The surgical treatment of chronic pulmonary suppuration in children with special reference to bronchiectasis

There can be no doubt, as has been pointed out by others, that the foundation of chronic pulmonary suppuration in adults is often laid during childhood. The radical treatment of this condition during childhood now has a reasonably low operative risk. This risk, with increasing experience, will become even less. Prevention of this condition is, of course, better than its treatment no matter how safe this may become. The group of cases that has as its etiologic agent a foreign body is the most obvious type for which preventive measures are useful. The aspiration of foreign bodies by members of this age group cannot be entirely prevented. The presence of a foreign body, however, should be recognized earlier than is often the case, and its removal effected at the earliest possible moment. In the cases of bronchiectasis in Group II, indications for operation seem clear and the prognosis seems good. But in considering Group II, it is important also to consider the cases cited of pulmonary gangrene. Would some of these have been, at an earlier stage in their disease, operable as regards lobectomy or pneumonectomy? As it is not possible to foretell which cases of pulmonary abscess, with or without chronic pleural infection, will go on to pulmonary gangrene, an earlier radical surgical attack might be made in some instances before the process has extended to such a degree that it is impossible to free the lobe or lobes without rupture of the lung. Many cases of lung abscess in children, however, clear up without radical surgery. It is probable that an earlier and more radical treatment of the so-called “chronic unresolved pneumonia” or “chronic pneumonitis,” that is associated with a fibrinous pleurisy but without appreciable free pleural pus, may prevent the establishment of a bronchiectasis or even gangrene. Further data, especially bacteriologic data, are needed before any absolute conclusions can be drawn as regards the time for election of radical surgery in this type of case. The most difficult sort of case in which to decide on the time for radical surgery is that exemplified by the cases of bronchiectasis in Group III. The duration of symptoms is usually long, and the symptoms are mild. There are a great many cases occurring in childhood in which the patient has repeated attacks of upper respiratory infection associated with cough, particularly during the winter and early spring. It seems unlikely that all such cases go on to bronchiectasis, or the incidence of the disease would be enormous. But do some of these children have a constitutional predilection to chronic pulmonary disease? Or may there be a particular organism that is a predisposing factor in the development of bronchiectasis? That the predominating organisms in the cases of bronchiectasis of Group III were the influenza bacillus and the streptococcus hemolyticus may or may not be significant. It is noteworthy, however, that in all these cases the post-operative course has been slow. The patients have had some mild and repeated attacks of upper respiratory infection since operation, but as yet there is no definite evidence of bronchiectasis developing in their remaining lobes. A good prognosis, however, cannot be assured. Complete and careful bacteriologic studies are much to be desired, and are now being carried out at this hospital. It is hoped that such studies here and elsewhere may give some reliable information on the etiology and prognosis of certain types of bronchiectasis in children.