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ADENOIDS AND DISEASED TONSILS
THEIR EFFECT ON GENERAL INTELLIGENCE
BY
MARGARET COBB ROGERS, Ph.D.
ARCHIVES OF PSYCHOLOGY
Edited by R. S. WOODWORTH
No. 50
Columbia University Contributions to Philosophy and Psychology
NEW YORK
April, 1922
AGENTS: G. E. STECHERT & CO.: London: (2 Star Yard Carey St., W. C.);
Paris (16, Rue de Conde)
CONTENTS
Introduction
Purpose of the Study. 5
Chapter I. 7
Previous Literature Concerning the Relation of Nose and
Throat Defects to Intelligence.
Chapter II. 24
Method and Procedure.
1. A Statistical Study.
2. A Study of Improvement After Treatment.
Selection of Cases.
The Tests.
Chapter III. 29
Discussion of the Results.
1. The Statistical Study.
2. The Study of Improvement after Operation.
Chapter IV. 53
Measurement of Improvement after a Second Interval of
Six Months.
Chapter V. 68
Summary.
Conclusions.
INTRODUCTION--PURPOSE
During the last decade or two there has been a growing interest among
physicians in defects of the nose and throat. This interest has centered
in part upon those two afflictions of childhood--adenoids and diseased
tonsils,--or even tonsils that are merely enlarged. There is no doubt of
the physical handicap borne by a child who is possessed of them. As a
seat of inflammation, a source of infection, a hindrance to proper
breathing,--in a multitude of ways they have seemed to deserve the
verdict,--"Have them out." Many physicians, to be sure, have cautioned
against the wholesale removal of tonsils, saying that tonsils which are
large in early childhood very commonly are absorbed at an early age.
But it is not my purpose to discuss the question of the efficacy of
removing adenoids and tonsils. The aim of this study is, rather, to
determine experimentally whether or not there exists any causal relation
between defect in this respect and lowering of intelligence level. One
hears statements made both pro and con by physicians and laymen but
there has been little experimental proof. It would seem to be rather
useful for a physician to know in advance with how much probability of
correctness he is speaking, when he advises a mother that the removal of
adenoids and tonsils from the throat of her backward child will make him
"bright." The question in the present case, however, is broader than
that of relation between these afflictions and mental defect. We are
inquiring not merely whether adenoids and tonsils are causes of sub
normality or dullness, but also whether they tend to lower the
intelligence quotient in general however high it may be. Would the
mentally normal child with adenoids and tonsils have been superior
without them, and would the superior child have been still more
superior? What is the relation between adenoids and tonsils, and
intelligence?
The method employed in the present experiment would seem to give it
value from the point of view of the clinical psychologist. With the
present emphasis upon exactitude in mental testing, investigators have
become interested in problem of the constancy of the I.Q. Adenoids and
abnormal tonsils have been suggested as possible factors affecting this
constancy. The results of the experiment should throw some light on the
question.
It should be understood that this study is concerned with general
intelligence, and not with the child's efficiency as a member of
society. The latter question is much broader than the one we are
investigating. It includes not only intelligence, but physical state,
emotional make-up, volition: in short, the personality as a whole.
Success in school work for example, depends upon all of these factors.
For that reason, the results to be reported here, cannot be interpreted
as applying to this broader conception. We cannot say at the end whether
or not the physical defects under consideration affect the child's
success as a member of society. We hope to be able, however, to
determine their effect upon one element of that success, namely
intelligence.
In presenting the results of this experiment, the writer is especially
indebted to Professor R. S. Woodworth, under whose auspices the
investigation was carried out, for his interest and advice; and to Dr.
Leta S. Hollingworth for the suggestion of the problem, practical aid in
obtaining subjects, and constant inspiration. She is indebted to the
School of Education, Teachers' College, for the provision of operative
treatment for the subjects; to Mr. Mark and his officers at Public
School 64; and to Superintendent O'Brien of the Manhattan Eye, Ear and
Throat Hospital. It must be said that by their hearty and generous
cooperation they have contributed in a large measure to whatever value
this study may possess.
ADENOIDS AND DISEASED TONSILS: THEIR EFFECT UPON GENERAL INTELLIGENCE
CHAPTER I.
