THE BEGINNING OF ORAL PATHOLOGY, PART II: FIRST DENTAL JOURNAL REPORTS OF NONODONTOGENIC TUMORS AND CYSTS, 1839-1860

Jerry E. Bouquot, D.D.S., M.S.D. *
Elizabeth C. Lense, D.D.S. **

* Director of Research, The Maxillofacial Center for Diagnostics and Research, Morgantown, West Virginia

** Director, Atlanta Biopsy Associates, Atlanta, GA; Associate Director, The Maxillofacial Center for Diagnostics and Research, Morgantown, West Virginia

ABSTRACT

Dental journals from the mid-nineteenth century are replete with clinical, surgical, and microscopic descriptions of oral tumors and cysts. Most of these have never been referenced during this century. The purpose of the present paper is, therefore, to report the earliest dental journal references for a variety of inflammatory masses, nonodontogenic neoplasms, soft tissue cysts, and oral cancers. These references are derived from a canvas of all dental journals published from the first journal, the American Journal of Dental Science, in 1839 to the appearance of Dental Cosmos and the organization of the American Dental Association in 1860.

Introduction

Oral Pathology appears to have had its origin during the first Golden Age of Dentistry, from 1835 through the organization of the American Dental Association in 1860.¹ This era saw the establishment of organized education-based dentistry and was integrally associated with an obvious fascination for pathologic processes and an inherent wish to share scientific and clinical knowledge with others in the dental profession. It encompassed the creation of the first professorship of "Dental Pathology," the publication of the first textbook dedicated to Oral Pathology/Oral Medicine as we know it today, and the first review of "Dental Pathology" cases in medical journals.^2-4 It also included the initial reports, in the 28 dental journals then in print, of many of today's well-established oral lesions.

Such reports frequently antecede by several generations the reports usually quoted as being the first for these lesions. A review of early cases of odontogenic tumors and cysts has been published.¹ The purpose of the present paper is to identify the first reported cases in dental journals of nonodontogenic tumors and cysts, including oral malignancies.

Methods

A listing of nineteenth century dental journals⁵ was supplemented by a four-year systematic perusal of journals in the libraries of West Virginia University, the University of Minnesota, the Mayo Clinic, and the National Library of Medicine. Almost all English-language articles published in all volumes of each journal were reviewed for references to oral pathologic entities.¹ Published dental textbooks, which probably numbered no more than 200 in all languages during all of history prior to 1850, were not reviewed, nor were the 40 medical journals in print by the 1860s.

While most diagnoses were obvious, even though the lexicon was different from that in use today, educated guesses were occasionally made for several lesions, as early investigators often did not provide detailed histologic descriptions. Such diagnoses are identified as questionable in the following text. Words placed in quotation marks in the present manuscript are taken directly from the terminology in use during the Golden Age. All lesions reported from 1839-1860 were recorded, whether first reports or not, and additional references are available upon request from the R. J. Gorlin Historical Registry of Oral Pathology, located in the Maxillofacial Center for Diagnostics and Research, Morgantown, West Virginia; this Registry can also be accessed online at www.maxillofacialcenter.com. 

INFLAMMATORY ORAL MASSES

Early dental surgeons frequently reported nonmalignant soft tissue and bony masses, but inadequate descriptions make exact identification difficult, if not impossible. Tables 1 and 2 list only the first dental journal reports of lesions with descriptions which were complete enough to make the diagnoses rather obvious. When reviewing inflammatory changes of the oral cavity, it should always be kept in mind that the germ theory of disease was unknown during the first Golden Age and the understanding of inflammation was rudimentary at best. Nevertheless, the first "dental surgeons" demonstrated a remarkable and comprehensive intuitive feel for inflammatory disease processes and their treatments. Much of what they presumed is still accepted today.

The first unequivocal oral tumor or mass reported in a dental journal was the parulis or "gum boil," an inflammatory lesion described in 1840 by Simon P. Hullihen,⁶ the Father of Oral and Maxillofacial Surgery. During the Golden Age the parulis was commonly accepted, apparently for the first time, as an inflammatory response to suppuration or "pus" from an abscessed tooth, rather than a primary and independent focus of infection. Once this concept was accepted, of course, it was also understood that a similar phenomenon could be noted on the facial skin if a "dental fistula" extended so far.^6,22,37,38 The appropriate treatment, then, was the extraction or endodontic treatment of the offending tooth rather than the surgical excision of the surface lesion or the intraoral use of leeches.^3,39

Root canal therapy at the time consisted of complete "extirpation" of the contents of the pulp canals via hooked or barbed silver pins, and then complete filling of the canals and pulp chamber with gold foil or blunted silver pins.^6,39 Endodontic procedures were remarkably similar to those in use today, as were the rationalizations for their use. For example, a good apical seal was considered necessary in order to prevent the egress of toxins into periapical bone. This concept altered during the Golden Age, as the seal was suggested initially to prevent toxins from entering the tooth from the bone, thereby causing the death of the pulp.

The pulp polyp or "nerve fungus" was described as a painless condition which was impossible to treat without extraction.⁷ Apparently it was noted frequently in patients with poor oral hygiene or ANUG, as there was "no disease of the mouth, which makes the breath so intolerable."⁷ Bilateral examples were reported, as were examples of polyps which hemorrhaged abundantly with each menses, a phenomenon known then as "vicarious menstruation."⁹⁹ Gingival hemorrhage in cases of gingivitis during pregnancy and otherwise was likewise first reported at that time, usually under the term "hemorrhoidal discharge in dysmenorrhea."²²

