Acute respiratory disease with special reference to pathogenesis, classification, and diagnosis

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Manson J. J Pediatr 1953;43:599-619

In this comprehensive review from 50 years ago, Manson proposes a classification system for acute respiratory illnesses in children based on the anatomic distribution of infections. Hence, he reviews in order viral and bacterial infections involving the larynx, tracheobronchial tree, lungs, bronchii, and bronchioles, emphasizing the not uncommon finding still recognized today of infections involving the upper airway progressing distally to affect the lower respiratory tract. Quite accurately, he describes the risks and consequences of secondary bacterial infections after primary viral respiratory tract disease. He also believes that a viral etiology exists for bronchiolitis but acknowledges the likelihood of “several causative viral agents.” Finally, he laments the lack of information regarding “viral behavior,” and by extension, the difficulties in isolating causative viruses in respiratory tract disease.

Manson's paper reflects a bias doubtless prevalent 50 years ago: that children are merely “little adults” and as such follow a similar clinical course of respiratory infections as adults with susceptibility to microbiologic pathogens identical to those found in adults. In fact, he relies heavily on several sources from the adult literature to describe causative agents of acute respiratory infections in children including a 1944 study commissioned by the Army and three studies by Reimann in adults from the 1940s. Current pediatric pulmonary textbooks^1., ^2. reflect subsequent studies describing age-specific differences in susceptibility patterns to different viral and bacterial pathogens an the subsequent clinical course. An important example of this is disease caused by the respiratory syncytial virus, capable of causing a severe, protracted illness in infants and small children but causing a mild coryzal syndrome in immunocompetent adults.

Manson's discussion of clinical and physical findings in children with respiratory illnesses is instructive. He emphasizes the importance of the physical examination and its daily, changing pattern as essential to diagnostic accuracy. The use of other “tools,” such as radiographs and laboratory studies, are merely suggested as afterthoughts and by implication, of use only as a last resort. His elegant, paragraph-long description of the physical findings in bronchiolitis is particularly evocative and is as accurate today as it was 50 years ago. In our current reliance on sophisticated microbiologic and radiographic techniques, perhaps we've forgotten, to some extent, the abundant clues provided by a careful physical examination.

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References 

1. Kending EL. Kendig's disorders of the respiratory tract in children. In:  Chernick V,  Boat T editor. Philadelphia (PA): WB Saunders Co; 1998;
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2. Pediatric respiratory medicine. In:  Taussig LM,  Landau LI editor. St Louis (MO): Mosby, Inc; 1999;
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