NECROSIS. 
By (I. P. W. BODPjCEBK, D.D.S., New York. 
(Read before the First District Dental Society of New York, March 5th, 1878.) 
I propose to speak to you to-night of the case alluded to a few 
meetings since, namely, necrosis of the inferior maxilla. I will re- 
capitulate its history. 
On the 27th day of Juno, 1877, the patient, a married lady, thirty- 
eight years of age, a native of France, applied to me. Her tempera- 
ment may be called bilio-nervous. The left eye protruded considerably 
from the orbit, the pupil was dilated to nearly twice the size of that 
of the right eye, and the patient was unable to use the other eye 
without shading or shutting the affected one. She complained of a 
had taste in her mouth since July, 1874. Her gums had been swollen 
for two days, in the region of the first and second molars of the lower 
jaw, on the left side. On the Gth of July, 1874, she had consulted an 
eminent oculist of this city, who (she says) told her that the protru- 
sion and partial blindness of the left eye was due to paralysis of the 
optic nerve. He applied electricity, and gave medicines internally, 
but without beneficial result. 
While under treatment a severe neuralgia developed, which in- 
volved the whole of the left side of the body, and continued with 
greater or less severity up to the time she consulted me. After the 
development of the neuralgia she had consulted further with a 
number of eminent general practitioners, but without gaining relief 
from the pain, bad taste, or disfigurement. 
I made a careful examination of her mouth, and found the first 
lower molar necrosed and loose. I advised the immediate removal 
of the tooth, which was assented to by the patient. I then dismissed 
the patient with the request that she would see me again. 
Fifteen days after, on the 12th of July, the patient returned, and, on 
further examination, I was convinced that this was a case of necrosis. 
1 made an injection of aromatic sulphuric acid into the socket, and 
informed the patient that the bone would have to be removed; that 
I believed the whole trouble originated there, and that perhaps, 
when it was taken out, she would he entirely relieved. The patient, 
greatly frightened, went to one of her physicians, who did not seem 
to understand the case, but took her to a professor of this city, and 2 
both denied the correctness of my diagnosis. The professor said he 
believed there was a tumor forming, and that which the dentist 
supposed was necrosis was nothing but a root of a tooth, which 
should be extracted. 
A few days after this the patient returned to me with a letter from 
the doctor, requesting the extraction of the root. I was surprised 
to receive such an opinion from such an authority. I reasserted my 
former diagnosis to the lady, and told her that both physicians had 
mistaken the dead socket, from which the tooth had been removed, 
for a root. 
For the satisfaction of the patient and myself, I invited her to see 
Dr. W. H. Atkinson, who, after examination, pronounced it to be an 
unmistakable case of necrosis, and advised a continuation of the 
aromatic sulphuric acid treatment every other day. For the removal 
of the debris, I advised the patient to use permanganate of potash, ten 
grains to an ounce of distilled water, taking a few drops of this in half 
a glass of water, and rinsing the mouth with it as often as necessary. 
After the ninth application of the acid I found a pretty large piece 
of bone loosening. I enucleated the yet attached periosteum and gum, 
and removed a sequestrum (measuring about one inch and a quarter 
in length) from the second molar to the first bicuspid tooth,—almost 
the whole mass, in thickness and depth, of the lower jaw,—leaving 
only the lower and outer border, and a very thin connection between 
the angle and symphysis, and involving the inferior dental canal, in 
which no living nerve nor vessel was present. I then rinsed the 
pocket with a solution of a teaspoonful of salt to half a pint of water, 
subsequently drying it with cotton, and again applying the aromatic 
sulphuric acid, and stuffing the pocket rather tightly with cotton. 
The next day the patient was in excellent spirits ; able to see with 
her left eye, and rid of the neuralgia, as well as of the bad taste. I 
dressed with wine of opium, using the aromatic sulphuric acid every 
third to fifth day, till the 14th of September. I then found, as I ex- 
pected, the second and first bicuspids loose, and extracted them, con- 
tinuing the alternate use of aromatic sulphuric acid and wine of 
opium. 
