Mental Changes After Removing Tonsils and Adenoids.
- Author:
Gladys M. Lowe,
University of Kentucky.
This paper presents the results of an attempt to measure the change in general mental alertness which followed the operation for diseased tonsils and adenoids. The comparisons made in this study involve the use of a control group with adenoids which did not undergo the operation. Only one other investigator has taken advantage of the fact that the best control group would consist of those suffering from the same defects but not operated upon. Three methods were used to determine the changes in mental ability; tests of mental alertness, teachers’ estimates of certain traits, and the actual scholarship records. Cornell estimates that about 8 per cent of school children suffer from diseased tonsils and adenoids. The prevalence and the easy correction of these defects make important the question of the mental changes after their removal.
There have been few studies attacking the problem in a scientific way. The four chief investigations are those made by Rogers (‘22), Terman (‘19), McPhail (‘20), and Cornell (‘12). See the bibliography at the close.
Doctor Rogers’ study of 28 children operated upon for defective tonsils and adenoids reveals no difference in the average I. Q. six months after the operation when compared with 28 children, of practically the same life age, possessing these defects. She says: “We find that the test group shows an average gain in I. Q. of 25 points. The median gain is 2 points, the total range 18 points and P. E. of the average is ?0.99. The control group shows an average gain very slightly higher, 3.25 points, the median gain being 3. The range in this case is 32 points, but P. E. is only ?0.47. The average of the compared gains of separate pairs is ?1.035… . Actually, we may say that the operative group as a whole showed no gain over the control group.” Retesting after one year 21 children available from each of the two groups, “the average gain of the test group was 3.09 points after twelve months, compared with 2.25 after six. The control group, however, made an average gain of 6.24 after twelve months, the gain after six months being 3.29. These numbers are insignificant as gains, but they at least show no improvement in the test group which the control group does not reveal as well.” This investigation was extended by comparing the I. Q.’s of a group of 236 children with diseased tonsils with a group of 294 children without this handicap. This comparison showed that the children of the normal group had as high I. Q’s. as those of the tonsil group. As shown by this investigation there was a small gain in weight, and also in the height-weight-age relationship for the operated group during the year following the operation. Other features of the study were tests for strength of grip, speed of tapping, and Healy’s Picture Completion test, number II. None of these tests showed a reliable gain in favor of the operated group, except speed of tapping, which did show a marked improvement.
Among children retested by Terman (interval between tests from a few months to seven years), using the Stanford Revision of the Binet tests, 27 children had diseased tonsils and adenoids removed. When the average I. Q’s. for the first and second tests were compared there was a gain of two points and a fraction. He regards this gain too small to be significant.
McPhaiPs study is based upon the school records of thirty-one school children. The scholarship records obtained ten months previous to the operation were compared with records obtained ten months subsequent to the operation. These showed that one-third of the thirty-one cases had improved. For a smaller number; namely, eighteen, the scholarship record for the second year showed that twelve had improved. Records for eleven of the original thirtyone cases were obtainable for the third year after the operation. These showed that the scholarship had improved in each case over the record obtained before the operation.
The results of this investigation are uncertain for it is not indicated whether or not the cases showing improvement the first year after the operation are in the main the same cases that showed improvement in the school year, and again in the third year following the operation. It is also questionable whether scholarship records taken in three different grades under different teachers are comparable. The study of Cornell concerns sixty-three school children. It includes three features; namely, age and grade at the time of the operation, mental improvement one year after the operation according to the teacher’s opinion, and according to the promotion from one grade to the next. He found that these children were strikingly retarded in comparison with the average of the different grades. In the teacher’s opinion forty-four had improved mentally, sixteen remained unchanged, and three had deteriorated. However, there were sixty-one who failed to be promoted a grade out of ninety-seven possible promotions. This means, then, that if the forty-four improved as estimated by the teachers, the improvement in some cases did not give them average ability as shown by the number who failed to be promoted.
The somewhat inadequate methods of some of the other investigations were partially avoided in this study by the use of a control group possessing the same defects as those removed from the operated group, and by the use of a standardized scale of tests of mentality. One hundred names of children, diagnosed by the city school physician as having diseased tonsils and adenoids, were taken consecutively from the records of the Lexington Public Health Nursing Association and were tested. Of this group sixty were available for testing after a lapse of one year. Twenty-five of this group of sixty failed to follow the recommendation for an operation. This group was used for comparison with the operated group of thirty-five. For statistical purposes the groups should have been paired according to life age. It was possible to pair only thirteen in this study, a group too small for results to be significant.
The Stanford-Binet test was given subsequent to diagnosis, always preceding the operation, usually by one or two weeks. All of the mental tests were given in the school buildings, and all made and scored by the writer, thus minimizing such factors as excitement and non-uniformity in method. In supplementing the testing by teachers’ estimates, each teacher was asked to think of the class (in which the pupil appeared) as divided into five groups of equal number, ranging from poorest to best,1 for each of the traits to be estimated. In an effort to select characteristics not measured by a mental alertness test the following traits were chosen: (1) companionship with fellows, (2) emotional self-control, (3) initiative, (4) self-expression (speech), (5) interest in school work, (6) attention, and (7) scholarship. As a final means of comparison of the two groups for the two years, the actual grade of the child and the average grade of the class in which the child belonged were obtained from the teacher.
