Osteomyelitis of the jaws in infancy treated with penicillin.

Osteomyelitis of the maxilla is a rare condition, about eighty cases having been reported since 1847. It produces a characteristic clinical picture, making recognition easy. Asherson (1939) in England and Lacy and Engel (1939) in the U.S.A. have given detailed accounts of the clinical picture and the differential diagnosis and have discussed the etiology and reviewed the literature. Their views on the treatment and prognosis agree fairly closely, but as these views antedate the use of penicillin, they are no longer tenable. The condition is practically confined to infants under the age of twelve weeks, whose previous history in relation to delivery and feeding is not significant. The condition has generally been progressing for several days before it is recognized as being one of more than mere local inflammation. In the present cases, this period averaged eight days. The characteristic feature is gross swelling of the affected side. In the case of the maxilla both eyelids are involved with proptosis and chemosis; the cheek is remarkably swollen and indurated. In addition there is frequently a unilateral purulent nasal discharge and occasionally pus discharges externally from below the inner canthus of the eye. Inside the mouth the alveolus and the hard palate are swollen and inflamed, and sinuses may be discharging either from the alveolus or the bucco-gingival fold; the bucco-gingival space may be markedly narrowed. When the mandible is involved the swelling is mainly in the submental region, whilst inside the mouth, although the lower jaw is affected, the condition is essentially the same. From any of the purulent discharges, staphylococcus aureus can be cultured. The etiology of this condition is not completely explained, since the portal of entry of the staphylococcus is unknown. Asherson (1939), Lacy and Engel (1939) and Mowlem (1944) agree that the bone infection is of haematogenous origin, though there is no record of a positive blood culture in their cases. Unfortunately in the first two cases here described this investigation was also omitted, but in the one case in which it was done a heavy growth of staphylococcus aureus was obtained within twentyfour hours. In the case of the maxilla, the bone infection is, on anatomical grounds, presumed to start in the tooth socket of the first molar. In mandibular infections the theories that have been advanced are 'diminution of local immunity' and ' specific organismal infection,' but as Mowlem points out these theories are ' meaningless and incapable of proof.' Although the tooth buds are not in close proximity to the vessels it is possible that the infection settles in a tooth socket.