Adenoids and Diseased Tonsils: Their Effect on General Intelligence

by Margaret Cobb Rogers

3304 Children, 10-14 years, grades 1-8

	Average grades completed	% lost
Children having no physical defects	4·94
Children having enlarged glands	4·20	14·9
Children having defective vision	4·94	0
Children having defective breathing	4·58	7·2
Children having defective teeth	4·65	5·9
Children having hypertrophied tonsils	4·50	8·9
Children having adenoids	4·24	14·1
Children having other defects	4·52	8·5

Cornell reports several investigations in the Psychological Clinic, January and May, 1908. Three of these, in which children were rated on the basis of grades received in school work, are here combined to show the grades of normal children, "average" children, generally defective children, those possessing adenoids and tonsils, and the deaf.

No. of cases	Normal	Average	General Defective	Adenoids & 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 Bright	Class 15 Children	Class 9 Dull	Class 11 Dullest
Number of children	50	39	32	29
Normal	36	32	20	13
Defective	14	7	12	16
Percentage of normal	72	82	62·5	44·8

In the same article, Dr. Cornell gives the results of another study of Philadelphia schools, made in 1906. The study comprised a comparison of children exempt from examinations on account of high standing, with those not exempt. The results follow:

	Exempt Normal		Children Defective	Non-exempt Normal		Children Defective
9th St. Primary	56		28	39		38
Rutledge School	87		35	75		34
Allison School	128		65	81		49
Camac School	183		71	103		75
Claghorn School	193		61	127		66
	647		260	425		262
Percentage Defective		28·8			38·1

When the four classes of bright and dull children were examined again, and the different sorts of defects compared for the groups, enlarged tonsils, adenoids, deafness, and nasal catarrh, were found to occur much more frequently among the two classes of duller children.

	Class 1 Bright	Class 15 Children	Class 9 Dull	Class 11 Dullest
Number of children	50	39	32	29
Nose and throat conditions, number defective	6	4	9	9
Tonsils	3	4	3	3
Adenoids	2	1	5	6
Deaf	2		5	1
Catarrh			2	3
Percentage of children, nose and throat defects	12	10·2	28·1	31

During the same year, another examination along the same lines was conducted in the William McKinley Primary School,[8] where a large number of dull children had been grouped in special classes.

None of these children were mentally defective, says Dr. Cornell, and only a few were really backward. The proportion of physical defect was found to be very large,—in 174 pupils, 188 physical defects (68 eye-strain, 40 nasal obstruction, 80 miscellaneous, 11 hypertrophied tonsils.) In a special class at the Wharton school, numbering 22 children, 14 of the children suffered from adenoids, associated in 3 cases with enlarged tonsils. Since no comparison is made with normal classes, this survey cannot be regarded as conclusive.

Wallin, in his book, "Mental Health of the School Child," discusses several other investigations of the relation of intelligence to physical defect. Only those studies in which were included adenoids and tonsil conditions will be reviewed here. Those by Ayres and Cornell have been described above.

In Elmira, New York, says Wallin, "an investigation of repeaters in the second grade showed that 21 per cent of those who required three years and 40 per cent of those who required four years to complete the grade had adenoids, as against only 19 per cent of those who required only two years to do the grade."

Another study described by Dr. Wallin was made by Heilman in 1907 of 1000 Camden repeaters. The correlation between pedagogical retardation and percentage of defect in each group was as follows:

Defects	Retardation
	1 yr.	2 yr.	3 yr.	4 yr.	5 yr.
	Per Cent
Health	16·5	21·3	28·0	19·0	37·5
Nutrition	13·4	8·9	17·2	20·2	17·5
Adenoids	6·2	7·3	8·1	9·6	7·5
Speech	5·2	5·1	4·2	10·5	20·0
Visual defects	15·5	15·9	18·2	22·8	22·8
Auditory	8·2	6·7	4·9	6·1	10·0

Burpitt[9] describes an investigation of 400 children, 200 male and 200 female, considered by their teachers to be "dull and backward, but not to fall within the meaning of feeble-mindedness as given in the Mental Deficiency Act of 1913." The children were examined for physical defects and other abnormal conditions. The author says that in 36 per cent of the cases, the cause for backwardness was found to be "inherent dullness." (The basis for judgment of inherent dullness is not given.) Adenoids and tonsillar tissue were found in 18·75 per cent of the cases, and were "more prevalent than among the children of the area as a whole."