When the two groups are compared as to the average increase in I. Q’s. we find no significant difference. The average I. Q. for the control group in the first test was 83.0. One year later the average was 85.4, showing an increase of 2.4 with a mean variation of 4.0. For the operated group the average I. Q. was 89.2, and one year later the average was 90.7, showing a difference of 1.5 with a mean variation of 2.2. The distribution of I. Q’s. for the two groups were very similar. For the control group in the first test the range was i The Evaluation of a Method for Finely Graduated Estimates of Abilities. James Burt Miner, Journal of Applied Psychology, June, 1917, Vol, 1,133-133. MENTAL CHANGES AFTER REMOVING TONSILS. 95 Table I.?Distribution of Changes in I. Q. Changes in I. Q. Operated. Control. 17.0-17.9. 16.0-16.9. 15.0-15.9. 14.0-14.9. 13.0-13.9. 12.0-12.9. 11.0-11.9. 10.0-10.9. 9.0- 9.9. 8.0- 8.9. 7.0- 7.9. 6.0- 6.9. 5.0- 5.9. 4.0- 4.9. 3.0- 3.9. 2.0- 2.9. 1.0- 1.9. +0.0- 0.9. -0.0- 0.9. 1.0- 1.9. 2.0- 2.9. 3.0- 3.9. 4.0- 4.9. 5.0- 5.9. 6.0- 6.9. 7.0- 7.9. 8.0- 8.9. 9.0- 9.9. 10.0-10.9. 11.0-11.9. 12.0-12.9. Total N. Average Increase. M. V M. E Median q ;; P. E. of Median.. 1 1 0 0 1 0 0 0 0 2 2 1 2 2 1 2 1 1 5 1 3 3 2 1 1 0 1 1 0 0 0 35 1.6 3.9 0.7 -0.1 3.8 0.6 0 1 1 0 1 0 1 0 2 0 1 0 1 0 2 0 2 3 2 0 0 1 4 1 1 0 0 0 0 0 1 25 2.2 4.7 0.9 0.9 4.5 0.9
from 40 to 114, with a median of 87.5. The range for the operated group in the first test was from 50 to 113, with a median of 92.9. In the second test the I. Q’s. of the control group ranged from 40 to 129, with a median of 82.6. The I. Q’s. of the operated group ranged from 60 to 125, with a median of 91.1 one year after the operation. The difference in the average gain for the two groups shows the gain to be in favor of the control group of 0.6 of a unit of I. Q. However, a gain or loss of even two or three points in the I. Q. is insignificant. We may say then that after an interval of one year the operated and the control groups showed similar changes in I. Q. The distribution of changes in I. Q. is shown in Table I. The median change for the control group was 0.9 of a unit of I. Q. with a Q. of 4.5 and a P. E. of 0.9. For the operated group the median change was ?0.1, Q. being 3.8, and a P. E. of 0.6. This, of course, shows the difference in the median change for the two groups to be negligible.
Comparing the two groups as to their life ages, we find the average age of the control group, 9 years and 6 months, is one year and one month less than the average age of the operated group. The median life age, however, of the control group, 10 years 7 months, with a Q. of 3 years 7 months, is five months more than the median age of the operated group, 10 years 2 months, with a Q. of 2 years 6 months. The error of this difference, 5 months, is 9 months, which makes the difference negligible.
The distribution of changes in mental age for the two groups is probably a more important comparison as to the effects of the operation. It is shown in Table II. The difference in the average months gained shows an advantage of 1.1 months in favor of the operated group. This average gain of 1.1 months (mean variation 1.8) for the operated group in excess of the average gain for the control group is noteworthy because it favors the operated group. However, when the amount of this excess in the average gain for the operated group is considered, it can not be said to be clearly indicative of greater improvement in the operated group than in the control group. It is to be compared with its error, which is 1.8 months. The median change in mental age for the control group is a gain of 11 months, with a Q. 15.5 months and a P. E. of the median of 3.1 months. For the operated group the median change was 14 months, with Q. 11 months and a P. E. of 1.7 months. This shows a median gain of 3 months (P. E. 3.6) in mental age in favor of the operated group. The chances are even that there is practically this gain of 3 months.
