tt ADENOIDS AND DISEASED TONSILS THEIR EFFECT ON GENERAL INTELLIGENCE BY MARGARET COBB ROGERS, Ph.D. ARCHIVES OF PSYCHOLOGY EDITED BY B. S. WOODWORTH No. 50 COLUMBIA UKIVEBSITT CONTRIBUTIONS TO PHILOSOPHY AND PSYCHOLOGY NEW YORK APRIL, 1922 AGENTS: G. E. STECHERT & CO. : Lon Star Yari^arey St., W. C.); Paris (18, rue 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. CHARTER 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 subnormality 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 su- perior child have been still more superior? What is the re- lation 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 prob- lem of the constancy of the I. Q. Adenoids and abnormal ton- sils have been suggested as possible factors affecting this con- stancy. 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 re- sults 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 Man- hattan Eye, Ear and Throat Hospital. It must be said that by their hearty and generous cooperation they have con- tributed 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. Char- acteristic of the latter is the following extract from an article in the Boston Medical and Surgical Journal, March, 1886.* " . . . it is a fact that their intelligence may become weak- ened 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 rap- id progress, and their comrades soon cease to make a laughing stock of them." The following quotation from an article by Irving Town- send, M. D., is in the same vein :f "Aprosexia is the rather imposing term applied to the im- perfect or arrested mental development attributed to this *F. Hooper, M. D., quoting from a paper by B. Frankel. tAdenoid Growths of the Naso-pharynx. Read before the Homeo- pathic Medical Society of New York, February, 1895. 8 ADENOIDS AND DISEASED TONSILS: condition. This is denied by some authors, who claim that the dullness of comprehension and inattention are only ap- parent, 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 im- proved." A most enthusiastic denouncer of adenoids and abnormal tonsils is H. Addington Bruce. Concerning their direful ef- fects upon the intelligence, and the magical results of their removal, he is continually reiterating:* "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 ade- noids, 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 adenoidsf is usually a mouth-breather because of the difficulty experienced in breathing through the nose. But mouth-breathing means dif- ficult 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. Ac- cordingly, 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." The following extracts are quoted from Burgerstein's "Handbuch der Schulhygiene" : "Bresgen und Heymann machen endlich darauf aufmerk- sam, dass die Ursache der Kephalalgie haufig in der Behin- *H. Addington Bruce, Psychology and Parenthood, 1916. fH. Addington Bruce in the Century Magazine, 1916 The Mind of the Child. THEIR EFFECT UPON GENERAL INTELLIGENCE 9 derung der Nasenatmung zu suchen ist, als Folgerscheinung von Verengerung der Nase bei ingen Baue des Knochengerus- tes, Knochenkaries und Geschwulsten, Schwelungen der Scheimhaute, akuten Schnupfen, Verstofungen der Highmor- shohle, Vergrosserung der Mandeln u. s. w." "Viele Kinder erscheinen schwachbegabt, ohne os zu sein, da bei denselben entweder nach behebung von Ohrenkrank- heiten, nach Herstellung der freien atmung oder Gebrauch einer entsprechenden Brille die scheinbare Geistesschwache schwindet."* Quotations like these, and equally unsupported by experi- mental 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.f "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, "Dis- eases of the Nervous System." Lee and Ferbiger, 1917, p. 903. "An important group (of mental defects) is due to ade- noid vegetations in the posterior pharynx. Under such con- ditions of ill health, development is impaired and does not pro- ceed 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 dis- inclination 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 pedagogi- cal and mental improvement after operation. The statistical studies of physical defects in the schools reveal almost universally a positive relationship between *The italics are mine. fPsych. Clinic, 1916, 10, 45-48. Anna Johnson. The Teacher in the Retarded School. 10 ADENOIDS AND DISEASED TONSILS: school retardation and possession of adenoids and diseased tonsils. One of these was conducted by Ayres for the Back- ward Children Investigation of the Russell Sage Foundation in New York City.* The investigators examined the school records of 20,000 children from fifteen schools in Manhattan. Eight thousand of these had been examined by school physi- cians. 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 re- tarded children were physically defective. This astonishing result was found upon retabulation 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 chil- dren will show a smaller proportion of defect. To overcome this difficulty, Ayres used an age basis in- stead of a grade basis in interpreting his results. Records of all the children at the ages of 10, 12, 13, and 14 were retabulat- ed, 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 Hypertrophied tonsils 26 19 12 Adenoids 15 10 6 Other Defects 21 11 11 Defective 75 73 68 Not defective 25 27 Average number of grades completed by pupils having no physical defects, compared with the number completed by those suffering from different defects : *Psych. Clinic, 1909, 3, 71-77. The Effect of Physical Defect on School Progress. THEIR EFFECT UPON GENERAL INTELLIGENCE 11 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 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 chil- dren, "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 70.8 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 com- prised a comparison of children exempt from examinations 12 ADENOIDS AND DISEASED TONSILS: on account of high standing, with those not exempt. The re- sults 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 ex- amined 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,* where a large number of dull children had been grouped in special classes. 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 in- telligence to physical defect. Only those studies in which were * Cornell, Psychological Clinic, 2, 1909. THEIR EFFECT UPON GENERAL INTELLIGENCE 13 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 Heil- man in 1907 of 1000 Camden repeaters. The correlation be- tween 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.S 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* 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 ab- normal conditions. The author says that in 36 per cent of the cases, the cause for backwardness was found to be "inher- ent 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." 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 ^- where n = number of years retarded, and A = age. Eighteen per cent of the chil- dren were so retarded that the fraction was greater than 3-9. *H. R. Burpitt. Relative Degrees of Dulness and Backwardness in School Children and their Causation. Journal of Mental Science, 1916. 14 ADENOIDS AND DISEASED TONSILS: 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 Turning to what the author calls single causes, present in 170 cases out of the 400, Causes 151 children 1-9 to 3-9 51 19 children 3-9 to 6-9 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 in- tensity, 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 with- out 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 examina- tion : * Group I Group II No. of children examined 287,456 1,541 No. with physical defects 206,72071.9% 1,38389.8% No. of defects found 226,639 2,986 * Transactions of the International Congress on School Hygiene, 1913, The Physical Condition of Retarded School Children. THEIR EFFECT UPON GENERAL INTELLIGENCE 15 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,* Dr. Newmayer found the following percentages of defect: 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 phy- sical 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 fol- lowing studies, which seems to be employed to a greater de- gree than formerly, consists of measurement of such improve- ment. 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 Feebleminded," 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 *Ayres: "Laggards in Our Schools." 