were when young. There is no need to be horrific or to exaggerate; in discussing such matters with children, it is better to appeal to their common sense. Parents, teachers and others in close touch with young people can do much to guide them by encourag-


[page 113]

ing worthwhile hobbies and interests, and by skilful praise of interesting and worthwhile behaviour of adults so that the young people will emulate what is good. And the community too can make its own contribution here: where there are many opportunities for lively and healthy recreation of every kind, drinking and smoking are not so likely to tempt.

During this century there has been a welcome reduction in the heavy drinking which at times in the 18th and 19th centuries caused great harm to our society and is still a danger in some countries today. In Great Britain the reduction is due partly to educational influences of every kind, which have undoubtedly had a sobering effect, and partly to such factors as better facilities for outdoor recreations and travelling, the cinema, sound radio and television, and the gradual development of other tastes and interests; all these have combined to make claims on the time and money which would otherwise have been spent on drinking. At the same time higher prices have made it more expensive to get drunk and restrictions imposed by law on the sale of intoxicating drinks have made them less easy to obtain. Nevertheless, during the years 1954-56 convictions for drunkenness amongst persons under 21 have increased, and there are therefore no grounds for complacency.

In smoking there has been a considerable increase, particularly in the form of cigarettes. These are not so difficult as alcoholic drinks for children to obtain. Yet the first attempts at smoking are seldom if ever pleasant and arise more out of curiosity or the desire to appear grown up than because smoking is really enjoyed.

Heavy smoking has long been considered injurious to health, chronic cough and bronchitis, for example, being often caused or aggravated by heavy smoking. In recent years, moreover, research conducted in many countries has suggested that cigarette smoking may also predispose an individual to cancer of the lung. The following statement was made in Parliament in May, 1956, by the Minister of Health:

"Since my predecessor made a statement in February, 1954, investigations into the possible connection of smoking and cancer of the lung have been proceeding in this and other countries. Two known cancer-producing agents have been identified in tobacco smoke, but whether they have a direct role in producing lung cancer, and if so what, has not been proved.

The extent of the problem should be neither minimised nor exaggerated. The number of deaths from cancer of the lung has risen from 2,286 in 1931 to 17,271 last year. To place the figures in perspective - in 1954, out of every thousand deaths of men aged between 45 and 74, 77 were from bronchitis, 112


[page 114]

were from strokes and apoplexies and 234 were from cancer, of which 85 were cancer of the lung. Deaths of women from cancer of the lung are still not very significant and represent a small fraction of the total.

The chairman of a committee of the Medical Research Council which has been investigating the subject considers that the fact that a causal agent has not yet been recognised should not be allowed to obscure the fact that there is, statistically, an incontrovertible association between cigarette smoking and the incidence of lung cancer. The statistical evidence from this and other countries to which he refers tends to show that mortality from cancer of the lung is twenty times greater amongst heavy smokers than amongst non-smokers.

The Government will take such steps as are necessary to ensure that the public are kept informed of all the relevant information as and when it becomes available."

In reply to supplementary questions, the Minister said that it would appear that pipe smokers faced a heavier risk than non-smokers but that the risk was substantially less than that incurred by heavy cigarette smokers.

In June, 1957, a special report of the Medical Research Council pointed out that, while knowledge of the causation of lung cancer was still incomplete, the evidence for an association between lung cancer and tobacco smoking had been mounting steadily. Evidence from many investigations in different countries indicated that a major part of the increase was associated with tobacco smoking, particularly in the form of cigarettes. In the opinion of the Council, the most reasonable interpretation of this evidence was that the relationship was one of direct cause and effect. The identification of several carcinogenic substances in tobacco smoke provided a rational basis for such a causal relationship.

Speaking on behalf of the Government in the House of Commons on 27th June, 1957, the Parliamentary Secretary to the Ministry of Health said:

"In their Annual Report, and more particularly in their special report on tobacco smoking and cancer of the lung, the Medical Research Council have advised the Government that the most reasonable interpretation of the very great increase in deaths from lung cancer in males during the past twenty-five years is that a major part of it is caused by smoking tobacco, particularly heavy cigarette smoking. The Council point to the evidence derived from investigations in many countries in support of this conclusion, in particular to identification of several carcinogenic substances in tobacco smoke.

[page 115]

The Government feel that it is right to ensure that this latest authoritative opinion is brought effectively to public notice, so that everyone may know the risks involved in smoking. The Government consider that these facts should be made known to all those with responsibility for health education. ...

Once the risks are known everyone who smokes will have to measure them and make up his or her own mind, and must be relied upon as a responsible person to act as seems best."

A Ministry of Health circular, dated 27th June, 1957, asked local health authorities to take appropriate steps to inform the general public as part of their health education work; and the Central Council for Health Education arranged to provide suitable publicity material for this purpose. The Minister of Education sent a copy of the statement made in the House of Commons to local education authorities and other educational bodies including the proprietors of all non-maintained schools and the national voluntary youth organisations.

Children and young persons clearly need to be warned of the risks involved in smoking. Most parents can be relied upon to do this themselves in their own way but the schools, too, will be expected to see that the risks are made known to every child at some stage in his school life.

Obviously it is easier to decide not to start smoking, or to give it up, before any habit has been formed. Many adults who have become habitual smokers have great difficulty in abandoning, or even reducing, their smoking; some deliberately take the risk of continuing the practice, while others do so against their better judgment. The value to both the race and the individual of the power to adapt to changing circumstances has been described elsewhere in this Handbook (Chapter 3, page 24), and consideration of these practices may serve to illustrate how important it is to retain the power of determining behaviour by judgment rather than by thoughtless repetition. Adults can help younger people best by their own example, by not encouraging them to feel that to smoke is to be grown up; more generally, too, they can help to make it clear that self-control or restraint is not the same as submission to external authority but represents something positive which comes from within.

It sometimes happens that in such matters the standard of behaviour expected in school will be at variance with that of the home. In such a delicate situation teachers may be relied on to do their utmost to minimise the risks of divided allegiance; the general relationship between school and parents is important in this context, and a teacher who is in close touch with the parents will find it easier to talk over a difficult problem when need arises. Success will depend not only on the cogency with which the teacher can put over the school's point of view, but also


[page 116]

on the tact with which he can listen to the other point of view as well. Such work, however difficult, is of great service to the community; in upholding ideals of temperance, self-control and tolerance, which are strongly though tacitly approved by the community as a whole, and in trying to work with parents and never at them, the teacher is not likely to weaken family ties.





[page 117]

Chapter 14

Nutrition and Food

NUTRITION AND GROWTH IN RELATION TO HEALTH

NUTRITION, growth and health are so closely interrelated that the study of one involves the study of all three. Growth is best defined in terms of natural increase in size; the science of nutrition is the study of the process by which food is utilised to provide energy, maintain bodily structure and function, and promote growth. In assessing growth and nutrition in their mutual relation it must be remembered that children vary greatly in type. Some children are constitutionally slender, some stocky. Between these two extremes we find all grades of physique. We cannot make slender children fat nor would we wish to. Thus it is difficult to say by mere inspection if a child is in a good state of nutrition, but it is comparatively easy to say if he is in a satisfactory state of health. A healthy child is well grown, and well covered (but not too fat), has a good carriage, glossy hair, good colour, elastic skin, bright eyes, and is cheerful and alert. The child who is not in a satisfactory state of health may look too thin or too fat; he tends to be listless, and his posture is often poor; his hair may be lank and his skin flabby; his school performance may be impaired and he often looks generally depressed or even miserable.

How far can a child's general health or physique be associated with his state of nutrition? If his health seems poor, this may be because the food given to him is insufficient to provide energy for his needs, or it may supply his energy requirements without containing enough essential nutrients. He may have access to a good balanced diet, to which he cannot do justice because of poor appetite, or for various reasons he may be eating enough without being able to utilise all that he eats. He may for a time be in subnormal health (as when he suffers from a mild infection such as a cold), or he may be suffering from a chronic infection or from organic disease. There is the possibility that he is not getting enough rest or fresh air, or he may be emotionally disturbed. The maintenance of good health depends on many factors of which food is only one. The important point is to recognise when a child is not as well as he should be. A teacher who knows his boys or girls well should be able to recognise any signs of subnormal health early, and will then refer them to the school doctor or nurse or, through their parents, to their own doctor.


[page 118]

THE NUTRIENTS OF FOOD

Food contains the following nutrients: protein, fat, carbohydrate, mineral substances, and vitamins.

Protein

Protein is an essential constituent of all animal and vegetable cells. Protein is used in the body for growth and for repair of waste, and is therefore of particular importance to the growing child. It is also a source of energy. When taken into the body, protein is broken down by digestion into amino-acids. These represent so many different components out of which the protein molecule is built; one protein molecule may contain as many as twenty of them. Probably at least ten amino-acids are essential for the growth of the child; they must be supplied in the food, as they cannot be made by the body. All these essential amino-acids are present in any one molecule of animal protein; in some vegetable proteins, however, one or more will be absent, though a suitable mixture of vegetable proteins may supply them all. If the amino-acids are to be fully used in building up the fresh proteins needed in the body, a complete assortment of them should be available in the diet. When milk, meat and cheese are scanty, they should be spread over several meals and eaten with bread, potatoes and cereal in order that the fullest possible use may be made of the amino-acids in the diet.

Fat

Fat is found in all animal fats, such as meat fat, butter fat, and oils. It is an important source of energy and heat. In animals, fat may be formed from carbohydrate.

Carbohydrate

Carbohydrate is the nutrient which supplies energy; it can be converted into fat. It occurs in foodstuffs in two forms, sugar and starch.

(i) Sugar. Glucose is the simplest form of sugar. Other forms of sugar such as fructose, lactose, sucrose, and maltose, are broken down to glucose by digestion in the alimentary tract. The molecules of glucose are then absorbed into the blood stream through the mucous membrane lining the small intestine.

(ii) Starch. Starch is a compound molecule containing many molecules of glucose. It also is broken down by digestion to glucose, and is then absorbed by the alimentary tract.

Starches and sugars are found chiefly in sugar, flour, bread, fruits and vegetables.


[page 119]

Minerals

Nineteen major inorganic substances (minerals) are contained in the body, all of which must be derived from food. Minerals are important in the formation of bones and teeth (especially calcium, phosphorus and magnesium), as constituents of body cells, and as soluble salts in tissue fluids. In addition iodine is concerned in thyroid metabolism, (1) copper and iron in red blood cell formation, and cobalt in combating anæmia (vitamin B12). Most of these minerals are needed only in very small amounts; they are widely distributed in nature.

Vitamins

Vitamins are organic substances necessary for life and health; they are found in very small amounts in natural foods. Some of the vitamins (e.g. A, D, E and K) are found mainly in fatty foods, and are called fat-soluble; others (e.g. B complex and C) are water-soluble. Vitamins were discovered early in the twentieth century; their chemical structures were not known for some years. They were named after the letters of the alphabet, or simply referred to as "factors" preventing certain diseases, e.g. vitamin D was known as the anti-rachitic vitamin. After recent advances in biochemistry we can now assign chemical formulae to several of the vitamins, and many of them can be synthesised in the laboratory; vitamin B12 for example, was first produced synthetically in 1948.

Vitamin A occurs in certain fats, and in the fatty parts of some foods. Carotene, a precursor of vitamin A, is found in certain vegetable foodstuffs. Carotene can be changed into vitamin A in the human body, but less efficiently than in the bodies of some animals; that is why animal sources of vitamin A are more effective than vegetable sources. Vitamin A is necessary in the body for growth, it is concerned in the perception of light, and it protects skin and mucous surfaces of the body from infection. If it is not well represented in the diet, bodily health will suffer. An excess of vitamin A, however, will not improve health; enough is as good as a feast.

The following are the sources of vitamin A; they are listed (like the other vitamin sources given in this section) in order of potency, beginning with the most potent source and ending with the least:

(i) Animal. Halibut liver oil, cod-liver oil, ox-liver, butter, margarine, cheese, eggs, sardine, herring.

(ii) Vegetable. Carrot, spinach, watercress, apricot, tomatoes, prunes.

Vitamin A is stored in the liver, so that a supply can be built up in the autumn for use in the winter.

(1) Metabolism is "The process in an organism or a single cell by which nutritive material is built up into living matter." - Shorter Oxford English Dictionary.


[page 120]

Vitamin D is concerned with the laying down of calcium and phosphorus in bone; it is therefore of particular importance during periods of rapid growth. Too little of this vitamin may cause rickets; too much may cause metabolic disturbances in infants. It may be obtained from food, or it may be formed in the skin by the action of sunlight. It is contained in cod-liver oil, sardines, herring, tinned salmon, margarine, eggs and butter. Like vitamin A, it is fat-soluble and heat resistant.

Vitamin E is necessary for normal reproduction in rats, but we do not know whether it plays any part in the fertility of human beings. It is found in milk, in wheat germ, and (in small amounts) in green vegetables.

Vitamin K is essential for the normal clotting of blood. It is found in green plants such as peas and cabbage.

Vitamin B group of Nutrients. All members of the group are water-soluble; they are widely distributed in foodstuffs, and are often found together. At one time only two components were recognised, vitamin B1, and vitamin B2. Today (1956) about twelve vitamins have been described, though it is not certain that all of them are necessary to the human economy.

Aneurin or thiamin (Vitamin B1) is concerned in the mechanism of releasing energy from carbohydrate. If there is not enough of this vitamin in the diet, growth is checked, a particular form of neuritis may develop, and there may be depression and irritability. If the deficiency is severe and prolonged, as it was in Japanese prisoner-of-war camps during the last war, beri-beri develops.

Riboflavin is also concerned in the process of obtaining energy from carbohydrate for use by the body. If it is in short supply, growth is slowed down, and cracks and sores may appear at the corners of the mouth, with the tongue becoming red and raw, and the cornea hazy.

Nicotinic acid (Vitamin B2) is also concerned in releasing energy from carbohydrate. When there is not enough of this vitamin in the diet, growth is checked, the skin is liable to become rough and red, and the tongue may be red and sore. If deficiency is severe and prolonged, diarrhœa and dementia may occur (pellagra).

Some other members of the B group are:
Pyridoxine, needed for growth, health of skin, and protein metabolism.
Pantothenic acid, necessary for growth and health of the skin.
Biotin, concerned with health of the skin.
Folic acid, concerned with growth; it is used in treatment of macrocytic anæmia.

[page 121]

B12 used in treatment of pernicious anæmia, is found in animal foods only, particularly milk, eggs and cheese. The other members of the vitamin B group are found together in the following foodstuffs:
Bread, meat (pork contains about ten times more B than beef or mutton), liver, yeast, oatmeal, green peas, peanuts, potatoes, meat extract, cheese, eggs, malt and milk.
Milk is an important source of riboflavin, and bread a less good one.

Vitamin C (Ascorbic acid) is concerned with the maintenance of the integrity of the connective tissue structures. If it is in short supply, growth will be checked, the gums and mouth will be liable to infection, healing will be slowed; prolonged deprivation is likely to lead to scurvy. This vitamin is found mainly in fruit and vegetables, is easily destroyed by cooking, and tends to deteriorate if food is stored. Ascorbic acid exists in high concentration in rapidly growing vegetables; new potatoes contain more of it than old potatoes. It is well represented in blackcurrants, sprouts, cauliflower, cabbage, watercress, orange, lemon, grapefruit, potato. Since fruits and vegetables tend to be expensive in the winter, the diet may easily be low in ascorbic acid. Great care must be taken to see that a good supply of this vitamin is available in diet.

It will be noticed that all the vitamins are essential to growth. Vitamins are needed only in small amounts; if an adequate amount of any particular vitamin is available in the diet, no benefit will be reaped by taking more. Various vitamin preparations are on the market. They have their uses, and are particularly valuable when food supplies are limited (as in time of war). In general, however, it is better to take the natural products whenever they are available.

FLUIDS

Water

Two-thirds of the body is made up of water. Water takes food to the body cells and removes waste products. At least 1½ pints [0.85 litres] of fluid should be drunk daily by an adult. Most children like water and they should be encouraged to drink whenever they are thirsty. Now that so many children stay at school all day, they must all be able to drink as much water as they need, and when they need it; drinking facilities should be made easy, attractive and hygienic. If there are practical difficulties in the way, local education authorities and teachers should combine to deal with them. It is particularly important that water should be available at the midday meal.

Tea, Soft Drinks, etc.

Both children and adults often like to drink water which has been flavoured in various ways; such drinks include tea, coffee, cocoa, fruit


[page 122]

juices and fruit drinks and mineral waters. Neither tea nor coffee is a real food; any food value in tea, as it is drunk in this country, is contained in the milk and sugar put into it. The difference between milk and tea lies in the fact that milk gives the body actual energy and strength, whereas tea can only stimulate the body to put forth and use the strength it has already. Tea or coffee in moderation are both most refreshing; but if they are taken too often because of their stimulating properties, the result may be anything but good; when the body is tired, it needs not stimulants, however harmless they may be in themselves, but rest and food. Mineral waters are usually very popular with children. Though their food value is negligible, they do supply some of the fluid necessary to health. Fruit juices and fruit squashes prepared from freshly squeezed citrus fruits are usually popular and, if properly prepared, are a valuable source of vitamin C and minerals.

