Clinical oral surgery

CLINICAl, ORAL SURGERY"" By THEonoR Bl,UM, D.D .S., :M.D. (PENN.) ,

NF,\V

YORK Crrv

Universal Medieina(! Doct or {Vi en tui} , FA .C.D., F..iI.C.S.

being' mainly a clinician, cannot be exp ecte d to write a paper T HonEtheauthor, pathology or bacteriology of the subj ect he wishes to present. On the contrary, it will be a r eport of a small numb er of interesting cases with which to emphasize certain points of importance to th e practitioner in daily routine work. It so happens that all the cases cited give the writer an opportunity to recommend particularly one main thought in the treatment of our patients, namely, conservatism . os'rEO:.\lYELITIS C A!;.E

1. t-Osteomyclitis of th o mandible.

F. S., femal e, aged fl, February 24, 1926 .

Chie f CQmplaint .- Pain and swelli ng of mandible from a ngle to angle. About six weeks ago , the patient had a toothache (l eft mandibl e) and the f ace became swollen. The physi cian advised hot applications externally but th e swelli ng spread. An x -ra y showed a honey-comb . condit ion of th e bon e ( F ig . 1). E xternal examination showed a swelling f rum angle to angle of the mandible but wit hou t r edne ss extern ally. 'I'he submaxillary gland was

6T

f3

and were loose and pus was exuding from swollen and sensitive. The tee th betw een this space. All mandibular te eth wer e loose; on the right buc cal si de, th ere was fluctuating swelli ng . Th e floor of th e mouth was also s wollen with ver y little redness. Th e patient could open a nd close the mouth easily . February 24, 1926, th e pati ent was admitted to th e hospital with a temperature of 101. (1° F . an d blood count of 2,760,000 red cells and 6,450 whit es. Th e next day, und er gas and et her anest hesia, th e sof t tissues a ll the buccal sid e were stripped off to a ffor d better dra in ag e and a ll deciduous teeth anteri orly to llril were removed . Th e bone was necrotic but not sequestrated. Dressings wer e changed a t intervals of for ty-eight hours and two weeks later t he patient left the hospital. Two weeks a f te r her discharge from the hospital, the patient presented herself with a swelling and tenderness in the left mandibular region. Blood count showed 4,100,000 red cells a nd 20,800 whites. Patient was r eadmitted to the hospital on March 26, 1926, when an external incision was made at the angle of the left side of the mand ible. Nine days later a large sequestrum was removed. At intervals of a few days, sever al small sequestra wer e removed f r om the left side of the mandible and about ten days later th e right side of the face became swollen and the patient was ag a in placed in the hospit al. An ex te;'na l incision was made under ga s and ether ane sthes ia ( Apr il 28, 1926) , at th e r igh t mandibular angle an d a. large amount of pus drained , The submaxillary a nd superi or cer vica l gla nds wer e f ound to he involved and t hese were drained. Several small sequ estra wer e al so r emoved. At th e sam e operation, the old in cisi on on the left side was enla rge d and addition al sequestra r emoved. At intervals, sequest ra wer e r emoved f or t he next six months when th e pat ient was again placed in th e hospital and under ga s and et her (N ovembe r 5, 1926 ) t he anterior border of the left a scend ing ramus was opened and three larg e sequest ra comp rising th e coronoid and cond ylo id 'Read before th e Scien tific Sectio n of Oral Surger y of th e F irs t Distr ict Dental Society. Sta te of New York. Mar ch 23, 1927. t The historie s report ed in thi s pa per were compiled fr om h o s p ita l a nd ome" record s by Dr. Robert M. Fi sch er. 42:)

426

Theodof Blum

proce~ses

removed. The left second molar and germ of the third molar were also removed. Since the last operation, the patient has shown marked improvement and oue week ago the

pulp test showed all remaining mandibular teeth were vital except (Fig. 2).

1"5 which

is doubtful

Fig. 1,

Osteomyelitis of the mandible or maxilla is a splendid example of.a condition in the treatment of which anything but conservatism is disastrous.

