LB £j+< &$^M v *&% Class _L&34#* Book UMs-Mte TREASURY DEPARTMENT UNITED STATES PUBLIC HEALTH SERVICE HUGH S. CUMMING, Surgeon General THE RELATION OF PHYSICAL DEFECTS TO SICKNESS A STUDY OF ABSENCE FROM SCHOOL ON ACCOUNT OF SICKNESS AMONG 3,786 CHILDREN IN FOUR LOCALITIES IN MISSOURI DURING THE SCHOOL SESSION 1920-1921 BY SELWYN D. COLLINS Assistant Statistician United States Public Health Serxice REPRINT No. 782 FROM THE PUBLIC HEALTH REPORTS September 8, 1922 (Pages 2183-2193) Z2^2/? l -('2- t j WASHINGTON GOVERNMENT PRINTING OFFICE 1922 THE RELATION OF PHYSICAL DEFECTS TO SICKNESS. A STUDY OF ABSENCE FROM SCHOOL ON ACCOUNT OF SICKNESS AMONG 3,78fi CHILDREN IN FOUR LOCALITIES IN MISSOURI DURING THE SCHOOL SESSION 1920-21.1 By Selwyn D. Collins, Assistant Statistican, United States Public Health Service. A number of studies of morbidity among observed groups of people have been published in the past few years. These studies have shown that disability from sickness varies with sex and age, and the few studies which show disability by occupation show considerable variation as between occupations. A previous study 2 based on the observation of sickness among children during the school session 1919-20, showed disability among children of different sex and age, regardless of the presence or absence of physical defects. It is the purpose of the present study to compare disability among children with certain common physical defects with disability among children with no physical defects, as measured by absence from school on account of sickness. In the course of a survey made in Missouri, school children were examined for physical defects, and certain physical measurements were made of them. On the same card on which the results of the examination were entered, the teacher kept a record of the absence of the child from school on account of sickness and from causes other than sickness. A group of 3,786 children from four fairly represent- ative localities in Missouri were observed during the school session 1920-21, and the records tabulated for this study. The following table shows the four localities and the number of children observed in each. Table I. — Distribution according to locality of residence of 3,786 children in Missouri observed for sickness during the school session 1920-21. City. All localities Hannibal Moberly TVarrerisburg. Joplin Countv. Marion Randolph. Johnson... Jasper Popu- Number lation of of city, children 1920. observed. 19,306 12,808 4,811 29,902 3,786 1,378 1,064 682 662 i From Field Investigations in Child Hygiene, United States Public Health Service, in cooperation with the Statistical Office, United States Public Health Service. Keprint from the Public Health Reports, vol. 37, No. 36, Sept. 8, 1922, pp. 2183-2193. a Collins, Selwyn D.: Sickness among school children. Public Health Reports, vol. 36, No. 27, pp. 1549- 1559, July 8, 1921. (Reprint 674 2 12881—22 2-IBKAHY OP CONriwss - N0V23J9£2 / u13 ^ -v © S[ r^. ^PHYSICAL defects and sickness in school children. 3 The children ranged in age from 5 to 20 years, but very few were under 6 or over 16. The following table shows the distribution of the observed children according to sex and age. Table II. -Distribution according to sex and age of 3,786 children in Missouri observed for sickness during the school session 1920-21 . Number. Per cent. Age last birthday (years). Both sexes. Boys. Girls. Both sexes. Boys. Girls. 3,786 1,891 1,895 100.0 100.0 100.0 430 418 420 478 427 428 414 375 235 114 47 218 200 209 239 229 206 201 183 126 62 18 212 218 211 239 198 222 213 192 109 52 29 11.4 11.0 11.1 12.6 11.3 11.3 10.9 9.9 6.2 3.0 1.2 11.5 10.6 11.1 12.6 12.1 10.9 10.6 9.7 6.7 3.3 1.0 11.2 11.5 8 11.1 9 12.6 10 10.4 11 11.7 12 11.2 13 . 10. 