PREVIOUS LITERATURE
Concerning the Relation of Nose and Throat Defects to Intelligence
There are very few experimental studies of the relation between
intelligence and the two defects considered here. There are a few
statistical studies, and among earlier writers especially many
statements of opinion on the matter. Characteristic of the latter is the
following extract from an article in the Boston Medical and Surgical
Journal, March, 1886.[1]
[1]: F. Hooper, M. D., quoting from a paper by B. Frankel.
"... it is a fact that their intelligence may become weakened and their
characters changed. They do not progress in their studies at school, are
generally at the bottom of the class and remain in it longer than the
prescribed time.... That the impairment of intellect and want of energy
manifested by these children is real, and not merely in the expression
of countenance, is made evident by watching these same children after
the growths have been removed. To the gratification and astonishment of
the parents and teachers, the children hitherto sluggish and dull of
comprehension, now make rapid progress, and their comrades soon cease to
make a laughing stock of them."
The following quotation from an article by Irving Townsend, M. D., is in
the same vein:[2]
[2]: Adenoid Growths of the Naso-pharynx. Read before the
Homeopathic Medical Society of New York, February, 1895.
"Aprosexia is the rather imposing term applied to the imperfect or
arrested mental development attributed to this condition. This is
denied by some authors, who claim that the dullness of comprehension and
inattention are only apparent, and due only to defective hearing. A
strong evidence of its reality lies in the fact that these children show
most marvelous intellectual development after the removal of the growth,
even in cases where deafness is not markedly improved."
A most enthusiastic denouncer of adenoids and abnormal tonsils is H.
Addington Bruce. Concerning their direful effects upon the intelligence,
and the magical results of their removal, he is continually
reiterating:[3]
[3]: H. Addington Bruce, Psychology and Parenthood, 1916.
"Often a surprising development of both mental and physical power
follows the removal of adenoids. In one case reported by Professor
Swift, a girl of fourteen grew three inches within six months after an
operation for adenoids, and at the same time showed an improvement in
her school work that contrasted strikingly with the dullness that
preceded it. Another, three years younger, grew six inches in about five
months, and from being a sad idler was transformed into an unexpectedly
attractive and bright pupil. A boy of twelve, backward both mentally and
physically, likewise lost his dullness and laziness within an
astonishingly short time after the impediment had been removed."
And again:
"The boy or girl suffering from adenoids[4] is usually a mouth-breather
because of the difficulty experienced in breathing through the nose. But
mouth-breathing means difficult breathing, and this in turn means
deficient oxidation of the tissues, with a resultant lowering of vital
activities generally and of the activity of the brain in particular.
Accordingly, the psychologist of today insists that every
adenoid-afflicted child should be given prompt medical attention, with a
view to correcting the vicious mouth-breathing habit, and thus aiding
the child to gain a fair start in the development of mental and physical
health."
[4]: H. Addington Bruce in the Century Magazine, 1916--The
Mind of the Child.
The following extracts are quoted from Burgerstein's "Handbuch der
Schulhygiene":
"Bresgen und Heymann machen endlich darauf aufmerksam, dass die Ursache
der Kephalalgie haufig in der Behinderung der Nasenatmung zu suchen
ist, als Folgerscheinung von Verengerung der Nase bei ingen Baue des
Knochengerustes, Knochenkaries und Geschwulsten, Schwelungen der
Scheimhaute, akuten Schnupfen, Verstofungen der Highmorshoehle,
Vergrosserung der Mandeln u. s. w."...
"Viele Kinder erscheinen schwachbegabt, ohne os zu sein, da bei
denselben entweder nach behebung von Ohrenkrankheiten, nach Herstellung
der freien _atmung oder Gebrauch einer entsprechenden Brille die
scheinbare Geistesschwache schwindet_."[5]
[5]: The italics are mine.
Quotations like these, and equally unsupported by experimental evidence,
might be multiplied indefinitely, especially if we look into the
literature of a dozen years ago. Since they can have little
authoritative value, I shall limit myself to two more specimens, one
taken from the Psychological Clinic, 1916.[6]
[6]: Psych. Clinic, 1916, 10, 45-48. Anna Johnson. The
Teacher in the Retarded School.