Clinical Oral S1tryery

427

F'ree drainage and watchful waiting arc indicated. Wherever pus is found, a surgical incision is made; whenever bone is separating as a sequestrum, it is removed. Occasionally an osteomyelitis is produced by an early incision and curettage in case of an acute periostitis, which without surgical interference would most likely have disappeared in due time. Curettage of painful and of so-

Fig. 2.

called dry sockets is frequently followed by infection of the surrounding bone, ending in the formation of sequestra. Many teeth can be saved during the treatment, especially permanent ones even though not fully developed. Assuming the responsible tooth has been removed, one should not hurriedly sacrifice all loose teeth-as most of them

428 l'h eodor Bluni

Clinical Oral SII/'f/cry

429

will be dur-ing the acute ~taw~-but rather wait for the subsidence of the acute symptoms, after which quite a few will become firm and continue to develop to become useful members of a damaged masticating apparatus. When the condyle and neck of the ascending ramus have been sequestrated in growing' patients, shortening of the afIected side can be largely prevented by continuous and faithful exercise. This consists of opening and closing the jaws either straight up and down or preferably somewhat toward the sound side and also keeping the closed jaws in proper (normal) occlusion, This exercise performed three times daily sufficiently stimulates the parts to new bone formation and restores fairly normal function.

Fig. ;"

POLLICULAR CYSTS CAS~] 2.-~'0Ilicular

cyst (originating from :3 I).

M. G., male, aged 3:3 years, November,

1918.

Chief Co-mplaint.-For the past ten or fifteen years the patient has had a slight swelling in the mouth, but no pain. Recently some teeth were extracted and a few days ago the mandible eommenced to swell. The patient also complained of considerable pain, which was also quite recent. The profile had the appearance of prognathism, although the bite was normal, due to the extension and distension of the outer cyst wall (Fig. 3). There was

i

3T

fluctuating swelling from (; to 1'5 inclusive and was missing. Upon aspirating and then incising, a large amount of cyst fluid containing cholesterin crystuls, polynuclear leucoeytes and fat globules was washed out. Blood and urine negative.

Th codor B l um

430 given.

Operation, on N ovember ~3, l!Jl S, right a nd left muudibulu r and bucca l infiltra t ion were Incis ion W :l S ma de n bo ut 1Jl em, below the g ingh-al bor der f rom to an d outer

tiT

fG

plat e and cyst wall rcm overl ; 3j (u nerupt ed ) was a lso r emove d (1<'i g . 4 ). On th e righ t si de the cyst exte nd ed 10 t he muudibnlur eUIl!11 exp osin g a bout one inch of this nerve a n a th e mental br unch es (Fig. :i ). The cyst mem br ane in thi s r eg ion was r emo ved to allow a clot to form ar ound th e lH'ITe. T he inner half of t he cyst meurb raue was le f t i nt act a s were all t he t eeth ( F ig s. 6 and 7) . CARE

3.- 1"oll it ulnl' cys t ( orig ina ting from

I :i ) .

A. L ., mal e, n Ke,l fifty -two, Apri l,

1924.

Fig- . 4 .

Chief Complain t.- Pat ient had n ot iced a swelli ng in t he mandible f or some time. T wo weeks ago, t he barber call ed a t t ent ion t o it a nd patient went to dentist who a dvised op eration.

71

17

'I' he out er plate of the mandi ble, exte ndin g fr om to bu lge d markedly. T he skin und lower bo rd er wer e no rr nnl. 4 1 fw d a nd -16 were mi ssing. P ra ct icall y th e entire lower buccal f old \\": IS obli t era t ed by the bu lg ing of th e ou ter pl ate. Ther e wa s a parch-

13

ment -lik e crepltnt ion of th e I'rotl'l Hlin g- p late. uri ne n ega ti ve, Opera tion, A p ril] 1,

1 9~ j ,

Pu lp test showed 4.3

I :"j

uon vi ta l,

Bl ood a nd

a b ila teral ma ndib ula r unest hesia wa s g iven and also b ucca l

in filtrati on. Se\'(~rn1 c.c. of da rk re d In-ow n fluid wer e as pi rat ed in r eg ion of 3j . I n cis ion wa s ma de a t th e lowest p oint of th e fir m att a chme nt of t he gingiva from molar regi on on t he right to mo la r regi on on t he lef t. Outer pla te \Vn8 removed with cys t mem brane attached to it , re vea li ng a cys t r-nvi ty con t nini ng a soft , pa sty m a ss of choleste ri n

i3

crystala a nd considera ble reddish brown fluid (Fig. S ) . which caused the cyst was found .l ying horizontall y a long" the l owes t pa rt of th e cys t a n d had t o b e chi seled fr OID the low er b or der of th e mandi ble to wh ich t he ey st cav it y ex t en de d. T h e w ou n d w as p a ck ed with iod of orm g a u ze w ithout d is tu r bin g t he remain in g cy s t membr an e a n d th e flap was fold ed in,

4:31

Ciinical Oral Slll'gel'y

6T to

One month after the operation all the teeth from were then treated and the roots filled (/<'igs. P and 10).