On the 24th of September I drilled away nearly the whole bone, 
from the second bicuspid to the canine tooth, leaving only enough to 
hold the jaw together. The part from which the first sequestrum 
had been removed was, by this time, almost filled by healthy granu- 
lations, and, on the whole outer side, had formed a sort of provisional 
callus, which enabled me to take away as much as I did without 
breaking the jaw. The patient, in this condition, was, of course, not 
able to eat anything but soft or liquid food. Continuing the dressing 
as before, small spiculse of bone separated and came out with the 
cotton dressing, or were removed by the forceps. 3 
On the 12th of November, the canine, and shortly after, on the 
24th, the central and lateral incisor teeth of the same side became 
loose, and were removed. After this my patient became so weak 
and nervous that I was obliged to give up the acid treatment, only 
using the wine of opium daily, after thorough cleansing with salt 
water, requesting the patient to take plenty of out-door exercise 
during sunlight, to eat oysters, eggs, etc., drink wine or porter; in 
short to live on highly nutritive semi-solid food. 
On the 15th of January, 1878,1 removed the rest of the dead bone, 
extending from the canine tooth to the symphysis. This I accom- 
plished, as before, with the large round bur of the engine, leaving but 
a thin plate of the body of the lower jaw, which I was sure was healthy. 
After this I made a few more applications of aromatic sulphuric acid 
and wine of opium, and to-day the patient is well. She has had no 
more neuralgia nor bad taste; can see with her left eye, though not 
as well as with the right one; but she is satisfied, and I am too. 
How is it to be explained that such general disturbances arose from 
a piece of necrotic bone in the jaw? I think, in the following manner: 
By a reflex irritation of the inferior dental nerve upon the submax- 
illary and otic ganglia, which are in connection with the anterior 
branches of the superior cervical ganglion, and in direct connection 
with most of the cranial and some of the spinal nerves, the almost 
constant neuralgia, on the affected side, is easily explicable. The 
bad taste, I believe, had a double origin: first, directly from the 
necrotic point; secondly, from perverted action of the gustatory 
nerve, a branch of the inferior maxillary division of the fifth; lastly, 
as to the dilatation of the pupil, I think it resulted from paralysis 
of the iris and ciliary processes, the protrusion of the eyeball from 
a relaxation of the recti muscles brought on, I believe, by the irri- 
tation of the ciliary ganglion in connection with the third nerve 
(motor oculi), which supplies all the outer muscles of the eye, except 
external rectus and superior oblique, and the short ciliary nerves 
distributed to the ciliary muscles and iris. 
Now as to the microscopical differences between normal and ne- 
crotic bone. The successful study of the elements of bone-tissue 
depends very much upon the method employed. The proper exami- 
nation of bone-tissue originated in the second and third decade of this 
century, and was pursued by Howship, Havers, Henle, and others; all 
of whom resorted to dry bone, which they divided into thin slabs by 
the use of the saw, after which these were ground thin by a variety of 
devices, reducing each specimen to semi-transparency. Observations 
made in this way resulted in the theory of canaliculi bearing a solu- 
tion of lime salts, hence the name “ canaliculi calchofori.” In 1850, 
Rudolph Virchow and F. C. Donders applied the cell doctrine of 
Schwann to the explanation of bone-tissue. They sometimes used 4 
dry and sometimes fresh bone in their investigations, macerating it 
in dilute hydrochloric acid, whereby they liberated the elements 
of the structure more or less distinctly. The bodies so isolated 
presented, sometimes, nucleated structures connected together by 
branches; at other times, completely isolated bodies consisting of a 
central mass with projecting processes, and to these they gave the 
name bone-cells. Donders, in 1853, drew attention to the fact that 
bone-tissue had spaces filled by cell-like structures similar to those 
of other kinds of connective tissue. E. Neumann, in 1863, asserted 
that the so-called bone-cells were not the cells designated by Schwann, 
but spaces with offshoots having a more densely calcified wall than 
the other basal substance, and thus better able to withstand the 
reaction of solvents. These bone-cells are no other than the lacuna), 
and their offshoots the canaliculi. Virchow came to believe that the 
cells were inclosed within the lacunae, though without filling the whole 
space, and to this day adheres to the cell doctrine of Schwann, and 
claims it to be the only possible explanation of the bone-cells being 
inclosed in the lacunae and their offshoots, containing a fluid, and 
ascribing to them the property of life, forgetting that a fluid as such 
is not endowed with life. 