"But when these physical defects (poor eyesight, defective hearing,
adenoids, bad tonsils, etc.) are corrected so that the mind can function
without any outcry from the physical body, these children recuperate
mentally and often make greater progress than the so-called normal
children in the regular grades."
The second is a quotation from Jelliffe and White, "Diseases of the
Nervous System." Lee and Ferbiger, 1917, p. 903.
"An important group (of mental defects) is due to adenoid vegetations in
the posterior pharynx. Under such conditions of ill health, development
is impaired and does not proceed at a normal rate. With ... infected
tonsils, which produce a constant toxemia, the child cannot be expected
to proceed in his development with normal rapidity."
In the medical and psychological literature of the last few years, along
with the growth of general discussion into the various phases of the
operation itself, we find a general disinclination to take on faith the
magic effect of adenectomy and tonsillectomy. This growth of critical
spirit has shown itself in statistical investigations, and in studies of
pedagogical and mental improvement after operation.
The statistical studies of physical defects in the schools reveal almost
universally a positive relationship between school retardation and
possession of adenoids and diseased tonsils. One of these was conducted
by Ayres for the Backward Children Investigation of the Russell Sage
Foundation in New York City.[7] The investigators examined the school
records of 20,000 children from fifteen schools in Manhattan. Eight
thousand of these had been examined by school physicians. The records of
the physical examinations showed that 80 per cent of the children who
were normal for their grade had physical defects while only about 75 per
cent of the retarded children were physically defective.
[7]: Psych. Clinic, 1909, 3, 71-77. The Effect of Physical
Defect on School Progress.
This astonishing result was found upon re tabulation of the data by
ages, to be due to the fact that for each defect there is a gradual
falling off in frequency from the age of six up to fifteen--eye-defect,
only, excepted. Since the retarded children in each grade will be the
older children in that grade, and since older children have fewer
defects, the retarded children will show a smaller proportion of defect.
To overcome this difficulty, Ayres used an age basis instead of a grade
basis in interpreting his results. Records of all the children at the
ages of 10, 12, 13, and 14 were re tabulated, a group of 3304 children,
and rated as dull, normal or bright according to the grade in which they
were found. The results were worked out in percentages of a group, and
are shown in the following tables:
Dull Normal Bright
Number of children examined 407 2588 309
Defects per child 1.65 1.30 1.07
Enlarged glands 20 13 6
Defective vision 24 25 29
Defective breathing 15 11 9
Defective teeth 42 40 34
_Hypertrophied tonsils_ _26_ _19_ _12_
_Adenoids_ _15_ _10_ _6_
Other Defects 21 11 11
Defective 75 73 68
Not defective 25 27 32
Average number of grades completed by pupils having no physical defects,
compared with the number completed by those suffering from different
defects:
3304 Children, 10-14 years, grades 1-8
Average grades
completed % lost
Children having no physical defects 4.94
Children having enlarged glands 4.20 14.9
Children having defective vision 4.94 0
Children having defective breathing 4.58 7.2
Children having defective teeth 4.65 5.9
_Children having hypertrophied tonsils_ _4.50_ _8.9_
_Children having adenoids_ _4.24_ _14.1_
Children having other defects 4.52 8.5
Cornell reports several investigations in the Psychological Clinic,
January and May, 1908. Three of these, in which children were rated on
the basis of grades received in school work, are here combined to show
the grades of normal children, "average" children, generally defective
children, those possessing adenoids and tonsils, and the deaf.
General Adenoids
No. of cases Normal Average Defective and Tonsils Adenoids Deaf
Allison 219
9th St. 64 84 21 8
Claghorn 179 252 13
Grade in language
9th St. 72.9 70.5 63.3 60
Claghorn 74.4 72.7 71.4
Grade in Arith.