Table II.?Distribution of Changes in Mental Age. Mental Age in Years and Months. Operated. Control. 2.7-2.12 2.1-2.6 1.7-1.12 1.1-1.6 0.7-0.12 +0.0-0.6 -0.0-0.6 0.7-0.12 1.1-1.6 Total N Average Increase, months. M. V M. E. of Average Median Q P. E. of Median 1 5 3 9 7 5 4 1 0 35 12.4 6.4 1.1 14 11 1.7 1 3 3 4 5 5 2 1 1 25 11.3 7.5 1.5 11 15.5 3.1
There are three chances out of four that there is some gain in mental age in the operated group over that of the control group, if we consider these median gains rather than the average gains. This slight excess gain in mental age favoring the operated group is a change not reported by any other investigator. None of the others have directly compared changes in mental age. It is probably true that in groups selected at random (such as these were) the mental age is a better measure of improvement than the I. Q., which is somewhat reduced by an increase in life age. Unfortunately, in the only other study in which the mental effects after one year are measured by objective tests the distribution of gains in mental age for the two groups is not given, so that no comparison of this criterion of change is possible.
The teachers’ estimates of the seven traits named above show an average rating slightly in favor of the second year for both the control and operated groups. For two traits the difference of the average change is in favor of the operated group (interest in school work 0.1 of a division and scholarship 0.1 of a division). These differences are too small to be significant. It is probable that the changes, if any, were not large enough on the average to be observable.
The average scholarship grade of the control group remained the same, “C,” for the two years, but the average grade of their Table III.?Distribution of Changes in I. Q. Rogers and Lowe. Changes in I. Q. Operated. Control. 26.0-27.9. 24.0-25.9. 22.0-23.9. 20.0-21.9. 18.0-19.9. 16.0-17.9. 14.0-15.9. 12.0-13.9. 10.0-11.9. 8.0- 9.9. 6.0- 7.9. 4.0- 5.9. 2.0- 3.9. + 0.0- 1.9. -0.0- 1.9. 2.0- 3.9. 4.0- 5.9. 6.0- 7.9. 8.0- 9.9. 10.0-11.9. 12.0-13.9. Total N. Average Increase. M. V M. E 0 0 0 0 1 2 1 1 2 3 6 4 8 5 7 7 4 1 3 0 1 56 2.2 3.8 0.5 1 0 1 1 1 2 2 2 1 2 4 3 4 5 3 2 6 4 1 0 1 46 4.1 4.9 0.7
corresponding classmates rose one scholarship rank, i. e., to “B”. The average grade of the operated group not only remains the same, “C”, but remains the same as the average of the classes represented, weighted for the number of pupils for such classes.
The average gain in scholarship rank was approximately the same for the two groups (0.2 advantage for the control group). When compared with classmates, the operated group compares more favorably, since they maintained the same average; whereas the control group fell one rank below the average of their classmates. The consistency between the estimated and actual scholarship records is not without significance. It seems to confirm the value of the method of rating used in this study.
Three cases were found in which there was a marked improvement in conduct at school and in scholarship. This, though not shown to be the general tendency, suggests possible secondary factors influencing improvement which should be investigated. Using data obtained from the two investigations carried out by Doctor Rogers and myself, Table III shows the distribution of changes in I. Q. for an operated group of fifty-six children and a control group of forty-six children. The average increase for the operated group was 2.2, with a M. V. of 3.8; for the control group. The average increase was 4.1, with a M. V. of 4.9. When the data is thus combined it indicates that the control group has gained on the average more in I. Q. than the operated group, as shown by the average difference of 1.9 units of I. Q. favoring the control group. This advantage of 1.9 for the control group shows a gain in the same direction as that found in my study (0.6 average gain in I. Q. for control in excess of operated). However, as discussed above, the nature of the I. Q. as a measure of change makes these small figures insignificant as indicative of improvement in either the control or the operated group.
Summary
1. There was a mean increase of 3 months (average 1.1) in mental age found to be in favor of the operated group. No other investigator has found any change in mental age as revealed by a mental test. The advantage was, however, only once its error. 2. The results show no reliable increase in I. Q. one year after the operation. 3. The non-operated group gained as much or more in scholarship than the operated group. 4. The teachers’ estimates of other mental traits revealed no difference one year after the operation. This may mean that 100 THE PSYCHOLOGICAL CLINIC. these were not adequate measures or that the changes in the traits were too small to be noticed. Bibliography. 1. Cornell, W. S.?Effects of the Removal of Adenoids.?School Hygiene May, 1909. 2. Gill, E. G., M.D., and Graves, K. D., M.D.?Tonsils from a Clinical and Medical Standpoint. Southern Medical Jour., June, 1921, pp. 39-41. 3. McPiiail, A. H.?Tonsils and Adenoids; A Study Showing How the Removal of Enlarged or Diseased Tonsils and Adenoids Affects a Child’s Work in School. Pedagogical Seminary, June, 1921, pp. 188-194. 4. Miner, James Burt.?The Evaluation of a Method for Finely Graduated Estimates of Abilities. Journal of Applied Psychology. June, 1917, Vol. I, pp. 123-133. 5- Rogers, Margaret Cobb.?Adenoids and Diseased Tonsils?Their Effect on General Intelligence. Archives of Psychology, No. 50, p. 70. 6. Simpson, J. C., M.D.?Tonsil Operations. Journal of American Medical Assoc., April 1, 1916, p. 37. 7. Terman, L. M.?The Inteligence of School Children. Houghton, Mifflin Co., 1919, pp. XXII+317.
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