The degree of retardation, based upon the number of school standards below normal, was ascertained for pupils who suffered from various defects. The relative retardation was expressed by the fraction n/(A-5) where n = number of years retarded, and A = age. Eighteen per cent of the children were so retarded that the fraction was greater than 3-9. These were divided into two groups,—3-9 to 4-9 and 4-9 to 5-9. The results are given in the following table:

Causes	46 children 3-9 to 4-9	24 children 4-9 to 5-9
Inherent dullness only	8	3
Inherent dullness and one or more physical defects	7	2
Irregular attendance with one or more physical defects	9	6
Irregular attendance	2	3
Adenoids only	2	0

Turning to what the author calls single causes,—present in 170 cases out of the 400,—

Causes	151 children 1-9 to 3-9	19 children 3-9 to 6-9
Irregular attendance	51	6
Adenoids	24	2
Inherent dullness	59	11

The term "cause" seems to be rather loosely used in this study. The author says concerning this,

"Dealing with physical defects first, although they amount in the aggregate to 53 per cent (omitting defective speech, which is a secondary condition), in 10 percent only do they represent the whole cause. This is made up of those cases where the defect is of such intensity as to produce retardation in otherwise ordinary children, and of other cases of less intensity, but sufficient to weigh down the balance against those near the level of what we may call for convenience the lower limit of normal intelligence." How he determines, without removing a defect, what the child's intelligence would be without it he does not explain.

The following table compares the physical condition of two groups, one comprised of children examined in the regular routine examinations during the year 1912,—the other a group of retarded school children, given a special examination:—[10]

	Group I	Group II
No. of children examined	287,456	1,541
No. with physical defects	206,720—71·9%	1,383—89·8%
No. of defects found	226,639	2,986

Defect	No.		%		No.		%
Anaemia					335		23·0
Malnutrition	8,303		2·9		557		36·1
Defective vision	21,078		9·3		536		34·7
Defective hearing	1,206		0·5		47		3·0
Defective nasal breathing	21,931		7·6		316		20·4
Hypertrophied tonsils	30,021		10·4		297		19·2
Defective teeth	142,168		49·4		796		51·6
Pulmonary disease	335		0·1		47		3·0
Cardiac disease	1,597		0·5		35		2·3
Average No. of defects per child		1·1				2·5

In an investigation of 3,587 exempt and 1,418 non-exempt children in the Philadelphia schools,[11] Dr. Newmayer found the following percentages of defect:

	Exempt Children		Non-exempt Children
Defect	No. Examined	%	No. Examined	%
Defective vision	371	10·0	171	12·0
Defective hearing	49	1·4	29	2·0
Defects of nose	54	1·5	21	1·5
Defects of throat	137	3·8	53	3·7
Orthopedic defects	25	·7	25	1·8
Mentally defective	6	·1	80	5·6
Skin diseases	918	26·0	423	30·0
Miscellaneous	214	6·0	128	9·0
Total	1,774	49·0	930	65·0

It is evident from the majority of these investigations that there is some relationship between physical defects and pedagogical retardation. But whether or not the relationship is a causal one, they do not indicate. Simple co-existence of two characteristics is not necessarily significant that one is cause of the other. Plainly, though, if the removal of a physical defect is followed by improvement in the school progress, it may be argued that the presence of the defect was a causal factor in the previous retardation. The method in the few following studies, which seems to be employed to a greater degree than formerly, consists of measurement of such improvement.

The Journal of Psycho-Asthenics, March and June, 1918, contains a paper on the "Results obtained from the Removal of Tonsils and Adenoids in the Feeble-minded," by Wm. J. G. Dawson, M. D. The author starts out rather discouragingly by regarding his hypothesis as an axiom. He says,

"It is a well-known fact that hypertrophy of the tonsils and presence of adenoids may produce more or less dullness of the intellect in normal children. This is a result of the imperfect aeration of the blood which supplies the brain, on account of obstruction to respiration. In the Feeble-minded, conditions are more or less similar."