9th St. 75.5 74 70 66.7
Claghorn 72 70 65.1
Grade in spelling
9th St. 75.4 72.8 64.8 65
Grade in geography
Claghorn 76.6 76.5 76.2
Average of grades
Allison 75 74 72.6 72 67
9th St. 74.6 72.4 66 63.9
Claghorn 74.3 73.1 0.8
An additional investigation of four classes in the same grammar grade of
the Claghorn School gives the following results:
Class 1 Class 15 Class 9 Class 11
Bright Children Dull Dullest
Number of children 50 39 32 29
Normal 36 32 20 13
Defective 14 7 12 16
Percentage of normal 72 82 62.5 44.8
In the same article, Dr. Cornell gives the results of another study of
Philadelphia schools, made in 1906. The study comprised a comparison of
children exempt from examinations on account of high standing, with
those not exempt. The results follow:
Exempt Children Non-exempt Children
Normal Defective Normal Defective
9th St. Primary 56 28 39 38
Rutledge School 87 35 75 34
Allison School 128 65 81 49
Camac School 183 71 103 75
Claghorn School 193 61 127 66
--- --- --- ---
647 260 425 262
Percentage Defective 28.8 38.1
When the four classes of bright and dull children were examined again,
and the different sorts of defects compared for the groups, enlarged
tonsils, adenoids, deafness, and nasal catarrh, were found to occur much
more frequently among the two classes of duller children.
Class 1 Class 15 Class 9 Class 11
Bright Children Dull Dullest
Number of children 50 39 32 29
Nose and throat conditions,
number defective 6 4 9 9
_Tonsils_ _3_ _4_ _3_ _3_
_Adenoids_ _2_ _1_ _5_ _6_
Deaf 2 5 1
Catarrh 2 3
Percentage of children,
nose and throat defects 12 10.2 28.1 31
During the same year, another examination along the same lines was
conducted in the William McKinley Primary School,[8] where a large
number of dull children had been grouped in special classes.
[8]: Cornell, Psychological Clinic, 2, 1909.
None of these children were mentally defective, says Dr. Cornell, and
only a few were really backward. The proportion of physical defect was
found to be very large,--in 174 pupils, 188 physical defects (68
eye-strain, 40 nasal obstruction, 80 miscellaneous, 11 hypertrophied
tonsils.) In a special class at the Wharton school, numbering 22
children, 14 of the children suffered from adenoids, associated in 3
cases with enlarged tonsils. Since no comparison is made with normal
classes, this survey cannot be regarded as conclusive.
Wallin, in his book, "Mental Health of the School Child," discusses
several other investigations of the relation of intelligence to physical
defect. Only those studies in which were included adenoids and tonsil
conditions will be reviewed here. Those by Ayres and Cornell have been
described above.
In Elmira, New York, says Wallin, "an investigation of repeaters in the
second grade showed that 21 per cent of those who required three years
and 40 per cent of those who required four years to complete the grade
had adenoids, as against only 19 per cent of those who required only two
years to do the grade."
Another study described by Dr. Wallin was made by Heilman in 1907 of
1000 Camden repeaters. The correlation between pedagogical retardation
and percentage of defect in each group was as follows:
Defects Retardation
1 yr. 2 yr. 3 yr. 4 yr. 5 yr.
Per Cent
Health 16.5 21.3 28.0 19.0 37.5
Nutrition 13.4 8.9 17.2 20.2 17.5
_Adenoids_ _6.2_ _7.3_ _8.1_ _9.6_ _7.5_
Speech 5.2 5.1 4.2 10.5 20.0
Visual defects 15.5 15.9 18.2 22.8 22.8
Auditory 8.2 6.7 4.9 6.1 10.0
Burpitt[9] describes an investigation of 400 children, 200 male and 200
female, considered by their teachers to be "dull and backward, but not
to fall within the meaning of feeble-mindedness as given in the Mental
Deficiency Act of 1913." The children were examined for physical defects
and other abnormal conditions. The author says that in 36 per cent of
the cases, the cause for backwardness was found to be "inherent
dullness." (The basis for judgment of inherent dullness is not given.)
Adenoids and tonsillar tissue were found in 18.75 per cent of the cases,
and were "more prevalent than among the children of the area as a
whole."
[9]: H. R. Burpitt. Relative Degrees of Dullness and
Backwardness in School Children and their Causation. Journal of
Mental Science, 1916.
The degree of retardation, based upon the number of school standards
below normal, was ascertained for pupils who suffered from various
defects. The relative retardation was expressed by the fraction n/(A-5)
where n = number of years retarded, and A = age. Eighteen per cent of
the children were so retarded that the fraction was greater than 3-9.