Milk

The value of milk as a part of our diet is emphasised by the National Food Survey for 1952 which shows that milk in the national diet provides the following percentages of nutrients in the national diet:

about 18 per cent of all Protein
about 47 per cent of all Calcium
about 13 per cent of all Vitamin A
about 13 per cent of all Vitamin B
about 38 per cent of all Riboflavin
about 10 per cent of all Calories
The importance of milk arises chiefly from its high protein, calcium and riboflavin contents. The fat in milk provides a concentrated source of calories. No single food is as valuable as milk, although it does not contain enough iron or vitamin C to be classed as a perfect food; however, both iron and vitamin C are easily supplied by a normal mixed diet. Milk is particularly important where rapid growth is in progress as in pregnancy, for nursing mothers, children and adolescents, and it has been proved almost essential if children are to realise their full potential. Even when the general diet is good and varied, it is seldom desirable to give a child less than one pint [568ml] a day. An exception to the general rule may be necessary where the subject suffers from milk allergy (1) but the condition is infrequent.

Milk should be kept in a cool place, especially in the warmer summer months; it should not be left exposed on the doorstep after delivery, since sunlight destroys riboflavin, one of its most beneficial constituents. If a refrigerator is not available, bottled milk may best be kept by being

(1) A special sensitivity to the protein constituent in cows' milk, just as some individuals, and especially children, are sensitive to certain foods, such as eggs, shellfish, lobsters or strawberries.


[page 123]

nearly immersed in cold water. If fresh milk, which is the best form in which milk can be taken, cannot be obtained, then several other forms of milk exist today. Skimmed milk can usually be obtained either fresh or dried; and skimmed milk may be used with advantage in cooking as a substitute for fresh milk, or, better still, to enrich milk puddings, sauces, custards, soups, puddings, and pastry; it makes an excellent body-building food, since only the cream has been taken off and what remains is still a rich source of protein, calcium and riboflavin. Condensed milk, whether sweetened or unsweetened, is pure, wholesome and nutritious, but not as good as fresh milk because of slight alterations which have taken place in the composition of the original milk during its preparation. Dried milk also is an excellent product; it forms an easily digested curd in the stomach and is therefore much used for feeding infants deprived of breast milk. Those who are normally indifferent to milk as a drink may find it more acceptable if it is served ice-cold instead of at normal room temperature, which is often found not so palatable; another pleasant alternative is to be found in flavoured milks.

Safety of milk

Ideally one would look for milk which has been obtained under clean conditions from healthy cows and then bottled under perfectly clean conditions. There are two main ways in which milk may often become contaminated with organisms of disease:

(a) pathogenic organisms (i.e. organisms harmful to man) may be transferred from a cow suffering from some bovine infection or disease, through its milk to man;

(b) milk may be contaminated at any time between the milking of the cow and delivery to the consumer, by dust or dirt, by dirty utensils, or by persons employed on the farm or in the dairies.

The pathogenic organisms which may be present in milk may infect the consumer with such diseases or illnesses as tuberculosis, undulant fever, diphtheria, scarlet fever, septic sore throat, paratyphoid and typhoid fevers, food poisoning and last, epidemic diarrhœa, an illness to which infants are specially liable.

All these pathogenic organisms can be destroyed by suitable heat-treatment, i.e. pasteurisation or sterilisation. Milk is pasteurised by applying heat for such time and at such a temperature that it will destroy the bacteria harmful to man, and then immediately cooling the milk. Pasteurisation does not impair the flavour of milk and the loss of nutritive value is very slight. Sterilisation is carried out by heating bottled milk to a prescribed temperature and then cooling it, so that at the end of the treatment the bottles are not only sealed hermetically but have been made sterile also. In England and Wales 90 per cent of the


[page 124]

milk sold by retailers is pasteurised or sterilised. All milk for human consumption, whether for drinking or in other preparations, should be pasteurised or sterilised; if such milk is unobtainable, the milk should be "tuberculin tested", that is, produced from cows which have not reacted to periodical tuberculin tests. But the term "tuberculin tested" implies only a presumptive warranty of freedom from tuberculosis and such milk may, like ordinary milk, contain other pathogenic organisms of bovine origin. Milk which has not been pasteurised or sterilised may be rendered safer by boiling and cooling quickly, and this is of particular importance where the milk is for babies and young children.

QUANTITY OF FOOD NEEDED

The amount of food normally consumed will depend on the age of the individual and on the type of exercise or work performed. For most people the appetite automatically balances their energy requirements. The amount of food taken can be exactly measured in terms of the energy which it will supply on complete oxidation and of the amount of protein in it. The energy is given as the number of calories and the protein as the number of grams required daily. (1) In winter rather more fat is needed than in summer for maintenance of body heat. But in general, children require quite as much food, and in particular as much milk, in summer as in winter. They tend to put on weight in the cooler months of autumn and winter, whereas they grow more in height during the warmer months and especially in spring; this rhythm seems to be related to temperature, judging by evidence from South Africa which suggests that there too children tend to put on weight in the South African winter, our summer, and to grow taller in the South African summer, our winter. Fruit and vegetables are of course desirable at all seasons.

HOW AND WHEN TO EAT

Apart from the composition of the diet, the conditions under which it is taken have much to do with the benefit the body derives from it. Sometimes appetite, and with it digestion, may fail because of worry and anxiety; a meal should be a serene and sociable affair. There is much to be said on physiological grounds for serving food in a pleasant and orderly way, in surroundings which are civilised, with flowers and a reasonable degree of amenity. More vital still is the absence of any sense of strain, rush or emotional distress; the meal should be enjoyed, and that will depend on flavour, cooking, service and, not least, the company.

(1) The large Calorie (the amount of heat required to raise the temperature of 1,000 grams of water by one degree centigrade) is the unit used in nutritional work, as distinct from the small calorie (the amount of heat required to raise the temperature of one gram of water through one degree centigrade).


[page 125]

As a rule it is convenient for family meals to be served at stated times and regular intervals, and there is everything to be said for such a practice. But occasionally babies and small children are allowed to go hungry, in order to conform to an arbitrary time-table of meals. Such harshness fails to take into consideration their emotional and physical needs; when these small children are hungry they should be fed, and there is no other rule that matters. As they grow older they should be more able to conform to adult conventions regarding fixed hours for meals. At all stages of development children of similar age and size may require different quantities of food, in so far as one child may digest and assimilate better than another; nothing is gained by either forcing a child to eat food he dislikes, or insisting that he should eat when he has no appetite. In the same way most children know when they have eaten enough; within reason their desire for more should be respected, though hardly to the point of allowing them up to five helpings of pudding or more, as is not unknown! Likes and dislikes should not be discussed in a child's hearing, but should be noticed and taken into account when planning the dietary. It sometimes happens that insistence on a standard of behaviour beyond their years is a cause of under-feeding and feeding difficulties in young children. To attempt to "civilise" at a primitive stage will only cause strain for all concerned; premature training in matters of social convention is not worth the time, trouble and irritation it imposes on the adult and children concerned. Feeding is a natural bodily function and in the early years should be treated as such; the less children have to think about it the better. If for any reason a child is faddy, it is better to take as little notice as possible; improvement is far more likely to come from association with other hungry children than from the admonitions of a well-meaning adult.

RELATIVE COSTS OF FOOD

Some of the essential body-building foods, such as meat and fish, are relatively expensive, but in considering such foods one should remember that the cheaper qualities of meat and fish are quite as nourishing as those which cost more. Herring, for example, supplies nearly as much body-building food as the same weight of salmon, and at a fraction of the cost; at least one child now grown up heard his parents speak of herring as "the poor man's salmon" and used to eat it under the impression that there was a mysterious biological connection between the two. The cheaper kinds of cheese contain as a rule rather more bodybuilding material than the more expensive sorts and are easier to digest. There are no healthier or cheaper green vegetables than kale, cabbage or spring greens; an orange is a better food than a peach.


[page 126]

SOURCE, DISTRIBUTION AND PROTECTION

Everyone should realise how important it is that all food should be as fresh as possible. Thus most fish is at its best when it has just been caught; the best milk is clean, fresh milk, made safe by pasteurisation; the best eggs are new laid eggs; the best vegetables and fruit come straight from the garden. But the conditions of living today make it necessary for people to obtain much food which has been some time in reaching them, often from other countries. If such food is to remain wholesome, it has to be specially treated by canning, chilling, etc., and canned fruit and vegetables are often better than many so-called fresh varieties, if these are stale by the time they come to be sold. The canned foods have been protected from exposure during transport and storage; even so, they inevitably come second to fresh, newly gathered supplies of comparable quality, and most of the tinned food is much more expensive into the bargain. The dependence of so many families upon tins is not a happy sign of the times; teachers can do much to encourage older children to take some trouble to choose fresh food, keeping tins in the background, not the foreground, of the weekly budget.

There are many Acts of Parliament and Regulations designed to control the use of preservatives in food and prevent its adulteration, and indeed the history of both makes a fascinating tale. (1) Today local authorities are charged with the duty of maintaining the purity and wholesomeness of the food supply in their areas. Much may be learnt about the distribution and protection of foods by visits paid to local markets, food factories and dairies, and attention should be drawn to the measures taken - or not taken - to prevent contamination of food by exposure to dirt or by unclean and unnecessary handling. In this connection the housecraft teacher has a valuable part to play. Throughout the cookery and general housecraft course there will be many opportunities for stressing the importance of always washing one's hands before food is touched, taking proper care of the larder and store-cupboard, and making suitably hygienic arrangements for the disposal of refuse. Full use should be made of modern insecticides to prevent contamination by flies, but chemicals of this kind should never be sprayed in a room where food is exposed at all.

SCHOOL MEALS AND MILK

There can be no doubt that school meals and milk have made an important contribution towards the improvement in the health and

(1) For one readable account see The Englishman's Food, by Sir Jack Drummond, with Anna Wilbraham, Cape, 1939. In the Roman Empire, in England in the time of Chaucer, and, indeed, until the middle of the nineteenth century, an almost unbelievable amount of adulteration was practised. Today the main problem is perhaps not so much one of adulteration, in the old sense of the word, as of the artificiality of so many foods.


[page 127]

physique of school children during the years since the war. It is most desirable that teachers should do what they can to encourage children to take school milk and to stay at school for their midday meal.

School Meals

Local education authorities were given the power to provide meals for school children by the Education (Provision of Meals) Act of 1906. By the beginning of the second world war about half of the authorities were providing free meals and some 150,000 pupils in elementary schools were having meals, including a comparatively small number who paid for them. In addition, something like 150,000 pupils in grammar schools were having dinner at school. In general, the provision was limited to necessitous children and those living at a distance from their school. With the impact of the war the school dinner assumed a new significance and the provision of school meals was rapidly expanded. It became a matter of national policy to provide a good dinner at school for children whose parents wanted them to have it, either on payment of a charge roughly corresponding to the cost of the food or free of charge in cases of hardship. The Education Act, 1944, placed a duty on local education authorities to make meals available for all children attending maintained schools; in practice, of course, this obligation had already been very largely accepted.

The growth of the school meals service is illustrated by the fact that over three million day pupils in maintained schools were taking the school dinner each day in the autumn of 1955 (representing just over 48 per cent of those in attendance) compared with about 300,000 at the beginning of the war. About 7½ per cent of the children taking the school dinner have it provided free of charge. The standard charge of 10d. [4p] for those who pay is roughly equivalent to the cost of the food provided but the gross cost of the meal works out at more than twice that amount. The school dinner is planned to serve as the main meal of the day and must provide a substantial proportion of a child's energy requirements; it should have an energy value of between 650 and 1,000 calories, according to the age and sex of the child. If it is to provide a sound diet for growing children, it should also supply an average of 20 grammes of protein of animal origin and 25-30 grammes of fat.

But the purpose of the school meals service is not merely to provide good meals for necessitous children, for those travelling long distances to school and for others who wish to participate. Under proper conditions the school dinner affords an opportunity for social training, teaching good manners and encouraging sound dietetic habits. It is generally regarded as an essential part of the corporate life of the school; and without the cooperation of head teachers and their staffs it cannot be a success.


[page 128]

The Milk in Schools Scheme

The Milk in Schools Scheme was launched by the Milk Marketing Board in 1934; milk was made available to children at school at the reduced price of ½d. per one-third of a pint [187ml], the local education authority paying this for necessitous children, and the teachers were responsible for the administration and the success of the scheme. The Education Act, 1944, placed on local education authorities a duty to make milk available for drinking by pupils at school; and in 1946 the Government made the milk free of any charge for all pupils, the cost being met by the Exchequer. Each child is entitled to one-third of a pint a day, but delicate pupils in special schools may receive two-thirds of a pint. The milk is normally supplied in third-of-a-pint bottles and drunk direct from the bottle by means of drinking straws. This method is convenient in that it eliminates the supply and washing up of beakers. It is also hygienic since it eliminates any handling of the milk at the school and the risk of infection from contaminated beakers. About 85 per cent of school children take school milk, but the percentage in secondary schools is a good deal lower than in primary schools. This is a matter for regret; older boys and girls need milk in their diet just as much as younger ones and they should be encouraged to drink it at school.




[page 129]

Chapter 15

Warmth and Clothing

THE PRIMARY SOURCE of all the body's heat and energy is food; this can be regarded as fuel to be burned up by the tissues so that the body may be kept alive and the muscles may perform their work. The muscles make up nearly half the weight of the body, and it is in the muscles, as a result of their activity, that most bodily heat is generated. Every child knows that he can warm his body on a cold day by running and jumping; an exceptionally high rate of muscular activity can more than double the rate of production of heat in the body. The greater the amount of muscular work performed, the greater is the amount of food required and consequently the greater the amount of heat produced. Body heat is lost chiefly from the skin, by the giving up of heat to the surrounding air and by the evaporation of sweat. Increased muscular activity causes the production of more sweat, which wets the skin; evaporation then brings about a cooling effect. Thanks to the general balance between the production and loss of heat, man's body temperature is so regulated that, in health, it remains the same in the heat of summer or the cold of winter.

In theory this might suggest that much of our clothing is really unnecessary. This may be so; fewer clothes are worn today than fifty years ago without any ill effects, Yet clothing has certainly enabled man to live in more widely varying environments than he would otherwise have found possible. In a temperate climate such as our own, clothes undoubtedly perform a valuable function in reducing the strain which would otherwise be placed upon the temperature-regulating mechanism of the human body; in particular they can do much to guard us from the risk of over-sudden loss of bodily heat, such as could otherwise occur after playing strenuous games or passing from a hot room into the cold air outside.

If the main physical function of our clothing is to help in the conserving of bodily heat, it should as far as possible be varied according to the air temperature and not according to the calendar. We should neither wear too much nor attempt to harden ourselves by wearing too little; in everyday life people are accustomed to add extra clothing or take it off as a matter of course according to need and comfort. But the putting on of extra clothes is not the only way in which additional heat can be conserved; equally important is the choice of materials. Because air is a bad conductor of heat, the warmth of clothing materials depends


[page 130]

upon the amount of air which they trap amongst their fibres. Wool contains 90 per cent air, enmeshed, so that it is warm to wear, and elastic so that it does not cling to the body when wet; it absorbs sweat rapidly and gives it up slowly, thus preventing chilling of the skin by rapid evaporation; unfortunately wool is apt to shrink and may irritate sensitive skins. Cotton and linen, which contain only 50 per cent air, are cool to wear; but they absorb sweat quickly, cling to the skin and may cause chilling as the result of evaporation, just because they dry so quickly. Open mesh or cellular materials imprison air in the meshes and are therefore relatively more efficient in retaining body heat. Fur is particularly warm, since it contains as much as 98 per cent of air. Wet clothing causes excessive loss of body heat and the danger is much greater in windy conditions. Woven materials cannot always keep out strong winds, but fur, leather, oilskin, rubber and some plastic materials are harder to penetrate; some of these materials, however, are very uncomfortable to wear for any length of time, since they cannot be properly ventilated, and too much heat and moisture may be retained. In recent years there has been a rapid development of synthetic fibres and various new materials for clothing; some are excellent, but the very width of the choice that is now available makes it all the more important to have a good understanding of the basic principles of health in relation to clothing.

Changing trends in fashion, improvement in social conditions and continuous education in health over the last fifty years have all done much to alter children's clothes for the better. The children of today are seldom either ragged or heavily over-clothed, and the practice of sewing them into their clothes for the winter has become rare. The importance of choosing comfortable clothes of simple design is generally appreciated; and yet it is still not so generally realised how quickly children lose heat and become cold. In cold weather small children and school girls are often too lightly clad and their brief under-garments expose large surfaces of leg and thigh, with excessive loss of heat. Young children, in particular, spend so much time out of doors that they are best protected by windproof garments of the dungaree type, closely fitting at the ankles. A loosely fitting jacket, which can be slipped on and off easily, will help to prevent any chills caused by sudden changes of temperature; anyone going out of a warm room into the open air should put on something extra if it is cold outside and he expects to be standing about.

For both boys and girls clothing should be warm, loosely fitting, light and comfortable in wear. Under-garments need be neither many nor heavy, but should protect the body from chill. The weight of all clothing for younger children should hang from the shoulder. Boys still tend to be too heavily dressed as compared with girls; in warm weather very


[page 131]

light clothing is sufficient and, when it turns cooler, a vest, pullover and loose jacket should be ample in addition. Vigorous exercise results in perspiration which makes the clothing damp; if this is followed by a spell of sitting still, the result may be a chill. Both boys and girls usually find it pleasant and desirable to change into suitable clothes for active exercise and to have a shower-bath or a rub-down with a towel before changing back again. Whenever clothes get wet, they should be changed immediately. A vigilant eye is needed to see that children never sit for any length of time in wet shoes or socks. The practice of always changing into house shoes at school has much to be said for it; if this is not possible, a change of shoes should be brought on wet days. In such matters, as indeed in the general choice of clothes for use at school, parents and teachers can help each other.