1 14 5.8 2.7 1.5 The data as reported by the teacher showed the total possible number of days the child could have attended school had he not been absent from some cause, the number of days on which the child was absent because of sickness, and the number of days absent from causes other than sickness. Sickness includes illness of any nature whatever. It is possible that some absence because of sickness may have been reported as due to causes other than sickness and that some absence from other causes may have been reported as due to sickness. It seems hardly probable, however, that the error was large enough to vitiate the results. The record of the child's physical examination showed what physical defects he had. The results of the hearing tests were reported so incompletely and imperfectly that no account was taken of hearing in any case; but all other physical defects were con- sidered. In tabulating the data, the children were divided into several classes according to physical condition. The following table shows the physical condition groups used, the number of children in each group, and the total days enrolled — that is, the total number of "child days" for which records were kept: 4 PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDEEN. Table III. — Distribution according to physical condition of S, 786 children (both sexes) in Missouri observed for sickness during the school session 1920-21. Physical condition. All physical conditions Group 1: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision (with and without decayed teeth) Group IV: Children with and without decayed teeth or defective vision, but wi th no other recorded defects Group V: Enlarged or diseased tonsils only (with and without decayed teeth or defective vision) Group VI: Adenoids alone or associated with other defects; enlarged or diseased tonsils associated with other defects; mouth breathing alone or associated with other defects; chronic nasal catarrh alone or associated with other defects (with and without decayed teeth or defective vision) Group VII: Defects other than those included in the above groups (with and without decayed teeth or defective vision) Total pos- sible num- ber of days of school attendance. 611,279 132, 995 83,259 57,382 372, 755 90, 788 32,701 Table IV shows the distribution according to age of the children in each physical-condition group. This table is included to show the extent of the data in the various age and physical-condition groups as an index of the reliability of the results. Table IV. — Number of children (both sexes) and the aggregate number of school days during which they were under observation for sickness. Age. Total. Defect group. » III IV VI VII NUMBER OF CHILDREN. All ages. 6-7 8-9 10-11.... 12-13.... 14-16.... 3,786 784 545 389 2,283 717 571 848 137 94 87 499 154 151 898 190 144 77 534 189 131 855 181 113 77 502 172 133 789 168 130 89 482 140 116 396 108 64 59 266 62 40 215 44 44 48 51 28 TOTAL POSSIBLE NUMBER OF DAYS OF SCHOOL ATTENDANCE. All ages . 6-7... 8-9. . . 10-11. 12-13. 14-16. 611,279 132,995 83,259 57,382 372,755 115,037 90,783 J 137,482 23, 693 14,018 12, 128 81,925 25,026 23,940 1 144,831 32,905 21,489 10,909 87,381 30,163 20,420 139,310 31,116 17,216 12,058 83,364 27,007 21,467 ! 127, 856 28, 139 20, 590 13,404 78, 166 23, 131 18,785 i 61,800 17, 142 9,946 8,883 41,919 9,710 6,171 | 32,704 6,591 6,876 7,472 7,774 4,000 a See Table III for definitions of the groups. The data on hearing were too incomplete to use; therefore all groups include children with defective hearing as well as normal hearing. Group I consists of children who had no recorded defects. Group II consists of children who had one or more decayed teeth, but no other recorded defects. PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. Group III consists of children with defective vision with and without decayed teeth, but with no other defects. The small number of children made it impossible to subdivide them into as definite and clear-cut groups as would be desirable for a complete analysis. It was, therefore, necessary to disregard both teeth and vision in making the following defect groups, in order to have sufficient numbers of children in the groups to give dependable results. The effect of decayed teeth or defective