Inasmuch as the dry method of examination of bone-tissue pre- 
vailed exclusively up to the introduction of the wet method, by Hein- 
rich Muller, in 1856, it is not surprising that it is frequently persisted 
in to this day. The nearer to the living state the examinations can 
be made, the more instructive and definite will the observation be. 
Hence the dry method is fast falling into disuse among those making 
histological researches. 
In 1871, Edward Lang introduced the examination of living bone 
under the microscope upon the heated stage, by which he noticed 
amoeboid motion in bone-corpuscles. By this management the lacuna) 
were proved to contain protoplasm, but the nature of the contents of 
canaliculi he said nothing about. The method of examining bone- 
structure introduced by Heinrich Muller, viz., to decalcify bone by 
the use of a solution of chromic acid, is to be prefex-red. Fresh, living 
bone should be introduced into a solution of chromic acid of from a 
half to one per cent., to which may be added, to hasten the decalcifi- 
cation, on every second or third succeeding day, a few drops o.f dilute 
hydrochloric acid. The vessel should be emptied and the fluid re- 
newed about every fifth day. In this way bones are decalcified in a 
short time, and without considerable change. For thin bones two to 
three weeks are sufficient to soften them enough to produce sections 
of any degree of thinness by the use of the razor. Such sections may 
be stained by placing them in a solution of chloride of gold, of one-half 
to one per cent, in strength. An examination of such pi-cpai’ations 
will show that, within the lacuna) of the bone, nucleated protoplasmic 5 
bodies are to be seen, with finely granular offshoots extending into 
the larger canaliculi, where they are lost to sight. From the surface 
of the protoplasmic body in the direction of the basis-substance many 
conical processes protrude towards the small canaliculi, with which 
they blend. 
In 1873, C. Heitzmann described the net-like structure of proto- 
plasm, and also observed the same arrangement in the protoplasmic 
bodies within the bone. He describes the net-like structure thus : 
“ The nucleolus is connected with the wall of the nucleus, and this 
again with the granules by very fine threads, which are to be regarded 
as the living matter proper, while the fluid contained within these 
meshes does not possess the property of life.” 
One year before, namely, in 1872, this observer described and illus- 
trated a bone-corpuscle from bone in the early stage of inflammation, 
in “Wiener Medicinische Jahrbiicher,” 1872, Plate IX. Fig. 3. This 
plate shows very plainly the shining, nearly homogeneous-looking 
bone-corpuscle, with offsfioots in every direction, filling the whole 
caliber of the canaliculi. It solves the question of the contents of the 
canaliculi in bone, by direct observation. The living granular proto- 
plasm in bone behaves precisely as in other tissues under the influ- 
ence of the inflammatory process,—that is to say, the central mass 
becomes a shining and nearly homogeneous lump, the offshoots from 
which occupy the whole caliber of the canaliculi, and by this the 
analogy of bone to all other tissues is established. That is to say 
here, as elsewhere, the living part of the protoplasm forms a con- 
tinuous net-work throughout the whole animal body, in the meshes 
of which a more or less fluid basis-substance is found, differing in its 
chemical properties in different situations, which in bone is glue- 
giving, and infiltrated with lime salts. 
