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C. Cases which had not had tonsillectomy or in whom the first onset of symptoms was before tonsillectomy.
This group was not divided into those with healthy tonsils and those with unhealthy tonsils owing to the difficulty
of making this differentiation accurately.

Cases in Group C who had complete tonsillectomy later, and who have developed further symptoms since
that date are as follows:—
1 developed more severe heart lesion.
1 developed chorea.
1 had a second attack of chorea.
8 had a second attack of juvenile rheumatism with cardiac involvement.
28 continued to have rheumatic pains.
Although the percentage of cases in which a diagnosis of Juvenile Rheumatism was made is higher in the
group which had not had tonsillectomy than in the group which had had complete tonsillectomy (71 per cent. to
56 per cent.), it cannot be shown that tonsillectomy is of any marked value in preventing the onset of rheumatism
in children, for it will be noted that out of 60 children who had had complete tonsillectomy 18 developed
rheumatism for the first time after the operation. Also 38 children, who had not had tonsillectomy at their first
attack, showed further rheumatic symptoms after the operation. Most of the children who had definitely
infected tonsils during their first attack have had tonsillectomy at a later date, but in a number of cases such a short
time has elapsed since the operation that no conclusions can be drawn.
It does appear, however, that tonsillectomy has had some beneficial effect in modifying the severity of the
disease as far as cardiac involvement is concerned. Out of 219 rheumatic children whose tonsils were intact,
there were 18 cases or 8 per cent. classified as severe, whereas in the other group only one out of 34, or 2.9 per
cent. was severe.
Also of the 7 cases of chorea whose onset was after complete tonsillectomy, none had carditis (although one
developed carditis during a second attack which was after tonsillectomy), whereas of the 40 cases before tonsillectomy
nine or 22 per cent. had an associated heart lesion.
This modifying effect upon the severity of the disease does not apply to chorea.
The 45 cases in which incomplete tonsillectomy had been performed are omitted, as in some the throat
appeared healthy, although some tonsillar remnants were present, whereas in others the throat was definitely
unhealthy.
Age and Sex.
The Rheumatism Scheme of the Royal Borough of Kensington concerns itself only with children under the
age of 16 years. The youngest child in the series was three years old and the eldest 15 years old. The ages of
rheumatic children when first juvenile rheumatism was definitely diagnosed is shown in the table below and
reproduced graphically on the next page. In the first Annual Report the ages when first the children presented
themselves at the clinic was represented, so that the average age was older than in the present graph. The
highest peak is at eight years, and there is a secondary peak at 12 years.