Adenoids and Diseased Tonsils Part 2

Exempt Children Non-exempt Children

Defect No. Examined % No. Examined % Defective vision 371 100 171 120 Defective hearing 49 14 29 20 _Defects of nose_ _54_ _15_ _21_ _15_ _Defects of throat_ _137_ _38_ _53_ _37_ Orthopedic defects 25 7 25 18 Mentally defective 6 1 80 56 Skin diseases 918 260 423 300 Miscellaneous 214 60 128 90 Total 1,774 490 930 650

It is evident from the majority of these investigations that there is some relationship between physical defects and pedagogical r.e.t.a.r.dation.

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 r.e.t.a.r.dation. 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 r.e.t.a.r.ded 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.

16 per cent deteriorated.

30 per cent deteriorated considerably.

Of those who had two chances of promotion, 63 per cent were promoted twice.

160 per cent failed twice.

333 per cent were promoted once.

333 per cent failed once.

With one opportunity, 110 per cent were promoted.

317 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 a.s.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 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 7404. Of these 25, or 555 per cent gave an average increase in monthly standing of 445 after operation, while the remaining 20, or 445 per cent suffered a decrease of 609.

The average of the boys in the control group was 7421 and for the first group after operation 7406. "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 7661. Compared to 45 in the same cla.s.ses not operated on, who had an average of 7456, the operative group is very slightly superior, 205 points.

Another study of pedagogical improvement, and a valuable contribution, is that reported by A. H. MacPhail in Pedagogical Seminary for June, 1920, ent.i.tled "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 322 Based on 18 cases 333 666 Based on 11 cases 363 635 100 Based on all groups 339 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.