I have followed the methods, in my examination of bone-tissue, 
as above described. This enabled me, by the use of the razor, to 
obtain sections fit to be examined by an immersion-lens magnifying 
800 to 1000 diameters. I noticed that the canaliculi could be plainly 
seen in sections, the basis-substance of which had retained a small 
quantity of lime salts; in completely decalcified specimens, they are 
very faintly discernible. According to my experience, it is better to 
stain the sections with a solution of chloride of gold of the half of 
one per cent., whereby a better view of both protoplasm and basis- 
substance is obtained. Another good way is to stain the sections 
with carmine and haematoxylin. 
The results of my observations with high magnifying powers, 800 
-1000 diameters, are that bone-tissue presents faint parallel lines, 
dividing it into the so-called lamellae, within which we find the bone- 
corpuscles, the shapes of which vary according to the direction of the 
cut and of the lamellae. As bone-corpuscles are flattened lenticular 6 
bodies, we will recognize them in this shape in the front view only. 
Longitudinal sections through these bodies give a spindle-shaped out- 
line, small when cut near the boundary, broad when cut through the 
middle line of the lentil. A cross-section through a bone-corpuscle 
shows a somewhat irregular body. A cross-section from the compact 
bone of a lower jaw presents invariably bone-corpuscles in all three 
varieties. 
Figure 1 shows three bone-corpuscles from the lower jaw of a man 
about thirty years of age, who 
died of an aneurism. All three 
bone-corpuscles are drawn in 
the front view, as seen by an im- 
mersion-lens of T. Grunow’s, 
of this city, magnifying, with 
the eye-piece, 1000 times. The 
basis-substance I have drawn 
a little darker than a chloride 
of gold or hfflmatoxylin prepa- 
ration would appear under the 
microscope, but it will give a 
clearer idea of the whole. In 
Figure 1 we see three large 
spaces, showing a number of ray-shaped offshoots. Besides these 
coarse offshoots, innumerable extremely fine light ones are present. 
The larger as well as the smaller all communicate with each other 
in this way, forming a delicate net-work through the whole of the 
basis-substance. Within the three lacuna? of Figure 1 are present 
protoplasmic bodies. We observe in the center of the protoplasmic 
bodies a and b,—a shining, oblong nucleus in a, and a round one in b, 
in which the nucleoli are not distinctly visible. Around the nuclei we 
see a narrow seam, traversed by numerous very fine threads, which 
are cone-shaped. Their bases are directed towards the nucleus, from 
the periphery of which they arise, while their points are in connec- 
tion with the nearest granules of the protoplasm. Within the pro- 
toplasmic substance there are finer and coarser granules, all being 
connected with each other by very fine threads. The seam around 
the nucleus, as well as the spaces between the meshes of the threads, 
are observable, being much lighter than the latter. 
From the periphery of the protoplasmic body numerous thick 
offshoots enter the larger canaliculi, wrhich sometimes can be followed 
up until they communicate with the protoplasm of other large neigh- 
boring canaliculi. Besides these many very fine offshoots run from 
the periphery of the protoplasm contained in the larger canaliculi 
towards the basis-substance. Some of them can be seen to enter the 
fine canaliculi, but their course cannot be distinctly followed. Figure 
Fig. 1. 7 
1, c, shows a protoplasmic body without nucleus ; probably this has 
been cut near to its periphery without touching the nucleus. C. Ileitz- 
mann states that the nucleus, the granules, and the threads represent 
the living matter which fills all the coarse canaliculi. My prepara- 
tions show a much finer net-work within the basis-substance than C. 
Ileitzmann’s figure before alluded to. Though I am not able to dis- 
tinctly demonstrate the presence of living matter in the finest canal- 
iculi, yet, as we find it in all other kinds of connective tissue, I am jus- 
tified in assuming it. In normal bone the lacunae and canaliculi are 
not entirely filled by the living protoplasm. On the periphery of each 
protoplasmic body we see a distinct light seam, traversed by the 
offshoots, which, in a cross-section, only show the living part of the 
protoplasm in the center of the canaliculus, hence leaving sufficient 
space for the nutrient circulation. 
The minute changes of necrotic bone are very interesting, but it 
is impossible to study the differences between it and normal bone if 
the specimens be prepared from dry osseous tissue. 