Gunnel¹² presented in 1844 a thoughtful description and treatment protocol for the focal hyperplastic inflammation now known as pericoronitis. He considered the lesion to be an example of tissue inflammation resulting from trauma from an opposing maxillary third molar, and he cautioned his readers that it could produce trismus. Pericoronitis was apparently a common as well as a serious, and occasionally fatal, condition before the advent of antibiotics. While we now have difficulty envisioning pericoronitis as a mortal affliction, it should be emphasized that early dental surgeons believed that as many as 10% of all childhood deaths could be ascribed to problems with the dentition.¹¹ Enlarged tonsils from acute tonsillitis were also considered to have very serious consequences for some patients.⁴⁰

Thackston⁴¹ described an antral polyp extending into the oral cavity via antral-oral fistulae in an extensive dissertation on maxillary sinus diseases. He was also the first to describe a maxillary sinus carcinoma in the dental literature, as well as a lesion which was likely an inverted papilloma ("fungating ulcer") but could have been a polyp with secondary inflammatory ulceration. Early American dental surgeons were usually physicians and published extensively on sinus diseases and therapies. Procedures for hemimaxillectomy and hemimandibulectomy were first reported during this time period, and treatments were reported for such contemporary problems as maggots and "worms" of the sinuses.^3,9,41-43

The pyogenic granuloma was putatively first defined on the skin in 1897,⁴⁴ but an oral pregnancy tumor was clearly described as early as the 1840s (Figure 1).¹⁰ This form of pyogenic granuloma was thought to arise from the "metastasis of the menstrual secretion from the uterus to the mouth,"^10,45 and it was known to sometimes be associated with "positive inflammation" of the gingiva caused by "uterine irritation," i.e. pregnancy gingivitis.¹¹ The first pyogenic granuloma outside pregnancy was probably reported by Chapin Harris⁴⁶ in 1846 from the maxillary antrum, although we should emphasize that almost all fungating, hemorrhagic masses were at that time considered to be malignancies and little follow-up data was offered. Many probable benign lesions, therefore, are now difficult to differentiate from cancers. The first head and neck pyogenic granuloma with a clear microscopic description was a laryngeal lesion reported just after the Golden Age but still several decades prior to the first skin lesion report (Figure 2).⁴⁷

Papillary hyperplasia of the palate, another inflammatory disease, was first reported when "air chambers" or palatal relief areas became popular features of maxillary dentures.¹⁹ It was clearly accepted as an abnormality produced by poorly designed or constructed dentures and must have been very common in an age when plaster and wax were the impression materials in most common usage and tin or vulcanized rubber were the typical denture bases.

Liston²⁵ reported an hemorrhagic epulis adhering to the neck of a tooth as "commencing in the periosteum." This may be the first reference to a peripheral giant cell granuloma, but a histologic description is lacking. Tomes¹⁷ mentioned a similar but larger and more bluish lesion, probably a peripheral giant cell granuloma from an extraction site, in his extensive and popular lecture series on dental physiology, dentistry's earliest attempt at continuing education in print. The need for such education is emphasized by a contemporary article reporting a probable case of peripheral giant cell granuloma associated with a retained root or "embedded fang" in an elderly female.⁴⁸ This was a walnut-sized, purplish, hemorrhagic mass and had been called cancer by her local physician. She came to surgery only after completing her final testament because so many clinicians had indicated that the lesion would likely be fatal, but she recovered nicely after surgery.

The sialolith or "salivary calculus" was reported as early as 1843 as an example of "earthy deposition" within the submandibular gland.⁴⁹ This entity had earlier been assumed to be simply another form of dental calculus or "tartar," but Dwinelle⁵⁰ clearly demonstrated that "dry black tartar" contained "but little earthy matter" and was scarcely soluble in acids, as would be characteristic of a sialolith. This investigator was, incidentally, among the first to suggest that tartar caused "gingivitis" rather than vis versus.

Inflamed or traumatic salivary lesions were seldom reported during the Golden Age, even as mistaken diagnoses. The first example of a simple swelling from acute bacterial parotitis was presented to the Virginia Society of Surgeon Dentists in 1844.¹⁴ As this was supposed to arise from an infected mandibular third molar, a diagnosis of simple cellulitis cannot be absolutely ruled out, but the author specifically mentions involvement of the parotid gland. Boykin¹⁶ shortly thereafter reported the same phenomenon in the submandibular gland.

The first mucocele reported in a dental journal was, ironically, not from the mouth at all but, rather, was from the maxillary sinus, although it appears to have been at least a true mucin-producing lesion rather than an antral pseudocyst.⁹ That a sinus mucocele should be reported long before a labial example, published in 1857,²⁰ is another reminder of the strong interest shown in maxillary sinus pathology by early dental surgeons.

The first reported ranula was considered to be a salivary infection, but it had the unusual history of intermittent enlargement and diminution.¹⁶ Although seldom reported, it is obvious from the tone of the 1858 report by Walton⁵¹ that ranulas were being routinely encountered in practice. He disagreed with the conclusion of Bond,³ who is perhaps the "Father of Oral Pathology,"¹ that marsupialization was ineffective as a primary treatment and he recommended surgical removal only after marsupialization had failed. As early as 1547 a priest-physician to Henry VIII of England suspected that ranulas, or "impostume," resulted from "too much humidity flowing to the place where the impostume is."⁵² Ranulas represented approximately 2% of all oral and pharyngeal surgical cases treated at Guy's Hospital of London during the 1850s.⁵³

Harris⁹ described a "fibrous tumour" of the maxillary sinus in 1842 and long before that Paulus Aegineta (circa 800 A.D.) made a clear distinction between a fibrous gingival epulis and a parulis.⁵⁴ But the first cases of oral irritation fibromas were not reported in the dental literature until 1845, under the diagnosis of "fibrous epulis."^15,55 It is of some interest to note that fibromas were universally considered benign lesions in distinct contrast to virtually every other oral or perioral mass. This entity represented less than 1% of oral and pharyngeal surgical cases at Guy's Hospital of London during the 1850s.⁵³

A probable peripheral ossifying fibroma, arising from a recent extraction site, was described two years before a routine irritation fibroma was reported,¹³ and Arnott⁵⁶ later described two lesions in such microscopic detail that there can be no doubt of their ossifying fibroma diagnosis. Peripheral ossifying fibroma was, paradoxically, not differentiated from other fibromas until the mid-twentieth century and is much, much less common than the irritation fibroma.⁵⁷ Perhaps this very uniqueness was responsible for its being reported, albeit without an appropriate name, in the mid-nineteenth century.

