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Report of the Medical Officer (Education)
159
way or other. In many cases suggestions have been made for treatment of a single paralysed limb,
for the improvement of some deformity, and for treatment of the children with tuberculous disease, in
the event of a recrudescence of the disease or development of an abscess.
Dr. Branson has summarised notes from 100 cases of organic heart disease in certain physically
defective schools. On the question of diagnosis he notes that it is seldom difficult to differentiate
organic from functional manifestations in the heart unless the physical signs consist of a systolic
apical murmur only. In this case it may be impossible to say with certainty whether the murmur
is due to organic disease or not. Soft systolic apical murmurs, often transitory, are very
frequently met with in childhood, especially, but not always, in weakly children, and since
experience shows that these murmurs generally prove to be not organic, all such equivocal cases
have been eliminated from this series. With regard to the diagnosis between congenital and acquired
lesions there is again seldom any difficulty, though the identification of the actual congenital lesion
present in a given case must often be more or less a matter of guess work. Leaving aside the
typical cases of congenital pulmonary stenosis about which there can be no mistake, the common
murmur significant of a congenital defect is a loud harsh systolic murmur heard widely over the
praecardial area and of maximum intensity either towards the middle of the sternum, or in the region
of the aortic valve. In the latter case it may be impossible to be sure that the lesion is not an acquired
roughening or stenosis of the aortic valve, but in the absence of a history of rheumatism and
of physical signs of incompetency of the valve the probabilities are in favour of a congenital lesion.
The ratio of congenital to acquired heart disease is shown by the fact that of the 100 cases 86
were acquired and 14 congenital.
Heart Disease
in Physically
Defective
Schools.
I. Acquired Heart Disease.—The sex incidence was as follows—Girls 52, Boys 34. It would
appear, therefore, that acquired heart disease is decidedly commoner among girls than boys.

The prognosis of chronic acquired heart disease in childhood is, in Dr. Branson's opinion,
governed by the following considerations:—
(i.) The mechanical disability.—In lesions of any standing, provided that compensation
is maintained (as is commonly the case among children well enough to attend school) the degree
of mechanical disability existing in a heart is accurately measured by the degree of resulting
hypertrophy. The position of the apex beat, combined with the sense of force imparted to the
hand laid flat against the chest over the heart, gives prognostic indications of far greater significance
than any consideration of the lesions alone, provided these are chronic and quiescent.
For example aortic regurgitation with little hypertrophy is more favourable than mitral regurgitation
with much.
(ii.) The risk of recurrent rheumatism or chorea.—This risk can only be appraised in general
terms. The more remote the original attack the less likely is a recurrence, and the younger
the child at the time of its first attack the more likely is it to be subject to recurrences.
(iii.) The life's work.—It is obvious that the prospects of health for a rheumatic subject
with a damaged heart turn largely upon the choice of occupation, for exposure and strain may lead
to the early ending of a life which in sheltered and sedentary surroundings might well have
attained the average expectancy.
In the case of school children the first of these three elements of prognosis is the only one
which can be estimated. Upon it is based the following statement of the prognosis in the 86 cases
under consideration. The term "Good" is taken to signify that the individual, given good fortune
as regards the items (ii.) and (iii.) above mentioned, may look forward to a practically normal existence;
the term "Moderate," that both life and usefulness will be seriously curtailed and that existence must
be one of semi-invalidism ; the term " Bad " that the prospects of the individual are chronic invalidism
and early death.
Prognosis—
Good 47
Moderate 17
Bad 21
Doubtful 1 (Disease apparently active).