1909. 16 ADENOIDS AND DISEASED TONSILS: of the intellect in normal children. This is a result of the im- perfect aeration of the blood which supplies the brain, on ac- count of obstruction to respiration. In the feebleminded, 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 re- corded as borderline, 39 as morons, 50 as imbeciles, and 17 as idiots. Adenoids were always removed when they were pres- ent. The results of the operation are as follows : Mouthbreathing Eneuresis Sore throats Ear trouble Change in voice Tonsillar tissue recurred in General physical health Mental improvement from observation Number before Operation 43 33 70 19 Number after Operation 31 32 2 2 38 improved 5 90 improved 6 borderlines 33 morons 42 imbeciles 9 idiots 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 im- provement is not mentioned, nor is the time interval allowed for the appearance of such improvement. There is no con- trol 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 be- ''nfi: taken as admitted. THEIR EFFECT UPON GENERAL INTELLIGENCE 17 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 exam- ined, 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 au- thor 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.' 'Improve- ment first term, not so much second.' 'Before removal, not transferred; after removal transferred.' 'Very much im- proved, both mentally and physically.' 'Has made progress.' 'Remarkable improvement.' 'Not transferred before removal, but after.' 'More attentive.' 'A very small but gradual im- provement.' '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 re- ports 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 his- tology of tonsils and adenoids, give marked evidences of men- tal impairment." This seems to be a rather sweeping state- ment 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 Phil- 18 ADENOIDS AND DISEASED TONSILS: adelphia schools,* where seventy more or less retarded pupils in grades one to four were operated on for adenoids. Accord- ing 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. "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 investi- gation as were mentioned in connection with the preceding ones. Teachers' estimates of improvement, especially when such improvement is expected, and without means of measur- ing 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 ade- noids, "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 As- sociation, 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 ton- sils. 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 selec- tion was for boys who were operated on long enough after com- ing to school to give an idea of scholastic ability; and long enough before the present study to permit a judgment as to *Wallin: "Mental Health of the School Child." 1914. THEIR EFFECT UPON GENERAL INTELLIGENCE 19 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 condi- tions. 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 com- pared 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 su- perior, 2.05 points. Another study of pedagogical improvement, and a valu- able contribution, is that reported by A. H. McPhail in Peda- gogical 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. 20 ADENOIDS AND DISEASED TONSILS: "Comparing the first period after the operation with the period before, it is found that only about one-third showed im- provement, and a little over half were doing poorer work. By comparing an average of all work done subsequent to the op- eration with what was done before, it became evident that im- provement 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 op- eration than in the period before. TABLE A Table showing where improvement begins. Per Cent of cases showing improvement Period I 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 : THEIR EFFECT UPON GENERAL INTELLIGENCE 21 "Here seems good reason to believe that the removal of diseased tonsils and adenoids is a factor in beneficially influ- encing 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 investigat- ed 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 re- sults. The first of these investigations is described by Wallin.* It was "an attempt to determine by controlled, objective, men- tal measures the influence of hygiene and operative dental treatment upon the intellectual efficiency and working capac- ity of a squad of twenty-seven public school children in Mari- on 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 psycholog- ical 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 aver- aged to represent the pupils' "terminal efficiency." *Wallin: "Mental Health of the School Child." 1914. 22 ADENOIDS AND DISEASED TONSILS: The results show the following influence of dental treat- ment 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 pro- ficiency and in improvement. 4. Improvement in one test does not presuppose improve- ment 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 larg- est 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 losses. Perception-attention, 69 per cent with 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 men- tation resulting from the physical improvement of the pupils would still be very considerable. There is corroborative evi- dence 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, THEIR EFFECT UPON GENERAL INTELLIGENCE 23 while six did thirty-eight weeks of work in twenty-four weeks, and one boy finished two years of work within the experiment- al year." The second investigation was equally careful in its method. It was pursued by the Rockefeller Foundation, under the di- rection of E. K. Strong, with the purpose of examining the "Effects of Hookworm Disease on the Mental and Physical De- velopment 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, formboard, 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 improve- ment 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 unmis- takably 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 men- tality, effects from which the individual may never recover." CHAPTER II. METHOD AND PROCEDURE The following investigation was carried on during the year and a half from October, 1919, to April, 1921. The subjects were pupils at Public School 64, Manhattan, or patients at the Manhattan Eye, Ear and Throat Hospital. All were boys, between the ages of six and fourteen years. The testing in the study of improvement was done by the investigator, assisted by three other examiners, all competent and experienced in the technique of giving psychological tests. A Statistical Study In addition to the more lengthy experiment, a statistical study was made, comparing the intelligence levels of two groups of children, the one selected for the presence of tonsils, the other for freedom from them. These two groups were ob- tained from a large group of 530 children whose I. Q.'s were gained from the records of Public School 64, where, so far as possible, all children are tested upon entering school. We had, therefore, a group unselected for intelligence level. All the children for whom we had I. Q.'s were examined by the school nurse or physician. On the basis of this examination the two groups were selected. The tonsil group consisted of those cases which in the opinion of the nurse or doctor, were pronounced enough to deserve treat- ment. The normal group was composed of those who were not defective, or in whom the defect was so slight as not to demand treatment. The two groups were arranged each in a surface of distribution according to the I. Q.'s of the members. The results of the distribution appear in Table I, and in Figs. I. and II. A Study of Improvement After Treatment The method employed here is based on the hypothesis that if a physical defect is the cause of retardation in mental or physical development, removal of the cause will tend to lessen 24 THEIR EFFECT UPON GENERAL INTELLIGENCE 25 "the retardation. In other words, if a child's working efficien- cy is lowered by the effects of adenoids and bad tonsils, their removal should, unless such lowering be permanent, be fol- lowed after a reasonable time by an improvement. But im- provement in efficiency, following the removal of adenoids and tonsils proves nothing unless we shall compare it with the change in efficiency of a control group, whose members have not been operated on, and who thus still suffer from the effects of the