Disinfection of the Skin of Operation Sites

factor is taken into account in the design of the study or the analysis of the data.This conclusion is re- inforced by the occurrence of most of the deaths from rheumatic fever (10 of 14) among cases with pre- existing heart disease, and the absence of deaths among the cases without heart involvement at start of treatment.No comparisons have been made with the conflicting reports of results obtained with large-dose hormone therapy, 7-l the most recent of which shows no advantage in a well-controlled study.11A firm deci- sion on the efficacy of large-dose hormone treatment of rheumatic fever will depend on controlled studies of adequate size in which the initial status of the heart is taken into account.Summary A study has been made at the end of five years after the conclusion of treatment of the 497 children who were admitted to the U.K./U.S. co-operative clinical trial of the relative merits of A.C.T.H., cortisone, and aspirin in the treatment of acute rheumatic fever.Four hundred and forty-five of the cases (89.5%) were followed for the complete five years, and the status of the heart was known for 426 of them.Only 16 (3.2%) had died, 14 of them from rheumatic heart disease; 36 (7.2%) were untraced.The very low fatality rate is striking.At the end of five years there is no evidence, on the treatment schedule used in this study, that the prognosis has been influenced more by one treatment than another.This confirms the findings reported at one year.The major factor in determining the incidence of rheumatic heart disease at the end of five years is the status of the heart at the time treatment was begun.For cases without carditis initially the prognosis was excellent, since in 96 % there was no residual heart disease.In cases with carditis initially, but without pre- existing heart disease, the proportion without residual heart disease decreased progressively from 82 % for those with only a grade 1 apical systolic murmur to 30% for those with failure and/or pericarditis.In cases with pre-existing heart disease the prognosis was poor.Only 30% of those without pericarditis or fail'ure and none of those with pericarditis and/or failure were without heart disease at five years.Cases with carditis and without pre-existing heart disease which had recurrences demanding retreatment during the follow-up period had on the average a more severe cardiac status at start of treatment than did those without recurrences requiring re-treatment.At five years a larger proportion of these re-treated cases had murmurs.These results make it clear that treatment of acute rheumatic fever cannot be properly evaluated unless the status of the heart of the patients at the start of treatment is taken closely into account.