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Mrs. Jacobson, the honorary secretary of the clinic, has learned to take the electrocardiograms and the
physicians wish to express their thanks to her for her most valuable aid. It would have been impossible for the
physicians to have taken more than a very limited number of tracings without her assistance owing to the large
attendance at the weekly sessions.
Clinical Report.
In the Fifth Annual Report, the result of an investigation into the value of tonsillectomy in the treatment
of juvenile rheumatism was given. The conclusions were as follows :—
(a) There is some evidence suggesting that preliminary tonsillectomy, in those requiring this operation,
may modify the severity of juvenile rheumatism as far as cardiac involvement is concerned in
those in whom the manifestation is choreic, as well as those in whom it is arthritic.
(b) The progress of the disease is the most satisfactory in cases who have healthy tonsils.
(c) In those whose tonsils are unhealthy, there is some evidence to suggest that preliminary
tonsillectomy is beneficial as far as the progress of the disease is concerned both in choreic and
arthritic cases.
It has been suggested by various authorities that tonsillectomy is apt to precipitate an attack of juvenile
rheumatism, especially of chorea. It was decided to investigate this point. The number of cases who have had
tonsillectomy and in whom we should know the immediate history is 114, of which 24 are cases of chorea. The
history of three children who had an attack of rheumatism within six months of tonsillectomy has been carefully
investigated. There is also one doubtful case.
1. There are no children who had juvenile arthritic rheumatism for the first time within six months of
tonsillectomy.
2. There are two children who had chorea for the first time within six months of tonsillectomy, and
one doubtful case.
Case 1.
Onset of chorea four months after tonsillectomy.
Case 2.
Choreic movements noted five days after tonsillectomy.
Case 3.
In this case, the notes are not absolutely clear. It is thought, however, that the tonsillectomy took place
after the onset of chorea. Unfortunately, it has not been possible to trace the case.
3. There is one child who had a relapse of arthritic juvenile rheumatism four months after tonsillectomy.
4. There are no children who had second attacks of chorea within six months of tonsillectomy.
The two cases in which attacks occurred four months after tonsillectomy can hardly be attributed to the
operation. The only case therefore that might be said to have been precipitated by tonsillectomy is the case of
chorea which is said to have begun within five days after the operation. It could, of course, be argued that this
is too early a response for the tonsillectomy to have been the cause, and it is also possible that the chorea was
present to a mild degree when the tonsillectomy was performed. A child is admitted for the operation, and it
is naturally nervous, and the definite choreic characteristics of the movements are not noted until a later date.
From these investigations, therefore, there is no definite evidence in support of the theory that tonsillectomy
is likely to precipitate attacks of juvenile rheumatism.
Although the cases supervised at the clinic and the number of attendances have increased this year, it was
thought that the number of acute cases seemed to be diminishing. Investigations have, therefore, been carried
out to ascertain whether this was correct. In Table 1 only cases which are definitely diagnosed as juvenile
rheumatism have been included in the figures and only the new cases coming to the clinic have been compared.

In this comparison, it will be seen that the percentages do not vary very much; indeed, in the years 1929,
1930, 1931 and 1933, they are almost identical. There is, however, a fallacy in these statistics. All doubtful
cases of juvenile rheumatism have been omitted. In the earlier years, cases which would have been classified
as doubtful at the time have since been proved by continual observation to be true cases of rheumatism by the
occurrence of an acute or sub-acute attack. They have, therefore, been included in these figures. The
observation of doubtful cases of the later years has not been continued over a long period, and it is certain that
a number of these will in future years prove to be rheumatic and should therefore be included in this table as nonacute
cases. It is possible, therefore, that the percentage of acute to non-acute new cases may be diminishing,
although it is unlikely that the change is very marked.