One hundred and twelve cases in the Sonoma State Home, Eldridge, California, were operated on. Of these 6 are recorded as borderline, 39 as morons, 50 as imbeciles, and 17 as idiots. Adenoids were always removed when they were present. The results of the operation are as follows:

	Number before Operation	Number after Operation
Mouth breathing	43	31
Eneuresis	33	32
Sore throats	70	2
Ear trouble	19	2
Change in voice		38	improved
Tonsillar tissue recurred in		5
General physical health		90	improved
		6	borderlines
		33	morons
		42	imbeciles
		9	idiots
Mental improvement from observation		27	improved
		4	borderlines
		15	morons
		7	imbeciles
		1	idiot

The inaccuracy of this investigation is evident. The mental improvement was measured by "observation," which is at best inexact, and susceptible to the influence of any expectation of improvement on the part of the observer. The degree of improvement is not mentioned, nor is the time interval allowed for the appearance of such improvement. There is no control group, and consequently, no way of knowing whether the improvement was due to the removal of the defect.

A similar, though rather more careful study is reported by Dr. Charles James Bloom in the New Orleans Medical and Surgical Journal for April, 1917. Dr. Bloom's experiment consisted of eighteen months' observation on the mental and physical state following the removal of adenoids and tonsils from one hundred and fourteen children. This number was later reduced to fifty-seven, because of the fact that a number failed to return. There was no selection, all the patients being taken as admitted.

The patient's physical and mental state was recorded at the time of admission. School reports were used as an index of intelligence. From this time on the patients were examined, weighed and measured at monthly intervals.

The ages of the children ranged from four to fourteen years, inclusive. Thirty-five per cent were under six years, and sixty-five per cent, therefore, over six. Twenty-nine were boys, twenty-eight girls.

Omitting a part of the study which though interesting has no bearing upon our problem, we turn to results in the way of mental status. There were fifty-seven cases, ten of whom were under the school limit. Of the remaining forty-seven, seven sent in no report. In four, or ten percent of the forty remaining, there was no progress. In thirty-six, or ninety per cent, appreciable progress was reported. One of the four unimproved cases was syphilitic, the other, the author says was a moron.

Quotation of the teachers' reports will be of interest.

"'Some improvement.' 'Better work than previous year.' 'More effort displayed.' 'Improved wonderfully.' 'Improvement first term, not so much second.' 'Before removal, not transferred; after removal transferred.' 'Very much improved, both mentally and physically.' 'Has made progress.' 'Remarkable improvement.' 'Not transferred before removal, but after.' 'More attentive.' 'A very small but gradual improvement.' 'Am happy to tell you that he is studying more since tonsils and adenoids were removed.' 'Greatly improved.' 'Attention better.' 'More concentration.'"

In this experiment like the preceding, the judges are liable to the effect of expectation of improvement. Although the reports are more explicit, they are still couched in general terms, and not commensurable. Some reports refer to intelligence and some to pedagogical standing. There is no control group.

On the basis of these results, the author concludes:

"Children exhibiting some alternatives in the normal histology of tonsils and adenoids, give marked evidences of mental impairment." This seems to be a rather sweeping statement in consideration of the number of intellectually superior children who suffer from adenoids and diseased tonsils.

Another investigation was made by Dr. Cornell in the Philadelphia schools,[12] where seventy more or less retarded pupils in grades one to four were operated on for adenoids. According to the teachers' reports—

30 per cent improved considerably.
40 per cent improved.
25 per cent did not improve.
1·6 per cent deteriorated.
3·0 per cent deteriorated considerably.
Of those who had two chances of promotion,
6·3 per cent were promoted twice.
16·0 per cent failed twice.
33·3 per cent were promoted once.
33·3 per cent failed once.
With one opportunity,
11·0 per cent were promoted.
31·7 per cent failed.

"The promotion record was thus decidedly poor. It is possible, however, that the time for promotion came before the orthogenic effects of the operations had become effective."