A generalized fibrous hyperplasia of gingiva was reported as "fungus excrescence" in 1856.³³ It was treated by conservative surgical removal and the disease process was discussed by Saurel²¹ shortly thereafter in the first review of oral fibrous growths. In this review, Saurel described a 60 year old man with a 30-year history of fibrous overgrowth so extensive that only the incisal and occlusal surfaces of the teeth were visible. Leonard Koecker,⁵⁸ the first person described in print as an "Oral Medicine" doctor,¹ removed all such hyperplastic tissue in one sitting "with a strong scissors" and, of course, without anesthesia. This was one of the few case reports with follow-up data; two-years after surgery there was no recurrence.

The mid-nineteenth century was a time when scurvy was a commonly encountered disease, but the contemporary dental surgeons seemed little aware of the fact that generalized edematous gingival enlargement with ulceration and hemorrhage was a typical presentation for scorbutic gingivitis (Figure 3).^3,58 Since probable scorbutic gingivitis cases were often reported in dental journals as being associated with fatal outcomes, it is impossible today to differentiate such cases from leukemic gingivitis. The gingival fibromatosis mentioned in the previous paragraph, however, differed substantially from reported cases of hemorrhagic gingival hyperplasias and was likely a familial or idiopathic form of fibrous hyperplasia.

BENIGN NEOPLASMS AND DEVELOPMENTAL MASSES

In 1915 Bloodgood,⁵⁹ a Johns Hopkins surgeon, pleaded with the dental profession to take an interest in benign oral tumors because physicians had long demonstrated a lack of interest. His argument was augmented by the fact that he personally saw many more oral cancers than benign masses. His concern seems justified by the earliest dental literature, which expended many, many more pages on cancers than on benign lesions. This interest is surprising in light of recent epidemiologic investigations reporting that many (3.4%) adults have benign oral masses, excluding tori, and that such entities are 30 times more common than oral cancers.^60,61

Chapin Harris²² reported the first benign nonodontogenic oral neoplasm, a hemangioma, in 1841, during a continuing education seminar given at the second annual meeting of the American Society of Dental Surgeons, the first national dental association in the world. His "bluish excrescence" was within alveolar bone, with blood flowing "in torrents" at surgery. Such a lesion might also have been an aneurysmal bone cyst or arteriovenous malformation but was described in an elderly patient and was neither cystic nor pulsating. The first soft tissue hemangioma, reported in 1847, extended throughout the cheek, contained several phleboliths, and was treated by ligation of the common carotid artery.⁶² It should be mentioned that Parmentier²⁰ referenced a 1795 French report of a "sanguinous" tumor of the palate.

The first lymphangioma, called chronic "clustered vesicles," was reported in 1850,²⁷ although not pictured microscopically until the report of a fatal congenital case in 1872.⁵⁶ All vascular lesions were treated by surgical removal, local injection of caustics, or "actual cautery." Some vascular malformations or neoplasms were also reported to have undergone "spontaneous cure" after local trauma from the teeth.⁶³

An osteoma was reported by Harris⁹ on the lateral wall of the maxillary sinus in 1842 and the author referred to a similar case from Beaupreau in France in 1767, but to the best of our knowledge no oral osteomas were reported during the Golden Age. An orbital ridge osteoma was the first to be reported with a histologic description.⁶⁴ One of the curiosities of the Age was that such common and obvious lesions as bony exostoses and tori were reported so rarely in the dental journals.^20,24 In fact, the term exostosis was typically applied to apical cementum hyperplasias rather than to bony lesions.¹

Lipoma, called either "fatty tumor" or "yellow epulis," appears to have been a well-understood benign neoplasm, with the first detailed dental journal report published in 1849.²⁵ It was seldom reported thereafter, however, even though it is now and probably always has been the most common mesenchymal neoplasm in humans.⁶⁵ No neural tumors were reported as such during the Golden Age, but the case of a probable traumatic neuroma was published in 1858 and cases of neurofibromatosis with oral involvement (Figure 4) were reported shortly thereafter.^35,66

Another seemingly well-established but seldom reported entity, the squamous papilloma, was first reported by Tomes¹⁷ in the mouth (gingiva) in 1848. Its only other mention was a lesion from the maxillary sinus,³¹ again confirming early in our literature the fact that the unusual lesions or those in unusual locations are likely to be reported before their more common counterparts. In the medical literature, an 1861 review of 175 surgical cases included two "warts" of the soft palate.⁵³

A review of laryngeal lesions published shortly after the Golden Age emphasized the more aggressive nature of multiple papillomas, or papillomatosis, as it occurs in the oropharynx and larynx (Figure 5). This different biological behavior is still acknowledged and essentially unexplained today, although differing strains of human papillomavirus may be associated with each.^65,67

Another epithelial hyperplasia, a one-inch long cutaneous horn was reported, with a detailed histologic description, on the lower lip of a 70-year old man in 1855, but not in a dental journal.⁶⁸ The first dental journal report was a three-inch long horn from the temple of an 84 year old woman.²⁶