These were divided into two groups,--3-9 to 4-9 and 4-9 to 5-9. The
results are given in the following table:
Causes 46 children 24 children
3-9 to 4-9 4-9 to 5-9
Inherent dullness only 8 3
Inherent dullness and one or more physical
defects 7 2
Irregular attendance with one or more
physical defects 9 6
Irregular attendance 2 3
_Adenoids only_ _2_ _0_
Turning to what the author calls single causes,--present in 170 cases out
of the 400,--
Causes 151 children 19 children
1-9 to 3-9 3-9 to 6-9
Irregular attendance 51 6
_Adenoids_ _24_ _2_
Inherent dullness 59 11
The term "cause" seems to be rather loosely used in this study. The
author says concerning this,
"Dealing with physical defects first, although they amount in the
aggregate to 53 per cent (omitting defective speech, which is a
secondary condition), in 10 percent only do they represent the whole
cause. This is made up of those cases where the defect is of such
intensity as to produce retardation in otherwise ordinary children, and
of other cases of less intensity, but sufficient to weigh down the
balance against those near the level of what we may call for convenience
the lower limit of normal intelligence." How he determines, without
removing a defect, what the child's intelligence would be without it he
does not explain.
The following table compares the physical condition of two groups, one
comprised of children examined in the regular routine examinations
during the year 1912,--the other a group of retarded school children,
given a special examination:--[10]
[10]: Transactions of the International Congress on School
Hygiene, 1913, The Physical Condition of Retarded School Children.
Group I Group II
No. of children examined 287,456 1,541
No. with physical defects 206,720--71.9% 1,383--89.8%
No. of defects found 226,639 2,986
Defect No. % No. %
Anaemia 335 23
Malnutrition 8,303 2.9 557 36.1
Defective vision 21,078 9.3 536 34.7
Defective hearing 1,206 0.5 47 3
_Defective nasal breathing_ _21,931_ _7.6_ _316_ _20.4_
_Hypertrophied tonsils_ _30,021_ _10.4_ _297_ _19.2_
Defective teeth 142,168 49.4 796 51.6
Pulmonary disease 335 0.1 47 3.0
Cardiac disease 1,597 0.5 35 2.3
Average No. of defects per child 1.1 2.5
In an investigation of 3,587 exempt and 1,418 non-exempt children in the
Philadelphia schools,[11] Dr. Newmayer found the following percentages
of defect:
[11]: Ayres: "Laggards in Our Schools." 1909.
Exempt Children Non-exempt Children
Defect No. Examined % No. Examined %
Defective vision 371 10.0 171 12.0
Defective hearing 49 1.4 29 2.0
_Defects of nose_ _54_ _1.5_ _21_ _1.5_
_Defects of throat_ _137_ _3.8_ _53_ _3.7_
Orthopedic defects 25 .7 25 1.8
Mentally defective 6 .1 80 5.6
Skin diseases 918 26.0 423 30.0
Miscellaneous 214 6.0 128 9.0
Total 1,774 49.0 930 65.0
It is evident from the majority of these investigations that there is
some relationship between physical defects and pedagogical retardation.
But whether or not the relationship is a causal one, they do not
indicate. Simple co-existence of two characteristics is not necessarily
significant that one is cause of the other. Plainly, though, if the
removal of a physical defect is followed by improvement in the school
progress, it may be argued that the presence of the defect was a causal
factor in the previous retardation. The method in the few following
studies, which seems to be employed to a greater degree than formerly,
consists of measurement of such improvement.
The Journal of Psycho-Asthenics, March and June, 1918, contains a paper
on the "Results obtained from the Removal of Tonsils and Adenoids in the
Feeble-minded," by Wm. J. G. Dawson, M. D. The author starts out rather
discouragingly by regarding his hypothesis as an axiom. He says,
"It is a well-known fact that hypertrophy of the tonsils and presence of
adenoids may produce more or less dullness of the intellect in normal
children. This is a result of the imperfect aeration of the blood which
supplies the brain, on account of obstruction to respiration. In the
Feeble-minded, conditions are more or less similar."