The same criticisms may be brought against this investigation as were mentioned in connection with the preceding ones. Teachers' estimates of improvement, especially when such improvement is expected, and without means of measuring it objectively, are necessarily inaccurate. Again there is no control group. Of even less value are the results of an investigation in New York City by Cronin, where, out of eighty-seven cases operated on for enlarged tonsils and adenoids, "many advanced three grades during the rest of the school year, and only three lost time."

An interesting study is one that is described by John C. Simpson, M. D., in the Journal of the American Medical Association, April 1, 1916.

Dr. Simpson's results are based on a study of 571 boys of Girard College who had been operated on for adenoids and tonsils. Improvement was studied along several different lines, among them scholastic ability. For this part of the study, 45 were chosen alphabetically, 3 from each section. The only selection was for boys who were operated on long enough after coming to school to give an idea of scholastic ability; and long enough before the present study to permit a judgment as to their improvement. Monthly averages were taken of each boy up to the time of the operation and from then to the time of this study. They were based on an average of 100 per cent. As a control group, there were chosen 45 boys who had had no operation, and who lived and worked under the same conditions. They also were taken alphabetically, 3 from each section.

The general average of the operative cases at the first measurement was 74·04. Of these 25, or 55·5 per cent gave an average increase in monthly standing of 4·45 after operation, while the remaining 20, or 44·5 per cent suffered a decrease of 6·09.

The average of the boys in the control group was 74·21 and for the first group after operation 74·06. "It is interesting to note," says the author, "that the standing of slightly more than half of those operated on was improved, but when compared with those not operated on, no difference is seen."

In a similar study of younger boys who had undergone the operation on entering college, and who had since had a year's study (again a group of 45), the general average was 76·61. Compared to 45 in the same classes not operated on, who had an average of 74·56, the operative group is very slightly superior, 2·05 points.

Another study of pedagogical improvement, and a valuable contribution, is that reported by A. H. MacPhail in Pedagogical Seminary for June, 1920, entitled "Adenoids and Tonsils; a Study showing how the Removal of Enlarged or Diseased Tonsils affects a Child's Work in School."

"The children studied were pupils in the Adams and Cranch Schools. Only cases were considered where there was a record of ten school months before the date of the operation, and where there was a record for at least ten month after the operation. There were thirty-one cases in all.

"School records were looked up for the ten school months preceding operation, and for each school month subsequent—up to the date of leaving school, or in the case of children still in school, up to the date of the study. There were thus longer school records for some than for others.

"The history of each case was divided into periods of ten school months each. Eighteen cases had a record of twenty months after operation and eleven cases of thirty months.

"Comparing the first period after the operation with the period before, it is found that only about one-third showed improvement, and a little over half were doing poorer work. By comparing an average of all work done subsequent to the operation with what was done before, it became evident that improvement in school work is not often observed until after a year from the date of the operation."

In the cases that had records for twenty months, 16 show that better work was done in the second period after the operation than in the period before.

TABLE A

Table showing where improvement begins.

	Per Cent of cases showing improvement
	Period 1	Period 2	Period 3
Based on 31 cases	32·2
Based on 18 cases	33·3	66·6
Based on 11 cases	36·3	63·5	100
Based on all groups	33·9	65·0	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 (operated upon)	32·2
Per cent of 100 children at random	42
B—Per cent of 18 children— 20 months (operated upon)	33·3	66·6
Per cent of 100 children at random	42	41
C—Per cent of 11 cases for 30 months (operated upon)	36·3	63·5	100
Per cent of 100 children at random	42	41	41

"... Immediately after operation, there seems to be a dropping off in the quality of school work done," but thereafter a marked improvement while the random group shows a comparatively static percentage of improvement from year to year. The conclusion of the author is:

"Here seems good reason to believe that the removal of diseased tonsils and adenoids is a factor in beneficially influencing the mental life of the school child. Not only is the health impaired by failure to remove these diseased parts but the mental life and activity of the child as well."

It is conceivable that pedagogical retardation might exist without any defect of intelligence. The physical effects of adenoids and tonsils might produce a tendency to fatigue, an emotional instability and consequent lack in attention, which would seriously influence the quality of school work, even though the child were of normal or superior intelligence. The relation of physical defects to intelligence has been investigated experimentally by a method which will be employed to some extent in the present investigation. In the two studies to which I refer psychological tests, rather than school standings were used as a basis for judging the intelligence. In each the effects of treatment were measured, and in one, a control group makes possible a more accurate interpretation of results.