Few salivary neoplasms were reported during the Golden Age. The earliest acceptable case was a rather obvious pleomorphic adenoma or "fibro-cartilaginous tumor" of the parotid gland treated by hemimaxillectomy (of all things!) in 1852.³⁰ Although Bond³ had earlier reported a long-standing salivary tumor the size of the patient's head, his case lacked histologic description. Microscopic drawings of a parotid "enchondroma" were first printed in 1857 in the earliest published series on salivary tumors. ⁶⁹ Also, a probable Warthin's tumor was described in 1852 as an "enlarged lymphatic gland" of the parotid region.²⁸ It had a 15 year duration, was found in an elderly male, and demonstrated lymphoid and epithelial cystic components. Parotid tumors were a common topic in the medical journals of the time, as illustrated in Figure 6.⁷⁰

Intraosseous lesions with cortical expansion were frequently mentioned in the 1839-1860 dental literature, but usually from the perspective of surgical technique, with little discussion of pathology. This was a time, we must remember, when the removal of all or a large portion of the maxilla or mandible was completely new and typically performed without anesthesia. Most of these now appear to be cases of large, often infected odontogenic cysts which were at the time considered to be malignancies, frequently called "cystic carcinomas," and were treated radically (Figure 7).^1,71 Numerous cases of true osseous malignancy were also reported, of course, and are discussed below.

The first acceptable benign (developmental) bony lesion was fibrous dysplasia reported in a 14-year old girl in 1845.¹⁵ The microscopic description of this "fibrous tumor of the jaw" included immature calcified trabeculae, but the description is not detailed enough to absolutely rule out central ossifying fibroma. A probable case was reported by Morgan⁷² as "true exostosis" of the bones of the face. This bosselated mass deformed the entire right side of the face and palate of a 24 year old man, and had been enlarging for nine years (Figure 8). It was comprised of "an outer hard thin shell of bone, completely enclosing a morbid mass of spongy cancellated structure," but no histologic description is provided. A bilateral case in a child was labelled "hypertrophy" and may have been an example of cherubism rather than fibrous dysplasia.³⁰

The only other obvious intraosseous benign neoplasms reported during this time period were an enchondroma (chondroma) of the anterior maxilla, and a central giant cell granuloma reported by a French surgeon as having cells called "myeloplaxes" with up to 30 nuclei.^31,35 All such lesions were removed by radical local excision.

SOFT TISSUE CYSTS 

Several nonodontogenic cysts were reported during the Golden Age (Table 2). The first was an epidermoid (inclusion) cyst of the oral floor.²⁹ At the time it was thought that yellow and yellow/white discolorations could only be produced by pus or fat, hence this particular lesion with its soft cheesy center was called a "painless abscess." By 1858 microscopic analysis had determined that such a cyst possessed the "elements of cancer" (i.e. epithelium), but was not really cancerous, because it possessed a distinct capsule.⁷³ Bond³ considered these "wens" to be common on the facial skin but rare in the mouth. Bryant⁵³ clearly showed in 1861 that this form of 'sublingual cyst," with its peculiar, granular, cheesy, semi-solid contents "smelling dreadfully" was distinctly different from ranula and was not associated with a salivary duct.

A small and semitransparent oral lymphoepithelial cyst was reported from the lingual tonsil as a "hydatid cyst" in 1857,²⁰ and a probable cervical lymphoepithelial (branchial cleft) cyst was reported by Bond³ as a "great sac" near the angle of the mandible in a young woman. A true salivary retention cyst of the palate was mentioned by Parmentier²⁰ in a translated treatise on palatal tumors, and a parotid cyst was described as a "cyst in the duct of Steno" in 1856.³²

ORAL PRECANCERS

Before leaving this discussion of benign lesions, it perhaps should be mentioned that the white premalignant lesion, leukoplakia, was not mentioned during the Golden Age, nor was any other premalignancy. This was, after all, long before the very concept of precancer was accepted. Sir James Paget,⁷⁴ however, noted in 1870 that as early as 1850 he considered "smoker's palate" (nicotine stomatitis) to be a tobacco-related sign of future cancer development, and he reported on a tongue cancer arising from "ichthyosis." Leukoplakia was not generally discussed in dental journals until the late nineteenth century.⁷⁵ In this light it is perhaps also important to note that, as early as 1806, at least some investigators, albeit not dental investigators, where of the opinion that there was "an alteration in the structure of a part...preceding that more obvious change which is called cancer."⁷⁶

ORAL MALIGNANCIES

Many, many cases of obvious malignancy were reported in the dental literature during the Golden Age, but these were almost always brief descriptions which lacked detail and seemed to fall more into the category of sensational journalism than scientific reporting. As a general rule, any soft tissue mass of the mouth, especially when painful or hemorrhagic, was considered to be malignant until proven otherwise by its clinical behavior. The few exceptions to this rule included irritation fibroma, lipoma and ranula.

From the beginning of the nineteenth century, cancer had been characterized principally as a disease with an "independent existence," a concept which was considerably different from all earlier theories.⁷⁶ Clinicians seemed to understand also that cancer was a systemic problem as opposed to benign neoplasms which remained localized. And while the pathophysiology of metastasis escaped them, they intuitively believed that primary malignancies somehow "induced" the nodes along adjacent lymphatics to undergo a "sympathetic tumefaction."

During the Golden Age of Dentistry the crucial cancer questions related to whether or not cancer was inherited, was contagious, was age-related, was associated with specific other diseases, was a primary or de novo disease or a disease resulting from "degeneration" of other entities. Questions were constantly being asked as to the most appropriate treatment, and it was during this time that medicine began to realize that treatment and prognosis for a breast cancer (for example) was different from treatment and prognosis for a tongue cancer.⁷⁶

Toward the end of the Golden Age, Cartier⁷⁷reviewed, in a dental journal, the various types of carcinoma, making it clear that the health professionals of the time knew that cancers differed depending on the organ and tissue of origin. His differential listing, however, was rather different from a modern one. He classified carcinomas as either epithelial ("flat, granular or wart-like"), bundle-like, gelatinous, fibrous, or medullary ("fungus"). He listed the lips, tongue and salivary glands as the third, fifth and sixteenth most commonly affected cancer sites, respectively, with uterine and breast cancer as the most common of all. He explained the "new formation" nature of both benign and malignant neoplasms and suggested the discontinuance of the use of the term "tumor" for such lesions, in order not to confuse them with inflammatory masses.