One hundred and twelve cases in the Sonoma State Home, Eldridge,
California, were operated on. Of these 6 are recorded as borderline, 39
as morons, 50 as imbeciles, and 17 as idiots. Adenoids were always
removed when they were present. The results of the operation are as
follows:
Number Number
before after
Operation Operation
Mouth breathing 43 31
Eneuresis 33 32
Sore throats 70 2
Ear trouble 19 2
Change in voice 38 improved
Tonsillar tissue recurred in 5
General physical health 90 improved
6 borderlines
33 morons
42 imbeciles
9 idiots
Mental improvement from observation 27 improved
4 borderlines
15 morons
7 imbeciles
1 idiot
The inaccuracy of this investigation is evident. The mental improvement
was measured by "observation," which is at best inexact, and susceptible
to the influence of any expectation of improvement on the part of the
observer. The degree of improvement is not mentioned, nor is the time
interval allowed for the appearance of such improvement. There is no
control group, and consequently, no way of knowing whether the
improvement was due to the removal of the defect.
A similar, though rather more careful study is reported by Dr. Charles
James Bloom in the New Orleans Medical and Surgical Journal for April,
1917. Dr. Bloom's experiment consisted of eighteen months' observation
on the mental and physical state following the removal of adenoids and
tonsils from one hundred and fourteen children. This number was later
reduced to fifty-seven, because of the fact that a number failed to
return. There was no selection, all the patients being taken as
admitted.
The patient's physical and mental state was recorded at the time of
admission. School reports were used as an index of intelligence. From
this time on the patients were examined, weighed and measured at monthly
intervals.
The ages of the children ranged from four to fourteen years, inclusive.
Thirty-five per cent were under six years, and sixty-five per cent,
therefore, over six. Twenty-nine were boys, twenty-eight girls.
Omitting a part of the study which though interesting has no bearing
upon our problem, we turn to results in the way of mental status. There
were fifty-seven cases, ten of whom were under the school limit. Of the
remaining forty-seven, seven sent in no report. In four, or ten percent
of the forty remaining, there was no progress. In thirty-six, or ninety
per cent, appreciable progress was reported. One of the four unimproved
cases was syphilitic, the other, the author says was a moron.
Quotation of the teachers' reports will be of interest.
"'Some improvement.' 'Better work than previous year.' 'More effort
displayed.' 'Improved wonderfully.' 'Improvement first term, not so much
second.' 'Before removal, not transferred; after removal transferred.'
'Very much improved, both mentally and physically.' 'Has made progress.'
'Remarkable improvement.' 'Not transferred before removal, but after.'
'More attentive.' 'A very small but gradual improvement.' 'Am happy to
tell you that he is studying more since tonsils and adenoids were
removed.' 'Greatly improved.' 'Attention better.' 'More concentration.'"
In this experiment like the preceding, the judges are liable to the
effect of expectation of improvement. Although the reports are more
explicit, they are still couched in general terms, and not
commensurable. Some reports refer to intelligence and some to
pedagogical standing. There is no control group.
On the basis of these results, the author concludes:
"Children exhibiting some alternatives in the normal histology of
tonsils and adenoids, give marked evidences of mental impairment." This
seems to be a rather sweeping statement in consideration of the number
of intellectually superior children who suffer from adenoids and
diseased tonsils.
Another investigation was made by Dr. Cornell in the Philadelphia
schools,[12] where seventy more or less retarded pupils in grades one to
four were operated on for adenoids. According to the teachers' reports--
30 per cent improved considerably.
40 per cent improved.
25 per cent did not improve.
1.6 per cent deteriorated.
3.0 per cent deteriorated considerably.
Of those who had two chances of promotion,
6.3 per cent were promoted twice.
16.0 per cent failed twice.
33.3 per cent were promoted once.
33.3 per cent failed once.
With one opportunity,
11.0 per cent were promoted.
31.7 per cent failed.
[12]: Wallin: "Mental Health of the School Child." 1914.
"The promotion record was thus decidedly poor. It is possible, however,
that the time for promotion came before the orthogenic effects of the
operations had become effective."
The same criticisms may be brought against this investigation as were
mentioned in connection with the preceding ones. Teachers' estimates of
improvement, especially when such improvement is expected, and without
means of measuring it objectively, are necessarily inaccurate. Again
there is no control group. Of even less value are the results of an
investigation in New York City by Cronin, where, out of eighty-seven
cases operated on for enlarged tonsils and adenoids, "many advanced
three grades during the rest of the school year, and only three lost
time."
An interesting study is one that is described by John C. Simpson, M. D.,
in the Journal of the American Medical Association, April 1, 1916.