The first of these investigations is described by Wallin.[13] It was "an attempt to determine by controlled, objective, mental measures the influence of hygiene and operative dental treatment upon the intellectual efficiency and working capacity of a squad of twenty-seven public school children in Marion School, Cleveland, Ohio (ten boys and seventeen girls), all of whom were handicapped to a considerable degree with diseased dentures or gums, and an insanitary oral cavity." The experiment extended over one year, from May, 1910, to May, 1911. The treatment included corrective work upon the teeth and mouth, and also instruction in oral hygiene, and follow-up work by an employed nurse. Five series of psychological tests were given at stated intervals during the course of the experiment. They included tests of immediate recall, spontaneous and controlled association (opposites), adding, and attention-perception (cancellation). There were six sets of each test, numbered from one to six, of equal difficulty, and given under uniform conditions. Tests 1 and 2 were given before the treatment began, and the average was taken as the "initial efficiency." The last four, or the last two, were averaged to represent the pupils' "terminal efficiency."

The results show the following influence of dental treatment upon the working efficiency of the pupils.

1. The indices of improvement are about the same for boys and girls.

2. Improvement was about the same for older and younger pupils.

3. There were great individual differences in initial proficiency and in improvement.

4. Improvement in one test does not presuppose improvement in another.

5. There is a decided gain in every test, "and not only are the gains decidedly more frequent than the losses but the largest gains are invariably emphatically larger than the largest losses."

6. The average gains in the tests were:

Memory, 19 per cent with 8 losses and 19 gains.
Spontaneous association, 42 per cent with 2 losses and 25 gains,
Addition, 35 per cent with 1 loss and 26 gains.
Controlled association, 29 per cent with 0 losses.
Perception-attention, 69 per cent with 0 losses.
Average gain for all tests, 57 per cent.

Unfortunately, Wallin was unable to form a control group, so that it is impossible to estimate accurately how much of this gain is due to the treatment of the defect, and how much to other causes, such as growth, etc. "But," the writer adds, "if we concede that one-half of the gain—and that is, I believe, a sufficiently liberal concession—is due to a number of extrinsic factors, such as familiarity, practice and increased maturity, the gain solely attributable to the heightened mentation resulting from the physical improvement of the pupils would still be very considerable. There is corroborative evidence to show that there was a general improvement in the mental functioning of these pupils. This evidence is supplied by the examination of the pedagogical record of scholarship, attendance and deportment. Most of the members of this experiment squad were laggards, and repeaters, pedagogically retarded in their school work from one to four years, but during the experiment year only one pupil failed of promotion, while six did thirty-eight weeks of work in twenty-four weeks, and one boy finished two years of work within the experimental year."

The second investigation was equally careful in its method. It was pursued by the Rockefeller Foundation, under the direction of E. K. Strong, with the purpose of examining the "Effects of Hookworm Disease on the Mental and Physical Development of Children."

The children were divided into five groups and tested at intervals of three and one-half months. The tests used were opposites, calculation, logical memory, memory span, hand-writing, form-board, and Binet-Simon. After the first test-series was given, the five groups were divided into sub-groups on the basis of this initial performance, so that the improvement was compared only for those sub-groups in which this was equal.

The improvement of Group A—uninfected children—proved to be greatest, and was taken as 100 per cent. On this basis, Group B—infected children not treated—showed the least improvement,—only 34 per cent. Group C—children completely cured of infection—improved 60 per cent. Group D—severely infected children, treated but not completely cured—improved 38 per cent, and Group Du—an older sub-group of D—improved 9 per cent as much as the normal children, and much less than the untreated younger children. Dr. Strong reaches the following conclusion:

"The figures show, then, that hookworm disease unmistakably affects mental development. Treatment alleviates this condition to some extent but it does not, immediately, at least, permit the child to gain as he would if he had not had the disease. And the figures apparently further show that prolonged infection may produce prolonged effects upon mentality,—effects from which the individual may never recover."

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