Cartier also described the distinction between the biological behaviors of benign and malignant neoplasms, attributing to benign lesions such features as slow growth, movability, soft texture, small size, encapsulation, and a lack of pain. Perhaps most remarkably, he suggested that the clinician always obtain a "microscopic analysis" of neoplasms. Nor was he alone is his expectations that the dental profession be knowledgeable oral pathology and oral cancer. Taft^77a wrote in an 1860 review of the province of the dentist:

"We shall now consider Dental Medicine. Heretofore, the knowledge of pathological conditions, beyond the immediate tissues of the teeth, was very limited indeed, with the greater portion of the dental profession...the consequence was that their treatment for these conditions was wholly at random and consequently ineffective, or was not attempted at all...No one is competent to treat any pathological condition without a thorough knowledge of that condition itself...The operator should be able to determine a malignant from a nonmalignant tumor or growth."

Relative to specific oral and paraoral cancers, it has already been mentioned that Thackston's⁴¹ report of a maxillary sinus carcinoma ("fungus haematodes") was the first unequivocal dental journal report of a head and neck cancer. At that time he emphasized the futility of such lesions and had the prescience to indicate that the only hope for cure was early detection and removal. During 1842, Thackston⁴¹ and Harris⁹ independently reported the first cases of sarcoma, maxillary osteosarcoma, under the diagnostic headings of "fungus exostosis" and "osteo-sarcoma" (Figure 9). A report of this disease was also the first attempt to subclassify orofacial cancers according to their clinical appearance and biologic behavior.⁷⁹

Harris⁹ was the first to mention an "oral carcinoma" or "malignant ulcer," but the first detailed attempt to characterize an oral cancer appears to have been an anonymous article pertaining to the natural history and progression of "cancerous ulceration" of the lower lip vermilion.⁸⁰ This was also the first reference to a "cured" oral cancer, although the author only provided a few weeks of follow-up. The very fact of an attempt at cure, in itself, is remarkable when one considers that lip carcinoma was deliberately selected as late as 1927 by Broders⁸¹ for his tumor-grading research because he considered it to be among the worst of human cancers.

Of 175 oral and pharyngeal surgical cases reported by Bryant,⁵³ 54 were lip "epitheliomas" and 18 were tongue cancers. He wondered why lip cancers were almost all found on the lower vermilion border and in men, and he mentioned a 15% recurrence for the lip cancers, with 35 of his 54 patients followed for 2-12 years. This appears to be the first instance of a follow-up study relating to oral malignancy.

The relentless progression of oral malignancy was first illustrated in 1850 with the case of a young woman who died of her disease (Figure 10).⁸² The malignancy was probably a fibrosarcoma, but histologic detail was lacking from the report.

Remarkable attempts were made toward surgical cure of maxillofacial malignancy during the Golden Age. Radical surgical excision, for example, was routinely performed without anesthesia and only occasionally without failure (Figure 11).^83,84 Eve⁸⁵ was the first to report in a dental journal the surgical treatment of intraoral carcinoma, although surgery for lip carcinoma goes back at least to the Ch'in Dynasty in China (255-206 B.C.).⁸⁶ Shortly after the report by Eva the first report of chemotherapy for an oral cancer was published. A member report ed to the annual meeting of the American Society of Dental Surgeons that the use of arsenic for a case resulted in the rapid demise of the patient, not from the disease but from the treatment.⁸⁷ Perhaps the state of the art of oral cancer therapy is best summarized by a direct quote from the waning days of the Golden Age. Choppin⁸⁸ reported "a case of removal of the tongue, for cancer, with the ecraseur." The operation lasted fifteen minutes and was most significant in that "it was accomplished with no hemorrhage." Whether or not the patient survived his cancer was not even mentioned.

There was, fortunately, a clear understanding that not all destructive ulcerations were cancers. For example, cancrum oris, tuberculosis, osteomyelitis, and other similar diseases were well known and easily differentiated from malignancy,^{3,17,53,89-91} even though their exact etiologies and pathophysiologies were poorly understood. Obturators and other prostheses were being made for those patients experiencing great destruction from nonmalignant disease but they were not constructed for cancer patients.¹⁸

As previously discussed, the concept of metastasis from a malignant neoplasm was poorly understood, and even after the Golden Age many in medicine and dentistry considered cancer to be almost an infectious process which arose simultaneously throughout the body to produce widespread and fatal proliferation and destruction. Cartier⁷⁷ considered that "swollen lymphatic glands in the neighborhood of cancers" had undergone a "transformation" of one cell type to another, a process referred to then as "endosmose." He was obviously wrong in his assessment, but he did correctly assume that cancers could spread through the blood stream in order to "clot" and "grow" in distant sites, especially the lungs, liver and spleen. This was such a common feature of malignancy that he wondered if cancer might not primarily originate in the blood. Acute, painful, short-duration ulcers such as aphthous ulcers ("aphthae") were also, of course, understood to be not related to malignancy. At the time they were thought to be produced by a "disordered stomach."⁹²

Bond³ appears to be the first to speculate on the etiology of oral cancers. His assumption that they were produced by trauma from the teeth was reiterated by Liston,⁹³ who stated clearly that "malignant action may take place." This became the usual and standard etiologic theory throughout the Golden Age and did not loose popularity until the mid-twentieth century. Slightly after the Golden Age, Obre⁹⁴ wondered about hereditary influences, reporting a lingual carcinoma in a 43 year old man whose uncle and great uncle had died of, presumably, the same disease.