[3f.

CASE 4.-Follicular cyst (originating from

["7

were found to be nonvital and

M. H. C., male, agell forty-six, July,

1926. Chief CMllfilaint.-l'atieut compluined of tenderness aud swelling in the anterior part of the mandible. When thirteen years old, the patient struck his chin while playing. A few years ago a spot tender to touch was discovered in the chin. There was a slight swell-

ing in the left mental regiou. labially from

2T

to

T5

if]

and

I3

were missiug.

inclusive and also lingually.

There was a marked swelling

There was also fluctuat.io» from the

buccal side through to the lingual in the apical regioll of Wassermann negative.

61

und ;)

I.

Blood, urine and

Fig. 5.

Operation, September 22, 1926, cunservu tive cyst operation was pei'fonned removing only malposed 8

+

25

13

(Fig. 11).

7 +

6 M

25

[)

+ 25

Columbia pulp test .Iuly 2:" 1921; showed the following:

4 +

3 +

25

25

2 + 40

1 + 40

1 + 40

2

+ 40

;,

4

M

+

5 +

~5

2fi

6 +

2;)

7 + <)~u

8

+

25

(Fig. 12) The central and lateral incisors responded at a higher index indicative in this case of marked pulpal changes though not devitalized. Cameron pulp test December, 1926, showed the following: 2 1 2 7 543 a 4 ;) 6 31 29 28 27 26 25 23 22 21 20 19 17 M +7 +7 +6 +7 +7 +1) +6 +[J +10

All teeth respond pared with 7 or 6.

III

varying \]('gn'l's as iudicated.

10 is a

Wl'~'

low response as com-

l'heodol" Blum

432

Radicular and follicular cysts are treated either radically or conservatively. Only in the larger cysts-particularly the ones adjoining the antrum or nasal chambers-the conservative treatment is employed, namely, the removal of the outer plate of bone and cyst wall, leaving th'e i~ner cyst wall in position; in other words, transforming the cyst cavity into a shallow accessory cavity of the mouth.

Fig. 6.-Condition of jaw 8 years 4 months after operation.

F'Ig; 7.--Condition

or jaw 8 years 4 months after' opera.tton,

A considerable number of follicular cysts develop from malposed mandibular canines. In these cases most of the teeth in the region of the cyst have remained vital and therefore can be saved (Fig. 13). If the apices extend into the cyst cavity or are likely to be injured at the time of the operation, their root canals should be filled before and their apices amputated at the time of the operation (seE' I<~ig. 9). Aft.er the operation the vital teeth

Clinical Or«! SUI"!JCI'!1 sho uld be pulp te st ed a t r eg-ul ar intervals on accoun t of th e p ossibility of loss of vitality du e t o injury durin g th e operation. It ma y not he ont of pl a ce t o mention her e th e case of a follicul ar cy st origi na t.ing fr om a supe r n umern rv tooth locat ed in th e wa ll separ at ing th e cys t. hom th e a 111rUllI. 'I'he tw o cavities w('rc communica t ing, an ext re mely

r a re occurren ce, due t o an ac ute infec t ion in th e cys t, th e con t ents of whi ch br ok e through th e point of least re sist allee-ill this ins ta nce throu g-h th e thin m embranous wall ab ove meutioncd-s-iuto th e antrum, M ULTILOCUI ,AR CYS TS ·

CASE 5.- M ult ilocula r cyst ( r igh t side of m andibl e ). Decem ber 14, 191 5.

H. \V., m al e, ag ed th ir ty -six,

Chie] C011l pltl illl.-S wellin g of r ig ht s ide of f a ce. Wh en patient was one a nd one -ha lf yea rs 01,1, he 11 :1<1 a swell ing on tlo(' r igh t sirl... of t l,,' neck. T'h is W:I1l opera te d upo u, hu t

434

T heodor RI1I111

Clinical Urul SUl'very

435

recurred sixteen years later, He again underwent an opcra tion and for twenty years had no further trouble until six months ago when a swelling appeared in the same region. A tooth was removed without helping t ho eonrlition-in tact the swelling became larger. The x-ray revealed a cyst (l<'ig. 14). 'I'he face was swollen in the I'cgion of t he Tight :lngle of the mandible. There was a

71

sinus through the socket of disdwrging a Iirownish fluid. The swelling was very hard. This was operated UpOIl December 20, H1l8, under ether arid the cyst curetted. 'rile inner and outer plates of the ascending ramus mal the body up to ::tj were entirely gone. The patient left the hospitnl one week lntcr aJl(1 wns discharged a few months later (Fig. Iii).