But clothes also perform certain secondary functions of real value in ministering to the desire of every individual human being to feel that he belongs to his own group, society, country, and generation; they are a visible expression of personality and, particularly for women and at many periods in history for men too, an acceptable form of display. All this can be accepted by the student of health; indeed, in day-to-day life at school or at home it is often better to link the health aspects of clothing with these other aspects than to impart too much abstract information in an atmosphere removed from everyday life. For example, older girls can be encouraged to study current fashions with plenty of practice in designing and making clothes which suit them and are appropriate for different occasions. Such work is likely to have a natural appeal for most girls, and in the process they can be introduced to some of the main points about fabrics, the physical properties of clothing and the need to cope with sudden changes of external temperature; they can also be given some guidance about the importance of avoiding fashions in clothing or footwear which may be harmful to health; history and art provide many examples of better or worse. Of course discrimination in the choice of clothes is linked with discrimination in the choice of footwear or hairstyles and in the use of cosmetics. Health is involved in all, and is not less important because it runs through the whole pattern as a single thread among others.

Finally, clothes are neither healthy nor attractive once they cease to be fresh and clean. Improved fabrics, modern methods of washing and cleaning, and the general inclination of the times have in recent years all contributed to an improvement of our standards in such matters. It has come to be accepted that anyone, young or old, boy or girl, who wishes to look at his best must be fresh and clean in his attire; children should learn to take this for granted in their own daily practice, and their elders should set them a high standard.


[page 132]

Chapter 16

Care of the Body

[Note: Within a single chapter it is clearly not possible to cover all the parts of the body that may need care and attention. Those discussed are the eyes, ears, teeth, feet and bowels; these are all important in themselves, and all will serve to illustrate how bodily well-being can be improved by reasonable care on the part of the individual.]

EYESIGHT

THE CHILD'S EYE is immature and growing. Although it will usually have reached its full size by the fourteenth year, slow growth may continue up to the age of twenty-three, when the general growth of the human body is usually complete. It seems unlikely that the growth of the eye can be influenced by any factor other than nutrition, which will exert an effect on the eye like any other part of the body. Infants are usually long-sighted, but this long-sightedness decreases during childhood. Binocular vision, which makes possible single vision and perception of depth, develops slowly up to the age of six or seven; really effective vision comes with use, though the eye should never be exercised for too long; a proper succession of exercise and rest is essential for proper functioning of the eyes. They can be injured by improper exercise, poor or excessive light, the use of unsuitable reading materials, or prolonged and close work.

The need to look after their eyesight throughout life should be impressed upon children by training in good habits. As much light as possible should be admitted into the house; curtains should be of the kind that can be completely drawn back to expose the whole window during daylight. When children are writing, the light should come from the left unless they are left-handed, when of course it should come from the right; in any event strong cross-shadows should be avoided. School books should be printed in a clear and reasonably sized type and children should be warned against reading badly printed books at home. Glare causes fatigue; it is particularly harmful to look straight at the sun or any very bright light. Reading in bed will do no harm if the light is good, so long as the reader sits up with his book held evenly in front of his eyes; but to lie on one's side with the book on the pillow is inviting eyestrain. With the increase of television viewing at home, and its possible increase in school, children should be told about the best posture and conditions for viewing. In this country, the ultra-


[page 133]

violet light rays in natural daylight are never strong enough to do the eyes any harm.

Children should be encouraged to mention any difficulty in seeing what is written on the blackboard or in reading from a book. They should realise that it is to their advantage to wear glasses, if medically advised to do so, and at the times advised; their teachers, too, should keep this in mind and see that any glasses are worn regularly. Defective vision is sometimes a cause of backwardness in school. Worried looks, frowning, blinking, face-twitching, the rubbing of eyes, the book held too close to the eye, and headaches, all may be early signs of eyestrain. If untreated, eyestrain may lead to headaches and general health can be affected too; conversely, good health will help to maintain good eyesight. Normally the tears keep the eye protected by washing away germs and dirt, so that the daily use of expensive eye lotions is quite unnecessary. For occasional bathing of the eyes, a pinch of salt in a few tablespoonfuls of boiled water will serve well. Children should learn never to rub an inflamed eye, and that any rag or towel used to bathe or wipe their eyes should not be used by anyone else.

HEARING

It is dangerous to put any foreign body into the ear and a blow on the ear may lead to serious harm; all children should be aware of this. Sometimes children are troubled by wax. The formation of wax is a normal process though some people get wax in the outer ear more quickly than others; if the wax accumulates, it should be removed only by a doctor or nurse. The Eustachian tube, which connects the ear with the throat, is much shorter, wider, and straighter in the child than in the adult, and this may have something to do with the greater number of infections in young children as compared with adults. Every child should be taught always to blow his nose gently, either without closing the nostrils, or gently closing one at a time, so that there is no risk of forcing nose and throat germs up the Eustachian tube to the middle ear. Since discharge from ears can often lead to impaired hearing, its seriousness should be emphasised and parents should be encouraged to see that children suffering from this condition receive early, regular, and persistent treatment. Swimming must not be allowed while a child has a cold in the head or a discharging ear. The outer ear is often plugged with cotton wool before swimming, but the plug must not be pushed in too far. The ears should always be washed carefully, preferably with a washcloth wrung out so that too much water is not allowed in.

EXAMINATION OF SIGHT AND HEARING

Both sight and hearing should be examined at regular intervals by the school health service. The eye lengthens as it grows; short sight is


[page 134]

not uncommon, particularly in adolescence, as a result of the process going too far. Another defect is squinting; as soon as any squint is noticed, treatment should be started; otherwise the child may fail to use the squinting eye properly and efficient binocular vision may never develop. Because of strain on their muscles of accommodation, children just learning to read may suffer from eyestrain, which can be relieved by the temporary wearing of glasses until their eyes are fully grown. Defects of hearing are usually less obvious than defects of vision; hearing may be deteriorating for some time before it is noticed. Deafness of any degree should be referred to the school doctor; a child's apparent inattentiveness may sometimes be a sign of unsuspected bad hearing.

TEETH

An efficient set of teeth is necessary for good digestion; even one decayed and tender tooth may lead to the habit of swallowing food without proper mastication. The function of the teeth in cutting, crushing and grinding the food and mixing it with saliva is the first step in the process of digestion, and is essential for proper nutrition and the maintenance of physical strength and vigour. Apart from any question of their primary function, teeth can be beautiful in themselves and are an essential part of good looks.

During the war the teeth of school children improved; at a survey in 1943 a considerable reduction of caries was observed in five-year-old school children, who at that time could have been affected little or not at all by the dietary supplements introduced during the war. Since the war children's teeth have deteriorated and surveys made in 1948 and 1953 showed caries in school entrants to be reverting towards the pre-war level, even though these children had received the dietary additions already mentioned. It would seem, therefore, that while these supplements (e.g. extra milk, cod liver oil, orange juice, vitaminised margarine and the addition of calcium carbonate to flour) help to lay a sound foundation for good teeth, they were not principal factors in either the war-time reduction or the post-war increase of dental decay in school children; on the other hand, during the war the average annual consumption per head of sugar in the United Kingdom was only about two-thirds of that before the war. At the present time it seems likely that by far the single most important factor tending to increase the amount of dental decay, particularly among school children in this country, is the indiscriminate use of refined sugars, whether at meals in dishes which are often all too sticky, or after meals, in snacks and innumerable kinds of sweets for sucking.

The prevention of dental decay by adding fluoride to the water supply has attracted much attention in the United States of America and Canada and some demonstration studies have been initiated in this


[page 135]

country; any improvement is bound to be gradual since the fluoride seems to be most effective while the tooth is being formed. In any case this can be no substitute for proper care of the teeth; at the present time prevention of decay depends mainly on reasonable self-control in eating sweet sticky things, especially between meals, and on keeping the teeth clean. After eating, the particles of food must not be allowed to stagnate round the teeth; refined sugars, for example, may be fermented inside the mouth by bacteria and converted into acid in a matter of minutes, so that tooth-cleaning, to be effective, should be carried out as soon as possible after meals. A child who is sensible about sweets between meals and cleaning his teeth after meals will be far less likely to suffer from teeth that need filling. Teachers can help by doing what they can to discourage mid-morning snacks of sugary, sticky foods, and sweets or chocolates.

Few children are naturally interested in their teeth; there is nothing in a child's own experience to suggest that neglect may have serious consequences or that good dental habits are worthwhile. The first step, therefore, will be to persuade children to take an interest and pride in their teeth. Young children should learn the practice before they understand the purpose, being encouraged to clean their teeth regularly and as a matter of course, with adequate inspection and demonstration. But they should before long have acquired some idea of the reasons for keeping one's teeth clean and not eating too many sweets at the wrong time. Older children should be expected to regard clean teeth as a personal and social obligation, like a clean body or clean hair; they should be given some information about the structure and development of the teeth in early years and about the effect on them of constitution and diet. Suitable visual aids, such as films, filmstrips, posters, charts or other material, may be very helpful. (1)

The rules for keeping the teeth clean are simple, but should not be overlooked. A small, soft brush is better than a large hard one, since too vigorous a use of a hard brush may hurt the teeth and gums. That the toothbrush itself should be kept clean is self-evident. The teeth should, ideally, be cleaned after every meal, but this is often not practicable; at the least cleaning should be carried out after breakfast and at night. The latter time is the more important, since during the hours of sleep natural methods of cleaning are in abeyance and decay-producing substances are active; of course, biscuits, milk or sweets should never be taken at night once the teeth have been cleaned. Natural methods of cleaning the teeth include ending a meal with fruit (preferably hard fruit) or taking a drink of water after a meal, particularly if the teeth can

(1) A well-produced and useful book suitable for teachers, entitled Dental Health, published by the Dental Board of the United Kingdom, can be obtained from: The General Dental Council, 44 Hallam Street, London, W.1.


[page 136]

to some extent be rinsed before the water is swallowed. A raw apple or carrot is an excellent cleaning agent.

Children can be helped to realise the value of dental inspection and treatment; the purpose of both should be made quite clear to them. The dentist with his skill and experience can detect the first signs of decay and should be able to put matters right without causing pain. Children who go regularly every year (or oftener) for dental inspection and follow the dentist's advice may hope to leave school with a complete and sound set of teeth.

CARE OF THE FEET

All babies and young children look flat-footed. But with most of them the long arches are really present, as one can see by getting them to rise up on their toes; it is when they are standing that their feet are placed in an abnormal posture, being allowed to roll over on the inner borders. The condition is really one of "knock ankle" and is often better left alone if there are no signs of any serious trouble; flat-footedness of this kind is rarely a cause of disablement in either childhood or adult life. Exercises for flat-footedness seldom do any harm but are a waste of time and effort, except in so far as the predisposing cause has also been found and treated. It is much more important that children should be carefully examined if any deformity or stiffness of the toes or front part of the foot is observed.

That the feet should perspire is only natural, although some individuals have trouble with feet which perspire too much. The feet should be washed every day and then dried thoroughly, especially between the toes; socks or stockings should be changed as often as necessary. Children suffering from warts (1) on the soles of the feet, or from a dry scaliness of the skin or a sodden, dead-white felting between the toes (which may point to fungus infection) should be referred to the school clinic.

Foot troubles are the cause of much discomfort and inefficiency among adults. This has usually been ascribed to faulty footwear, particularly during youth. Surveys in the north of England showed that four girls out of five were wearing shoes that were too small for them. It is true that a survey of children's feet and footwear carried out in Somerset by two orthopædic surgeons and a team of five members of the firm of C. and J. Clark, Ltd., in November, 1953, revealed that, although out of every 10 children one had shoes that were too long, six had shoes that were too short, and only three had shoes that fitted properly, the number of defects was much less than expected and there was no correlation between foot deformities and shoefitting; (2) even so,

(1) See Chapter 17, p. 151.

(2) The Health of the School Child: Chief Medical Officer's Report for 1952 and 1953, p. 17. Her Majesty's Stationery Office, price 5s. 0d.


[page 137]

there can be no excuse for such common practices as buying shoes by post without a proper fitting or handing them down to younger brothers or sisters as older children outgrow them. If children are to grow up having healthy feet, the state of their shoes and socks is most important. Shoes should be waterproof, strong and well-fitting; they should be pliable yet firm enough to give proper support, so that the foot can develop without cramping or distortion. Most of the fashionable women's shoes are not suitable for growing girls. Wellingtons are excellent in wet weather, but these and light rubber-soled shoes (of plimsoll type) should not be worn for long periods. Girls as well as boys should be provided with thick boots or shoes for field games such as hockey. Ankle socks or socklets should always be worn if stockings are discarded, but it should be remembered that these, like shoes that are too small, may cause injury to feet if outgrown or badly shrunk by washing; most woollen socks are worth buying a size too large, to allow for shrinking. Frequent holes in socks are an indication that they are too small or that shoes fit badly.

For children and adults alike, shoes and socks are usually needed during working hours. Yet no one who has watched a baby kicking, crawling or learning to walk will fail to realise how good it is for the human foot to have opportunity of moving free and unencumbered by any trappings. Most adults find that the conditions of civilised life make this impossible, except perhaps when bathing, or playing on the sand, or performing special exercises; but for children, and especially young children, there should be more scope. Not that they ought to play everywhere in bare feet; the possibilities vary according to climate, place and circumstances, and in many places the risk of cuts from glass or nails or sharp stones would make shoes always necessary. But, particularly in infant and junior schools, there is much to be said for providing the children with opportunities for play or general movement in bare feet during the physical education periods. Once they are used to taking their shoes off, running about in bare feet and putting shoes on again at the end, a new and happy form of experience will have opened up and there could be no better form of exercise for developing their feet.

BOWELS

The oft-repeated statement that the bowels should always be opened every day, whilst no doubt true for most, is quite inapplicable for some people and has caused far too much unnecessary mental and physical harm. What matters is that each individual should be allowed to follow his own natural rhythm, whatever that is found to be. Aperients should seldom be necessary, if sufficient attention can be paid to regular habits, exercise, fluid and diet. This holds good both for adults and children, the only difference being that adults are responsible for their own actions


[page 138]

while children are still learning what is necessary. In such a matter adults can be of great assistance to the children with whom they come into contact at home or at school if they know the facts and, without being fussy, encourage each child to develop regular habits according to his own natural rhythm. Little need be said, and that but seldom; it is rather a matter for unobtrusive good sense with an observant eye for the rare occasions when anything seems wrong. Often parents can help by seeing that the children are able to go to the lavatory at their own normal time, and with sufficient time - they are sometimes in too much of a hurry. And both at home and at school the lavatory should be clean and fresh; it is then more likely to be properly and regularly used.





[page 139]

Chapter 17

The Prevention of Communicable Diseases

INTRODUCTION

DIAGNOSIS OF DISEASE and prescription for its treatment are medical responsibilities, and for teachers to attempt either would be both unwise and dangerous. But teachers are particularly well placed for cooperating with school doctors and nurses; they can recognise the signs of illness at an early stage, make sure that advice is sought in good time, and help to see that such advice is carried out. It follows that every teacher should have some knowledge of the commoner communicable diseases and of their characteristic features.

THE TRANSMISSION OF COMMUNICABLE DISEASES

Communicable diseases are those which are caused by living germs, when these are transferred from one person or animal to another person or animal. This transfer may be by direct contact, or indirectly through the medium of household articles, clothing, toys, food, water, or sewage, or by way of insect pests. Infection is said to occur when disease producing germs gain entry to the body and multiply there. An epidemic arises when a disease spreads rapidly, attacking many people within a short space of time; sometimes what began as an epidemic becomes endemic, that is, continually recurring in a particular area. Each communicable disease is caused by a distinct type of germ or virus, which is capable of causing that particular disease alone and no other, though in a few cases differences in the site of infections or in their severity result in symptoms to which different names have been given. (1) Thus the diphtheria germ causes diphtheria, the poliomyelitis virus causes poliomyelitis; but neither the one nor the other can cause typhoid fever, which can follow only from infection of the body by the typhoid germ. Germs are lowly and minute living things, so small as to be invisible to the naked eye; indeed viruses, as the smallest of them are called, can as a rule be made visible only with the aid of the electron microscope. Like other living things, whether plant or animal, germs need suitable conditions in respect of food, warmth and moisture for

(1) The hæmolytic streptococcus, for example, can produce most varied symptoms; see p. 145.


[page 140]

their growth and reproduction; given such conditions, a single germ may multiply rapidly, producing many millions in twenty-four hours. The varieties of germs which are capable of producing diseases are very few in number compared with those which are either harmless or beneficial, even essential, to agriculture and industry. Thus a human being may act as a kind of host to bacteria which live in his bowels and are able to manufacture vitamin B; this is then absorbed by the host who thereby derives benefit from his association with the bacteria concerned. Other kinds of bacteria assist in the nitrification of the soil and thus indirectly in the nutrition of plants, or help in the production of butter and cheese, or are used in the retting, tanning and pulping industries.