vision on absence from school did not seem to be great. Also, unless the defects of teeth or vision were associated in some way with the other defects considered there would be no greater proportion of children with decayed teeth or defective vision in one defect group than in another or in the group who had no general defects when teeth and vision were not taken into account. (Group IV.) Group IV consists of children with and without decayed teeth or defective vision, but with no other recorded defects. Group V consists of children with and without decayed teeth and defective vision who had enlarged or diseased tonsils, but no other recorded defects. Group VI consists of children with and without decayed teeth and defective vision, but who had adenoids alone or associated with other defects ; enlarged or diseased tonsils associated with other defects ; mouth breathing alone or associated with other defects; chronic nasal catarrh alone or associated with other defects. Group VII consists of all children with and without decayed teeth or defective vision and with defects other than those included in the above groups. Since the children could not be divided into groups according to specific defects, but had to be sorted according to groups of defects, Table V is introduced to show the number of specific defects included in each of the groups who had defects other than decayed teeth or defective vision. Table V. -Number of children in each of the physical condition groups who had certain specific defects. All physical conditions. Number of defects in each group, a Defect. Defects per 1,000 children. Number of children. IV. V. VI. Vli. 1,000.0 603.0 3,786 2.283 2, 283 2,283 717 571 215 No general defects (teeth and vision not taken 95.1 ! 360 48.9 ' 185 6.1 1 23 4.2 | 16 274.2 1,038 20.3 | 77 360 185 23 16 325 41 Deflected septum or other nasal obstruction 713 36 a See Table III for definitions of the groups. 12881—22 2 PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. Table V. — Number of children in each of the physical condition groups who had certain specific defects — Continued. All physical conditions. Number of defects in group. each Defect. Defects per 1,000 children. Number of children. IV. V. i VI. VII. Ear discharging 2.6 .3 3.4 4.5 .3 2.1 14.8 9.8 2.9 8.5 3.7 .8 3.4 .8 .5 .3 1.1 1.3 1.8 .5 .5 .8 10.8 .5 13.5 1.6 2.1 .3 30.4 .3 .3 .3 .5 5.5 10 1 13 17 1 8 56 37 11 32 14 3 13 3 2 1 4 5 7 2 2 3 41 2 51 6 8 1 115 1 1 1 2 21 2 8 1 Ear drum obscured by wax 10 14 1 4 22 23 7 23 9 1 9 3 2 Strabismus 34 Glandular enlargement, cervical 9 ., 1 1 2 3 Deformity nf hann" or arm 3 4 2 2 2 20 1 Speech defect °1 9 26 3 4 9 5 3 4 1 .50 1 1 1 65 Orthopedic defect (not otherwise specified) Glandular enlargement (not otherwise specified) . . 9 Miscellaneous 11 10 The children observed have now been classified into the various groups and the groups have been defined. The next step in the study is the comparison of the absence on account of sickness among the children in these various groups, that is, the comparison of the absence on account of sickness among children with no defects with absence among children with the various specified groups of physical defects. The following table (Table VI) shows, by sex, age, and physical condition, the percentage of the total school days which were lost on account of sickness and of causes other than sicknes . 3 Figures 1 and 2 compare graphically the time lost from sickness by children with various physical defects. Figure 1 compares the averages for all ages, and Figure 2 makes the comparison by age groups. Sickness in each case is not limited to sickness directly connected with the defect, but includes all illness from any cause whatever. •If a child was permanently separated from school he was no longer counted as enrolled. In the case of absences for short periods, the total time absent was counted rather than drop the child from the roll and reenter him upon return, as is sometimes done in keeping school records. Obviously, the record desired was the total time absent because of sickness . PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. 