growths. Selection of Cases The selection of the children for the experiment was effect- ed in the following manner. The teachers at Public School 64 wre asked to report any cases which had come to their notice, as being seriously afflicted with adenoids and diseased tonsils. In this way a fairly large group was obtained. The parents of the children were visited with the purpose of obtaining per- mission for examination and operation at the Post Graduate Hospital. It was fairly easy to obtain permission to have the children examined. They were taken in groups of four or five to the clinic, the experimenter attending in person every ex- amination in order to learn from the doctors the degree of the defect. As a result of this method, we discarded all those cases where there was any doubt as to the serious nature of the defect. From the large group examined, we were finally successful in securing operative treatment for 10 children. Discarding the cases where defect was slight, there remained a number of children who, for one reason or another, did not undergo op- eration. In some instances the parents refused their permis- sion, in some they failed to keep appointments, in one or two there was sickness in the family, and in a number the hos- pital was overcrowded and could not receive the children. All members of this group were examined, to the number of fifty-six, and from them the control group was finally selected. Since we were unable to secure a large test group from Public School 64, the experiment was continued at the Man- hattan Eye, Ear and Throat Hospital where opportunity was given for testing the children after they had been admitted for operation. In order to be sure that in each case the defect was sufficiently pronounced to render decisive the results of the experiment, each child's card was examined. Only those 26 ADENOIDS AND DISEASED TONSILS: children were included who were undergoing operation for' both adenoids and tonsils. It may be here remarked that mental tests were given to these children on the morning of operation, and in some cases only a short time before it. The possibility suggests itself, therefore, that the results of the tests may have been influ- enced by excitement or fright on the part of the patients. Ac- tually, however, this did not seem to be the case. The children were perfectly cheerful and showed no signs of nervousness. The tests were given in a waiting room with the door closed so that any disturbing sights and sounds were eliminated. The possible lowering of the performance by the causes mentioned would tend to exaggerate the improvement shown by the re- tests, so that in the light of the results, it will be seen that they could have had little effect. The test group, then, was composed of forty members; ten from Public school 64, who received operation at the Post Graduate Hospital, and the remaining thirty from various schools throughout the city, patients at the Manhattan Eye, Ear and Throat Hospital. The control group of forty was se- lected as previously described, and the pairs were arranged so as to have the ages of the members of one pair as nearly as possible the same. The Tests Since the main interest of this investigation lies with intellectual development, two tests of intelligence were given : namely, Terman's revision of the Binet test, and Healy's Pic- ture Completion Test, number II. The starred Terman was always used, since it was necessary to economize time. It was expected that improvement in general health would probably follow the removal of the defects. This physi- cal gain should come to light in increased height and weight. In every case, therefore, height and weight were measured. It is conceivable that adenoids and tonsils might have no effect upon general intelligence, and yet might cause a notice- able pedagogical retardation, simply as a result of the child's physical handicap, tendency to fatigue and consequent defect in attention or sustained effort. In order to gain some meas- ure of this physical factor, strength of grip and speed in tap- ping were found. An effort was made, also, to obtain teach- THEIR EFFECT UPON GENERAL INTELLIGENCE 27 ers' estimates of the pedagogical rankings, but this was for the most part unsuccessful, since in many cases teachers mis- understood directions, and in others the tests were made too soon after the opening of school for any such estimates to be possible. The tests described above were given before the operation to each child in the test group, allowing as short an interval as possible between test and operation. In the case of the Manhattan Hospital children, test and operation fell on the same day. In no case did the interval exceed ten days. The members of the control group were tested, each one within a week of his partner.* Six months after his first test, each child was re-tested, whenever possible. Since some children had dropped out of the groups for one reason or another, the final number in each group was twenty-eight. It was necessary to rearrange the control cases somewhat in order to fill in spaces left va- cant by those who were lost. In this rearrangement, the effort was made, 1. to pair cases whose ages were approximately the same; 2. to pair cases whose first tests were dated fairly close together. Since all the children were tested and re-tested under approximately the same conditions, this rearrangement will probably not greatly influence the results. The tests were always given in the same order. The following table shows a list of the two groups, as originally paired, and as finally rearranged, with dates of tests and retests. Dates of operation are given for the first group. *In a few cases where the operation was postponed after the test had been given, the child and his control were retested just previous to the operation. Since both cases were retested, practice effect is of no great importance. 28 ADENOIDS AND DISEASED TONSILS: TH Tji m CD us CD t- oo oooo oo o> OO OOOOO _ . CMcg eg eg eg eg eg eg eg eg eg eg eg eg eg 08 I: Cg Cg There is therefore no V n correlation between improvement in intelligence and gain in weight. TABLE IX Improvement in I. Q., 28 Pairs N* Test Group (A) Testl Test 2 Gain 27 110 109 1 20 106 102 4 8 91 86 5 24 131 124 7 21 64 67 3 3 94 91 3 12 98 95 Q 23 85 94 9 11 103 100 3 15 97 94 3 18 98 98 4 96 96 26 80 76 4 16 65 73 8 28 81 84 3 5 95 99 4 2 107 114 7 10 110 109 1 17 71 77 6 7 91 99 8 1 82 83 1 6 95 101 6 19 96 101 5 9 83 93 10 25 77 76 1 13 70 78 8 22 91 100 9 14 96 107 11 Av. 91.53 93.78 2.25 M 2 75%ile 7 25%ile 3 Q 5 P. E. (distribution) 5.25 P. E. (average) .99 Control Group (B) Test 1 Test 2 Gain 72 118 98 89 86 82 98 81 101 78 90 83 90 74 95 114 91 104 96 95 80 88 98 87 145 66 63 140 92.93 A B 96 24 25 131 13 17 104 6 11 92 3 10 97 11 8 85 3 6 101 3 6 96 15 6 102 1 4 79 1 4 94 4 4 85 2 2 88 2 2 82 8 98 3 117 3 1 96 5 2 100 4 3 99 3 3 99 4 4 76 4 5 89 1 5 98 5 90 3 7 137 8 7 64 2 10 62 1 10 137 g 14 96.21 3.285 1.035 3 1 4 5 1 6 2.5 5.5 2.5 5 .47 1.10 Av.= .94 P. E. M. = , ,99 P. E. *Numbers refer to cases as listed on Table II. THEIR EFFECT UPON GENERAL INTELLIGENCE 45 TABLE X Improvement in Performance of Healy Test, 24 Pairs N* Test Group (A) Test 1 Test 2 Gain 7 6 28 22 13 43 42 1 17 29.5 12 17.5 15 7 25 18 26 22.5 7 15.5 10 12 6.5 18.5 19 57.5 49 8.5 24 54.5 63 8.5 20 11 11 9 3.5 10.5 7 11 8 6 14 16 49 47.5 1.5 1 25 2 27 22 48.5 43.5 5 18 13.5 12 1.5 23 49.5 68 18.5 3 21.5 22.5 1 12 20 21 1 14 12.5 48.5 36 27 25 15 40 2 28.5 30 1.5 25 8 25 17 21 20 32 12 28 29.5 73.5 44 Av. 17.29 24.94 7.64 M. 4.25 75%ile 18 25%ile 5 Q 11.5 P. E. (distribution) 10.6 P. E. (average) 2.16 Control Group (B) Test 1 Test 2 Gain 4.5 - 1.5 1.5 1 56 27 -22 ' 31.5 30 34 -29 30 -50 34.5 -32 4 17 -10 - 5 2 3 29.5 70.5 64.5 12.12 A B 27.5 23 45 30.5 32 33 15 13.5 31 42.5 41.5 23.5 61.5 5.5 21.5 65 38 19.5 -11 11 19.5 59.5 28 19.5 35 5 16 55 21 14 - 3.5 25.5 11.5 37 7 8.5 -16 34 7 33.5 1 4 -28 4 2.5 25 21 2.5 19 2 ^ -12 2 3 25.5 30.5 6.5 27.5 25.5 14.5 -11 14 15.5 29 .5 17.5 58.5 12 24 51.5 13 57 25.69 13.56 5.85 12.25 7.75 25.5 3 .5 19.5 13 11.25 10.56 13.65 2.16 3.05 Av.