Three factors are necessary for the spread of communicable diseases. There must be a source of infection from which the germs are spread, a route by which they are transferred, and a region in which they are able to settle and grow; this last is the body of a susceptible person. The source of infection is always another person, or an animal, in whom the particular type of germ has established itself; usually the chief source of human infections is man himself. The individual who is responsible in any one case is most often a patient suffering from the disease, but sometimes a convalescent who has just had the disease; occasionally he represents the "missed case" in which, owing to the mildness of the symptoms, the infection has not been recognised. Anyone passing through the incubation period of an infection may be infectious to others for several days before signs and symptoms indicate the onset of the disease in him. The "carrier" is another well-recognised source of infection; he is a person who, without exhibiting in himself any symptoms of a communicable disease, is nevertheless harbouring the germs somewhere in his body, so that he is liable to spread them to others. He may be either a convalescent carrier recovering from an infectious illness or a healthy contact carrier, exhibiting no indications whatever of any disturbance of health. In carrier-borne diseases the germs concerned are most commonly found in the nose and throat or in the intestines. Carriers may unknowingly be responsible for causing scattered cases as well as "explosive" outbreaks of a disease.

Disease germs may pass out of the human or animal source of infection through the agency of breath, saliva, sputum, fæces, urine, milk, blood, or skin. From their source they may reach other persons by a direct route, by an indirect route or through an intermediate host. The direct route of infection is the most important, the germs gaining entrance to the body by being inhaled, or swallowed, through a breach in the skin, or through a mucous membrane such as that lining the nose or mouth cavity. Infection is often spread by the process known as "droplet infection". The breath of a person suffering from a disease of


[page 141]

the nose, throat or lungs, or carrying disease germs in these parts, may contain many of the germs responsible for causing the disease; if so, whenever he breathes or talks (and still more when he is shouting, coughing or sneezing), he propels into the air, for a distance of 3 to 6 feet [1-2 metres], minute droplets of moisture which are heavily laden with bacteria. The larger droplets may directly infect the nose, throat or eye of anybody in the immediate neighbourhood. Smaller droplets often evaporate, leaving suspended in the air minute infected particles which may be inhaled by other people at a considerable distance. Efficient ventilation will remove some of these infected droplets, but many settle on the floor or on articles of furniture, especially bedding, where the moisture enclosing the germs dries up so that they become part of the ordinary dust in the room. Such household activities as bed-making, dusting or sweeping launch them once again into the air, from which they can be inhaled, in this way spreading disease; the actual infection is, of course, conveyed by the droplets and dust in the air and not by the air itself. Fortunately, most of the germs die fairly rapidly, since, like other plants and animals, they need moisture and food, as well as warmth, to stay alive. Fresh air, light and sunshine help to speed their demise. Germs from saliva can reach new victims by contaminating crockery and cutlery, or such things as pencils which children have a way of putting in their mouths; soiled handkerchiefs also provide an obvious source of infection. Food may become infected by people engaged in its handling and preparation, if they are suffering from a communicable disease or are carriers.

Animals and insects frequently act as sources of infection. A cow may have tuberculosis of the udder, or undulant fever, so that the germs causing these diseases easily get into its milk. Mice often contaminate food with intestinal germs capable of causing outbreaks of food poisoning. Flies breed in refuse and manure and often alight one moment on filth and the next moment on food which they leave contaminated with germs that have adhered to their bodies; in order to feed at leisure, they actually regurgitate what they have already eaten, often upon human food, and the marks left by flies upon windows and walls are caused in this way. In countries where typhus fever exists lice provide the germ with a means of transit from an infected person to a healthy one. Malaria is transmitted by certain kinds of mosquito which suck up the parasite in the blood of an infected person; the parasites then go through further stages of development in the mosquito, to be subsequently injected into their next human host with the mosquito's saliva when it bites.

Whatever route germs may use in entering the body, there is always an interval, called the incubation period, between the infection of the susceptible person and the appearance in him of actual symptoms; the


[page 142]

length of this period varies in different diseases and, while it lasts, the germs are settling down, multiplying and producing their poisons. Anyone who has been in contact with a case of communicable disease must be kept under observation in case he is going to develop the disease; this is particularly important during the last few days of the incubation period when the potential victim may already be highly infectious to others, without actually feeling ill himself.

Whether disease follows infection depends upon the number of germs, their virulence and the individual's power of resistance. Immunity is the power to resist disease and may be natural or acquired. Everyone possesses a certain degree of natural immunity which varies from person to person, and in the same person at different times; it is due to certain constituents of the blood and tissue fluids and is greatest in those who are in good health. Natural resistance can be increased by fresh air, sunlight, exercise, sufficient rest and sleep and the right amount of food of the right kind. Many disease germs are almost always to be found in the nose and throat; but they do not cause disease unless resistance is low, or lowered for the time being, perhaps by overtiredness or exposure to cold. A more specific form of immunity from some communicable diseases may be acquired by an attack of the disease, as a result of which protective substances are formed in the body, making subsequent attacks unlikely. Although second attacks of most of the communicable diseases are known to occur, they are rare. Immunity may also follow from the repeated subjection of the individual to infection through small doses of germs which, without being enough to cause the particular disease in question, are capable of stimulating his tissues to build up full resistance against it. Probably many adults who have escaped certain diseases in childhood do not get them in later life because they have built up a good acquired immunity through exposure to repeated small doses of the germs involved. A similar process is used to produce immunity artificially, by vaccination or inoculation against such diseases as smallpox, diphtheria, typhoid, paratyphoid, tetanus, cholera and plague; such artificial immunity lasts for varying periods of time, towards the end of which it can be renewed by further inoculation.

In the prevention of infection both the individual and the community have important parts to play. In accordance with the Public Health Act, 1936, and regulations made thereunder, all cases of certain communicable diseases must be notified to the local medical officer of health, who is thus kept informed of the number of cases in his district and can take any necessary steps to prevent or reduce their spread. The Registrar General publishes weekly returns based on figures supplied by the district medical officers, so that any undue incidence of such diseases in any part of the country can be accurately assessed and


[page 143]

the necessary action taken. Whenever international action is necessary, this is put in hand through the agency of the World Health Organisation at Geneva, which took over the responsibility in 1948 from the original International Office of Public Health established in Paris in 1907.

Infectious patients are isolated either in their own homes or, if they are suffering from one of the more serious communicable diseases, in an infectious diseases hospital, where modern methods of treatment may bring about rapid cure; this will also help to reduce the risk of infection being passed on to others. Anyone who has been in contact with cases of certain communicable diseases, such as smallpox, may have to be placed in quarantine, that is, kept under surveillance for a period of time equal to the longest incubation period of the disease concerned. Because children are particularly susceptible to the more common infections, they may be excluded from school after contact, although adults in the same family can safely continue to work; on the other hand, with several of the milder infectious diseases which are commonest among children; there has been a tendency in recent years to relax the rules about quarantine and exclusion from school. (1) When anyone concerned with milk production, or with preparing food for public consumption, has been in contact with infectious disease, he may have to be prevented from going on with his work until it is demonstrably safe to resume. Some contacts may prove on examination to be carriers; they will probably need treatment to clear up the condition. By means of disinfection an attempt can be made to destroy the germs producing the disease; all discharges from the patient, as well as any articles used by him, may have to be disinfected daily, and at the end of the illness his room and all articles and furnishings which may have become contaminated can be disinfected. In the past many elaborate chemical and physical methods of disinfection have been tried, but today it is generally found sufficient after most infections to rely on simpler methods such as washing with soap and hot water, exposure to sunlight and thorough ventilation. Small articles, such as handkerchiefs, crockery and cutlery, can be sterilised by boiling after a preliminary washing. When smallpox breaks out, vaccination may be offered to all who have been vaccinated a long time ago or not at all. Over a long period such public health measures (already mentioned in earlier chapters) as good housing, the prevention of overcrowding, proper ventilation, the supply of purified drinking water and pasteurised mille, efficient disposal of refuse and sewage, and the cleanliness and protection of our food supplies, have

(1) The reader is referred to the Memorandum on the Closure of Schools and Exclusion from School on account of Infectious Illness, issued jointly by the Ministry of Education and the Ministry of Health, which gives guidance in the matter of quarantine and exclusion of contacts from school. Her Majesty's Stationery Office, price 1s. 3d.


[page 144]

been most effective in controlling and even stamping out some of the communicable diseases.

Everyone responsible for children at home or at school should understand how to minimise or if possible prevent the spread of infection. Obviously not all the possible sources of infection can be guarded against; but there are one or two basic rules which, if properly understood and put into practice, can do much to keep infection within reasonable limits. Merely to bring children together in school or nursery means in itself incurring some extra risk from droplet infections such as colds, bronchitis, measles, whooping cough and similar ailments. All children, and especially younger children, are relatively more susceptible than adults; if they are crowded together, they will be exposed to more varied types and a more massive dosage of germs. Overcrowding is always dangerous, particularly in winter when droplet infections are most prevalent. The present tendency to break up large groups into smaller units, wherever possible, and to avoid any action which involves massing small children together, is all to the good. Proper ventilation will help to disperse or dilute germs in the atmosphere, and so reduce the risk to the individual child. If children appear to be ill, parents should keep them at home for observation, in case they are incubating an infectious disease. Staff and children should always take care with the details of personal hygiene; "Coughs and Sneezes Spread Diseases", and anyone who must either cough or sneeze should have a handkerchief ready, with his face turned well away from other people. Paper handkerchiefs are best, because they can be burnt. There is always a risk of infection from germs lurking in dust, whether on floors, furniture or bedding. Frequent use of soap and hot water for cleaning floors and other surfaces, and free access of light and air to all parts of the house will between them help greatly in removing or killing germs; soap and water are excellent disinfectants. Finally there must be a clear understanding among teachers, kitchen staff and children that in everything which has to do with the school meal absolute cleanliness is essential.

Measles

Measles is so infectious that to prevent the spread of infection from one child to another at home or school is most difficult; even so, isolation of the first victim at the very outset may be successful. Measles is caused by a virus which is spread by droplet infection. The disease begins with a condition very similar to a common cold; it is at its most contagious during this early stage, often before the appearance of the rash on the fourth day of illness suggests what the trouble really is. Mortality is highest among children under the age of two, and it is worth doing everything possible to postpone an attack until after this age. An attack may also lead to much chronic ill health; in particular,


[page 145]

any children who develop chest complications should be kept under observation and treated, so as to reduce the risk of pulmonary disease in later life.

Whooping Cough (Pertussis)

The germ of this highly infectious disease also is spread by droplet infection. The characteristic whoop is not always present and occasionally diagnosis may be most difficult to confirm without resorting to laboratory tests. Any cough accompanied by vomiting is suspicious. The disease often begins in an indefinite manner; for some time there may be no suggestion that a child is suffering from anything more than an ordinary cold in the head and cough, yet it is just at this stage that the disease is most infectious. The termination of the disease also is very indefinite and children often continue to whoop for weeks after ceasing to be infectious. From about six weeks after the onset of the illness, or four weeks after the beginning of the characteristic cough, there is no longer any risk of the patient infecting other people. Although deaths from whooping cough are not now common, the risk is very much greater to infants under one year old. Vaccination against whooping cough gives good protection and is frequently carried out at the same time as immunisation against diphtheria.

Scarlet Fever

In the middle of the nineteenth century this disease stood out among the infectious diseases of childhood as one of the main killers. Since then it has ceased to be a serious and fatal disease, although still prevalent. Scarlet fever is caused by the hæmolytic streptococcus, which is frequently found in the nose and throat of healthy carriers; this is also the germ responsible for tonsillitis, enlargement of neck glands, discharging nose and ears, sinusitis, one type of impetigo, wound suppuration, and erysipelas amongst other diseases, and it is only the occurrence of the rash in scarlet fever which makes this manifestation of the germ's activity particularly noticeable. It is now generally accepted that a patient suffering from scarlet fever need not be admitted to hospital as a matter of routine if he can be attended to at home.

Diphtheria

Diphtheria is caused by a germ which produces lesions, usually in the nose, throat, larynx or windpipe, and occasionally in sores and ulcers of the skin. It is a serious, often dangerous, and highly infectious disease. The lesions of the throat and larynx may obstruct the breathing and cause death, or the toxin (the poison of the germ which circulates in the blood) may cause heart failure or paralysis of muscles.

The disease is spread by "droplet" infection, contact with infective persons, and through such items as linen, blankets, clothes, towels,


[page 146]

etc. The germ is sometimes found in the throats of healthy people not giving rise to any symptoms; such carriers can spread the disease to others and require isolation and treatment just as if they were actual cases of diphtheria. Before the outbreak of the second world war, there were about 50,000 cases of diphtheria each year, mostly among children under ten, and between 5 per cent and 6 per cent were fatal. But experience in Canada and America had already shown that the disease could be almost completely eliminated by immunisation. This involves treating the toxin or poison of the germ in such a way as to render it harmless, and when the prepared toxin is injected into the body it stimulates the production of antibodies. A person who has been immunised is thus armed against an attack. Immunisation was made freely available to all children between one and fifteen from 1940 onwards, through local health clinics and general practitioners. The result has been acclaimed as one of the most remarkable victories of medical science and the number of cases reported annually is now well below two hundred. In 1954 less than ten people died from the disease. During the first quarter of 1956 there were only twenty cases and no deaths.

The ideal to be aimed at is that 75 per cent of all children should have had a complete course of immunisation before their first birthday. The course usually consists of three injections at monthly intervals and causes only a very slight upset in the vast majority of children; it will give protection against the disease germs for about five years. About the time the child starts school and enters a new community, a booster dose of the immunising injection is necessary, and this will give protection for a further five years. Before the war, even when there was no outbreak of the disease, most schools had a few carriers, and with any epidemic there was a considerable increase in the number of carriers. Though today it is rare to find carriers and cases are few, a high rate of immunisation, especially among children, is still needed in this country if the disease is to be eradicated altogether. Experience in Europe during the last war showed that the disease could reassume its old incidence and severity where immunisation was interrupted.

German Measles

This is a mild feverish infection with a rash that may resemble that of measles or of scarlet fever or a mixture of both. Like measles it is caused by a virus. It is of short duration and generally without complications, though there is enlargement of the lymphatic glands in varying degree. It has risks, however, for the expectant mother in the early months of pregnancy since the virus may attack her unborn child and damage certain of its organs at a vulnerable stage of their development. This might cause the child to be born with serious defects,


[page 147]

possibly of eyesight, hearing or of the heart. Second attacks of German measles are rare and a person who has suffered from this infection in childhood is usually immune for the rest of his or her life.

Mumps

This is another disease caused by a virus. Here the infecting organism has a bias towards the saliva producing glands and affects particularly the parotid glands, which lie in front of the external ear on both sides of the face, causing them to swell. More rarely other glandular tissue, such as the ovary or testis, may be attacked; for this reason the disease carries a hazard for persons past puberty. Though painful, mumps is otherwise usually a mild and short-lived ailment. Its spread is caused by droplets of saliva from an infected person.

Chickenpox

This highly contagious disease is one of the commonest of childhood; probably the greater part of the town dwelling population has contracted chickenpox by the age of 15 years. When the infection invades a school, it is apt to persist until most of the susceptible children have caught it. Transmission of the causative virus from person to person occurs by direct contact or droplet spread or occasionally through clothing or bedding freshly contaminated by a patient. Chickenpox is characterised by a skin eruption which is like nettle-rash at the outset, passing rapidly into a stage of water-blisters which finally dry to form scabs; the illness may be more severe in adults than in children, but it is essentially a mild complaint.

Acute Poliomyelitis

Acute poliomyelitis is an infectious disease of the nervous system, caused by a virus; it is most prevalent in the warm dry weather of late summer and autumn, and the number of cases has increased greatly in recent years. The disease is popularly known as infantile paralysis, a most misleading term, since adults may also be infected and in any case paralysis does not always follow the infection. Indeed, it has been calculated that for every case recognisable through the onset of paralysis several other persons become infected without ever developing any paralytic symptoms; some of them, nevertheless, are capable of spreading the disease. The virus can be demonstrated in the nose, throat and fæces of patients and in the fæces of healthy contacts, so that it can be spread by persons who are apparently healthy, as well as by patients. Infection appears to be spread by the pharyngeal and intestinal excretions of infected persons; contamination of the hands with the virus, or of food or utensils, may play a part in the spread of the disease. It is therefore particularly important that everyone


[page 148]

should always wash his hands after going to the lavatory and before meals; nothing else can do so much to limit the spread not only of poliomyelitis but of other intestinal diseases. There is evidence that operations for the removal of tonsils performed when poliomyelitis is prevalent may be followed by the most fatal form of the disease, in which the brain, as well as the spinal cord, is affected; for this reason operations on the nose and throat are not advisable when poliomyelitis is prevalent in a district. There is no need to close swimming baths during an epidemic, so long as they are well supervised, not overcrowded, and the highest possible standards of cleanliness are maintained. Fatigue, exhaustion and strenuous exercise may possibly transform a non-paralytic case of poliomyelitis into a paralytic one; it is therefore essential, when there is any risk of infection, for adults and children alike to avoid physical stresses. Any infected child should be isolated from other children for six weeks from the onset of the disease. Children in an infected household should remain away from school for a period of twenty-one days after isolation of the patient. Similarly teachers, school nurses, school meal workers, caretakers and others coming into intimate daily contact with children should be excluded from school for twenty-one days following the occurrence of a case in their household.

As has been shown in the case of diphtheria, an effective means of eradicating a disease is to increase the immunity of susceptible persons by means of immunisation. Many years of research on a vaccine to give protection against poliomyelitis culminated in 1954 in a successful field trial, in the United States, of a vaccine containing poliomyelitis virus which had been inactivated by formalin. This vaccine was devised by Dr. Jonas E. Salk, and is known as the Salk vaccine. After an initial setback due to a fault in manufacture of the vaccine, which was subsequently corrected, vaccination against poliomyelitis proceeded on a large scale in the United States and Canada, and to a lesser extent in Denmark, Germany and South Africa, By the end of 1955 it was estimated that some 10,000,000 children had been vaccinated, and the first reports indicated that the rates of attack were between 2 and 5 times less among vaccinated than among unvaccinated children. Early in 1956 it was announced that a British vaccine of the Salk type was available and that vaccination of children in Great Britain would begin later in the year. This measure holds out the greatest promise of reducing, and, if all goes well, of finally eliminating, the hazards of poliomyelitis.