I have made microscopical examinations of necrotic bone from the 
lower jaw, in the foregoing case, and from another piece from an 
upper jaw removed by Dr. Frank Abbott. The methods employed 
were exactly the same as before described from normal bone. In 
both cases the necrotic sequestra, as soon as they had been taken 
from the mouth, were put into the solution of chromic acid, and cut 
in due time. As these pieces were small, I imbedded them in a 
mixture of paraffine and wax (after the extraction of the water by 
treatment with alcohol for twenty-four hours), whereby I was enabled 
to obtain extremely thin sections, some of which I stained with chlo- 
ride of gold, some with hiematoxylin, and some I mounted unstained. 
The results of these examinations were as follows : 
The outer surface of the necrotic bone, which, to the naked eye, 
looked rough and eaten out, when brought under the microscope 
showed bay-like excavations, known formerly as “ Ilowship’s lacunae,” 
in which there was visible a granular mass mixed with pus-corpuscles. 
In the middle of the bone 1 found all the Haversian canals more or 
less enlarged, some showing the bay-like excavations. The contents 
of the Haversian canals were everywhere the same,—a conglomerate 
mass of darkly-shaded granules, which I was unable to stain with 
carmine. These masses are the same that we see in decomposition 
of organic matter,—“ micrococci.” Here and there some medullary 
corpuscles and multinuclear protoplasmic bodies (myeloplaxes of 
Itobin, giant-cells of Virchow) were recognizable. I did not see 
blood-vessels in any of the Haversian canals. In the necrotic bone 
I found the traces of former osteitis. The enlargement of the Haver- 
sian canals and lacunae are direct proofs of this; the dissolving out 
of the basis-substance on the periphery may, on the contrary, have 8 
been due to chemical changes, produced by infiltrations from the 
neighboring inflamed tissues. Billroth has shown that if pieces of hone 
or ivory are driven into living hone, in which they excite inflamma- 
tion, they will afterwards exhibit a peculiar dissolving out of basis- 
substance analogous to that which wo see in the primary stage of 
inflammation. The Haversian systems and concentrical lamella) were 
unchanged. The lacuna) and canaliculi were yet preserved. In the 
necrotic preparation from the lower jaw I observed many lacuna), in 
which the protoplasmic body, with its living net-work, was yet dis- 
tinguishable, especially where the sequestrum had been attached 
to the periosteum. I found also, in the preparation from the upper 
jaw, some comparatively unchanged bone-corpuscles. But the ma- 
jority of the hone-corpuscles, and especially in the neighborhood of 
the Haversian canals, had the ap- 
pearance of a Homan numeral II; 
they werq either empty, or their 
protoplasmic bodies were shriv- 
eled up (probably the remains of 
the living matter), only showing 
a few coarse granules, illustrated 
in Figure 2, a, b ; but no signs of 
fatty degeneration could be seen, 
for the granules were stained violet 
by chloride of gold. Many lacuna*, 
as in c, showed no structure at all, 
the contents looking rather like a 
mass of coagulated albumen. In none of these lacuna) was the char- 
acteristic structure of protoplasm recognizable. 
To sum up my observations, I found,— 
First. The lacuna* contain a protoplasmic body, with a distinctly- 
visible net-like arrangement, to be regarded as the living matter of 
the protoplasm. 
Second. The basis-substance is pierced by numerous coarse and 
fine canaliculi, communicating with each other, as well as with the 
lacunae. 
Third. The protoplasmic bodies, which do not quite fill the lacuna*, 
send offshoots of the living substance into the canaliculi, but can 
only be seen in the coarser ones. 
Fourth. In necrotic bone, traces of former osteitis are visible, but 
no blood-vessels present in the Haversian canals, which are filled with 
micrococci. 
Fifth. In necrotic bone, most of the lacunae contain no protoplasm, 
but either a coarsely granular or a structureless mass,—remnants of 
the living matter and coagulated albumen. 
Fig. 2.