There was much opinion and superficial discussion of malignant lesions in the dental literature of the Golden Age. While little of this was substantiated by clinical or basic research, its value was nevertheless considerable in that it opened a public discussion of a heretofore verbotten topic and it helped to create the interest and speculation which eventually became the foundation of future research investigation. In any event, there was much more emphasis on such serious pathologic entities in the old dental journals than in the modern journals for general dentistry.

AFTERTHOUGHT

Obviously, the dental surgeons of the first Golden Age of Dentistry were well aware of the basic clinical, and occasionally the basic microscopic characteristics of both benign and malignant tumors. Their interest was great in this arena, as is demonstrated by the large number of articles published on the subject between 1839 and 1860. Least we come to believe, however, that the professional interests of these men was of too serious a nature or that they spent more time with tumors than with dental restorations, we wish to conclude with a poem from the New York Dental Newsletter which was said by the editor of that popular journal to have been altered by himself from an entry in the medical journal, Scalpel, in order to relate to the removal of a tooth instead of the removal of a tumor, as was the original intent of the poem. It shows a most human side to the often dour reporting of the Golden Age.

COGITATIONS OF A PATIENT AWAITING THE DENTIST⁹⁵

Yes! I'll have it out! I will not suffer more
From such a wretched, constant, mad'ning bore;
Projecting from my gum, as if a quid of Indian weed
Had found a lodgment there, for future time of need.

Out with it--yes! zounds! had I but now a knife,
I'd out with it myself, and run the risk of life.
The clock strikes two; where does that dentist stay?
The ladies' are to ride!--he's gone out for the day.

But now I'll sit me down and attempt to read this book,
Forgetful of that long-faced dentist's most mischievous look;
But hark! who comes? 'tis he! methinks it scarce were sin,
Softly to lock the door, and say I'm not within.

But 'tis too late! here's for it! I sit in that dread chair,
While he, with face all smiling, without a fear or care,
Upon the table spreads with noise and much display,
His lancet, hooks and forceps--a most dread array.

And smiling most benignantly, "now sir, I'm ready if you please,"
As if he were to carve a steak, he seemed so much at ease.
"But , doctor, it don't hurt now! I guess I'll call again,"
"No! No!" quoth he--"now is the time to ease you of your pain."

C-r-a-s-h! goes the knife. "Hold still! 't will soon be done;"
C-r-a-s-h! c-r-a-s-h! "Mercy! how the blood does run."
"Once more! hold still a moment, till I apply the key,"
"And you, sir, pray keep still, and don't take hold on me."

REFERENCES

1. Bouquot JE, Lense EC. The beginning of oral pathology, Part I: First dental journal reports of odontogenic tumors and cysts, 1839-1860. Oral Surg Oral Med Oral Pathol 1994; 78:343-350.

2. Lintolt WH. To the editor of the London Lancet: progress of dental science in America. Am J Dent Sc 1842; 2:300-301.

3. Bond TE Jr. A practical treatise on dental medicine. Philadelphia: Lindsay & Blakiston, 1848.

4. Salter JA. Contributions to dental pathology. Guy's Hosp Report 1859; 5 (3^rd series):319-331.

5. Johnson EA, O'Rourke JT, Partridge BS, et al. The status of dental journalism in the United States. Baltimore, MD: Waverly Press, Inc., 1932:1-44.

6. Hullihen SP. Observations on tooth-ache. Am J Dent Sc 1840; 1:105-111.

7. Hullihen SP. Abscess of the jaws, and its treatment. Am J Dent Sc 1847/48; 8:106-112.

8. Hayden HH. On conjoined suppuration of the gums and alveolus. Am J Dent Sc 1941; 2:214-297.

9. Harris CA. Dissertation on the diseases of the maxillary sinus. Am J Dent Sc 1842; 3:20-132,153-189.

10. Hullihen SP. Case of aneurism by anastomosis of the superior maxillae. Am J Dent Sc 1844; 4:160-162.

11. Westcott A. Dissertation on the claims of the medical science upon the practitioner of dental surgery. Am J Dent Sc 1844; 5:3-31.

12. Gunnel JS. A remedy for the painful affection produced from cutting the lower dens sapientia or wisdom tooth, etc. Am J Dent Sc 1844; 4:43-44.

13. Shepherd SM. Alveolar exostosis. Am J Dent Sc 1844; 4:46-47.

14. Lethbridge S. Transactions of the Virginia Society of Surgeon Dentists. Am J Dent Sc 1844; 5: 120-123.

15. Hodgson. Fibrous tumor of the inferior maxilla. Am J Dent Sc 1845; 5:319.

16. Boykin EM. A case of acute inflammation of the sublingual glands. Dent Regist West 1848/49; 2: 97-100.

17. Tomes J. A course of lectures on dental physiology and surgery (lectures I-XV). Am J Dent Sc 1846-1848; 7:1-68, 121-134; 8:33-54, 120-147,313-350.

18. Cone CO. Report on practical dentistry. Am J Dent Sc 1848; 9:3-82.

19. Berry A. A partial set of teeth sustained by air chambers instead of clasps. Dent Reg West 1851; 9: 114-116.

20. Parmentier. Essay on tumors in the palatine region. Am J Dent Sc 1857; 7(new series):324-339, 456-465,545-561.

21. Saurel L. Memoirs upon the tumors of the gums, known under the name epulis. Am J Dent Sc 1858; 8(new series):33-43,212-231.

22. Harris CA. A physiological and pathological inquiry concerning the physical characteristics of the human teeth and gums, the salivary calculus, the lips and tongue, and the fluids of the mouth. Am J Dent Sc 1841; 2:39-120.

23. Taylor J. Opening address delivered before the Mississippi Valley Association of Dental Surgeons. Am J Dent Sc 1844; 5:91-104.