Tuberculosis

Tuberculosis in man is caused by either the human or the bovine type of tubercle bacillus. People who suffer from active tuberculosis of the


[page 149]

lung, commonly known as consumption, spray infected droplets into the air as they talk or cough. These droplets are often inhaled directly into the air passages and lungs of other people; or else they may fall to the ground, where they dry up and become part of the dust of our surroundings. Cows infected with tuberculosis of the udder excrete tubercle bacilli in their milk, from which the germs pass into the bowel and so perhaps into the system of anyone who drinks it. The human type of bacillus causes many more cases of lung disease than the bovine type, which particularly affects glands, bones or joints, is responsible for more cases in infancy and childhood than later on and can be prevented by the use of pasteurised milk. Many persons reaching early adult life appear to have successfully overcome a primary tuberculous infection at some previous period. If the child's general health is good, immunity may result, but if he is frequently exposed to heavy doses of infection and his general health is poor, actual tuberculosis may follow. It is now believed that children in what appear to be tuberculosis families do not inherit tuberculosis, but acquire it by exposure to infection. The annual death rate from tuberculosis has been steadily declining during the past 50 years, except during the two world wars, when the decline was temporarily arrested. So encouraging a trend has been due to a number of factors, such as improved sanitary and economic conditions and better diagnosis and treatment. Any scheme that will improve the general health of the population will at the same time increase its resistance to tuberculosis; good housing and town planning have played an important part by reducing overcrowding. Good food is essential; this is largely a matter of full employment, adequate wages and making sure that housewives are educated to make the best use of the available money.

The earlier tuberculosis is detected the greater is the chance of limiting its spread to others and of curing the patient; as a rule, tuberculosis that is discovered early can be speedily arrested by modern methods of treatment. To this end, facilities for early diagnosis and treatment have been provided throughout the country. X-ray examination of the chest provides a most valuable means of early diagnosis, and since 1943 the use of mass radiography has made it possible to sift out from the general population those people who are suffering from early tuberculosis of the lung, so that early treatment can be offered. By the end of 1954 the total number of persons thus examined in England and Wales was above 16 million, and active tuberculosis of the lungs was revealed in 3.3 persons per thousand. Special precautions must be taken to protect organised groups of children from any risk of infection by adults suffering from tuberculosis. It is advisable for students to undergo an X-ray examination of the chest before admission to a training college for teachers, and this is com-


[page 150]

pulsory on completion of the course of training. No candidate for employment involving close contact with groups of children should be engaged without a medical examination, which should include an X-ray examination of the chest; such examinations should be repeated annually. No person suffering from tuberculosis of the lungs should be employed in close contact with children until the disease has been proved to be quiescent. (1) In 1949 a scheme was started by the Ministry of Health for the use of B.C.G. vaccine in this country for persons who are known to have been in contact with tuberculosis. This vaccine is made from an innocuous strain of the tubercle bacillus, developed in France by Calmette and Guérin, and known as bacille Calmette-Guérin, from which the vaccine derives its name. The intention is to produce an artificially acquired resistance to the disease in selected members of the community, such as contacts in tuberculous households. In November, 1953, the Ministry of Health extended these arrangements so that local authorities could offer B.C.G. vaccination to school children in their fourteenth year.

COMMUNICABLE SKIN DISEASES

(pediculosis, scabies, impetigo and ringworm)

Despite the increased attention now given to cleanliness inspections, verminous conditions in school children are still a major problem. In most areas there are families which persist in remaining a reservoir or breeding ground for head lice, despite continuous efforts on the part of members of the school health service to cleanse them. In such families it is usually found that the pre-school children and young adult workers are infested as well as the school children. Such lousiness is, indeed, a family affair, and the aim should be to treat the head of every member of the family at the same time, so that there can be no re-infestation of cleansed beads from dirty heads in the same family. From the children of such families infestation often spreads to the child from a clean home, so that all parents will be well advised to inspect children's hair regularly, washing it frequently and seeing that it is brushed and combed daily. The need for this can be explained to children, and they should at the same time be encouraged to take pride in the appearance of their hair. When the school nurse visits a school for her routine cleanliness inspection, she should take pains to see that children found to be verminous, and therefore in need of cleansing, are not brought to the notice of their school fellows; it is wrong to penalise the child because of possible lack of care or training on the part of

(1) See Ministry of Health Circular No. 64 of July, 1950, and Ministry of Education Administrative Memorandum 418 and Circular No. 248, both of March, 1952.


[page 151]

its parents. Owing to the more prolonged effect of some of the newer insecticides, such as D.D.T. and gammexane, a cleansed child will be protected to some extent against re-infestation from other infested members of the family. But cleansing is not enough by itself; continuous education in personal cleanliness offers the only permanent solution.

Scabies

Scabies is caused by the itch mite, which burrows into the skin. It is commonly associated with overcrowded and dirty conditions, although occasionally it is acquired by a member of a clean family. The irritation caused by the mite makes the affected person scratch the place so much that often the skin is broken and becomes secondarily infected by ordinary skin germs, sores and pustules resulting. Scabies is usually a family infection, and it is wise to treat all members of the family at the same time, in order to effect a certain cure; clothes and bedding should be thoroughly washed and well ironed with a hot iron. Regular washing and bathing help to prevent the skin from becoming infected with scabies in the first place.

Impetigo

Impetigo is an infection of the skin caused by a streptococcus or staphylococcus. The exposed parts of the body, such as face and hands, are chiefly affected. Head lice should always be suspected if the scabs of impetigo are found on the scalp or neck. When the infection occurs in folds of skin, as at the corners of the mouth, or in the nose or behind the ears, troublesome cracks are likely to form, and healing is delayed. This skin condition is now much less commonly encountered than formerly; its spread is unlikely when strict attention is paid to cleanliness.

Ringworm

Ringworm is a fungus infection of the scalp or of the skin of the body. It is transmitted to man either from another human being or from animals, such as cattle, cats and dogs. Ringworm of the scalp is almost entirely confined to children, adults hardly ever being affected. The fungus spreads from the skin of the scalp to the hairs, which become brittle so that they can be pulled out easily, leaving a bare patch. Modern treatment consists in producing temporary depilation (i.e. removal of the hair) by means of a dose of X-rays, after which the remaining fungus can easily be killed by the application of appropriate ointments to the bare skin. Since the introduction of this form of treatment, ringworm of the scalp has become a comparatively rare condition. Ringworm of the body and the areas between the toes is caused by a fungus different from that which affects the scalp. It


[page 152]

responds readily to the application of preparations capable of killing the fungus.

Plantar warts

Plantar warts (verruca plantaris), are caused by a virus infection of the skin of the sole of the foot. The weight of the body pushes the warty growth inwards so that, unlike warts in other sites on the body, they do not project outwards. Their presence is sometimes noticed because pressure makes them painful, but often they remain unnoticed. Girls seem more often affected than boys; cases are usually more often found in secondary schools than in junior schools, whereas infant schools seem quite free of them. Swimming baths and school showers, physical education in bare feet, and communal use of gym shoes have all been considered as possible sources of infection; mild injury may possibly play a part. Preventive measures must include the treatment of wood floors used for bare-foot physical education or dancing, to minimise the danger from rough surfaces or splinters; such floors must be kept clean and can be treated regularly with disinfectant solutions. Communal use of gym shoes should be avoided. Periodic examination should be made of the children's feet; infected children should not be allowed to go bare-foot during physical education or dancing and should not use the swimming bath until the condition has been cured; for physical education any infected child should, for the time being, wear suitable sandals and have the exclusive use of the pair chosen.

FOOD POISONING

Every year several thousand cases of food poisoning are notified to medical officers of health by medical practitioners, in accordance with Section 26 of the Food and Drugs Act, 1955. (1) There must also be thousands more which do not come to official notice, often because they take place at home. But for the individual victim food poisoning is likely to be equally unpleasant whether it is the result of eating poisoned food at home or anywhere else. The effect of bacterial or chemical contamination of food is much the same wherever it occurs. Thus the paragraphs which follow are in principle as relevant for the home as for the large-scale restaurant; in both, prevention is better than cure, and prevention is mainly a matter of cleanliness.

There bas been a great increase in the number of cases of food poisoning in recent years, largely because more food is now being produced in the mass. For our feeding habits have changed of late, particularly since the war, and there has been a striking growth of

(1) The provisions of this Section of the 1955 Act replace similar provisions of the Food and Drugs Act, 1938.


[page 153]

communal feeding as a result of the development of the school meals service, factory canteens, and local authority restaurants; for social reasons, too, people today are more inclined to eat some of their meals away from home than formerly. The link between this and the increased incidence of food poisoning is not hard to perceive. At home, where there may be six to cook for, any chance contamination of the food will be limited in its effect. But in a kitchen capable of cooking, say, 600 meals at the same time, the food is handled by many more individuals than would ever be the case at home, so that the initial risk of contamination is greater; moreover, a far wider circle of consumers is exposed to risk should contamination occur, and such an outbreak may be far-reaching. Another hazard lies in the manufactured foods, some of them particularly susceptible to bacterial contamination, which are produced daily in enormous quantities and given very wide distribution. In one outbreak of food poisoning in 1953, for example, some 1,149 persons were affected, of whom five died; the vehicle in this case was a series of meat pies baked in a single bakery.

Most food poisoning is due primarily to bacterial contamination. There are several kinds of harmful bacteria which may find their way into food in the course of its preparation; and having gained entry into the food, they multiply at a great rate in the rich medium it provides. How rapidly they do so may be judged by the fact that a single germ after about 12 hours' continuous growth can become 7,000 million germs. When the contaminated food is eaten, these germs, or the poisons they have secreted, act on the alimentary canal to produce some or all of the characteristic symptoms of food poisoning, such as nausea, vomiting, abdominal pain, and diarrhœa. There may be a constitutional upset of varying degree, sometimes resulting in collapse and severe prostration. Bacteria may cause food poisoning in two ways: they may either cause an infection of the victim, resulting in an actual illness, or they may bring about a simple intoxication, by pouring out into the food or retaining in their own bodies a highly irritating toxin or poison. The commonest producers of infection in contaminated food are the Salmonella organisms, a large group of bacteria of which several hundred different varieties have now been distinguished. The group includes the typhoid and paratyphoid germs as well as a very common organism that causes a kind of enteric fever in mice and a similar though milder ailment in human beings. It is probable that illness only occurs if these organisms are consumed in large numbers, so that chance contamination by a small quantity of them may cause no ill-effects. If, however, they are given time to multiply in the food, which may well have been allowed to stand for some time in a warm room, then the dose of germs in the food will reach dangerous proportions. Symptoms of the infective type of food poisoning usually


[page 154]

appear in from 12 to 24 hours and the illness lasts for from one to eight days.

Of the toxin-producing varieties of organism responsible for food poisoning, the commonest are the staphylococcus and the bacillus or germ known as Clostridium welchii. The staphylococcus is widely distributed and is a not uncommon denizen of the nose, throat and skin of healthy individuals; it may also be the infective organism in whitlows, boils, suppurating wounds, and one variety of impetigo. Staphylococci of a particular strain will, in a suitable medium - such as custard or gravy, though few types of food are entirely exempt - kept in a warm room, secrete a toxin as they multiply; this toxin causes the symptoms of food poisoning. The symptoms usually come on rapidly, from two to six hours after the tainted food has been eaten, with vomiting, colic, and diarrhœa; recovery is likewise rapid and should be complete within six to 24 hours. The other intoxicating organism, Clostridium welchii, is interesting because of its notorious family connections. An organism of the same species, should it penetrate a deep wound, can cause gas-gangrene, the complication which worked such havoc among the wounded of the first world war. A member of a different species of the same group, Clostridium botulinum, can cause food poisoning of the deadliest sort, from which few victims recover, although botulism, as the condition is called, is now fortunately rare. The same cannot be said of outbreaks due to Clostridium welchii, which are becoming increasingly frequent. This organism flourishes in airless conditions, and the strain responsible for food poisoning can resist boiling for more than four hours. In most outbreaks the germ is probably already contaminating the meat on delivery to the kitchen, and in meat dishes which have been cooked and allowed to stand in a warm room, or to cool slowly, it will multiply. A certain amount of toxin exudes into the surrounding food and some remains in the bacterial bodies themselves. When the food, thus admixed with germs and toxin, is ingested, symptoms begin to show in from eight to 22 hours, and usually last for between 12 and 24 hours; they consist mainly of abdominal pain and diarrhœa.

Both raw and processed foods are subjected to a great deal of handling and may be exposed to considerable risk of contamination before reaching the kitchen. Vegetables may be soiled by manure of fæcal origin which, perhaps, contains the eggs of parasitic worms as well as disease-causing germs. Unpasteurised or "raw" milk may harbour a variety of germs causing illnesses common to man and the cow, such as tuberculosis, undulant fever, and streptococcal infections; it may also have germs inadvertently introduced into it by the person who does the milking. Meat may be contaminated in the slaughterhouse with a Salmonella organism or Clostridium welchii. Salmonella organisms have


[page 155]

been recovered from the intestines of many different creatures forming part of the human dietary, such as turkeys, geese, pigs, chickens, and cattle. Duck eggs are particularly liable to infection; the organisms invade the bird's ovary, and, when the egg is laid, its contents are already contaminated. Salmonella organisms are rarely found inside hens' eggs; these, however, may become contaminated while they are being broken in large quantities for freezing or spray drying, when fragments of shell, soiled with fæcal matter, drop into the egg mixture. For this reason dried or frozen eggs should be regarded as potential sources of infection, only to be used in foods that are well cooked.

In the kitchen itself the risks are intensified; as we have seen, the greater the number of meals turned out the more far-reaching may be the results of contamination. Any one of the food handlers may be a possible danger, since quite unwittingly he may be carrying harmful bacteria and introducing them, again unwittingly, into the meal at a critical stage of its preparation. There is a further risk, not so far mentioned, of contamination by minute but harmful quantities of poisonous metals while the food is being prepared. This type of food poisoning is rare, but it does occur from time to time; lead, zinc, and copper utensils have all been incriminated in different outbreaks. A number of children and school staff became ill on one occasion after eating stewed apples that had been cooked in a copper vessel. The vessel was tin-lined, but the metallic copper was exposed where the lining had been worn away in places; copper, in harmful amounts, was subsequently detected in the remnants of stewed apple. In the kitchen itself it is always necessary to be on guard against contamination by rats, mice and insects. Mice, as has been observed, may be infected with Salmonella organisms and transmit them in their droppings. Similar organisms have been isolated from cockroaches. Greenbottle and bluebottle flies have been found to be carriers of Clostridium welchii. Our food is, indeed, menaced from every quarter.

In spite of the many dangers to be negotiated, cooks do nevertheless succeed daily in piloting meals safely through. The measure of their success may be judged by the fact that the school meals service, for example, in a year in which 500,000,000 meals were served, experienced only 32 outbreaks of food poisoning associated with them; ideally, of course, there should have been no cases at all, so there is still room for improvement. The same, no doubt, could be said of many canteens and domestic kitchens. The strict observance of certain principles will go far to achieving absolute food safety. First and foremost the kitchen staff should be fit and have high standards of hygiene. Food handlers with septic fingers, sore throats, or diarrhœa should be excluded from the kitchen. Proper provision should be made for washing the hands


[page 156]

after going to the lavatory, and the staff should be drilled in its use. Clean finger-nails, hands, aprons, and suitable head-coverings should be insisted upon. The food itself should be at least in visibly sound condition on reaching the kitchen and must not be handled more than necessary. Bearing in mind the danger, which is always present, of possible contamination by the staphylococcus or heat-resistant Clostridium welchii, meat, gravy, and custard should be cooked on the day they are to be eaten and never left to stand in a warm kitchen. If meat has to be cooked and kept overnight, it should be cooled quickly after cooking so that its temperature may soon fall below the point at which germs multiply most rapidly; finally, not less than two hours after cooking, it should be put in a refrigerator for further storage. Duck eggs should be cooked for at least twenty minutes before being eaten. Dried egg mixtures should be used at once after being reconstituted and not allowed to stand in a warm room; both dried and frozen egg mixtures, as has already been pointed out, need thorough cooking. Cooking utensils and implements must be kept clean and in good repair, and the kitchen itself maintained in good order. Windows, particularly in the store-rooms, should be fly-proofed and infestations by rats, mice, or cockroaches promptly dealt with; the local health department will always be ready to give advice about this. Walls, floors, sinks, washing up bowls and cloths, should all be kept scrupulously clean. Crockery and cutlery should be properly washed and sterilised after use; the best method is the two-process system, which means washing them in water as hot as the hand can bear, and then rinsing them in water half-way further on to boiling point (i.e. at 170° to 180° F. [77 to 82C]) for half a minute; the dishes are then allowed to drain without wiping and are stacked on covered shelves. Large food containers need special attention. Washing-up machines and detergent powders or solutions should all be effective when properly used. Drying cloths are best avoided. Staff in any way engaged in dealing with food or food utensils should be clean in person and intelligent enough to realise the risk to others that may result should they depart in the slightest degree from a high standard of kitchen hygiene.