= 1.92 P. E M. =2.54 P. E Similarly, it might be thought that the children who had suffered from the defects for a comparatively short time, might reveal greater improvement in intelligence after six months than those who had been afflicted for a longer space of time. We had no way of knowing definitely how long the defects had been present in the cases studied. Roughly, though, we may say that in general the older boys have had defective tonsils and adenoids for a longer time than the younger ones, and that the older the boy, the older the defect. On this basis, if correlation of youth with gain in I. Q. should give a larger positive value for r, we might be justified in say- ing that the younger boys, who have been handicapped for a lesser period, show greater mental recuperation than their *Numbers refer to cases as listed on Table II. 46 ADENOIDS AND DISEASED TONSILS: older companions. Such a correlation was attempted in the test group, correlating age at the first test with gain in I. Q. The same methods and formulae were used as in the weight and intelligence comparison, the greatest gain in I. Q. being given first position, and the lowest age. The resulting value for r was .24, with an unreliability of .186. The relation- ship would appear to be in the other direction but it is so small, with an unreliability measure so large as to be insignificant. Once more, then, we find in our results no correspondence between recency of defect and quick mental recovery. TABLE XI Showing percentile ratings of the members of the two groups at the beginning and end of the six months' interval Weight 1 .29 .44 1C .43 .54 2 .04 .10 2C .38 .55 3 .46 .59 3C .65 .69 4 .33 .44 4C .27 .32 5 .16 .20 5C .50 .53 6 .12 .15 6C .31 .40 7 .03 .07 70 .01 .02 8 .62 .71 8C .18 .37 9 .31 .41 9C .60 .65 10 .26 .35 IOC .21 .22 11 .24 .23 11C .08 .09 12 .25 .40 12C .06 .15 13 .95 1.00 13C .87 .89 Height .25 .40 .27 .45 Grip .47 .40 .33 .47 Tapping .51 .33 .17 .30 .04 .20 .11 .32 .16 .25 .16 .40 .16 .80 .25 .28 .32 .74 .49 .81 .44 .54 .56 .67 .52 .51 .58 .42 .39 .51 .52 .78 .16 .18 .13 .19 .18 .28 .20 .47 .33 .40 .23 .87 .06 .22 .10 .38 .10 .27 .23 .41 .05 .03 .15 .07 .07 .16 .06 .24 .40 .16 .27 .63 .31 .75 .40 .24 .67 .72 .27 .43 .23 .11 .47 .76 .53 .89 .26 .76 .47 .89 .71 .63 .51 .78 .26 .23 .43 .37 .44 .24 .33 .67 .01 .02 .04 .51 .25 .09 .43 .17 .33 .36 .67 .36 .40 .86 .08 .11 .15 .02 .08 .53 .04 .01 .08 .12 .03 .99 .93 1.00 .96 .99 .94 1.00 .96 .90 .78 .66 .36 THEIR EFFECT UPON GENERAL INTELLIGENCE 47 TABLE XI (Continued) Showing percentile ratings of the members of the two groups at the beginning and end of the six months' interval Weight Height Grip Tapping 14 .49 .66 .67 .74 .72 .67 1.00 .57 14C .92 .93 .96 .98 .93 .98 .97 .97 15 15C .56 .79 .80 .68 .59 .66 .70 .67 .70 .95 .62 .94 .54 16 16C .49 .34 .53 .28 .74 .50 .79 .54 .81 .24 .77 .24 .69 .69 .51 17 17C .53 .17 .50 .15 .53 .24 .11 .05 .40 .78 .34 18 18C .57 .17 .20 .38 .30 .34 .33 .10 .06 .45 .09 .51 .03 19 19C .95 .38 .99 .45 .94 .30 .98 .37 .94 .67 .88 .40 .93 .09 .31 20 20C .13 .63 .75 .37 .56 .88 .33 .67 .44 .16 .78 .23 .86 21 21C .83 .67 .89 .77 .84 .55 .61 .76 .81 .76 .67 .80 .62 .44 .57 22 22C .85 .83 .92 .81 .93 .91 .97 .78 .82 .95 .91 .92 .33 .99 .89 23 23C .36 .73 .74 .45 .70 .82 .36 .55 .70 .53 .78 .36 .63 .62 24 24C .59 .62 .69 .63 .67 .59 .71 .81 .67 .85 .67 .89 .86 .66 .86 25 25C .47 .73 .60 .74 .57 .60 .63 .64 .53 .44 .91 .62 .70 .78 .79 26 26C .74 .76 .89 .81 .74 .70 .85 .79 .53 .84 .76 .54 .40 .57 .40 27 27C .11 .07 .12 .23 .12 .23 .16 .10 .04 .16 .18 .30 .06 .25 28 28C .86 .87 .90 .93 .87 .83 .90 .86 .97 .88 .88 .78 .98 .91 .94 48 ADENOIDS AND DISEASED TONSILS: TABLE XI (Continued) Showing percentile ratings of the members of the two groups at the beginning and end of the six months' interval N* 1 1C .25 .21 I.Q. .27 .15 .10 .01 Healy .29 .12 Total .30 .53 Possible Gain 415 462 Average .05 .089 2 2C .84 .45 .89 .51 .60 .29 .66 .18 .38 .07 416 358 .063 .011 3 3C .49 .25 .44 .32 .49 .44 .51 .45 .40 .30 328 287 .066 .05 4 4C .59 .27 .59 .32 .38 .71 .22 .42 168 195 .073 .14 5 5C .53 .89 .71 .90 .10 .77 .42 .24 213 133 .14 .08 6 6C .53 .37 .77 .38 .02 .04 .55 .27 229 210 .183 .09 7 7C .45 .53 .71 .71 .22 .34 .07 .59 .37 .74 478 393 .062 .148 8 8C .45 .67 .34 .81 .70 .33 .52 .50 .10 303 241 .125 .025 9 9C .27 .35 .46 .40 .23 .73 .39 .89 .71 .72 375 217 .118 .12 10 IOC .88 .81 .86 .73 .15 .57 .35 .97 .34 1.39 400 392 .056 .218 11 11C .79 .77 .73 .79 .20 .05 .34 .23 .21 .44 379 379 .035 .073 12 12C .67 .67 .53 .77 .47 .19 .49 .15 .11 .19 161 208 .036 .032 13 13C .09 .06 .19 .05 .79 .24 .78 .67 .02 .06 129 178 .003 .01 14 14C .59 .97 .84 .96 .41 .21 .84 .56 .69 .41 212 104 .115 .068 15 15C .62 .19 .49 .20 .38 .26 .55 .79 .12 .66 106 193 .04 .11 16 16C .05 .13 .12 .25 .86 .66 .82 .76 .15 .24 205 313 .03 .04 17 17C .09 .59 .17 .71 .63 .27 .40 .43 .66 .21 223 174 .220 .053 18 18C .67 .40 .67 .49 .13 .04 .15 .07 .08 .18 175 247 .027 .03 *Numbers refer to cases as listed on Table II. THEIR EFFECT UPON GENERAL INTELLIGENCE 49 TABLE XI (Continued) Showing percentile ratings of the members of the two groups at the beginning and end of the six months' interval Possible N* I. Q. Healy Total Gain Average 19 19C .59 .67 .69 .67 .91 .11 .85 .18 .16 .16 67 287 .032 .027 20 20C .82 .91 .79 .94 .25 .66 .18 .75 .06 .20 177 65 .02 .066 21 21C .05 .34 .07 .62 .47 .99 .69 .92 .16 .46 209 157 .032 .077 22 22C .45 .03 .73 .02 .84 .74 .81 .72 .87 .74 120 275 .174 .123 23 23C .32 .23 .49 .59 .86 .33 .98 .50 .65 1.26 168 253 .163 .21 24 24C .94 .38 .92 .46 .88 .68 .95 .93 .06 .54 89 179 .012 .09 25 25C .17 1.00 .15 .97 .37 .63 .55 .60 .49 .53 280 134 .098 .088 26 26C .21 .40 .15 .37 .51 .90 .36 .94 .04 226 184 .007 27 27G .88 .11 .86 .59 .10 .29 .43 .59 .05 1.49 268 320 .013 .25 28 28C .23 .53 .29 .67 .63 .96 1.00 .87 .59 .24 153 83 .097 .048 Table XI expresses the results of Table II, with the scores given in percentile values. In each test, the group was taken as composed of the two scores of every individual the total number of scores in tests and retests, eliminating those scores where the other member of the pair was lacking, or where no retest was given. Thus case number 1 was just within the lowest 27% of the group in weight at the first weighing, but had advanced to the 44 percentile at the second. In height he gained from the 25 percentile to the 40 percentile. His total gain in all tests is 30 percentile out of a possible 415, and the average gain is .05. The reader may see by scanning the table that the gains in the test group are practically equalled by those in the control group. There seems to be no consistent re- lationship between a low score in the first test and a large gain. This is true even though the method of calculation tends to minimize gains at the high end of the group, and losses at the 50 ADENOIDS AND DISEASED TONSILS: low end. In table XII this may be seen more clearly in respect to I. Q. and the results for all the tests taken together with the I. Q. weighted by being counted twice. A large possible gain indicates that the score at the first testing was low, and vice versa. Considering I. Q. values, the largest possible gain in the test group was 95 per cent of the group. This occurred twice, in one case the actual gain being 7% of the group and in the other 2%. In the control group, the largest possible gain was 97% of the group, but actually this case fell 1% of the group. If we correlate possible gain with actual gain for each group, using the formula r = 2sin (-^ p ) when p 1 *(^i) we get a coefficient of correlation .36 in the test group, and .19 TABLE XII Showing gains in percentile rating for I. Q., and for a total of all the tests with I. Q. weighted by being counted twice. I. Q. Total 1st P.R. 2d P.R. A possible gain B actual possible gain gain actual gain Av. Gain 1 1C 25 21 27 15 75 79 2 g 415 462 30 53 5 8.9 2 2C 84 45 89 51 16 55 5 6 416 358 38 rj 6.3 1.1 3 3C 49 25 44 32 51 75 5 7 328 287 40 30 6.6 5 4 4C 59 27 59 32 41 73 5 168 195 22 42 7.3 14 5 5C 53 89 71 90 47 11 18 1 213 133 42 24 14 8 6 6C 53 37 77 38 47 63 24 1 229 210 55 27 18.3 9 7 7C 45 53 71 71 55 47 26 18 478 393 37 74 6.2 14.8 8 8C 45 67 34 81 55 33 11 14 203 241 50 10 12.5 2.5 9 9C 27 35 46 40 73 65 19 5 375 217 71 72 11.8 12 10 IOC 88 81 86 73 12 19 2 g 400 392 34 139 5.6 21.8 11 11C 79 77 73 79 21 23 6 2 379 379 21 44 3.5 7.3 THEIR EFFECT UPON GENERAL INTELLIGENCE 61 TABLE XII (Continued) Showing gains in percentile rating for I. Q., and for a total of all the tests with I. Q. weighted by being counted twice. I. Q. Total A B 1st 2d possible actual possible actual Av. Gain P.R. P.R. gain gain gain gain 12 12C 67 67 53 77 33 33 6 10 161 208 11 19 3.6 3.2 13 13C 9 6 