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Where the diagnosis is doubtful the child is kept under observation as a potential rheumatic. If the general
health remains good, that is all that is necessary. Should the child lose weight, be languid and easily tired or
lose appetite, closer investigation is arranged by the private doctor or the hospital.
It is also impossible to be dogmatic as to the early signs of cardiac involvement, authorities differ considerably
as to those signs, and much investigation has still to be undertaken, and our clinical knowledge enlarged before
there can be any certainty in the diagnosis of the earliest manifestations of rheumatic carditis.
*Dr. Carey Coombs believes that signs of cardiac insufficiency do not appear until the lesions are already
established and severe, the earliest symptoms being entirely constitutional not cardiac. In any case the presence
of a single sign, except perhaps enlargement of the heart, of which it is not easy to be certain when present to a
minor degree, does not always make the diagnosis clear.
For instance, should one examine a case and find the following signs present, one would have no doubt
that cardiac involvement was present.
(1) Tachycardia.
(2) Localised apical systolic murmur.
(3) An accentuated second sound in the pulmonary area.
(4) A mid diastolic murmur or audible third sound.
Taking these signs separately, however, it will be found that their presence as a single sign is not diagnostic.
Tachycardia. ,
Under this heading 414 cases have been analysed.

A comparison between the cases which were definitely juvenile rheumatism and the doubtful cases shows:-
All cases 42% were juvenile rheumatism 58% were indefinite cases.
All cases with pulse over 100 46.6% ,, „ ,, 53.4% ,, ,, ,,
All cases with pulse over 120.50% ,, ,, „ 50% ,, ,, ,,
The cases which were definitely not rheumatic are omitted as the object of the investigation was to ascertain
whether the pulse rate was markedly higher in the child definitely suffering from juvenile rheumatism as compared
with the case in which the diagnosis is not certain. As the pulse rate increased the percentage of cases
which were definitely rheumatic increased, but to such a small extent that tachycardia cannot be said to be of
much value as a diagnostic sign.
Apical Systolic Murmur.
Dr. Treadgold† has found that a localised apical systolic murmur can be detected in 50 per cent. of healthy
young people if examined after exercise, prone and in the left lateral position. The writer has had a similar
experience in examining healthy school children and statistics will be given in a later report.
Accentuated Pulmonary Second Sound
The pulmonary second sound is normally more marked than the aortic second sound in young children,
and a slight accentuation is not important as a diagnostic sign
Audible Third Sound
The presence of an audible third sound at the apex is thought by some authorities to be a sure indication of
active carditis, but even here Dr. Treadgold asserts "A triple rhythm is also of comparatively frequent occurrence
at the apex in the left lateral position without necessarily having any clinical significance per se" The writer
is of the opinion that, although this sign may not be definite evidence of rheumatic cardiac involvement in the
child suffering from pains which may or may not be rheumatic in origin, it is, however, a sign which does not
occur in an absolutely normal heart.
Value of Tonsillectomy in Rheumatism Cases.
An analysis of 414 cases.
These are divided into three groups.
A. Cases in which the first onset of symptoms was after complete tonsillectomy. The date of cardiac
involvement in relation to tonsillectomy is often not known, but in rheumatic cases of this group there was no
history of pains before tonsillectomy, although there was often a history of constant colds and sometimes of
tonsillitis.
B. Cases in which the first onset of symptoms was after incomplete tonsillectomy.
* Carey Coombs. British Medical Journal. Feb. 1930.
† Treadgold. Proceedings of Royal Society of Medicine. Vol. xxiii, 1930.