Finally, if in spite of every precaution an outbreak should occur, the compulsory notification already mentioned on page 152 is very important; it means that cases, and also suspected cases, can be brought promptly to the notice of the local medical officer of health, who can carry out investigations and take any necessary action. Investigation usually involves intensive enquiries at homes, schools, factories, or other places connected with the affected persons, as well as the collection of suitable material for laboratory examinations. At any stage of the investigation it may be possible to prevent further cases by such measures as stopping the sale of suspected food, recovering unconsumed


[page 157]

portions already sold, or refusing to allow a food handler, who may be a source of contamination, to continue at work. Many school kitchens make a practice of preserving a sample of the day's meal in the refrigerator in case it is required for examination. It is particularly important for teachers to realise that, when food poisoning is first suspected, steps should be taken immediately to ensure that no left-over food is thrown away. Any suspected foodstuffs should be kept cool, if possible in a refrigerator, until they can be removed to a laboratory for examination.





[page 158]

Chapter 18

Mental Health

Introduction

GOOD HEALTH depends on the state of both mind and body. Each exerts a direct influence on the other, but owing to the power of mind over matter good mental health is of supreme importance. It is a complex subject to which justice cannot easily be done in a pamphlet of limited scope. However, in view of the importance attached in previous chapters to the mental and spiritual aspects of health, a brief review of at least some aspects of mental health is essential. Such a review may serve as an introduction to further study.

Normal Development

In order to learn how good mental health can be nurtured it is essential to know something about the normal emotional development in a child which leads up to the maturity of the mental health in an adult. For unless this normal process receives due attention it is difficult, if not impossible, to reach a right understanding of its variations or to appreciate when deviations from the normal are taking place, particularly if these are slight. On the other hand, a behaviour manifestation, such as aggressiveness, which would be normal at a certain stage of development, may be thought abnormal by anyone not familiar with the normal stages through which a child grows up to maturity.

Every child needs love and security from birth. All through his childhood his sense of security depends very largely on the quality of affection, care and protection which he receives from his parents, especially from his mother (particularly, though not only, in the very early years) and also from his teachers during the years at school. Given these two basic requirements, he can feel that he is someone, that he is wanted and that he belongs to someone, thus laying a sure foundation on which his emotional development can be built up.

In 1950, the Minister of Education appointed a committee to enquire into problems relating to maladjusted children. During their deliberations the fundamental importance of this basic knowledge of normal development was recognised and in their report (1) a chapter was devoted to it. Owing to its essential significance this chapter has been included in this pamphlet as an appendix. Its study warrants close attention so as to promote a wiser and better understanding of mental health.

(1) Report of the Committee on Maladjusted Children, 1955


[page 159]

Mental Ill-health

At the end of 1954, of the 480,000 hospital beds available for all forms of illness nearly one-half were occupied by patients who were either mentally ill or mentally deficient. Surveys have also shown that absence from work for illness of all kinds is more frequently caused by functional mental or nervous conditions than by any other cause. But no statistics give a true picture of the total amount of mental ill-health in the community, for so much of it is unrecognised by, and remains personal to, the individual concerned. Nevertheless, this does not make it any less serious either for the individual or, because of its social implications, for society. Failure of an individual to adapt himself to the stresses and strains of modern life may lead to anxiety, depression, anger, irritability or other manifestations which point to mental ill-health. Marital disharmony preys upon the minds of the parents and is bad for their children. Their emotional development may become warped, inwardly they often rebel against environmental or home influences, they may become ill at ease with persons or things or they may retreat into themselves, becoming solitary, quiet and silently fretful. Their emotional upheaval may lead to anti-social behaviour, such as viciousness, lying, disrespect of persons or things, or stealing. Many delinquent acts of children are incited by their own mental ill-health.

"Prevention is better than cure" applies with particular force to mental health. Once there is a serious breakdown, recuperation is likely to be a long, difficult and expensive process. It follows, therefore, that the sooner mental ill-health can be detected the better are the chances of rapid treatment and final recovery. But the goal should always be to prevent mental ill-health from arising by the promotion of good mental health through right personal relationships and happy environments.

Mental ill-health in the adult can frequently be traced back to a failure in personal relationships as a child or to some other harmful influences which affected him in childhood. Childhood, therefore, is the best time in which to lay the foundations of good mental health. The younger the child, the more important this is. But it may well be that, before the child enters school, some seeds of mental disharmony have already been sown, and it then falls largely to the teacher to deal with it, either within his own wisdom or by seeking help or advice from others with greater knowledge. Teachers, therefore, occupy a place of prime importance in the nurturing and furtherance of good mental health in children.

The Teacher's Personality

In the first place, the teacher's own personality is of the greatest possible importance. Unless he has himself reached an emotional maturity which is stable and healthy, he is not equipped to exert the


[page 160]

right influence on the receptive child. For he possesses such a vital power in the shaping of the child's personality that what he is himself cannot help making a very significant impression for good or ill upon most of the children in his care. Therefore, he should know himself. If he has problems or misgivings, either personal or in relation to his work, he should seek advice, when he feels the need, from others who can help him; this may come from any person who possesses the right qualities and experience, such as a relative, a friend, a fellow teacher, a doctor or a minister of religion.

Next, personal relationships with relatives, friends, associates, parents and other persons require careful scrutiny. Good relationships are among the hall-marks of a good personality. If they are slow to develop, or even perhaps wanting altogether, it is well to ask why. The other person is not necessarily at fault; it may be salutary to examine one's own self. Close friends and acquaintances who are well informed and understanding can often help in this by their intimate friendly criticisms and helpful observations. No one relishes criticisms, even if fair and offered in a spirit of warm comradeship; but without them it is hard for a man to know himself.

The physical health of the teacher can have repercussions on the child as well as on himself. It may well be that, if he is off-colour, weary or suffering from an ailment, he tends to become impatient, irritable and lethargic; work is less satisfying and the results are not so good as they should be. Indeed, unwittingly, he may be doing harm to the child. So it is of real importance to the individual to ensure that health and well-being are maintained and that advice is sought or adequate treatment obtained if any signs of sickness arise.

The Teacher's Understanding

The child is an individual, with his own body, mind and personality; no two children are alike. This being so, the knowledge and understanding of children can only be acquired and built up over the course of years. Initially, a student's knowledge of children must start with his own childhood with its personal associations, joys and difficulties. His judgment in his early years will mainly have been formed by impressions gained from brothers, sisters, and other relatives, and from the children whom he met and played with. As he grows older, his knowledge increases, becoming more mature even though it may not be completely correct in main conception or detail. The young student will have prejudices, fears, doubts and assertions which to him seem correct and worthy and may tend, therefore, to colour his views and outlook. He may find it difficult to assess the qualities in another except from personal standards of right and wrong which, however good in themselves, are often narrow and somewhat immature. Then, as training continues, an


[page 161]

adjustment and a broadening of views should begin to follow from living in a community, studying, getting to know children under supervision and guidance. Understanding of children develops and begins to take a more definite shape, their similarities and differences become more apparent, as the student shakes off prejudice and gains confidence with increasing experience.

This informed training in child development and health should lay the foundation of the knowledge and understanding of children, but only experience and association with children can promote and nurture the growth of a wider and fuller wisdom. For something fresh can be learnt from each child a teacher meets. Year in and year out everybody else is adding to one's own personal stock of experience, which is therefore never complete or all-embracing. But as this experience grows, so does understanding of the child; it should be possible to build up by degrees both knowledge and real understanding of a normal child. The limits of normality are astonishingly wide; what may be normal in one child may be abnormal in another; indeed, what may be normal in one child may in certain circumstances or conditions be abnormal in the same child. These facts can only be fully grasped as experience mounts up.

The Teacher's Part

Once a wider knowledge of the normal child has been acquired, any deviations from the normal will be more accurately assessed. Initially, only the more gross maladjustments of mental health may be easily recognised. Later, with increasing understanding of children, the less obvious ones may be identified; while later still, in the fullness of experience, the subtler indications of trouble may be suspected. These changes, when noticed, require immediate attention, and the earlier they are noticed the better are the chances of returning to normal. For it must be evident that unless maladjustments receive enlightened attention early, they tend to deteriorate, becoming deep-rooted and perhaps capable of resisting even skilled treatment.

Whether consciously or not, everyone has some impact on the mental health of each child with whom he comes into contact, and everyone, wisely or unwisely, exerts an influence on that child. But the wiser the individual, the more he will recognise his own limitations beyond which he should not venture for fear of damaging the child's mental health. It is the recognition as early as possible of insidious or suspected deviations from good mental health which is of such vital importance if the complex problems involved in readjustment are to be tackled comprehensively. Any child in whom signs of maladjustment or emotional disturbance have been recognised should be at once referred to someone with greater knowledge, for further investigation and treatment. This


[page 162]

early attention is of immense significance; many children who now have to receive prolonged treatment in a clinic or institution might not have needed it if only recognition had been made in time.

Thus the teacher's part in this preventive field is necessarily limited, though in itself of the greatest importance. However wise he may be and however willing to learn, he is not himself an expert. He must turn to others for help and guidance, both in considering what should be his own attitude to any particular child and also in obtaining skilled advice about any child who may be giving him cause for concern.

The attitude of adults towards a child must always be consistent. Contradictory orders or the toleration at one time of conduct which is forbidden at another cannot but undermine a child's feeling of security. A child must be allowed to grow up knowing what he can expect from day to day; it is wrong to treat him like a plaything one moment and expect from him something like adult behaviour the next. He must realise that praise and appreciation naturally follow from good behaviour and that bad or anti-social behaviour is likely to lead to the opposite. All children require training; so long as this is consistent and understanding, it should help to increase their sense of security. Training should invariably attempt to provide a child with something positive that he can do, and not with a frequent repetition of negatives of the "Don't do this", or "Don't do that" order. In a situation that might provoke a clash of wills it is often helpful to associate oneself with the child through a positive suggestion, "Let us do so and so", thereby avoiding a negative command.

Play is of course essential from a very early stage of childhood; as children grow up, work gradually takes the place of a great deal of the play, but for a full and happy life both are necessary. Opportunity and space for children to engage in noisy active play must be found; space is very important for them, though they also need cubby holes and nooks and corners to which they can retire occasionally, and provision for these should not be forgotten. Children need long periods of free play as well as organised activities; during free play it can be observed how very great are the differences in the rate and direction of their individual development. The varied activities of very young children, so incessant and often so aimless to the adult eye, should not be needlessly hindered. So many adults fail to appreciate how important apparently simple things may be to children. If only those in charge of children would keep fresh in their minds the days of their own childhood, they might be less quick to prevent some childish activity merely because its meaning and interest are not obvious to them. It is true that much of the behaviour and actions of a young child may be disturbing to the adult (though perfectly normal for the child's development); but this does not justify describing such behaviour or actions as abnormal or bad. In fact there is


[page 163]

little that a healthy energetic child does that is bad, in the sense that it calls for correction or is worth a scene. If there are any difficulties, it is better to give a simple explanation of what is wrong than to tell a child in general terms that he is naughty or bad.

No attempt should be made to force on a child standards which are too mature for his age and stage of development; children are keen to learn and quick to imitate the behaviour and actions of adults. It has already been suggested more than once in the course of this pamphlet that, if adults set high standards for themselves, their example will do more than anything else to educate a child. Thus courtesy and good manners between adults, and between them and the children, will in the long run always have their effect; in the same way a child will be truthful if parents and teachers have deep respect for truth; promises must never be broken nor made if they cannot be kept.

Adults must also take seriously the innumerable and varied questions which a child asks, and truthful answers suitable to his understanding should invariably be given. Every child is a personality whose likes and dislikes, hopes and fears, and general outlook should be acknowledged and respected. It may often be better to deal with a child as if he were emotionally older than he is than to treat him in too babyish a fashion; the point is particularly relevant when dealing with older children. As a child grows, he should be encouraged to become increasingly independent and capable of accepting responsibilities suitable to his age. Children generally like to be helpful and only practice can make their hands confident and steady; any jobs that they do should be adjusted to their age and capacity. Even though the adult may be able to do the job better and quicker, a child has to learn and his initiative should not be curtailed. The successful accomplishment of a piece of work will give him great satisfaction. Failure can be helped by encouragement and advice. Appreciation and thanks should be given where they are due, just as they would be between one adult and another.

The sanctity of childish collections and possessions must be respected; possessions need a home of their own to which the child alone has access. A place can always be found for a treasure-drawer or bag for the sole use of the child.

Most children are eager to go to school and enjoy the time spent there. They welcome the chance to learn new things, especially if they have been encouraged at home to do things for themselves. A child's sense of security is all-important; school and parents can help to maintain it by keeping in step with each other about matters which concern his welfare. Teachers must be careful not to do anything which might cause any conflict of loyalties between school and home, and of course no child should ever be allowed to hear criticism of his parents or home. It is particularly important to bring every child into the picture, and not


[page 164]

merely some of them. The noisy, boisterous or aggressive child is readily noticed and seldom neglected; but the shy, retiring child, so silent and good, is apt to be overlooked, even though he may be insecure, unhappy, and in need of remedial treatment. It is not natural for any child to be always very "good" or very quiet; if he is either, then the teacher should consider whether there is any underlying trouble which might be making him unduly passive.

Some children feel insecure when they constantly experience frustration or failure to achieve what might reasonably be expected of them. Occasionally failure may be due to defective vision or hearing which has passed unnoticed, or to innate dullness or the efforts of parents or teachers to drive the child beyond his capacity. In any case, evidence that a child is not doing as well as might have been expected of him should be taken as a sign that some skilled investigation is called for.

In the field of mental health it follows from all that has been said that the teachers in a school should be conscious of one overriding aim; they should strive to ensure, as far as possible, that the emotional development of all the children passing through the school matches all other aspects of their development. Without normal emotional development other aspects of progress are bound to suffer; thoughts, actions, bodily functions and sometimes maladies, all are affected by emotional warping or stresses, for mind has power over matter. Hence, it is of supreme importance that the mind of each child is attuned aright so that he can grow up as healthy as possible in body and spirit alike.

Sources Available for Help

Within the schools there are two main sources for counsel. First, the services of an educational psychologist should be readily available. He is one of the specialists in the field of child guidance, being an expert in the psychology of both the normal and its deviations. He should be in the closest touch with the teachers and their schools as a result of frequent visits, which should enable him to give first-hand advice on the spot, learning from teachers of their difficulties with individual children and investigating any cases in special need of help. The maladjustment of so many children is closely involved with educational difficulties or misfits, and the psychologist, with his expert knowledge, can often bring about a readjustment; he is also able to select those children who should be sent to other experts. This intimate personal contact with the schools is essential if preventive work is to flourish.

Second, the school health service itself can offer a great deal. An experienced school medical officer will have much knowledge and experience of the normal child and his development. It falls to him to be able to recognise any deviation from the normal, and to give advice to parents and other interested persons. He should also know when to pass


[page 165]

on to specialists those children who require further investigation and treatment; no less than the teacher, the school doctor must realise at once when the condition of the child begins to fall outside his own expert knowledge in the field of normality. Teachers may ask advice from him when he visits the schools or they can send a child to the school clinic for an examination, seeking an opinion about the next step to be taken. The school nurse, too, in her more frequent visits to the schools, can give advice within her capacity. It is particularly important that in this field there should always be the closest liaison between the schools and the school health service.

Outside the schools, but very closely associated with them through the psychologist and the school medical officer, is the Child Guidance Clinic. Here children with emotional disturbance can be referred for a full investigation and the initiation of treatment by the team of skilled workers, which also includes a psychiatrist and a psychiatric social worker. Reference to the clinic can be made through the educational psychologist or through the school medical officer, or in special circumstances, direct by head teachers. Parents, too, have the right to make a personal approach to the clinic, if they wish to do so.

The Team as a Whole

Close liaison between teachers and other workers, much as has been described in this chapter, is essential if fruitful results are to be achieved. Every teacher belongs to a team whose aim is to promote and maintain a healthy emotional state in the child. Each member of this team has an important part to play; it may be only a small part - indeed, without special training and qualification it can and should be only a small part - but each helps to make the work of the whole more effective and complete. If the liaison is slight or non-existent, there is clearly something wrong in the relationships in the area concerned. A psychologist may not always be available, but there is always the school health service. Teachers cannot really give the best that is in them without the help of the school health service; conversely, the school health service cannot do its work effectively without the full cooperation of teachers. Each is interdependent on the other. All who work with or for children are members of a comprehensive team, and this team should be all-embracing if good mental health is to flourish.



[page 166]

Appendix

Chapter III of the Report of the Committee appointed in 1950 by the Minister of Education "to enquire into and report upon the medical, educational and social problems relating to maladjusted children, with reference to their treatment within the educational system."

NORMAL DEVELOPMENT

Development and Maturity

EDUCATION is deeply concerned with the process of maturing: indeed, it is in essence the means by which the immature are enabled to become mature. In this sense it takes place not only at school; the whole environment, both human and material, in which the child grows up is the true educative medium. Modern research suggests that the most formative influences are those which the child experiences before he comes to school at all, and that certain attitudes have then taken shape which may affect decisively the whole of his subsequent development.

No human being is fully mature, nor does the degree of his maturity remain constant. Under stress of violent emotion anyone can regress temporarily to a childish form of functioning - as when a man kicks and abuses the door which "will not" open. The level of a person's maturity will vary with his state of health, the ease or difficulty with which his basic needs are being met at the time, or the company in which he finds himself. In essence it may be said that the mature person is one who accepts the responsibility of ordering his own life and making his own decisions, and who does not act simply on the impulse of the moment.