19 5 91 94 10 1 129 178 2 6 .3 1 14 14C 59 97 84 96 41 3 25 I 212 104 69 41 11.5 6.8 15 15C 62 19 49 20 38 81 13 1 106 193 12 66 4 11 16 16C 5 13 12 25 95 87 7 12 205 213 15 24 3 4 17 17C 9 59 17 71 81 41 8 12 223 174 66 21 22 5.3 18 18C 67 40 67 49 33 60 9 175 247 8 18 2.7 3 19 19C 59 67 69 67 41 33 10 67 287 16 16 3.2 2.7 20 20C 82 91 79 94 18 9 3 3 177 65 6 20 2 6.6 21 21C 5 34 7 62 95 66 2 28 209 157 16 46 3.2 7.7 22 22C 45 3 73 2 55 97 28 1 120 275 87 74 17.4 12.3 23 23C 32 23 49 59 68 77 17 36 168 253 65 126 16.3 21 24 24C 94 38 92 46 6 62 2 8 89 179 6 54 1.2 9 25 25C 17 100 15 97 83 2 3 280 134 49 53 9.8 8.8 26 26C 21 40 15 37 79 60 6 3 226 184 4 .7 27 27C 88 11 86 59 12 89 2 48 268 320 5 148 1.3 25 28 28C 23 53 29 67 77 47 6 14 153 83 59 24 9.7 4.8 52 ADENOIDS AND DISEASED TONSILS: in the control group. With the small number of cases involved the probable error is too great to allow either of these measures as indicative of relationship. We may say, then, that there is no definite tendency for those of low I. Q. to improve in six months after operation to a greater degree than those of high- er I. Q. Finally, in order to compare the results of the various tests, the measures of the gains of the test group in excess of the control were, for each test, expressed in terms of P. E. The averages and medians of these measures are collected in Table XIII. They show a very slight tendency toward gain in weight, height, and weight-height-age relationship ; neither improvement nor loss in grip, tapping f atigueability and I. Q., and a rather curious tendency to loss in the Healy scores. This latter is very probably not a true measure since performance in the Healy Picture Completion test shows a rather high variability, and the cases are so few as to make the influence of single very high or low scores unduly great. TABLE XIII Showing improvement in various tests of operative group over and above such improvement in control group. Expressed in Terms of P.E. Weight Height Height- Grip Tapping Tapping I. Q. Healy Weight fatigue P.E. P.E. P.E. P.E. P.E. P.E. P.E. P.E. Average 2.85 1.00 2.02 .50 .03 .50 .94 1.92 Median 2.80 1.25 .55 .83 .32 .50 2.54 CHAPTER IV MEASUREMENT OF IMPROVEMENT AFTER A SECOND INTERVAL OF SIX MONTHS In view of the fact that one of the experimenters* found improvement in school work when her study was extended to cover a second time interval after operation, it was deemed advisable to similarly extend the present investigation in or- der to determine whether our operated cases showed any im- provement after twelve months. To this end, the fifty-six children composing the final groups of the first study, were sought after a second interval of about six months. Conditions made it impossible to give all the retests exactly twelve months from the time of the operation. As a matter of fact, the period ranges from ten to seventeen months. An effort was made to keep the interval between tests equal for the two members of a given pair. The same tests were given as in the first study. About half of the testing was done by one of the former examiners, but she was obliged to turn the work over to another before it had been completed. The second examiner was highly recom- mended, and had had training and practical experience in the giving of tests. She was instructed in the methods which had been employed previously, so that conditions were as far as possible kept constant. The results of the tests are collected in Table XIV. In the first column is given the length of the time interval for each case. It may be seen that the final group was composed of forty-two children, forming twenty-one pairs. There were fifteen pairs which received a second rating in weight; thir- teen in height; thirteen in grip; fifteen in tapping, eleven in fatigue as shown by tapping, twenty-one in I. Q., and eighteen in the Healy Test. These numbers while they are smaller than we could wish, would seem to be great enough to indi- *A. H. Mac Phail, Adenoids and Tonsils: A study showing how the Removal of Enlarged or Diseased Tonsils Affects a Child's Work in School. Fed. Sem., June, 1920, pp. 188-194. 53 54 ADENOIDS AND DISEASED TONSILS: TABLE XIV Results of the Tests after an Interval of from 10 to 17 Months N* Mos. Weight Test 1 Tests Height Test 1 Test 3 Grip Test 1 Test 3 1 1C 15 15 50.4 53.5 63.5 62.8 46 46.4 49.7 49.7 13 11 18 15 2 20 15 17 40.9 52.3 47.9 65.5 42.6 45.2 45.9 49.8 9 10 10 15 3 3C 16 14 55 61.5 67.5 57.8 47 51.7 50.2 54 12.8 14 13 14.5 4 4C 13 13 51.1 49.4 60.2 54.2 47.5 48.9 50.5 50.8 9 9.5 7 7C 14 12 39.9 38.4 45.8 42.1 42.9 41.9 45.6 43.7 7 9 6 14 8 8C 11 11 60.8 45.4 69.2 57.9 50.8 36.8 52.3 48.7 10 15 __ 10 IOC 11 11 48.9 47.1 56.7 51.8 46.1 45.6 48.6 48.1 12.5 10 12 12 11 11C 12 12 47.8 41.6 55 47 45.8 43.6 49.5 46.8 11 11.5 11 7.5 12 12C 12 11 48 41 66.5 69.6 44.8 41.5 14 6 13 13C 12 12 90 74.7 112 88 61.3 56.8 61.8 60.0 26.5 22 28.5 27 14 14C 12 12 56 81.9 66 98 51 57.9 53.3 59.5 16 22 17 22.5 15 15C 12 10 57.5 67.2 __ 51.1 50.1 15.5 15 , -- 16 16C 12 11 56 51.2 60.3 55 51.6 48.7 53.5 50.1 19 10 18.5 10 18 18C 12 11 58.2 45.3 47.3 46.7 18 8 19 19C 12 11 90 52.4 108 59 57.7 46.7 60.5 48 22 15 20 18 20 20C 12 11 44.2 61.3 47.2 49.6 _. 11 15 21 21C 12 10 70.7 62.4 85.5 69.2 54.1 49.6 16.5 19 15 17 23 23C 12 11 51.7 64.1 47.8 51.4 11.5 14.5 15 16 27 27C 12 11 43.7 41 __ 45.4 44.6 9 8 6 9 28 28C 12 11 71.3 74.2 78.5 85.8 54.9 53.4 56.3 55.9 23.5 21 *Numbers refer to cases as listed on Table II. THEIR EFFECT UPON GENERAL INTELLIGENCE 55 N* TABLE XIV (Continued) Tapping I. Q. Healy 1 1C Testl 135 106 Test3 142 134 (1) 82 80 (3) 93 85 (1) 25 50 (3) 11 11 2 2C 105 152 135 139 107 91 113 86 28.5 3 24.5 19.5 3 3C 136 135 144 135 94 82 91 96 21.5 17 15.5 25.5 4 4C 103 109 96 83 111 102 8.5 33 7 7C 125 105 91 95 93 112 6 4.5 16 11 8 8C 113 131 128 121 91 98 92 111 32.5 4 10 IOC 68+ 74 70+ 74 145+106 148+124 110 104 116 107 12 27 11 48.5 11 11C 125+ 90 155+125 120+125 102+112 103 101 102 95 8 29 15.5 20 12 12C 98+ 69 102 98 98 86 90 20 10 1 41.5 13 13C 160+165 150+109 176+187 188+174 70 66 61 60 43 1.5 62.5 21.5 14 14C 190+172 175+152 228+215 165+186 96 140 102 138 12.5 5 77 48.5 15 15C 172+167 140+115 192+186 145+133 97 78 97 98 7 1 19 54.5 16 16C 145+131 145+ 99 65 74 74 81 49 30 79 45.5 18 18C 133+115 100+ 99 126+145 108+ 92 98 90 101 92 13.5 32 13.5 35 19 19C 168+136 100+115 96 98 97 90 57.5 22 60.5 15 20 20C 105+115 150+120 122+118 154+154 106 118 116 140 30 55 48.5 21 21C 152+111 140+136 154+155 174+150 64 86 66 93 20 70.5 38 88 23 23C 150+119 122+115 157+157 141+141 85 81 80 88 49.5 4 62.5 64 27 27C 108+ 92 115+105 114+ 95 101+118 110 72 112 98 25 2 25.5 39.5 28 28C 150+148 178+148 176+168 172+157 81 95 83 94 29.5 64.5 77.5 83.5 56 ADENOIDS AND DISEASED TONSILS: cate any very consistent tendency toward improvement. The question, whether or not the results are affected by the differ- ences in time interval, will be considered later. In weight, the test group showed an average gain of 11.013 pounds, with a median of 9.1 (Table XV). The average gain of the control group was 9.113 pounds and the median 6.8. The gains in the test group are less variable than those of the control. The average of the gains of the test group in excess of those of the control is 1.9 pounds, and the median is 2.2 pounds; while the unreliability of the difference is -f 1.46. The average, then, is only 1.30 P. E. and the median 1.51 P. E. If we turn to Table III and compare the results there set forth with the results at the end of the second period, we find the gains of the test group exceed those of the control in the following manner. TABLE XV Weight, Second Retests, 15 Pairs N* 12 2 14 28 8 16 11 7 10 1 4 21 13 19 3 Av. Test Group (A) Test 1 Test 3 Gain 48 40.9 56 71.3 60.8 56 47.8 39.9 48.9 50.4 51.1 70.7 90 90 55 58.45 66.5 47.9 66 78.5 69.2 60.3 55 45.8 56.7 63.5 60.2 85.5 112 108 67.5 69.50 M 75%ile 25%ile Q P. E. (distribution) P. E. (average) 18.5 7 10 7.2 8.4 3.7 7.2 5.9 7.8 13.1 9.1 14.8 22 18 12.5 11.01 9.1 13.52 7.15 3.18 3.81 1.00 Control Group (B) Test 1 Test 3 Gain 41 52.3 81.9 74.2 45.4 51.2 41.6 38.4 47.1 53.5 49.4 62.4 74.7 52.4 61.5 55.13 A B 69.6 28.6 10.1 65.5 13.2 6.2 98 16.1 6.1 85.8 11.6 4.4 57.9 12.5 4.1 55 3.8 .1 47 5.4 1.8 42.1 3.7 2.2 51.8 4.7 3.1 62.8 9.3 3.8 54.2 4.8 4.3 69.2 6.8 8 88 13.3 8.7 59 6.6 11.4 57.8 3.7 16.2 63.58 9.11 1.9 6.8 2.2 12.67' 5.22 4.47 4.07 4.1 4.65 4.19 6.1 1.07 1.46 Av.