24. Roux M. On exostoses: their character. Am J Dent Sc 1848; 9:133-134.

25. Liston. Gum boils--fungous growth of the gums-epulis. Dent Regist West 1848/49; 2:191-195.

26. Blasbury. Horny growth from the head in the human subject. Am J Dent Sc 1849; 9:388.

27. Castle AC. A novel case of aneurism from my notebook. NY Dent News Letter 1850; 3:91-92.

28. Canton. Removal of a tumor embedded in the parotid gland. Am J Dent Sc (new series) 1852; 2:312.

29. 1852, epid cyst (painless abscess)

30. Gross SD. Observations on excision of the superior maxillary bone: illustrated by seven cases. Am J Dent Sc (new series) 1852; 3:131-151.

31. Giraldes JA. Diseases of the maxillary sinus. Am J Dent Sc 1856; 6(new series):482-497.

32. Rudolfi M. The treatment of salivary fistula. Dent News Letter 1856; 9:125-126.

33. Goddard WH, Gross. Case of hypertrophy of the gums. Dent Regist West 1856; 9:276-282.

34. Culter. Glossal papillary tumor. Dent News Letter 1858; 11305-306.

36. Guersant. Clinical remarks upon congenital cysts. Dent Cosmos 1860; 1:498-499.

35. Nelatin M. Tumors of the lower jaw. Am J Dent Science 1858; 8 (new series): 325-331. (translated from the French without reference to original article)

37. Brown AM. Review of Burdell and Burdell's Observations on the structure, physiology, anatomy and diseases of the teeth. Am J Dent Sc 1839; 1:19-24.

38. Brown AW. Remarkable case of alveolar abscess and ulceration of the fang. Am J Dent Sc 1839; 1:58.

39. Arthur R. Treatment of dental caries, complicated with affections of the pulp and periodontal membrane. Am J Dent Sc (new series) 1851; 1:229-240.

40. Yearsley J. Elongated uvula and enlarged tonsils. Am J Dent Sc 1843; 4:61.

41. Thackston WWH, A dissertation on the diseases of the maxillary sinuses. Am J Dent Sc 1842; 2:279-291.

42. Gross SD. Observations on excision of the superior maxillary bone: illustrated by seven cases. Am J Dent Sc (new series) 1852; 3:131-151.

43. Taylor J. Opening address delivered before the Mississippi Valley Association of Dental Surgeons. Am J Dent Sc 1844; 5:91-104.

44. Poncet et Dor A. De la Botryomycose humaine. Rev der Chir (Paris) 1897; 18:996-997.

45. Dayton AC. Letter to editor. Am J Dent Sc 1849; 10:42-43.

46. Harris CA. Case of fungus tumor occupying the left maxillary sinus, successfully treated by the extraction of the first and second superior molares of the affected side. Am J Dent Sc 1846; 6:318-320.

47. Gibb PG, Czermak. Warty growth of the larynx. Tran Path Soc London 1863; 14: 53-54.

48. Anonymous. Removal of a tumor. NY Dent News Letter 1849; 3:45.

49. Mandl M. Salivary calculus. Am J Dent Sc 1843; 4:141-142.

50. Dwinelle WH. Dissertation on salivary calculus. Am J Dent Sc 1844; 5:32-42.

51. Walton. Ranula, removal by dissection, after the failure of incision and the Seton. Dent News Letter 1858; 11:306.

52. Boorde A. Breviarie of Helthe. 1547. Quoted in: Ring ME. Dentistry, an illustrated history. St. Louis; C.V. Mosby, 1985.

53. Bryant T. The surgery of the mouth, pharynx, abdomen, and rectum, including hernia. Guy's Hosp Report 1861; 7 (3^rd series):1-101.

54. Referred to in: Hockley A. An historical review of dental surgery from the earliest period to the commencement of the present century. Dent News Letter 1858/1859; 12:120-126, 282-289 (translated from Kurt Sprengel's Geschichte der Medicin).

55. Shillitoe B. Fibrous tumor from near the angle of the lower jaw. Trans Pathol Soc London 1865; 16:223-224.

56. Arnott H. Macro-glossia, or congenital enlargement of the tongue. Trans Pathol Soc London 1872; 23:109-111.

57. Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: report of 376 cases. J Am Dent Assoc 1966; 73:1312-1320.

58. Koecker L. Case of extraordinary fungous disease of the gums and sockets of the teeth; its constitutional effects and successful treatment. Am J Dent Sc 1843; 3:240-245.

59. Bloodgood JC. What every dentist should know about surgical lesions of, and in the region of, the upper and lower jaw; with especial reference to the early recognition of the precancerous lesions. J Natl Dent Assoc (later the J Am Dent Assoc) 1915; 2:3-19.

60. Bouquot JE. Common oral lesions found during a mass screening examination. J Am Dent Assoc 1986; 112: 50-57.

61. Bouquot JE, Gundlach KKH. Oral exophytic lesions in 23,616 white Americans over 35 years of age. Oral Surg Oral Med Oral Pathol 1986; 62:284-291.

62. Post. Venous erectile tumor of the cheek. Dent Intel 1847; 3:137-138.

63. Anonymous. Aneurism of the coronary artery, of the lower lip. Am J Dent Sc 1846; 6:331.

64. Canton E. Orbital exostosis. Am J Dent Sc (new series) 1851; 2:146-147.

65. Neville BW, Damm DD, Allen CA, Bouquot JE. Oral and maxillofacial pathology. Philadelphia: W. B. Saunders, 1995:259-261.

66. Photo of neurofibroma, figure 4

67. Bouquot JE, Wrobleski GJ. Papillary (pebbled) masses of the oral mucosa, so much more than simple papillomas. Pract Perio Aesth Dent 1996; 533-543.

68. Gray H. Horny tumor from the lower lip. Trans Pathol Soc London 1855; 6:163-164.

69. Warren JM. Tumors of the parotid region. Am J Dent Sc 1857; 7:587-595.

70. Arnott H. Soft enchondroma of the parotid gland. Trans Pathol Soc London 1869; 20:186-187.

71. Forget A. Dental anomalies and the influence upon the production of diseases of the maxillary bones. Dent Cosmos 1860; 1:229-236, 283-290, 398-404,448-456.