A feature of maturity is that conduct becomes expressive and characteristic of the person himself. Principles and values are integrated into a coherent system which gives shape and stability to the personality. Inner conflict and indecision are thus reduced, and it becomes possible for an individual to exercise control and persistence, and to pursue remote ends.

Meaning of Normality

Normal development, therefore, is development towards independence, stability and control, and the gradual drawing together and realisation of all a man's capacities. One very important point at the outset is the meaning to be attached to the term "normal". A criterion of normality is peculiarly difficult to obtain, for the following reasons:

(i) What is normal for one child may not be normal for another.

[page 167]

Every child is unique, and his personality is a complex blend of hereditary traits and environmental influences - the latter including not only the people and objects round a child, but also the attitudes, feelings and events which affect him or to which he may respond. On a child's make-up will depend what is normal for him. A child of introverted temperament will, for example, normally be cautious in making friends with other children, but an extrovert will not. The child of high intelligence will normally not be slow in learning to read, but the dull child will.

(ii) Behaviour of a certain kind may be normal at one stage but not at another. It is natural, for example, for a very young child to be completely dependent on his mother; but it would be abnormal if this continued until he was much older.

(iii) Development takes place in many directions, and not all of a child's powers will mature at the same rate, though for good adjustment and healthy growth there should be some degree of harmony between them. Concentration on one aspect of growth may temporarily retard the growth of another, as when a baby becomes less vocal while he is perfecting manual dexterity, or a six-year-old more demanding and dependent while he is struggling with formal work at school. On the other hand, the development of one power often assists the development of another, as when a child of twelve months becomes more tractable as he begins to crawl, or a two-year-old as he learns to speak or becomes steadier on his feet.

(iv) Normal behaviour is not always "good" behaviour. All children will from time to time display behaviour problems, but, if development is taking place normally, so far from these holding up the maturing process they will promote it. Compare, for example, the frantic compulsive destructiveness of a maladjusted ten-year-old, which teaches him nothing and may so stifle his curiosity that he is unable to learn at all, with the dispassionate destructiveness of a normal two-year-old, which helps him to understand the material world better and so to control it.

From what has been said it is clear that the normal must be thought of as a group which includes wide variations rather than as a single type. This notion is generally accepted in the sphere of intelligence, where the normal group is thought of as comprising the central 50 per cent of the population. Progress towards maturity is even more difficult to measure than intelligence, and it is not possible to chart dearly either the range within the normal at any age or the line of progress from one stage to the next. All that can be attempted is a description of the manner in which a child progresses and the series of experiences and satisfactions which naturally come his way.


[page 168]

The Way a Child Progresses

As a child grows, he should increasingly become independent and at the same time capable of forming satisfactory and lasting relationships with other people. This is in essence an affair of the feelings, but the feelings do not mature in isolation and there is constant interplay between all the aspects of the child's growing self.

Each phase in development has its own appropriate emotional satisfactions. The normal course of development seems to be to experience these satisfactions in an unhurried, confident fashion, gaining something from them and either leaving them behind or building them into the next stage. Deprivation, curtailment or perversion of these natural satisfactions may lead to regression or to a general disinclination to go forward; and advance to the next stage is only possible if previous stages have been satisfactorily accomplished. Even on the physical plane this seems true: it may be said, for example, that an infant learns to walk from the neck downwards, progressively coordinating the muscles of the neck, back and limbs, as he learns first to hold up his head, then to heave a shoulder off the pillow, then to sit up, crawl, stand and finally stagger forwards.

Advance toward maturity is helped at each stage because the child's mind, body and feelings mature together. He is constantly discovering, often by accident, substitute satisfactions for those it is time to leave behind, and these new satisfactions in their turn help on the maturing of his feelings. When he begins to run about, for example, he can occupy himself better in play and find new interests for himself, so that he has alternative pleasures to fall back on when his mother is too busy to give him her attention. Painful contacts with table corners or doorsteps help him to distinguish fact from fantasy, and to adapt his responses to it. He also plays his way into a dim realisation of what it will be like to be a grown-up person and may find it both possible and likeable. In this way he is helped by seeing older children, as well as his parents and other adults, obviously enjoying a more mature way of living which, because of its manifest controls and disciplines, may to the natural man in him seem impossibly difficult and distasteful. In this way he is led on towards maturity, finding at each step that he gains more than he loses and that he is equal to the increasingly complex demands which are made on him.

Infancy and Early Childhood

The first act of the drama in a child's struggle for independence is normally played out within the family, and in it the mother normally takes the leading role, since it is she who makes his first essay at independence possible and it is from her that he must first detach himself. But before the child becomes the man, the struggle has to be repeated more than once, each time on a more complex and conscious plane and accompanied at each repetition by the possibility of stress and break-


[page 169]

down. Roughly speaking, the first cycle takes seven years and may be described as the period of infancy and early childhood, in which the support and approval of adults are the most potent influences on a child's development.

To enjoy satisfactory relationships with people is always vital for a child's development, but his capacity for making them will largely depend on the quality of his emotional and physical experience in the first years of life. An infant has all his feeling in his body; from the start he feels the attitudes of other people through their care of his body - for example, through the way in which his mother picks him up, holds him to her and feeds him. The world is presented to him right from the beginning as predominantly good or bad according to the quality of the mothering he receives. He needs one person constantly with him, not only to feed, care for and love him, but also to allow him to enjoy this relationship. In this way he builds up the sense of security which he needs if he is to reach out or respond to other people sufficiently to commit himself and run the risk of getting hurt; and it is not until a person has the confidence to take this risk that he can fully give or receive affection. The same early experiences appear to affect a child's moral sensitiveness, his curiosity and liveliness of mind, and his ability to learn up to the limits of his native capacities.

Even for an infant who is loved and wanted, life soon presents problems. He quickly realises that the giver of good things can also refuse them. The first great crisis of separation occurs when he is weaned and has to learn to take solid food. Even at this early stage the principle of substitute satisfactions is at work, for by this time an infant is usually learning to sit up, curiosity is developing and he is beginning to play.

If a child is assured of his mother's love he can bear to be away from her, and by about the age of two has advanced sufficiently both in knowledge and bodily skill to want to do so, although at first only for short periods. The good mother, while maintaining a steady, secure intimacy with the child, is at the same time directing his interest away from herself, helping him to improve his speech and the use of his body and encouraging him to make friendly advances to other children. It is, however, during this period, somewhere between six months and three years, when a child is detaching himself from his mother through play and exploration, that he needs her most and that maternal deprivation is most damaging. This is seen in the way he will sometimes not play with a new toy until his mother gives it to him; and in the way he rushes back to her for protection as soon as anything goes wrong with his attempts at friendliness with other children or with animals.

The question whether the world is fundamentally a friendly or a hostile place is continually before a child in his first years. Somewhere about the third year this uncertainty culminates in a period of conflict


[page 170]

with authority, when he is often wilful, aggressive and difficult to control. On the handling he receives at this time will largely depend his ability to accept discipline and frustration in later years.

At this period, a child's relationship with his father becomes increasingly important. The father takes his place as the embodiment of authority in the family, not only protecting and supporting the mother, but by firm though affectionate control buttressing the young child against his own aggressive feelings and designs. It is natural for a child to want to be grown up, and the father, by giving a satisfactory example of grown-up life and by allowing the child to watch and share some of his masculine activities, provides a further means of stimulating development. Through this second and significantly different relationship the child emerges out of a world centred on his mother into one of wider human relationships.

If the period of conflict with authority is brought to a satisfactory conclusion, a child normally enters on a much calmer phase, greatly helped in his progress towards independence by the development of a genuine desire for friendship with other children. This stage is often reached during the fifth year and makes the second great separation from the mother, when he goes to school, much easier to endure.

From this point the teacher takes over some of the functions of the mother, and it falls to the teacher to give the child in school the warmth of affection needed if he is to learn satisfactorily. The teacher also makes it possible for him to continue his emotional education. To this end she encourages the formation of small groups, both for play and work, and, while seeing that children do not harm each other, allows scope for feelings to be expressed naturally, including feelings of hostility and aggression. Like the good mother, the teacher has to accept a child's dependence and need for protection and at the same time encourage him in every way to become independent of her. In this, skilful teaching in the narrower sense is a great help; for the more a child knows, the more confidence he has in managing his own affairs. Growth in understanding the use of numbers, for example, may encourage him to layout his pocket money for himself, and being able to read may make him less dependent on adults for his pleasures.

The young school child will, however, transfer to his teachers the attitudes he has taken over from his parents; he will welcome the chance to learn new things if he has a mind "innocent and quiet" and has been encouraged at home to do things for himself. As he progresses through the school, he has gradually to forsake real things for symbols and learn to deal with the abstract; this will be a very difficult and painful process if growth is not continuing satisfactorily on the emotional side, as, for example, if he has been unable to tolerate the separation from his mother. Many children go through a period of nervous tension at about the time when the formal business of learning to read and write commonly begins,


[page 171]

but this is normally quickly over; most children enjoy going to school and probably find membership of a large group a relief from the close-knit, intimate atmosphere of the family.

The fact that important steps forward are being made on the intellectual level at this stage also helps on emotional adjustments in other directions. The child of six or seven can usually distinguish between fact and fantasy, although the ability to do this is likely to break down under emotional stress (as when he is badgered to "own up"). Having a better understanding of the world around him, he can accept it more easily' he realises, for instance, that if he wants parts for his Meccano set he must wait until he has saved up enough for them. At the same time, he may still protest violently if he does not get his own way. He also begins to grasp that the rules and restrictions of life apply to other children as well as to himself. As he grows up physically he gains more confidence in his relationships with other children. Fortified in all these ways he enters, somewhere about the eighth year, on the period of later childhood.

Later Childhood

It used to be held that the years between the ages of seven and twelve constituted a kind of golden age, when a child gave little trouble and lived happily and thoughtlessly, reaching an almost mature state of stability and reasonableness towards the end of the period. It has, however, recently been remarked that the eighth and ninth years constitute one of the peak periods for references to child guidance clinics, and educational backwardness also becomes a pressing problem at about the same age. There is some truth in both points of view. Whether a child is happy and stable in this period, or unhappy and out of step with society or with his lessons, largely depends on one thing - the adequacy of his early nurture.

The average child of eight has developed a capacity for stepping outside himself, as it were, and viewing himself as he appears to others. He needs the approval of other children and has become keenly aware of any differences between himself and them which are likely to diminish their approval. This may have either good or bad effects on the maturing process. For example, he may first begin to suffer consciously at this age from failure, whether at work or play. On the other hand, the result may be an improvement in his standards on both the social and the intellectual planes. He likes to look at the work of other children and compare it with his own, he considers their skill in relation to his own, he notices how they behave in the face of frustration, rebuke or victory. He wants to know as much as they do and to be as well thought of, and so he strives to emulate them. Above all, he wants to be accepted by them, and this often stimulates him to control his feelings and adapt his behaviour to the requirements of the group. If he is accepted, he can be very generous


[page 172]

in his praise of others who are more successful than he is.

In this way he identifies himself with a larger group and can enjoy vicariously its success, so that the quality of his own individual performance matters less. As a result of his identification with the group, he thinks less about himself. Like the child of two or three years, he becomes absorbed in outside interests, and these are no longer confined to what is happening in his immediate environment. His actual world is likely to be rather restricted; he does not travel much, does not meet many people and cannot exercise much control over the kind of experience which comes his way. But his imagination, though realistic and practical, is well developed and active, and in poetry and story or through the cinema and wireless he can enter into the lives and feelings of people still more remote and unfamiliar. He turns from one interest to another without much persistence, but all the while he is comparing, noting, and widening his experience. In this way he lives in a perpetually expanding universe, and his mind and feelings expand in harmony with it.

Although the influence of other children is very great at this stage, adults still play a most important part in his development. At school what some of his teachers say and do will have a lasting effect on him. The most formative influence in his life will, however, still be his home, and the security of a good home is vital for his sound growth.

One of the most important factors in fostering this sense of security is a harmonious relationship between the child's parents. Another is the existence, in the parents and the other adults with whom children come into contact, of firmly held moral principles and standards of conduct. These will not necessarily be based on religious beliefs; many parents without religious beliefs bring up their children satisfactorily, just as others with such beliefs fail to do so. But there are many people who feel that children who are brought up believing in a loving and merciful God are thereby helped to develop harmoniously and without constraint; and that a child can more readily get rid of a sense of guilt after wrong-doing, and can more readily forgive other people, if he knows that he himself is loved and forgiven.

In this period a child's life and interests are no longer entirely centred on his home and his school. He may join other groups where he will meet adults in a rather different guise, as leaders of cooperative enterprises in a freer and more friendly atmosphere than is usually possible in school. His passion for experimentation, his desire for independence or the influence of other children may occasionally lead him to lie, cheat or pilfer, but by the end of the period he has normally developed considerable resistance to temptation and is reliable, cheerful and cooperative.

Adolescence

Adolescence is often thought of as an unsettled period between two


[page 173]

relatively settled ones. The junior school child should have adjusted himself to the world of childhood, and he can usually disregard the problems of the adult world. His body and mind serve him so well and his feelings trouble him so little that he is not tempted to introspection or self-mistrust. When maturity has been finally reached he will normally return to a like state of stability and serenity, and will feel himself confident to deal with the problems which in childhood he disregarded. Whether the transition from childhood to adult life is made easily or with difficulty will to a considerable extent depend on whether the early nurture of the child has been good or bad, and on the degree of strain and pressure which his environment is exercising at the time.

The far-reaching physical changes of puberty are matched by equally far-reaching emotional and intellectual changes. These may be described as the breaking down of an established pattern and its forming again on a more adult and complex level. The adolescent has to learn to manage a more adult body and to deal with unfamiliar and stronger feelings. This is made even more difficult, because the system of values which sufficed to control feeling during the previous period is itself being broken down and re-formed. The adolescent will have a wider interest in the world around him - in its day-to-day problems as they most immediately affect him, in broader political and social issues, and perhaps in the nature of the universe and the purpose and meaning of his and its existence. There will at this time often be an awakening or deepening of his religious feelings and a quickening of his aesthetic sensibility. He has to re-mould and make his own the principles and beliefs with which he has been growing up in infancy and childhood.

The period of adolescence is one of such instability that it is particularly difficult to determine what constitute the normal limits of behaviour and adjustment. An adolescent may, for example, give way to uncontrollable bouts of temper or crying, may wander off, pilfer or romance, and may swing from exultation to depression, now flinging into society, now withdrawing into solitariness. All this may merely mean that, like the infant, he is adjusting himself to an unfamiliar and complex world by means of a personality which is itself unfamiliar and fluid, and that, also like the infant, he has to experiment in order to understand and control.

Adolescence has been described as having more in common with infancy than with the intervening period of childhood. The main need of the adolescent, as of the infant, is emancipation. Whereas, however, the infant has to emerge from a life centred on his mother into the family, the adolescent has to emerge from the family into the world at large. He has to free himself finally from dependence on adults, and to accept the responsibility of ordering his own life, even though he may go on living at home. In a way, therefore, he repeats the infant's struggle with


[page 174]

authority and may experience again something of the infant's hostility and antagonism to his parents. But his struggle is more conscious, and is often accompanied by an ability to formulate and express criticism which may make it far more bitter and distressing both to himself and to the adults around him. Out of it, however, normally comes fuller understanding, an increased tolerance and a new relation of friendly equality. He may experience again something of the conflict which occupied him as an infant, in that he desires both protection and freedom, both fears independence and is irresistibly attracted to it. But between him and his infancy lies the period of childhood in which he has experienced the pleasure of comradeship with his peers, and the natural course of his maturing feelings is to drive him still further beyond the family, to form lasting friendships and to find new objects for his affections.

In the early part of adolescence there is generally a greater emotional interest in the same sex. This is a normal phase, which ordinarily gives place in the later teens to a greater emotional interest in the opposite sex. If a person has had ample opportunity to experience the progressive emotional stages of infancy, childhood and adolescence, he will as a young adult make a satisfactory adjustment more easily in the sphere of personal affections.

The adolescent needs also to come to terms with his work and to develop ambitions which are both possible of achievement and satisfying to his feelings of self-respect and self-interest. If he has to leave school at fifteen or sixteen he may not have much choice in what he does and may have to look elsewhere for his main interests, but at least he has the satisfaction of earning his own living and of having money to spend as he pleases. Absence of this obvious stage of independence may make the period more difficult for those who continue full-time education, but they have compensating opportunities for pursuing the career of their choice and for achieving intellectual emancipation, and have more leisure for reflecting on the world in general. In either event, the adolescent as he matures identifies himself to some extent with both his work and the community at large; he is prepared to accept the requirements and restrictions of both and to contribute what he can to their successful functioning.

Summary

In reviewing this process of development from infancy to maturity one can pick out various pointers to normality or the reverse. At every stage the child who is progressing satisfactorily is able to profit from the experiences which can normally be assimilated by someone of his age and innate equipment. A child will, for example, learn to talk or to read at about the time when children of his intelligence commonly do. On the emotional side also, he becomes increasingly sensitive to the feelings and


[page 175]

wishes of others and is able to profit to the normal degree from the opportunities which life offers him of learning to control his feelings. One might even say that physically he profits in the same way; his food does him good and he is built up by fresh air and exercise. The concept becomes clearer if one considers instances where something has gone wrong with the process of development: the child of average intelligence who, though present at all the lessons, does not learn to read; the nervous child who may eat voraciously and who fails to thrive for no obvious physical reason; the clever child who remains pig-headed and babyish in dealing with frustrations; or the ten-year-old delinquent whose face still looks chubby and infantile, as if experience had washed over it without leaving its customary mark.