7 Table VI. — Physical defects and absence from school on account of sickness. Percentage of the total school days which were lost by children with no defects compared with children with various physical defects. [3,786 children in Missouri— School session 1920-21.] Physical condition. All Age. 6-7 8-9 10-11 12-13 14-16 BOTH SEXES. All physical conditions Group I: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision Group IV: With and without defective teeth or vision but with no other defects Groups V-VII: Defects of any kind Group V: Enlarged or diseased tonsils only Group VI: Adenoids alone and adenoids, tonsils, etc., associated with other defects Groups V-VI: Adenoids, tonsils, etc., alone or asso- ciated with other defects Group VII: All other defects 3.5 4.9 3.5 3.0 2.9 3.2 4.5 3.5 2.8 2.7 3.3 4.7 3.5 2.7 3.0 3.5 3.3 3.5 3.8 3.8 3.2 4.7 3.2 2.6 2.8 3.9 5.2 4.0 3.5 3.1 3.6 4.5 3.9 3.4 2.9 4.2 5.9 4.0 3.9 3.2 3.9 5.2 3.9 3.6 3.0 4.0 5.3 4.5 3.0 3.1 2.3 1.9 2.3 2.8 2.1 2.8 2.5 2.4 4.6 All physical condit'ons Group I: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision Group IV: With and without defective teeth or vision but with no other defects Groups V-VII: Defects of any kind Group V: Enlarged or diseased tonsils only Group VI: Adenoids alone and adenoids, tonsils, etc., associated with other defects Groups V-VI: Adenoids, tonsils, etc., alone or asso- ciated with other defects Group VII: All other defects 3.3 5.0 3.2 2.8 2.8 3.2 4.4 3.5 3.2 2.9 3.3 3.8 3.6 3.0 3.1 2.6 3.0 2.2 2.9 2.0 3.1 4.7 3.0 2.6 2.5 3.7 5.4 3.5 3.2 3.2 3.6 4.7 3.8 3.1 3.5 3.8 5.7 3.3 3.5 2.9 3.7 5.3 3.5 3.3 3.2 3.9 6.4 3.5 2.3 3.2 2.3 1.7 3.2 3.1 2.2 2.4 1.9 2.1 4.3 All physical conditions Group I: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision Group IV: With and without defective teeth or vision but with no other defects Groups V-VII: Defects of any kind Group V: Enlarged or diseased tonsils only Group VI: Adenoids alone and adenoids, tonsils, etc., associated with other defects Groups V-VI: Adenoids, tonsils, etc., alone or asso- ciated with other defects Group VII: All other defects 3.6 4.8 3.9 3.2 3.1 3.1 4.7 3.5 2.5 2.6 3.2 5.6 3.4 2.4 2.9 4.1 3.5 4.4 4.2 5.1 3.4 4.7 3.5 2.7 3.1 4.0 5.0 4.5 4.0 2.9 3.6 4.4 3.9 3.6 2.4 4.7 6.1 5.3 4.5 3.7 4.0 5.1 4.3 4.0 2.9 4.1 3.4 5.7 4.0 3.0 2.4 2.2 .8 2.6 2.0 3.2 3.0 2.7 4.7 See Table III for detailed definitions of groups. Figure 1 compares absence among children (all ages) with no defects with children with various groups of defects. Children with no defects were absent 3.2 per cent of the school days as against 3.9 per cent by children with defects of any kind. Considering these percentages as rates (days absent per 100 days enrolled), the rate of absence from sickness for children with defects is 22 per cent greater than the rate for children with no defects. The rate of absence from PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. sickness for children with enlarged or diseased tonsils is 12 per cent greater than the no-defect rate, and the rate for children with adenoids, defective tonsils, etc., associated with other defects, is 31 per cent greater than the rate for the children with no defects. The rate for children with defective vision was 9 per cent greater and the rate for children with decayed teeth was 3 per cent greater than the no- defect rate. Figure 2 takes up the rates in the various age groups and shows what differences are consistent for the different ages. It shows for five age groups for both sexes combined the percentage of the total school PHYSICAL DETECTS AND ABSENCE TBoM School ON ACCOUNT o? SICKNESS .Perce.nt.Qga of -the Total School Da^s whicn were. L°s"fc b^ Children (all ages) with No Defects compared with Children wifc-Vi Various Physical De-fects " Physical Condition Percent , 2 3 I No defects II Decayed teeth only III Defective vision IV No general defects V-VII Defects of any Kind V