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than 70 per cent. of such cases gross and permanent cardiac damage resulted. Fortunately
this type of onset is not very common, only 53 cases occurring in this series
of 1,000.
Even where there is no definite history of tonsillar infection, there is some evidence
that, when the tonsils have been removed prior to the first attack of rheumatism,
there is slightly less risk of severe cardiac involvement occurring. An analysis of 1,500
cases admitted to the rheumatism units showed that, of those children whose torsils
had not been removed before the onset of the first attack, 24.6 per cent. suffered
definite and somewhat severe permanent cardiac damage. On the other hand, in those
children whose tonsils had been removed, the heart was permanently and severely
damaged in only 18.9 per cent. of cases.