Pig. lO.-Comlition of jaw 2 ,years 11 months after operation.

Approximately four years af'tor the last operation, the patient returned with pain and swelling in the same region ns be f'orv. }>dcrn:illy the appearance was normal except for a slight fulness over the mussetcr musc!e. Iutraorully there was a mass about 2 em, long and Ph em. wide in the retromolar t rin nglc J't'gion. The mass was movable and cartilage-like and the mucous membrane over it 1I01'1llnl. Two months later the anterior border of the asccuding ramus presented marked fluctuation and the area 'Preyiously noted had enlnrgcd considerably. Under general anesthesia (May 17, 1923) an incision was n.ad« along t h« nnterior border of the ascending ramus to the region of

61' and

a large part of coruuuid process as well as alveolar process

in the region of 8-7-61 removed. The cystic area \vas completely curetted. 'I'he wound was partly sutured and packed. Two weeks Intel' radium treatment was commenced and up to

'l'hcvtl vi' l U I/III

406

th e "resell! th ere ha s (we ll 110 re'''I1"1"e111'(', a ll ho llg h a slls l'i, ·illllS urea ramus wi ll he kept und er obsorvatio u ( F ig . 16 ) . C ASE 6 .-~IuJti locu lar <'Y8t ( r ig ht side of mandihle ) :

Jun e

1 ~,

ill

l lu - ri g-ht hori zouta l

B, :\1., f emal e, :Ig l'rl twenty -seven,

19 19 ,

Clii r ] (' olllplllillt.-- f' IH'll illg of till' right s id e of the fa Ct'.

F ig . ll.

On e year ago, th e pat ien t felt something sna p in the r igh t side of th e mandible whil e eat ing, hut ignored i t. E ight mont h s later, she visited her de nt is t who re moved 11 to oth ami some growth in t h e sam e r egi on. A swelli ng re sulted , whereup on she cons ult ed a g eneral surgeon who aspirated som e flu id from th e region of the sw elling, but the swelli ng continu ed to in cr ease. T here was no pain except at night. J<'luid and a section of the growth t aken fr om the first m olar region of th e r ight side of th e mnudi ble wer e di agnosetl microseopienl ly as cys t fluid :lJul ndumnnt.in om u, re spectively . A la rge illCisi oll wa s m nrlo in tIll' l'E'gion of

Clinica! 0 1'1I1 S Il I'gCI'!J

c-i

n bf.

~

e
n

i£;

437

438

T heodol' m nm

th e ascending ra mus t o r elieve t he s welli llg n nd es tnblillh d ra inage. 'I' he p atient wa s ad m itted t o u hospituI t wo mon th s ]a te l' wh ere , un der gns 11/ \( 1 eth er (.J un e 4 , 191 9) , a n in tra oral in cisi on wa s mad e :lnd t he e ntil'e cvst me rnbrn ne curetted ( F ig . 17 ). Dressin gs wer e cha nged at f or ty ,eig h t h our iu t vrvals u iul Dobc ll ts so lution us ed as a mouth wa sh , 'I'hree weeks la ter th e x-ruv J't'\ 'eal ,',l small ('ys l k nrou s i ll th e a nte rior p urt of th c a ffe ct ed region ( Fig , I S ) awl t hre e mon t hs lut r-r <1"11lllt,, sig ns of recurrence were seen . Eight mon th s a fte r th e first opcrn t ion , th e pa tient 'V:lS :lg aJn p lnced ill a hos p ita l and on F ebruary Il, 1 !l ~ O , und er local nnes t hesin ( mnndibuln r a nrl bu ccal ) , t he cyst membrane wa s curett ed a nd iodoform g:lllz e dressin g s i nse rt ed. Th e s pec ime n wns aguin dia gn osed a s multil ocul ar a da ma nt ino ma . Fortunately later on, th e s peci me n re move d f rolll th e cys t by a previous opera to r was ob t a in ed for mi cro scopic cxu m luntion. It showed :1Il nrru u gnme nt of cells ver y mu ch rc sembling the solid ndamnritin orna ( ~'ig, 10).

CASE 7_-MultiIocula l' ('y st ( ndnma n tinom u, left side of ma nd ible ) . f orty -nin e, Oct ober, 192 5.