Enlarged or diseased tonsils only VI Adenoids or tonsils associa- ted with other defects V-VI Adenoids or tonsils alone or, with other defeots All other defeots Fig. 1. See Table III for detailed definitions of groups. days which were lost on account of sickness by children in the various physical conditions. In each small graph in the figure, the curve of sickness for children with no physical defects (Group I) is repeated so that a comparison can more readily be made between this group and each of the other groups. Graph A compares children with no defects (Group I) with those who have some general physical defect (Groups V to VII inclusive). The differences are considerable and are consistent in the various age groups. Graph B compares children with no defects with children who have decayed teeth and with children who have defective vision. In neither case are the differences consistent for the various age groups. Vision appears to have some influence; but with the few data avail- able no very definite conclusion can be drawn unless the results are consistent for the various ages. It is possible that the effect of certain defects might be shown to be greater at certain ages than at others if there were sufficient data. PHYSICAL DEFECTS AND SICKNESS IN" SCHOOL CHILDREN. 9 In the two lower graphs, the children with no defects (Group I), are compared with a group with enlarged or diseased tonsils or both (Group V) and with another group who have adenoids alone or PHYSICAL DEFECTS AND ABSENCE FROM SCHOOL ON ACCOUUT OT SICKNESS Psrc.ent.ogis o-p the. Total School P&ys which viere. Lost b>f Children (Both Se.xe.sj with No Pe.-fec.ts Compered with Children with VariotLS Physical De-Pec/ts 3,7efei Children i» Missou.r. - School Session 1^2.0-2,1 AGE GR0VPS fc-7 8-S lo-ll l^-fS 4= AGE GROUPS 8-1 lo-ll 12-13 Gr. I - No de-fe.ct.3 &r. I- No. a^^ect* 5 ■" • 4 "- 3 •" 2 "- » -- . Or. It - Deca^ =it.iaris o-f efrou-ps. associated with other defects, defective tonsils associated with other defects, mouth breathing and chronic nasal catarrh alone or asso- ciated with other defects (Group VI). Graph D shows each group separately and graph C shows the two groups combined. The group with defective tonsils only (Group V) lost more time at every age group except 6-7 years than the group with no physical defects (Group I). The group with adenoids, defective tonsils, etc., asso- 10 PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. elated with other defects (Group VI) lost considerably more time at every age group than the no-defect group (Group I) and also more time than the group with defective tonsils only (Group V) in every age group except 14-16 years. The records also showed the time lost from school from causes other than sickness. Table VII shows by sex and age groups the absence from causes other than sickness for each of the physical-condition groups used in tabulating the absence from sickness. Figure 3 com- pares, for all ages combined, the time lost from causes other than sickness, by children with no defects, with the time lost by children with the various physical defects. PHYSICAL DETECTS AH P ABSENCE TR.OM SCHOOL TltoM CAUSES OTHEB THAN SICKNESS Percentage of the Total Sch 00 | Pajs wh'.ch were Lost by Children (all ages) with No Pefects compared With Children w'.ih Various Physical Pefects Physical Condition. I No defects II Decayed teeth only III Defective vision IV Ko general defects Y-VII Defects of any kind V Enlarged or diseases tonsils only VI Adenoids or tonsils associa- ted with Other defects V-VI Adenoids or tonsils alone or with other defects VII All other defects Pig. 3. See Table III for detailed definitions of groups. Table VII. — Physical defects and absence from school from causes other than sickness. Percentage of total school days which were lost by children with no defects compared with children with various physical defects. [3,786 children in Missouri— School session 1920-21.] Age. Physical condition. All ages. 6-7 10-11 12-13 BOTH SEXES. All physical