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