=1.30 P. E, M.=1.51P.E. 6 months 12 months Average of gains in test group in excess of control 1.37 1.9 Median 1.2 2.2 P. E. of difference .48 1.46 Average in terms of P. E. 2.85 1.30 Median in terms of P. E. 2.80 1.51 *Numbers refer to cases as listed on Table II. THEIR EFFECT UPON GENERAL INTELLIGENCE 67 After a twelve months' interval, therefore, the actual av- erage and median gains are slightly larger than after the first six months, but the variability is very much greater. Therefore, when expressed in terms of P. E., the gains are smaller. One of the test group cases (No. 13) who had gained 8 pounds after six months, gained 14 pounds in the second period of six months, making a total gain of 22 pounds. This gain is exceeded, however, by one in the control group (No. 12) who gained 3.5 pounds in six months, and 25.1 pounds more in the ensuing five months. This is certainly an enor- mous gain for five months, under any circumstances. Turning to Table XIV we find no corresponding gain in I. Q. for this child. Indeed there is a loss of five points. Other children in the test group who made large gains, were case 12, with a gain of 18.5 pounds after twelve months, compared with 4.5 pounds after six months ; case 19, gain of 6.3 pounds after first six months, and 18 pounds after 12 months; case 21, whose gain after the first period was 5.8 pounds, but who gained 14.8 pounds after twelve months. In these cases the gain in the second period greatly exceeds that for the first. TABLE XVI Height, Second Retests, 13 Pairs N* Test Group (A) Control Group (B) Test 1 Test 3 Gain Test 1 Test 3 Gain A B 13 61.3 61.8 .5 56.8 60 3.2 2 7 2 42.6 45.9 3.3 45.2 49.8 4.6 i!s 28 54.9 56.3 1.4 53.4 55.9 2.5 1.1 8 50.8 52.3 1.5 46.8 48.7 1.9 .4 10 46.1 48.6 2.5 45.6 48.1 2.5 .0 1 46 49.7 3.7 46.4 49.7 3.3 .4 11 45.8 49.5 3.7 43.6 46.8 3.2 .5 16 51.6 53.5 1.9 48.7 50.1 1.4 .5 14 51 53.3 2.3 57.9 59.5 1.6 .7 3 47 50.2 3.2 51.7 54 2.3 .9 7 42.9 45.6 2.7 41.9 43.7 1.8 .9 4 47.5 50.5 3 48.9 50.8 1.9 1.1 19 57.7 60.5 2.8 46.7 4.8 1.3 1.5 Av. 49.63 52.17 2.5 48.74 51.16 2.42 .08 M 2.7 2.3 .5 75%ile 3.15 2.85 .85 25%ile 1.6 1.75 .92 Q .775 .65 .885 P. E. (distribution) .66 .78 .82 P. E. (average) .18 .22 .28 Av.= .29 P. E. M. =1.79 P. E. *Numbers refer to cases as listed on Table II. 58 ADENOIDS AND DISEASED TONSILS: In weight, then, the mean gain of the test group over and above the control continues to increase through the second period of six months. The variability, however, increases enormously, which fact is due possibly to varying conditions which may enter in during the longer period to affect the health and thus lessen the gain of some of the children. In order to determine whether the slight inequalities in interval length have any considerable effect on the results, we have calculated the relation between the length of interval and amount of improvement. The coefficient of correlation by the method of rank differences is equal to .03. The small number of cases renders the unreliability of correlation very great, but we can at least say that there is no consistent re- lationship between improvement and time interval, within the narrow limits here set. We are probably justified in taking twelve months as the interval, since such was the case in eight out of the fifteen test cases, while the greatest variation above this made was four months, and below it, one month. The gains in height after twelve months are shown in Table XVI. The average gain of test group in excess of control, is only .08 inches, and the median .5 inches. Variability is about the same as at the end of six months, P. E. .28. The aver- age is only .29 P. E., but the median is a little larger, 1.79 P. E. If these measures are compared with the results after the first period, we have : 6 months 12 months Average of gains of test group in excess of control .16 .08 Median of gains of test group in excess of control .2 .5 P. E. of difference .16 .28 Average in terms of P. E. 1.00 .29 Median in terms of P. E. 1.25 1.79 There seems to be little gain in height after the first period. Test cases 1 and 11 each show a gain of 3.7 inches after fifteen and twelve months respectively, compared with gains after six months of 1.6, and 1.9 inches. But case 2 in the control group, makes still greater comparative gain, -\-1.8 inches after six months and 4.6 inches after seventeen months, In this case there are almost six additional months for the child to grow, which may account for the larger gain. Con- trol case 1, however, may be compared with his partner, mentioned above, since the interval between tests was the same for both. This boy grew 1.4 inches in six months, and 3.3 inches after 15 months. This is practically equal growth THEIR EFFECT UPON GENERAL INTELLIGENCE 59 with test case 1. Control case 11 also shows relatively great growth during 12 months, +3.2 inches, whereas the growth in six months was only 1.3 inches. Out of the test group, 7 cases gained more in the first period of six months, than in the second, while only 6 gained more in the second than in the first. Of the control group, 7 cases made more than half of their total gain during the second six months of the total twelve months' period. Since this is true, it seems likely that whatever increase in growth we find during the second half of the twelve months' interval, may be explained by in- cidental causes, and that so far as actual gain in height is considered, there is no further effect from the operations, after six months. As was mentioned in the previous chapter, height and weight are of less significance when considered alone, than when taken in relation to each other and to the age of the individual. The gain in this weight-height-age relationship following upon operation for adenoids and tonsils, will be considered in the same manner as were weight and height gains. We have, then: TABLE XVII Height-Weight Relationship, Second Retests, 13 Pairs Showing changes in per cent over or underweight after 12 months' interval N* Test Group (A) Control Group (B) Testl Test3 Change Test 1 Test 2 Change A B 8 1 + 7 + 8 13 +13 5 16 16 17 1 13 9 + 4 5 11 3 6 3 9 10 1 2 14 13 6 + 7 5 + 4 + 9 2 19 + 6 +10 + 4 + 1 + 7 + 6 2 28 7 4 + 3 + 5 + 5 2 10 1 + 1 6 6 + 1 7 8 g n 9 2 +2 2 8 4 + 4 + 9 +10 + 1 +3 4 7 4 + 3 15 15 +3 1 + 6 + 6 + 8 + 5 3 +9 13 13 + 6 +19 11 12 1 +20 3 + 6 +13 + 7 5 20 15 +22 Av. 5 .54 4.46 5.08 3.85 1.23 3.23 M 4 2 6 75%ile 6.75 2.75 3 25%ile 2.50 2.75 2 Q 4.625 2.75 2.50 P. E. P. E. (distribution) (average 2.54 .71 3.23 5.23 .90 1.15 Av.=2.81 P. E. M. =5.22 P. E. *Numbers refer to cases as listed on Table II. 60 ADENOIDS AND DISEASED TONSILS: 6 months 12 months Average of gains of test group in excess of control 1.83 3.23 Median of gains of test group in excess of control 4.00 6 P. E. of difference 91 1.15 Average in terms of P. E 2.02 2.81 Median in terms of P. E 4.40 5.22 The mean of the actual gains in the second period ex- ceeds that of the first. Again the second group of results is more variable, decreasing the reliability. There seems, however, to be a definite increase in the net gain of the test group during a second six months' period. Some individual cases may be cited. The greatest gain after six months is 8 units in the test case, matched by an equal gain of 8 units in the control group. After twelve months, the test group shows one gain of 19 units, the highest gain in the control group being 13. Six cases in the test group, and 13 in the control had lost at the end of six months, but after twelve months, all but 2 of the test cases showed a gain, and all but 5 of the controls. In 10 test cases out of the total 13, more than half of the gain occurred during the second six months. In the control group, six of the cases made more than half of their gain during the second six months, and the second interval gains of the other 7 cases exceeded the 50 per cent mark by so little that they may be accounted for by chance. These results seem to indicate a slight but actual increase in the net gain of the test group during the second six months of the experiment, and an accompanying growth in the vari- ability of these gains. It will be remembered that the results described in the previous chapter show no gain in strength of grip as a re- sult of operation. Comparison of the 13 cases tested after the second interval, with the 16 cases at the end of the first, gives results as follows : TABLE XVIII Gain in Grip, Second Retest, 13 Pairs N* Test Group (A) Control Group (B) Testl Test 2 Gain Testl Test 2 Gain A B 7 7 6 1 9 14 5 6 19 22 20 2 15 18 3 5 2 9 10 1 10 15 5 4 27 9 6 3 8 9 1 4 13 26.5 28.5 2 22 27 5 3 10 12.5 12 .5 10 12 2 2.5 16 19 18.5 .5 10 10 .5 THEIR EFFECT UPON GENERAL INTELLIGENCE TABLE XVIII (Continued) 61 N* Test Group (A) Control Group (B) Testl Test 2 Gain Testl Test 2 Gain A B 3 12.5 13 .5 14 14.5 .5 14 16 17 1 22 22.5 .5 .5 21 16.5 15 1.5 19 17 2 .6 1 13 18 5 11 15 4 1 23 11.5 15 3.5 14.5 16 1.5 2 11 11 11 11.5 7.5 4 4 Av. 14.27 14.61 .34 13.54 15.19 1.65 1.31 M 1.5 1.5 75%ile 1.25 3.75 .62 25%ile 1.38 .12 .4 Q 1.31 1.81 .51 P. E. (distribution) 1.34 1.65 2.31 P. E. (average) .37 .46 .59 Av.