Dr. Simpson's results are based on a study of 571 boys of Girard College
who had been operated on for adenoids and tonsils. Improvement was
studied along several different lines, among them scholastic ability.
For this part of the study, 45 were chosen alphabetically, 3 from each
section. The only selection was for boys who were operated on long
enough after coming to school to give an idea of scholastic ability; and
long enough before the present study to permit a judgment as to their
improvement. Monthly averages were taken of each boy up to the time of
the operation and from then to the time of this study. They were based
on an average of 100 per cent. As a control group, there were chosen 45
boys who had had no operation, and who lived and worked under the same
conditions. They also were taken alphabetically, 3 from each section.
The general average of the operative cases at the first measurement was
74.04. Of these 25, or 55.5 per cent gave an average increase in monthly
standing of 4.45 after operation, while the remaining 20, or 44.5 per
cent suffered a decrease of 6.09.
The average of the boys in the control group was 74.21 and for the first
group after operation 74.06. "It is interesting to note," says the
author, "that the standing of slightly more than half of those operated
on was improved, but when compared with those not operated on, no
difference is seen."
In a similar study of younger boys who had undergone the operation on
entering college, and who had since had a year's study (again a group of
45), the general average was 76.61. Compared to 45 in the same classes
not operated on, who had an average of 74.56, the operative group is
very slightly superior, 2.05 points.
Another study of pedagogical improvement, and a valuable contribution,
is that reported by A. H. MacPhail in Pedagogical Seminary for June,
1920, entitled "Adenoids and Tonsils; a Study showing how the Removal of
Enlarged or Diseased Tonsils affects a Child's Work in School."
"The children studied were pupils in the Adams and Cranch Schools. Only
cases were considered where there was a record of ten school months
before the date of the operation, and where there was a record for at
least ten month after the operation. There were thirty-one cases in all.
"School records were looked up for the ten school months preceding
operation, and for each school month subsequent--up to the date of
leaving school, or in the case of children still in school, up to the
date of the study. There were thus longer school records for some than
for others.
"The history of each case was divided into periods of ten school months
each. Eighteen cases had a record of twenty months after operation and
eleven cases of thirty months.
"Comparing the first period after the operation with the period before,
it is found that only about one-third showed improvement, and a little
over half were doing poorer work. By comparing an average of _all_ work
done subsequent to the operation with what was done before, it became
evident that improvement in school work is not often observed until
after a year from the date of the operation."
In the cases that had records for twenty months, 16 show that better
work was done in the second period after the operation than in the
period before.
TABLE A
Table showing where improvement begins.
_Per Cent of cases showing improvement_
Period 1 Period 2 Period 3
Based on 31 cases 32.2
Based on 18 cases 33.3 66.6
Based on 11 cases 36.3 63.5 100
Based on all groups 33.9 65. 100
These cases were compared with a control group chosen at random. They
comprised a total of 100 children who had records for four consecutive
school years.
TABLE B
Table showing how time of improvement of "operated cases" compares with
improvement among children at random.
Period 1 Period 2 Period 3
A--Per cent of 31 cases 32.2
(operated upon)
Per cent of 100 children 42
at random
B--Per cent of 18 children--20 33.3 66.6
months (operated upon)
Per cent of 100 children at 42 41
random
C--Per cent of 11 cases for 30 36.3 63.5 100
months (operated upon)
Per cent of 100 children at 42 41 41
random
"... Immediately after operation, there seems to be a dropping off in
the quality of school work done," but thereafter a marked improvement
while the random group shows a comparatively static percentage of
improvement from year to year. The conclusion of the author is:
"Here seems good reason to believe that the removal of diseased tonsils
and adenoids is a factor in beneficially influencing the mental life of
the school child. Not only is the health impaired by failure to remove
these diseased parts but the mental life and activity of the child as
well."
It is conceivable that pedagogical retardation might exist without any
defect of intelligence. The physical effects of adenoids and tonsils
might produce a tendency to fatigue, an emotional instability and
consequent lack in attention, which would seriously influence the
quality of school work, even though the child were of normal or superior
intelligence. The relation of physical defects to intelligence has been
investigated experimentally by a method which will be employed to some
extent in the present investigation. In the two studies to which I refer
psychological tests, rather than school standings were used as a basis
for judging the intelligence. In each the effects of treatment were
measured, and in one, a control group makes possible a more accurate
interpretation of results.