A. S. , male, aged

Chief Comp laint . -P a tie nt compla ined of s welli ng of left. side of fa ce ill the r egi on of th o mandibl e. Seve nte en years ago pa ti en t. had s \\'e lling of t he sa me re g ion acc ompa nie d by p ain. At t ha t t im e cy st ic fluid was a sp ira ted fr om the j a w. P atient h a s had five op erations

since .

Ab out three ye a rs p rev iou s t o t he onse t of th e swelli ng'

18' wa s

ext ract ed.

'I'he pati ent presented himself wi th a swt' lli ng extendi ng fro m below the zygoma on th e left side to the lower bo rder of th e ma ndible a nd f'or wu rd t o with in 1 em. of th e side of th e n ose. The skin was uorm ul. Lnt ra orn lly the. swelling begu n in th e regi on of I II a nd extended linguall y a nd bu cea lly ba ck t o th e a nterior pillar of th e fa uces, U was covered by normal mu cous m embran e e xcept in one pl ru-e nl oug th e I'jdge wh er e the re wer e s ome

Clinical Ora! Suryery

4:19

granulations. There was marked fluctua lion (Fig. ~()). Blood, urrnc and 'Wassermann negative. Patient was placed in a liospitul awl under general anesthesia (October 14, 192;';), an external incision was made a nd the buccal wu 11 of the maudlble removed, membrane cnretterl and remn in der of the (':lYity c:·l11tniz(',l.

Fig. 1;;.

Fig. IG.

Following this operation a thin fluid was noticed constunt ly present in the wound. One month later a fluctuating mass 3% em. by ~% em. was noticed along the left mandibular ridge in the premolar region. Eleveu weeks Intor, under local anesthesia, this was incised and a cyst exposing the mandibular dell tal nerve and its mental branches was curetted (Fig.

440

l'h eodol' Blum

~1 ) .

On e week la ter, th e putieut wa s referred for ra rlium trea tment a ft er an ot her ~eetiCJn ha d been exa mine d a nd di agn osed as a dru uunt inomn.

At p r esent ( Ma rch 22, 1927 ) , th ere is a ve ry noticeabl e flu ctu ating s\\'elling in th e left c!tpek J URt a n te rior t o t he as cendi ng ra mus nud between th e mu udi hle and mnxilla, a ll p ointin g t owar d R r('('lllTe ll('e ( F ig . 22 ) .

Fig. ]7.

Fig. 18.

Th e treatment of multil ocular cysts is r adical , whi ch means that every part whi ch is visible to th e nak ed ey e mu st be r emoved . At intervals of from six months t o on e y ear, th e affect ed jaw mu st be r eexamiu ed and x-ray ed again and, if found disea sed , r eop erat ed upon . It is t he n not a r ecurren ce, but th e continued growth of fo r mer ly invisible cys ts .

Clini('({( Or« ! S urgery

441

If a multilocular cyst can not -b e era dic ate d by operation alo ne Oil acco unt of ext.re me in volvement of bon e a nd soft ti ssu es, then an ope ra t ion sho uld be per f or med firs t. a nd as m uch of the cys t as possib le r em oved , without disfigurement of the pa t ieu t a nd with out loss of f unct ion, fo llowed by th e use of radiu m, th e success of whic h has been show n in two cases repor te d above. At any rate, this treat ment sho uld be give n a trial. In on e case r epor t ed, the simu ltaneo us occu r re nce of a solid ad am anti nom a in t he mid dl e of a large mu ltilocu lar cyst str engt he ns t he a ut ho r in his belief th a t t he tw o a re ill real it y one pathologic cond it ion,

F i!; . 19. -C o nd iti on or jaw 7 yea.rs a rt er o pera ti o n .

'Wh ile th e maj or ity of cases arc found i n the mandibul ar ang le, t he author has also encountered one in t he h or-izontal r amus and ot her observers h a ve seen th em in the maxilla . The w isd om of per sistent regula r r eexamin a ti on cannot he d eni ed and must be impressed upon t he patie nt wit h great emp hasis. MAI,!GNAN'l'

T U ~I ORS

CASE 8.-Epidermoitl earcinoma (left side of the mandible ) , th irt y -seven , Se pte mbe r 13, 1921.

E. H'I f emale, agl'tl

442

'l'hcodo!' BtulII

Chief Complaint.-Swellillg in the region of the left side of the mandible. Two J'ears ago the left side of the face began to swell, increasing gradually in size but without pain. There mIS a s\ycl!ing extending from just anterior to the angle of the left" side of the mandible to the angle of the mouth. 'I'h« swel1illg does not extend below the lower

Fig. 20.