All through the process of development the normal child keeps in reasonable touch with the world around him (though with many sidesteps into fantasy and evasion), respects it and tries to adapt himself to it. In this way he gradually learns to control fantasy, accept discipline and persevere in the pursuit of more distant goals, and his prevailing mood is one of serenity and optimism. Year by year he is building up his own style of life, developing characteristic ways of meeting situations and dealing with problems. The older he gets, the more difficult it becomes to alter his life pattern and to modify a faulty style. His way through life from birth to maturity may be likened to the progress of a Channel swimmer, necessarily affected by waves and current and exulting in the resistance they offer him, but shaping a course to the opposite shore in spite of them.




[page 176]

Index

Accidents, Chapter 12
    at home, 104
    at school, 105
    common causes, 103 fol.
    road, 106
    schools' part in prevention of, 104 fol., 110

Adolescence, 43 fol., 57, 58, 62, 97, 100

Adult Education and Health Education, 67 fol.

Air pollution, 88, 91 fol.

Air purity and health, 90 (see also Fresh air)

Alcohol, 62, 112 fol.

Anatomy, in courses of health education, 75

Animals, care of, 30, 41, 43
    as source of infection, 30, 123, 141, 148, 15 I, 154

Arderne, John, 11, 87

Area Training Organisations, 76

Bacteria, 140, 153

Bacteriology, foundation of science of, 7

Bathing, 4, 39, 58, 65, 85, 87 fol.

B.B.C., 49

B.C.G. Vaccine, 150

Bedding, cleanliness of, 86

Bedroom, child's, 99

Bedtime, 99 fol., (see also Rest)

Biology, v fol.
    and health education in training colleges, 74
    and sex instruction, 55 fol.
    basis of health education, Chapter 3
    in secondary schools, 44, 109
    social, in training colleges, 76

Black Hole of Calcutta, 90

Body, care of, Chapter 16
    cleanliness, 85
    structure, study of, 26, 42, 46

Bowels, 137

Breathing, 91

Bronchitis, 93, 113, 144

Camping, 63, 65, 85, 98

Carbohydrate, 1I8

Carefulness and craftsmanship, 108 fol.

"Carriers" of infectious diseases, 140 fol.

Central Council for Health Education, 17

Chadwick, Edwin, 6

Chickenpox, 147

Child Care, 51 fol. (see also Mothers and Mothercraft),
    help from maternity and child welfare services, 9, 69, 70

Child Guidance Clinic, 17, 164 fol.


[page 177]

Child, and society, 34, 44, 53 fol., 64 fol., 98
    discipline and training, see Discipline and Habit training
    growth and development, see Development
    need for security, 34, 38, 158 fol., 163 fol.
    relationships with parents, teachers and others, see Personal Relationships
    Welfare Services, 13, 15, 17, 18, 69 fol.

Cholera, 5 fol., 47, 88, 142

Cigarette smoking, 112 fol.

Classrooms, heating and ventilation, 90 fol.

Clean Air Act, 1956, 94

Cleanliness, environmental, Chapter 10 (see also Environment)
    in food preparation, 46, 85, 155
    personal, 10 fol., 84 fol., 87 fol., 131, 135
    and infectious diseases, 144, 148 fol.
    at school, 42, 46
    young people, 62, 65

Clostridium Botulinum, 154

Clostridium Welchii, 154

Clothing, 42, 129 fol.
    at nursery and infant school, 39 fol.
    cleanliness of, 86, 131
    materials, 129 fol.

Coffee, 111, 121

Communicable diseases (see also under names of diseases), Chapter I7
    notification of, 142
    transmission of, 139 fol.

Cookery lessons, 52

Cooperation, parent (home)/teacher (school), v, 36 fol., 40, 49,52, Chapter 8, 102, 163
    alcohol and tobacco, 115
    medical inspections, 71 fol.
    sex education, 56
    parent/health and welfare services, 10, 37, 68, 71
    teacher (school)/health and welfare services, 17 fol., 164

Cosmetics, 45, 131

County Colleges, 63, 66

Cowpox, v

Crimean War, 4

Darwin, 24

Daytime rest, 40, 100

Dental health, 134 fol.

Dentist, School, 17,20,42,50

Development of Child, 19, Chapter 4, 62, 97, 117
    emotional, 43, 57 fol., 62, Chapter 18 especially 158, 164
    mental, 37, 40, 43, Chapter 18 (see also Mental health)
    normal, 158, Appendix

Diet, 52, 117-124

Diphtheria, 17, 19, 123, 139, 142, 145 fol., 148

Discipline,
    effect on mental health, 162 fol.
    self, 33, 44 fol., 57, 64, 113-116
    (see also Habit training)

Droplet infection, 140 fol, 144 fol., 148


[page 178]

Drugs, 111

Ear defects, 18, 133 fol., 164

Ears and hearing, care of, 133 fol.

Ecology, 46

Education Act, 1870, 9

Education Act, 1944, 13, 16 fol., 22, 63, 127 fol.

Education, Board of, 10, 76

Education (Provision of Meals) Act, 1906, 127

Emotional development, see Development strain, 100 fol.

English as a school subject and health education, 48 fol.

Environment, at home and in school, 40, 48
    effect on child's mental health, 159
    human, and health, 8, 13 fol., 16, 24, 26, 72, 86

Environmental cleanliness, Chapter 10
    studies, 45 fol.

Epidemic disease, 4, 7, 9, 139

Evening Institutes, 63

Evolution, 24, 25 fol.

Exercise, 9, 29, 39 fol., 42, 129, 142, Chapter 11

Eye defects, 18, 132, 164

Eyesight, care of, 132, 133

Factory, Acts, 7, 63
    safety in, 108 fol.

Family, and child relationship, 34
    cycle, 67 fol.
    head lice, 71, 150
    responsibilities, school studies as foundation for, 53
    social services help, 16, 67 fol.
    study of in training colleges, 76
    (see also Home)

Fatigue, 100 fol., 148

F.A.O. (Food and Agriculture Organisation), 48

Fats, 118

Feet, 136 fol.

First aid, value of teaching to children, 75, 109

Fleas, 31

Flies, 30 fol., 141, 155

Fluids, 121 fol.

Fog, 92

Food and Drugs Act, 1938, 8
    1955, 16, 152

Food, and growth, 29, 32, Chapter 14
    contamination of, 30, 141, 153 fol,
    cost of, 125
    handling and preparation, 46, 52, 85, 155
    in nursery schools, 39
    normal bodily needs, 32, 124, 129, 149
    poisoning, 152 fol.
    protection of, 126, 143
    sources and distribution, 126
    world supply, 27, 48


[page 179]

Footwear, 39, 41, 131, 136 fol., 152

Free play, 162

Fresh air, 9, 29, 39, 91, 142

Further education and health education, 63

General Board of Health, 8

General Practitioners, 15

Genetic inheritance, 26 fol.

Geography, as a school subject and health education 47 fol., 55

German Measles, 146

Germs, disease, 6 fol., 42, 89, 139 fol.
    food contamination, 152 fol.
    immunisation against and resistance to, 142

Growth, 117 (see also Development)

Habit training, vi, 26 fol., 33 fol., 39, 41, 44, 84 fol. 138 (see also Cleanliness and Discipline)

Hæmolytic Streptococcus, 139, 145, 151

Hair and head, care and cleanliness, 85 fol., 150, 151

Handicapped children, 17 fol., 71, 77

Health, definition of, vii, 13

Health Education Board of Studies, 76

Health Education, importance as a school subject, 35 fol., 37 fol., 69
    in nursery school, 38
    in infant school, 39
    in junior school, 41
    in secondary school, 43 fol.
    relationship with other subjects in secondary school:
        English, 48
        geography, 47
        history, 47
        housecraft, 46
        science, 45
    in further education and youth organisations, 63
    in adult education, 67 fol.
    advanced courses in training colleges, 76 fol.
    qualifications, 75

Health, mental see Mental health

Health, Ministry of, 8

Health Services see National and School

Health Visiting, 9, 13, 18, 67, 69 fol.

Hearing, see Ears

Heat, see Warmth and Temperature

Heredity, 25 fol.

Highway Code, 107

Hippocratic Oath, 3

History, as a school subject and health education, 47, 49, 55 (see Chapters 1 and 10 for historical background of health education)

Home, accidents in, 104
    cleanliness of, 86
    environment, 45
    habit training, 84
    management, study of, 46
    (see also Cooperation, Family and Personal relationships)


[page 180]

Hospital Service, 5, 8, 15 fol.

Housecraft,
    and health education in college, 74, 105
    and health education in school, 43 fol., 46, 56, 105, 126

Housing, 5, 11 fol., 15 fol.

Hygiene, 9 fol., 35, 38, 44, 45 fol., 75, 85

Immunisation, 15, 142
    diphtheria, 145 fol.
    poliomyelitis, 147 fol.

Immunity to disease, 141, 146, 149

Impetigo, 86, 145, 151, 154

Industrial Revolution, 5, 88 Inoculation

Infant mortality rate, 9, 70

Infant school, 39 fol., 76

Infection, prevention of, 142 (see also Communicable diseases)

Inoculation, 7, 14, 142

International Office of Public Health, 143

Jenner, Edward, 7

Junior school, 41 fol.

Koch, Robert, 7

Lavatory, W.C., etc., 3, 39,41, 65, 86, 87, 138, 147, 155

Leisure-time, activities for young people, 65, Chapter 11 especially 102

Lice, 6, 31, 85, 86, 141, 150

Life saving, value of teaching to children, 109

Lighting, effect on eyes, 132

Litter and landscape, 85

Local Government Act, 1888, 8

Lunacy and Mental Treatment Acts, 17

Lung cancer, 113 fol.

Lungs, 91

Maladjusted children, 17, 71, 164
    committee report, vi, 158, Appendix

Malaria, 31, 47, 141

Malnutrition, 18

Marriage, education for, 11, 51 fol., 68

Materials for clothing, 129 fol.

Maternal instinct, 32, 72

Meals at school, 39 fol, 47, 126 fol.
    behaviour, 125

Measles, 102, 144

Medical Inspection, 17, 20, 71

Medicine, preventive, 9, 14, 18, 21 fol.
    patent, 111

Menstruation, 58

Mental health, 10, 13, 15, 17,75, Chapter 18
    of teachers and effect on children, 160

Mental ill-health, 159

Milk, 122 fol., 128
    contamination of, 123, 141, 154
    infection (T.B.), 148 fol.


[page 181]

Milk, continued
    in school, 126 fol.
    safety of, 123
    value of, 122

Minerals, 119

Mosquitoes, 31, 141

Mothercraft, at school, 5 I fol.
    and maternity and child welfare services, 9, 69 fol.

Mothers, 32, 52, Chapter 8, 69, 158

Mothers' Clubs, 70

Movement, 39 fol., 97 fol. (see also Physical education)

Mumps, 147

Municipal Reform Act, 1835, 8

National Council of Social Service, 21

National Health Service, 7, 8, 13, 15 fol., 20 fol., 29, 67

Normal development, 158, Appendix

Notification of Births Act, 1908, 9

Nurture, 26

Nursery schools, 38 fol., 76
    visits to for rnothercraft lessons, 52

Nutrients of food, 118

Nutrition, 10 fol., Chapter 14

Out of door activities, 91, 97 fol.
    nursery and infant schools, 39 fol.
    youth organisations, 64 fol.

Over-stimulation at school, 101 fol.

Parentcraft, 10, 51 fol., 59, 68 fol.

Parent, and child and school and teacher relationships, etc., see Cooperation and Personal relationships

Parents, 14, Chapter 8

Parent Teacher Association, 36

Partnership, school/parent/health and welfare services, see Cooperation

Pasteur, Louis, 7

Patent medicines, 111

Pediculosis, 150

Personal cleanliness, see Cleanliness

Personal relationships, boys and girls, 58, 66
    parent and child, 32, 34, 52 fol., 62, 158 fol.
    teacher and child, v, 35 fol., 43, 53 fol., 58, 74 fol., 159 fol.
    teacher and parent, Chapter 8 especially 71 fol., 77 fol., 116 (see also Cooperation)
    youth worker (and others) and young people, 66

Pests, 30 fol., 48, 139, 141

Pets, care of, 41, 55

Physical education, 10, 19, 42 fol., 45, 74, 78, 97 fol.
    bare feet, 137, 152
    (see also Movement)

Physiology, 8, 55 fol., 75

Plague, 4, 11, 47, 142

Plant life, 30

Plantar warts, 136, 151 fol.


[page 182]

Play, importance of, 32, 38 fol., 162, Chapter II

Poliomyelitis, 20, 139, 147

Posture, 26, 41, 42, 91, 132
    defects, 98

Primary schools, 38 fol.

Protein, 118

Psychologist, school (or educational), 17, 164

Public Health Act, 1848, 8
    1936, 8, 16, 142

Puberty, 43, 55

Pulmonary disease (see also Tuberculosis),
    risk from measles, 144

Quarantine, 143 fol.

Radio-activity, 46

Reading in bed, 132

Red Cross, 48

Refuse and sewage disposal, 89, 143 (see also Sanitation)

Remedial work, 98

Reproduction, 27 fol., 55

Resistance to disease, powers of, 142, 149

Rest, 29, 39 fol., 98 fol., 117, 142

Rickets, 10, 18

Ringworm, 18, 151

Road accidents, safety instruction, 106 fol.

Royal Commissions, 6, 9 fol.

Royal Society for the Promotion of Health, 75

Safety precautions, education in, 42, 104 fol.

Salk, Jonas E., 148
    vaccine, 148

Salmonella organisms, 153 fol.

Sanitation, 3, 5, 6, 16, 75, 86 fol., 89 fol., 143

Scabies, 85 fol., 151

Scarlet Fever, 6, 123, 145

School Health Service, 10, 13, 17 fol., 37, 49, 71 fol., 78, 164 fol. (see also Medical Inspection)

School, accidents at, 107 fol.
    dentist, 17, 20, 42, 50
    exclusion from for communicable diseases, 143
    home cooperation, see Cooperation
    meals, 10, 39 fol., 127 fol., 152, 155 fol.
    medical officer, see School Health Service and Medical Inspection
    nurse, 18, 20, 150
    precautions against communicable diseases, 144
    psychologist, 17, 164

Secondary schools, subjects in, 43 fol.

Security, child's need for, see Child

Sex, instruction in, 44, 49, 54-61, 65 fol., 76

Science and health education in schools, 43, 45 fol., 55

Shoes, 39, 41, 131, 136 fol., 152

Skin infections, 18, 150

Sleep, 39 fol., 62, 99 fol., 142


[page 183]

Sleeping Sickness, 47

Smallpox, 6 fol., 17, 142 fol.

"Smog", 93

Smoke, abatement, 11, 94
    air pollution, 91 fol.

Smoking, tobacco, 62, 112 fol.

Snow, John, 7

Social, biology, 76

inheritance, 26 fol.

Socks, 131, 137

Soft drinks, 121 fol.

Soot, 94

Special Educational Treatment, 18,76

Staphylococcus, 153 fol.

Starch, 118

Sugar, 101, 118
    effect on teeth, 134 fol.

Sunlight, 29, 95, 142

Sweet eating, 135

Swimming, 45, 65, 133, 148, 152

Tapeworms (Tærnia solium), 31

Tea, 121 fol.

Teacher, importance of personal health, 160
    relationships with children, parents and health and welfare services, see Cooperation, Personal relationships and Teamwork
    training and health education, 10, Chapter 9

Teamwork, health education in training colleges, 75
    school/parent/health and welfare services, v, 17 fol., 37, 49, 71 fol., 164 fol.

Teeth, care of, 42, 134 fol.

Tetanus, 142

Temperance, 10, 112 fol.

Temperature, body, 129
    room, 90 fol. (see also Ventilation)

Threadworms (Oxyuris), 31

Tobacco, 62, 112 fol.

Town and Country Planning, 84, 88, 149

Training Colleges, health education in, Chapter 9
    sex education in, 60

Training of child, 162 fol. (see also Discipline and Habit training)

Truthfulness, 163

Tuberculosis, 8, 17, 19, 48, 91, 101, 123, 141, 148 fol., 154

Typhoid, 6, 89, 123, 139, 142, 153

Typhus, 6, 86, 141

Ulcers, duodenal, 14

Ultra-violet Rays, 95, 132

UNICEF, 48

United Nations, 12, 48

Vaccination, 7, 15, 17, 19, 142, 148, 150

Vaccine, Salk (poliomyelitis),. 148

BCG (tuberculosis), 150

Ventilation, 14, 46, 75, 87, 90 fol., 99, 144

Vermin, spread of disease, 6, 30, 86, 141, 153 fol.


[page 184]

Verminous condition in schoolchildren, 18,71, 85 fol., 150

Virus infections, 23, 31, 139 fol., 144, 146 fol., 151

Vitamins, 10, 29, 95, 119 fol.

Voluntary organisations, 11, 20 fol., 44, 64

Warmth of body, importance and conservation, 29, 42, 129

Warts, 136, 151 fol.

Water, and cleanliness, 84
    body's need for, 121 fol.
    pollution and purity of supply, 4, 6, 13, 88 fol., 143
    requirements and supply, 75, 89

Whooping Cough, 145

World Health Organisation, 12, 48, 142

X-Ray, 18 fol., 149, 151

Yellow fever, 31, 47

Youth clubs and organisations, 44 fol., 63 fol.

Youth leaders, 66