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Although two centuries have now passed since the association of angina faucium and rheumatism was first noted, their true relationship still remains in doubt. The uncertainty which shrouds the problem is best reflected in the difference of opinion with regard to tonsillectomy in rheumatic cases, a point on which the medical profession have never been able to agree.The original plan of removing septic tonsils in an attempt to eradicate or prevent rheumatic infection was based on a logical line of reasoning. But the method soon got out of hand and the operation was recommended by some enthusiasts in every case of rheumatism, regardless of the state of the tonsils and the condition of the patient. Many failures resulted and a reflection was cast on a method which at first was only intended for limited application. Reaction followed and there is now a fairly widespread disbelief in the operation as a potent factor in arresting the rheumatic process.Notwithstanding this there is still general agreement that rheumatic children are specially subject to chronic tonsillar infection. Those who desire statistical evidence of this have only to turn to the special Medical Researchl Council Report', or to the writings of Mackie2, Lambert3, Miller4, and St. Lawrence5. The percentage incidence of septic tonsils given by the last two authors, although working as far apart as England and America, is almost identical, namely, 83 per cent. and 82 per cent. This is the more remarkable since it is not always easy to exclude a septic tonsil and there is no accepted standard. Large tonsils are not necessarily diseased and it is often a small harmless looking pair with corresponding enlarged glands which harbours infection. Enquiry into a history of sore throats in rheumatic children (Poynton , 31 per cent. ; Bertram7, 28 per cent. ; Miller4, 33 per cent.), reveals a much lower incidence than the great frequency of septic tonsils would suggest. This is not surprising considering the evanescent and often painless nature of tonsillitis in childhood.

Intractable diarrhoea with failure to thrive for eighteen months. No respiratory symptoms, but large opacity in right hemithorax discovered on X-ray. Transferred for investigation and removal of tumour, aged 2 years 7 months. On examination: Fretful, wasted child with marked gaseous abdominal distension. Profuse sweating and considerable thirst. Brassy cough. No stridor. Fullness of right upper chest with impaired movement, dull percussion note and absent breath sounds anteriorly and posteriorly. Mediastinum displaced to left. Persistent hypertension with blood pressure 150/110 to 260/150. No abnormal neurological signs. Investigations: Urine: routine normal. X-rays of chest: uniformly dense opacity right hemithorax (Fig 1). Deformity right 3rd rib. Abdomen: multiple fluid levels in distended gutcorrected

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