72. Morgan J. Exostosis of the bones of the face, disease of the cranium and fractures of the frontal and parietal bones, requiring operations. Guy's Hosp Report 1836; 1:403-406.

73. Erickson, Harley. Movable tumor of the cheek. NY Dent News Letter 1858; 11:305.

74. Paget J. Cancer following ichthyosis of the tongue. Trans Clin Soc Lond 1870; 3:88.

75. Bouquot JE, Whitaker SB. Oral leukoplakia--rationale for diagnosis and prognosis of its clinical subtypes or "phases." Quint Internat 1994; 25:133-140.

76. Baillie, Simms, Willan, et al. Queries and responses from The Medical Committee of the Society for Investigating the Nature and Cure of Cancer. Edinburgh Med Surg J 1806; 2:382-389.

77. Cartier AL. On pseudoplasmata. Am J Dent Science 1858; 8 (new series):297-324.

77a. Taft J. The province of the dentist. Dent Reg West 1860; 14:313-316.

78. Skull with osteosarcoma, Fig. 9.

79. Roux. Cancer of the bone. Am J Dent Sc 1847; 7:395.

80. Anonymous. Cancerous ulceration of the lower lip; history and progress of the disease; operation for its removal; cure. NY Dent News Letter 1849/50; 3:21-32.

81. Broders AC. Carcinomas of the mouth; types and degrees of malignancy. Am J Roentgen 1927; 17: 90-93.

82. Girl with cheek ca, progression. [Fergusson M. Case of affectation of upper jaw. Amer J Dent Sc 1848; 9: 136-138. 36 y/o female, max. left]

83. Gibson CG. Osteo-sarcoma of the lower jaw -- amputation -- cure. Amer J Dent Sc 1842; 3:139-142.

84. Thomspon R. Resection of the left superior maxillary bone. Am J Dent Sc 1850; 10:172-179.

85. Eve PF. Operations on the jaws with the result of thirteen cases. Am J Dent Sc 1848; 8:367-374.

86. Ring ME. Dentistry, an illustrated history. St. Louis; C. V. Mosby, 1985.

87. Burr WH. Minutes of ninth annual meeting of the American Society of Dental Surgery, held at Saratoga, August 1, 1848. Am J Dent Sc 1850 (new series); 1:36-66.

88. Choppin S. A case of removal of the tongue. Dent Cosmos 1860; 1:558.

89. Sheppard SM. Case of spontaneous destruction of the alveoli of the second bicuspid and first molaris. Am J Dent Sc 1848; 8:350-352.

90. Middlethwait. Cancrum oris. Am J Dent Sc 1848; 9:135.

91. Anonymous. Gangrene of the mouth in children. Dent Regist West 1848; 2:186-187.

92. Handy WR. Pathological relations of the mouth. Am J Dent Sc 1849; 10:1-12.

93. Liston. Ulcers of the tongue from decayed teeth. Dent Regist West 1848; 2:195-196.

94. Obre H. Epithelial cancer of the tongue. Trans Pathol Soc London 1863; 14:160.

95. Hayden JJ. Cogitations of a patient awaiting the dentist. NY Dent News Letter 1850; 3:95.

Table 1: First reports of nonneoplastic, usually inflammatory benign oral masses in dental journals, 1839-1860; listed by year of publication.

* some original terms are taken from other contemporaneous articles

** exact diagnosis is in doubt

Table 2: First reports of nonodontogenic benign neoplastic and developmental oral masses and cysts, as reported in dental journals, 1839-1860; listed by year of publication.

 * some original terms are taken from other contemporaneous articles
** exact diagnosis is in doubt

Table 3: First reports of oral and maxillofacial malignancies, as reported in dental journals, 1839-1860; listed by year of publication.

LEGENDS FOR FIGURES

Figure 1: A pyogenic granuloma (pregnancy tumor) in a 22-year old pregnant woman was a "very red protuberance" which separated the central incisors.¹⁰ The lesion increased in size with successive pregnancies and was hemorrhagic enough to be called an "aneurysm" by the reporting surgeon. Surgical excision apparently affected cure.

Figure 2: These two trauma-induced pyogenic granulomas of the vocal cords were described in microscopic detail three decades before the classic "first" report (from the skin).⁴⁷

Figure 3: This case of hemorrhagic and spongy gingival hyperplasia had an acute onset and a fatal outcome.⁵⁸ It could have been either leukemic gingivitis or scorbutic gingivitis.

Figure 4: Neurofibroma of the tongue was a large, pedunculated mass.⁶⁶

Figure 5: A case of laryngeal papillomatosis shows multiple leaf-like papillary masses of the vocal cords.⁴⁷

Figure 6: The clinical and microscopic appearance of a pleomorphic adenoma of twenty years' duration, in a middle-aged male, was reported just after the close of the Golden Age.⁶⁹

Figure 7: Infected odontogenic cysts often presented with extensive destruction of surrounding soft and hard tissues, leading to the false conclusion that they were "cystic carcinomas."⁷¹

Figure 8: Guy's Hosp 1:403 (1836), fibrous dysplasia, face ⁷²

Figure 9: The first oral sarcoma reported was a maxillary osteosarcoma, as in this classic case published shortly after the Golden Age and reproduced in numerous twentieth century publications.⁷⁸

Figure 10: This is a pictorial depiction of progression of an apparent soft tissue malignancy (fibrosarcoma?) of the buccal region in a young woman who died of her disease.⁸²

Figure 11: Before and after illustrations of a 51 year old black male Virginia slave who underwent hemimaxillectomy without the aid of anesthesia for probable osteosarcoma.⁸⁴ The patient apparently was cured by the procedure.