= 2, ,22 P. E. M.= 2.54P.E. 6 months 12 months Average of gains of test group in excess of control .24 1.31 Median of gains of test group in excess of control 1.00 1.50 P. E. of difference .48 .59 Average in terms of P. E .50 2.22 Median in terms of P. E 2.08 2.54 The greatest gain in the test group after twelve months is 5 Kg. (Case 1). During the first six months this case lost 1 Kg. There are two gains of 5 Kg. in the control group. Of these two (cases 7 and 13) had gained 1 Kg. during the first interval and another (case 2) 2 Kg. The greatest loss in the test group after the twelve months' period was 3 Kg., by case 27, which had already lost this amount at the end of six months. The greatest loss in the control group was suffered by case 11, a loss of 4 Kg., all in the second period. After the first period, 9 out of 16 cases in the test group gained in strength of grip, and 13 in the control group. After the second period, the test cases show- ing gain numbered only 7 out of 13, while all of the control cases had gained except 2. Of the test group 8 cases in the second period either gained less than half of the amount they had improved in the first period, or dropped from the scores they had made at that time. The corresponding num- bers for the control group are 6 and 7. There is evidently no improvement in strength of grip twelve months after operation. The unreliability of the re- sults is very great. However, there is certainly no tendency toward improvement. Why this should be is a question. It *Numbers refer to cases as listed on Table II. 62 ADENOIDS AND DISEASED TONSILS: may be that the change in examiners is partly responsible, for performance in this test is influenced to a surprising ex- tent by the manner in which it is presented. TABLE XIX Tapping Second Retest, 15 Pairs N* Test Group (A) Test 1 Test 3 Gain 21 152 13 160 1 135 18 133 23 150 10 68 3 136 20 105 15 172 27 108 8 113 28 150 2 105 11 125 14 190 Av. 133.47 M 75%ile 25%ile Q P. E. (distribution) P. E. (average) 154 2 176 16 142 7 126 7 157 7 145 77 144 8 122 17 192 20 114 6 128 15 176 26 135 30 120 5 228 38 150.6 17.13 15 21.5 5 8.25 ) 10.13 2.67 Control Group (B) Testl 149 150 106 100 122 70 135 150 140 115 131 178 152 155 175 134.6 est3 Gain A B 174 34 32 188 38 22 134 28 21 108 8 15 141 19 12 148 78 ^ 135 8 154 4 13 145 5 15 101 14 20 121 10 25 172 6 32 139 13 43 102 53 48 165 10 48 141.8 7.2 9.93 4 11 21.5 26.75 10.75 16.5 16.12 21.62; 17.2 22.07 4.53 5.26 Av.:=1.89 P. E. M. =2.09 P. E. There were 15 pairs of cases who performed the tapping test at the end of twelve months. Comparison with the 21 pairs after six months yields the following results: 6 months 12 months Average of gains of test group in excess of control .09 9.93 Median of gains of test group in excess of control 11 P. E. of difference 3.10 5.26 Average in terms of P. E 03 1.89 Median in terms of P. E 2.09 The gain in the second interval is greater for the tapping test than for any of the tests yet described. After the first six months there is no gain. At the end of ten months the av- erage gain is 9.93, and the median 11 taps per half minute. After six months' interval, 11 of 21 test group cases had lost. At the end of twelve months, only 2 out of 15 had lost. The *Numbers refer to cases as listed on Table II. THEIR EFFECT UPON GENERAL INTELLIGENCE 63 control group, on the other hand, lost in 11 out of 21 cases after six months, and in 6 out of 15 at the end of twelve months. All but one of the test group cases made more than half of their gain in the second period. Of the control group only 7 cases did this. The variability of gains after 12 months is about equal to the variability at the end of six months. Strangely enough, decrease in f atigueability as described in the previous chapter does not show itself after 12 months. In fact, the negligible loss in ability noticeable after six months has increased after a period of twelve months. In only 4 out of 11 test group cases, is the gain in the second peri- od equal to that of the first, a similar result to that found in the control group, where 5 out of the 11 cases made half their total gain in the second interval. The results are compared below. 6 months 12 months Average of gains of test group in excess of control .020 .06 Median of gains of test group in excess of control .015 .09 P. E. of difference .04 .036 Average in terms of P. E .50 1.66 Median in terms of P. E .38 2.50 TABLE XX Tapping for Fatigue, Second Retests, 11 Pairs N* Test Group (A) Control Group (B) Test 1 Test 3 Gain Test 1 Test 3 Gain A B 20 .10 .03 .13 .20 .0 .20 .33 27 .15 .17 .02 .09 .17 .26 .28 10 .09 .27 .36 .06 .16 .10 .26 14 .09 .05 .04 .13 .13 .26 .22 13 _.Q3 .06 .03 .27 .07 .20 .17 28 .01 .05 .04 .17 .10 .07 .11 15 .03 .03 .0 .18 .08 .10 .10 23 .11 .0 .11 .06 .0 .06 .05 21 .27 .01 .28 .29 .14 .15 .13 11 .28 .04 .32 .11 .01 .12 .20 18 .14 .15 .29 .01 .15 .14 .43 Av. .078 .031 .047 .143 .035 .107 .06 M .03 .12 .09 75%ile .153 .20 .07 25%ile .062 .02 .275 Q .107 .09 .172 P. E. (distribution) .087 .093 .19 P. E. (average) .02 .03 .036 Av.= 1.66 P. E. M. = 2.50 P. E. *Numbers refer to cases as listed on Table II. 64 ADENOIDS AND DISEASED TONSILS: The point of greatest interest in the present study is, as has been said, improvement in intelligence. Does operation for adenoids and tonsils result in improvement in intelligence, as measured by I. Q. ? If such improvement does not manifest itself after six months, can it be found after a second period of the same length? The latter question is answered by observa- tion of Table XXI and attention to the following facts, gath- ered from the 21 pairs of cases who were given intelligence tests after the twelve months' interval. v 6 months 12 months Average of gains of test group in excess of control 1.035 3.14 Median of gains of test group in excess of control 1 3 P. E. of difference 1.10 1.84 Average in terms of P. E .94 1.71 Median in terms of P. E .99 1.63 The result after twelve months remains the same as that after the six months' interval. A gain or loss of two or three points in I. Q. is negligible, so that the mean gain of the test group in excess of the control is practically zero at the end of each period. Variability increases with the length of the interval. One case in the test group (case 4) gained nothing in six months, but showed a gain of 15 points after 13 months. However, there is a control case to match this, case 15, who gained 1 point in the first six months and 20 points after 10 months. Case 20 in the test group lost 4 points in the first six months, but gained back these and 10 additional in the second period. But control No. 1 gained 5 points in the second interval after having lost 4 in the first. On the other hand several cases lost in the second period, as compared with the first. Test group case 7, for example, gained 8 points in the first six months, and lost 6 of them in the second. Case 3 in the same group lost 3 points in the first period, and failed to regain any of them. Case 12 lost 3 points in six months and 9 more before the end of 12 months. In the control group, case 23 gained 15 pounds in the first six months and lost eight of them in the second. Summing up gains and losses in the second period, for both groups: THEIR EFFECT UPON GENERAL INTELLIGENCE 65 TABLE XXI I. Q ., Second N* Test Group (A) Testl Tests Gain 27 110 112 2 15 97 97 3 94 91 3 7 91 93 2 20 106 116 10 23 85 80 5 8 91 92 1 12 98 86 12 21 64 66 2 4 96 111 15 13 70 61 9 18 98 101 3 16 65 74 9 10 110 116 6 28 81 83 2 11 103 102 ^ 1 82 93 11 14 96 102 6 19 96 97 1 2 107 113 6 9 83 102 19 Av. 91.5 94.6 3.0 M 2 75%ile 6 25%ile .75 Q 3.37 P. E. (distribution) 2.09 P. E. (average) .45 Control Group (B) Testl Tests Gain A B 72 98 26 24 78 98 20 20 82 96 14 17 95 112 17 15 118 140 22 12 81 88 7 ^2 98 111 13 12 98 91 _ 17 5 86 93 7 5 83 102 19 4 66 60 6 3 90 92 2 1 74 81 7 2 104 107 3 3 95 94 1 3 101 95 6 5 80 85 5 6 140 138 2 8 98 90 8 9 91 86 5 11 87 91 4 15 91.2 97.5 6.2- 3.1 5 3 13.75 4.5 4.25 ^2 9.00 8.25 8.24 8.86 1.79 1.84 Av.