conditions Group I: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision Group IV: With and without defective teeth or vision but with no other defects Groups V-VII: Defects of any kind Group V: Enlarged or diseased tonsils only Group VI: Adenoids alone and adenoids, tonsils, etc., associated with other defects Groups V-VI: Adenoids, tonsils, etc., alone or asso- ciated with other defects Group VII: All other defects 2.5 2.9 1.8 1.5 2.4 3.0 2.5 4.1 2.3 2.6 2.8 3.4 2.8 3.5 2.5 3.2 2.7 3.3 3.3 3.5 2.1 1.9 2.6 ] 1.7 1.6 1.8 1 2.0 1.7 2.3 2.5 1.8 1.8 2.0 1.7 2.5 2.2 2.3 2.7 2.3 2.1 2.6 1.6 2.2 2.7 2.0 2. 2 2.7 ! 3.9 2.9 3.0 i 3.6 3.0 4. 1 2.5 3.4 4.2 4.9 4.4 3.5 PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. 11 Table VII. — Physical defects and absencefrom school from causes other than sickness — Con. Percentage of total school days which were lost by children with no defects compared with children with various physical defects. Physical condition. Age. All 8-9 12-13 All physical conditions Group I: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision Group IV: With and without defective teeth or vision but with no other defects Groups V-VII: Defects of any kind Group V: Enlarged or diseased tonsils only Group VI: Adenoids alone and adenoids, tonsils, etc., associated with other defects Groups V-VI: Adenoids, tonsils, etc., alone or asso- ciated with other defects Group VII: All other defects 2.7 3.3 2.2 2.1 2.7 1.9 1.8 1.5 1.6 1.9 2.5 3.0 1.8 1.8 2.4 2.9 4.0 3.6 1.9 1.9 2.5 2.9 2.1 1.8 2.5 3.1 3.9 2.5 2.4 3.0 3.3 4.2 2.7 2.2 3.2 2.6 3.9 1.4 2.4 2.5 3.0 4.0 2.1 2.3 2.8 3.8 3.2 5.0 3.4 4.0 4.1 3.3 4.5 2.7 3.7 5.0 6.2 4.0 5.3 3.4 All physical conditions Group I: No recorded defects Group II: One or more decayed teeth only Group III: Defective vision Group IV: With and without defective teeth or vision but with no other defects Groups V-VII: Defects of any kind Group V: Enlarged or diseased tonsils only Group VI: Adenoids alone and adenoids, tonsils, etc., associated with other defects , Groups V-VI: Adenoids, tonsils, etc., alone or asso- ciated with other defects Group VII: All other defects 2.2 2.5 1.9 1.8 2.4 1.7 1.1 1.8 1.5 1.8 2.4 3.0 2.2 1.6 2.2 2.3 4.2 1.6 1.7 1.8 2.1 2.3 1.9 1.7 2.4 2.4 2.8 2.0 2.1 2.5 2.4 2.9 2.0 2.1 2.2 2.4 2.4 1.9 2.0 3.1 2.4 2.7 1.9 2.0 2.5 2.8 4.0 2.5 2.4 2.1 3.1 2.8 3.5 2.4 2.9 3.5 3.6 3.4 3.6 See Table III for detailed definitions of groups. For some reason, absence from causes other than sickness also varies in the different physical-condition groups. Those groups with defects were absent more than the group with no defects. Part of this difference may be due to incorrect reporting of the causes of absence, but it seems unlikely that it could all be due to such causes. Summary. 1. Records of physical examination and school attendance during the school session 1920-21 were kept for 3,786 children in four fairly representative localities in Missouri. 2. These children were classified according to physical condition, and the absences from sickness and from causes other than sickness were compared by age groups for children of different physical con- ditions. 3. Children with no defects were absent from school on account of sickness consistently less than those with defects. Children with enlarged or diseased tonsils were absent more than children with no defects, and those with enlarged or diseased adenoids 12 PHYSICAL DEFECTS AND SICKNESS IN SCHOOL CHILDREN. or tonsils associated with other defects were absent considerably more than those with enlarged or diseased tonsils only. Decayed teeth showed little or no effect on absence, and defective vision failed to show a consistent effect on absence from school on account of sickness. 4. Absence from causes other than sickness showed variations some- what similar to absence from sickness; the groups with defects were absent more than the group with no defects. ADDITIONAL COPIES OF THIS PUBLICATION MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASHINGTON, D. C. AT 5 CENTS PER COPY