Fill'. 21.

border and the skin over it W:IS normal. 'I'he soft t issues were movable but a hard lump approximately 5 em. long and 2% em. high ('0111<1 be felt. Intraorally there was a mass about 1% em. anteroposteriorly along the nlvcola r ridge and 1 em. wide, which had a eauliflower appearance, but was hurd and not very Y;lSCU!a.r. 'I'he tumor extended down to the mylohyoid ridge. Thc crowns of the teeth ill the maxilla struck this mass when the mouth was closed (Fig. 23). Blood, urine and Wasscnuauu negative.

Clinical Oral Surgcry

443

Under local anesthesia, November 1;;, Hi21, an incision W;IS urade in back of the posterior extremity of the tumor, starting at the anterior border of the ascending ramus and extending forward through the buccn limucoua membrane to the lwemo]ar region. 'I'he incision was continued Imguully, but not cnu nected posteriorly. .Iust posterior to the mental foramen, the mandible was divided with a Gigli saw, but the posterior part of the tumor had to be chiseled out en musse. Sntuj'(~s ;11)(1 a pneking were inserted and the jaws wired together.

Fig. 22.

Fig-. 23.

The specimen was diagnosed as cp idermoid carciuomn.

(f~pithelioma.)

Two weeks later, radium treatment was commenced. 'I'lu-aa weeks after tlte operation pus appea red below the middle of the lo\ve)' border of tlte mandible nnd twenty days later, a sequestrum was removed. Eleven wreks affer the operutiou tl,e wires were t.ikcn off. There was no recurrence (Fig. 24).

l'heodol' Blum While the treatment of malignant tumors must necessarily be radical, still a certain group of cases call be taken care of, apparently successfully, without disfigurement or loss of function. More can be accomplished by radium and x-ray followed by operation than any other method known to the author. Carcinomas of the mucous side of the cheek, the floor of the mouth,

Fig. 24.-Condition of jaw one year 2 months after operation.

others beginning at the mucous membrane covering the alveolar ridge and involving the bone, etc., have remained without recurrence for at least four years, and-nota bene-without having' undergone operations, the results of which would have kept the patient secluded on account of the disfigurement and made him miserable on account of loss of function.

Clinical Orai &uryery

445

This treatment of ma.lignancies of the oral cavity, consisting of radium and x-ray followed by operation, is of course not always successful, but certainly more so than any other method. The case of epidermoid carcinoma reported was pathologically not a very malignant one and was operated on first and then treated with radium and x-ray as was thought best at that time. Fortunately, up to date no recurrence has been noted (Fig. 25). This discussion of diseases of the jaws is based on actual cases treated and should therefore accentuate the importance of the remarks made in their connection. The main reason or excuse for reporting' them is to preach and spread the gospel of couservatism. Good surgery is not radical. DI8UUSSION

Dr . .Armil~ Wald, New Yorl: City, N. Y.-It was indeed a great pleasure to heal' and see :111 that Dr. Blum so ably presented to us this eyening and there is little that I cun say, except in praise of his work und to ask you to think seriously 011 the point he atresses, namely that of good surgery. When the essayist speaks of radical and conservative surgery and their relative merits, he really has in mind goo(l smgery. When radical methods are imperative, he too is the advocate of them, and when conservative methods are indicated, the essayist, as we all, I am sure, would operate to conserve anrl restore, In malignancy, radical operations in and about the mouth arc beyond the field uf tl.« average oral surgeon and when these conditions progress to that stage where radical removal of all possibly infected tissue is imperative, I am sure that Dr. Blum will agree that it would be poor surgery to be conservative, On the other hand, to interfere in this manner il~ treating an osteomyelitis, that is, to remove radically all tissue that might possibly become infected would certainly end disastrously and be poor surgel'Y. It is not surgel'y at all that leads the tyro to curette the dry socket, or to abuse the case of acute periost it is as described by Dr. Blum, and I doubt if anyone here present would advocate such procedure. "Fools rush in where angels fear tu tread." The importance of conservation of tissues of the mouth and the restoration of diseased tissues is the constant problem of the dentist am] the oral surgeon. The disfiguring results of radical surgery, the unsightly depressions so IndUing to tluart of the posthodontist can ofttimes be avoided by conservative operations which though less spectuculur are most gratifying in results. Conservation of tissue is as important in the mouth as in any other part of the body and to ruthlessly destroy that which elm he ('011served is not practising good surgery. Radical 01' conservative, there euu unly he une kind of surgery and that is good surgery.