= 1 .71 P. E. M.= 1 .63 P. E. Test group Control group Lost in 2nd Gained in 2nd No Gained equally period period change with gain in 1st period 9 11 1 9 10 11 8 The average gain of the test group was 3.09 points after 12 months, compared with 2.25 after six. The control group, however, made an average gain of 6.24 after 12 months, the gain after six months being 3.29. These numbers are insig- nificant as gains, but they at least show no improvement in the test group which the control group does not reveal as well. On the basis of the results, we may say that there has been no improvement in I. Q. as a result of operation, either after six months or after twelve. There remains to be considered only the result of the Healy Picture Completion Test. We have scores in this test for 18 pairs of cases. When these scores are compared with those in the former tests, the results stand as follows : *Numbers refer to cases as listed on Table II. 66 ADENOIDS AND DISEASED TONSILS: Average of gains of test group in excess of control 5.85 3.36 Median of gains of test group in excess of control 7.75 1 P. E. of difference 3.05 3.38 Average in terms of P. E 1.92 .87 Median in terms of P. E 2.54 .26 The figures given above show no gain in the Healy test as a result of operation. Both after six months, and after twelve, we find that the test group has gained no more than the con- trol group. As before there are individual cases showing con- siderable gain in the second period, but these are matched by control cases which reveal equal or even greater gains. In the test group, 5 cases lost in the second period in comparison with the first, 18 gained, and 7 gained as much in the second period as in the first. The control group lost in the second period in 5 cases, gained in 18, and gained as much as in the first period in 7 cases. The two groups, then, are practically equal, both showing a gain in the second period, but this gain cannot be due to the operations, since the control group did not undergo operation. TABLE XXII Healy A, Second Retests, 18 Pairs N* 12 23 15 1 2 3 19 13 21 10 14 27 11 16 7 28 18 20 Test Group (A) Test 1 Test 3 Gain 20 49.5 7 -22 28.5 21.5 57.5 43 20 -12 12.5 -25 - 8 49 - 6 29.5 -13.5 13.81 1 62.5 19 11 24.5 15.5 60.5 62.5 38 11 77 25.5 15.5 79 16 77.5 13.5 55 Av. 13.81 36.92 M 75%ile 257oile Q P. E. (distribution) P. E. (average) 19 13 12 36 4 6 3 19.5 18 23 64.5 50.5 23.5 30 22 48 27 55 23.11 22.5 33 7.5 12.75 11.5 2.7 Control Group (B) Testl Test3 Gain A B 10 41.5 51.5 70.5 4 64 60 47 1 54.5 53.5 41.5 50 11 61 25 3 19.5 16.5 20.5 17 25.5 8.5 14.5 22 15 7 4 1.5 21.5 23 3.5 70.5 88 17.5 .5 27 48.5 21.5 1.5 5 48.5 53.5 11 2 39.5 37.5 13 29 20 9 14.5 30 45.5 15.5 14.5 45 11 6.5 15.5 64.5 83.5 19 29 32 35 3 30 30 48.5 18.5 36.5 5.77 32.25 26.47 3.36 18.75 1 44 14.5 8.75 22.25 17.62 18.37 17.72 17.86 4.22 3.88 Av.= .87 P. E. M. = + .26 P. E. *Numbers refer to cases as listed on Table II. THEIR EFFECT UPON GENERAL INTELLIGENCE TABLE XXIII 67 Weight in Height in Height-weight Grip in Gains pounds inches percents Kg. Ib. P.E. in. P.E. % P. E. Kg. P. E. Av. 1 1.37 2.85 .16 1. 1.83 2.02 .24 .50 Av. 2 1.90 1.30 .08 .29 3.23 2.81 1.31 2.22 M. 1 1.20 2.80 .20 1.25 4.00 4.40 1.00 2.08 M. 2 2.20 1.51 .50 1.79 6.00 5.22 1.50 2.54 P. E. 1 it .48 .16 .91 .48 P. E. 2 1.46 .28 1.15 .59 TABLE XXIII (Continued) Gains Taps in Tapping in l / 3 min. fatigue ratios I. Q. Healy Score taps P.E. ratio P.E. Pts. P. E. Pts. P. E. Av. 1 .09 .03 .02 .50 1.035 .94 5.85 .92 Av. 2 9.93 1.89 .065 1.66 3.14 1.71 3.36 .87 M. 1 0. 0. .015 .38 1. .99 7.75 2.54 M. 2 11. 2.09 .09 2.50 3. 1.63 1 .26 P. E. 1 3.10 .04 1.10 3.05 P. E. 2 5.26 .036 1.84 3.88 In Table XXIII are collected the results discussed in the foregoing chapter. The mean results are expressed in terms of P. E. and as gross values, so that the various tests may be compared. CHAPTER V. SUMMARY The results obtained from the experiment may be summar- ized as follows: 1. Six months after operation for adenoids and tonsils, there seems to be a slight but not very reliable gain in weight as the result of the operation. After twelve months this has increased; indeed, it has very nearly doubled. 2. Gain in height, resulting from operation, is so slight as to be unreliable. This gain does not increase during a sec- ond period of six months. 3. The height-weight-age relationship is an excellent measure of the physical well-being of the child. The figures expressing this relationship show no very reliable gain in the first six months, but improvement increases considerably dur- ing the second period. 4. The test group shows no gain over the control group in strength of grip. There seems on the other hand to be a slight loss; which does not decrease in amount during the second period. 5. Speed of tapping did not increase during the first peri- od, any more for the test group than for the control. During the second period, however, there is a marked improvement. 6. Operation for adenoids and tonsils does not lessen fa- tigueability as shown by the tapping test. The probability is, however, that the test is at fault. 7. No rise in I. Q., as a result of operation, makes itself evident after six months or after twelve months. 8. There is no improvement in the performance of the Healy test either after six months or after twelve. 9. In every test except grip and tapping, there is a marked increase in the variability of the gains after the second period. This is possibly due simply to the fact that the longer interval 68 THEIR EFFECT UPON GENERAL INTELLIGENCE 69 permits the intervention of more extraneous factors which may influence the scores in one direction or the other. 10. A group of 236 children with diseased tonsils showed equal distribution of I. Q. with a group of 294 children who were normal in this respect. CONCLUSIONS The article by MacPhail, which has been reviewed in a former chapter, showed pretty conclusively that the removal of adenoids and tonsils was followed by improvement in school work. That such improvement was not due to a rise in gener- al intelligence can be concluded from the present experiment. That efficiency in school work does not rest wholly upon in- telligence has been demonstrated more than once. The ten- dency here noted to improve in general physical tone may, per- haps, serve as a sign of the factor upon which such improve- ment depends. Improved health means better attention, bet- ter emotional response, greater resistance to fatigue, and probably increased efficiency. Interesting investigations of such improvement in efficien- cy might be made by administering educational tests to groups similar to those of the present study. The results of such an experiment would be exceedingly instructive, and would be more significant than conclusions drawn from school marks. By this means also we might determine along what special line efficiency is most affected. Since there was no recuperation in intelligence resulting from operation for adenoids and tonsils, it is reasonable to expect that there had been no retardation from which to re- cuperate. This supposition is borne out by results of the sta- tistical study, wherein we found that a group of children suf- fering from diseased tonsils possessed equal intelligence with a group which was free from such defect. We can say to physicians, then, with fair amount of assur- ance, that removal of adenoids and tonsils will probably not raise to any great degree the intelligence level of the mentally defective child who is brought to him. We can say to students of the constancy of the I. Q., that it is not greatly lowered by adenoids and diseased tonsils and we may say to the clinical psychologist that these defects have no demonstrable effect upon general intelligence, whatever effects they may have on 70 ADENOIDS AND DISEASED TONSILS: volitional and emotional normality, the two elements which, along with intelligence are necessary for the maintenance of the individual as an instrument of social efficiency. f -...\ UC SOUTHERN REGIONAL LIBRARY FACILITY A A 000027845 7