The first of these investigations is described by Wallin.[13] It was "an
attempt to determine by controlled, objective, mental measures the
influence of hygiene and operative dental treatment upon the
intellectual efficiency and working capacity of a squad of twenty-seven
public school children in Marion School, Cleveland, Ohio (ten boys and
seventeen girls), all of whom were handicapped to a considerable degree
with diseased dentures or gums, and an insanitary oral cavity." The
experiment extended over one year, from May, 1910, to May, 1911. The
treatment included corrective work upon the teeth and mouth, and also
instruction in oral hygiene, and follow-up work by an employed nurse.
Five series of psychological tests were given at stated intervals during
the course of the experiment. They included tests of immediate recall,
spontaneous and controlled association (opposites), adding, and
attention-perception (cancellation). There were six sets of each test,
numbered from one to six, of equal difficulty, and given under uniform
conditions. Tests 1 and 2 were given before the treatment began, and the
average was taken as the "initial efficiency." The last four, or the
last two, were averaged to represent the pupils' "terminal efficiency."
[13]: Wallin: "Mental Health of the School Child." 1914.
The results show the following influence of dental treatment upon the
working efficiency of the pupils.
1. The indices of improvement are about the same for boys and girls.
2. Improvement was about the same for older and younger pupils.
3. There were great individual differences in initial proficiency and in
improvement.
4. Improvement in one test does not presuppose improvement in another.
5. There is a decided gain in every test, "and not only are the gains
decidedly more frequent than the losses but the largest gains are
invariably emphatically larger than the largest losses."
6. The average gains in the tests were:
Memory, 19 per cent with 8 losses and 19 gains.
Spontaneous association, 42 per cent with 2 losses and 25 gains,
Addition, 35 per cent with 1 loss and 26 gains.
Controlled association, 29 per cent with 0 losses.
Perception-attention, 69 per cent with 0 losses.
Average gain for all tests, 57 per cent.
Unfortunately, Wallin was unable to form a control group, so that it is
impossible to estimate accurately how much of this gain is due to the
treatment of the defect, and how much to other causes, such as growth,
etc. "But," the writer adds, "if we concede that one-half of the
gain--and that is, I believe, a sufficiently liberal concession--is due
to a number of extrinsic factors, such as familiarity, practice and
increased maturity, the gain solely attributable to the heightened
mentation resulting from the physical improvement of the pupils would
still be very considerable. There is corroborative evidence to show that
there was a general improvement in the mental functioning of these
pupils. This evidence is supplied by the examination of the pedagogical
record of scholarship, attendance and deportment. Most of the members of
this experiment squad were laggards, and repeaters, pedagogically
retarded in their school work from one to four years, but during the
experiment year only one pupil failed of promotion, while six did
thirty-eight weeks of work in twenty-four weeks, and one boy finished
two years of work within the experimental year."
The second investigation was equally careful in its method. It was
pursued by the Rockefeller Foundation, under the direction of E. K.
Strong, with the purpose of examining the "Effects of Hookworm Disease
on the Mental and Physical Development of Children."
The children were divided into five groups and tested at intervals of
three and one-half months. The tests used were opposites, calculation,
logical memory, memory span, hand-writing, form-board, and Binet-Simon.
After the first test-series was given, the five groups were divided into
sub-groups on the basis of this initial performance, so that the
improvement was compared only for those sub-groups in which this was
equal.
The improvement of Group A--uninfected children--proved to be greatest,
and was taken as 100 per cent. On this basis, Group B--infected children
not treated--showed the least improvement,--only 34 per cent. Group
C--children completely cured of infection--improved 60 per cent. Group
D--severely infected children, treated but not completely
cured--improved 38 per cent, and Group Du--an older sub-group of
D--improved 9 per cent as much as the normal children, and much less
than the untreated younger children. Dr. Strong reaches the following
conclusion:
"The figures show, then, that hookworm disease unmistakably affects
mental development. Treatment alleviates this condition to some extent
but it does not, immediately, at least, permit the child to gain as he
would if he had not had the disease. And the figures apparently further
show that prolonged infection may produce prolonged effects upon
mentality,--effects from which the individual may never recover."