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68
Clinical Report.
In the report of 1930-31, an investigation into the value of tonsillectomy in cases of juvenile rheumatism
was reported. An analysis of 544 cases was undertaken mainly to find out whether tonsillectomy had any value
in the prevention of the onset of juvenile rheumatism, but it also revealed certain suggestions with regard to the
progress of the disease after tonsillectomy. The summary was as follows :—
(1) There is no definite evidence that tonsillectomy is of value in preventing the onset of juvenile
rheumatism.
(2) There is some evidence to suggest that tonsillectomy may modify the severity of the disease as far as
cardiac involvement is concerned. In chorea it is less common to find an associated cardiac lesion after
tonsillectomy.
It was realised that some of these suggestions were not in accordance with the evidence produced by some
other workers, notably that of Dr. Leonard Findlay, Dr. James Macfarlane and Dr. Mary Stevenson, reporting
cases seen at the Department of Paediatrics, Glasgow University, and Royal Hospital for Sick Children, Glasgow.
These workers agree that tonsillectomy may modify the severity of the juvenile rheumatism as far as cardiac
involvement is concerned, when the manifestation of the disease is arthritic, but they do not agree that the
same modification holds good in the case of chorea. Their conclusions are as follows :—
A preliminary tonsillectomy or one performed early during the course of the infection may possibly, in
the case of arthritis, render the heart less liable to be attacked, but not so in the case of chorea.
Tonsillectomy in the case of carditis following arthritis seems to have a beneficial effect on the progress
of the disease, but not so in carditis following chorea.
It was decided therefore to undertake further investigations on these lines, as it was realised that in some of
the cases mentioned in the previous analysis a long enough period had not elapsed since the onset of juvenile
rheumatism or of chorea on which to base statistics relating to the progress of the disease.
All the cases now reported have been under observations for a minimum of two years since the attack discussed
in the report, and in all cases where no carditis has been noted there has been chorea or a definite arthritis ;
pains in the limbs only, however suggestive it is that these pains are rheumatic in origin, have not been included.
On account of the suggestion that the value of tonsillectomy varies in children in whom the manifestation of
rheumatism is arthritic as opposed to those whose rheumatism takes the form of chorea, three groups have been
taken. In all three carditis may or may not be present as will be shown in the sub-divisions :—
Group 1 Arthritic cases.
„ 2 Cases of chorea
„ 3 Cases of chorea and arthritis.
Each group is divided and then sub-divided as follows :—
P. Cases with no cardiac disease. (Potential cardiac disease.)
A. Cases with transient carditis during acute phase.
B. Cases with continued signs of cardiac involvement, but no symptoms of the disease.
C. Cases with signs and moderate symptoms of carditis.
D. Cases with signs and marked symptoms of carditis.
GROUP I.
Arthritic
cases.
Number
of
cases.
Classification
when
first
seen.
Classification
at least two
years later.
Progress in
reference to
cardiac
condition.
Progress in
reference to
general
health.
Tonsillectomised
later.
Nontonsillec
tomised
later.
Improved.
Unchanged.
Deteriorated.
Improved.
Unchanged.
Deteriorated.
I. Non-tonsillectomised
before onset of
juvenile rheumatism.
(a) Requiring
tonsillectomy.
(b) Not requiring
tonsillectomy.
II. Tonsillectomised
incompletely before
onset of juvenile
rheumatism.
III. Tonsillectomised
before onset of juvenile
rheumatism.
IV. Cases from Group
la tonsillectomised
before 2nd attack.
70
10
16
21
13
P 4
A 11
B 18
C 36
D 1
P 1
A 5
B 3
C 1
D —
P 1
A 3
B 9
C 3
D —
P 2
A 9
B 7
C 3
D
P 1
A 2
B 2
C 8
D —
P 3
A 7
B 26
C 14
D 5
P 1
A 5
B 4
C —
No
further
op.
p i
A 3
B 8
C 2
D —
P 1
A 9
B 10
C 1
D —
P 1
A 2
B 4
C 5
D 1
P —
A 4
B 7
C 4
D —
Complete
tonsillectomy.
P —
A —
B 2
C —
D —
1
10%
14
20%
1
6.2%
2
9.5%
2
15%
9
90%
51
73%
15
94%
18
85.5%
10
77%
5
7%
1
5%
1
8%
8
80%
41
58.5%
10
62.5%
16
76%
7
54%
2
20%
20
28.5%
5
31.2%
4
19%
5
38%
9
13%
1
6.2%
1
5%
1
8%