The Beginning of Oral Pathology, Part II: First Dental Journal  Reports of Nonodontogenic Tumors and Cysts, 1839-1860
©The Maxillofacial Center for Diagnostics & Research
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Huge pleomorphic adenoma of the parotid gland, circa 1851.

The Maxillofacial Center, 165 Scott Avenue, Suite 100, Morgantown, WV 26508 USA
Phone: 304-292-4429   Fax: 304-291-5149    Email: MFC@aol.com

Authors: Bouquot JE, Whitaker SB, Lense EC

Jerry E. Bouquot, D.D.S., M.S.D.: Director of Research, The Maxillofacial Center for Diagnostics and Research, Morgantown, West Virginia; Director, Head & Neck Diagnostics of America, Morgantown, West Virginia

S. Bryan Whitaker, D.D.S.: Private Practice of Endodontics, Springdale, Arkansas; Associate Director, The Maxillofacial Center for Diagnostics and Research, Morgantown, West Virginia

Elizabeth C. Lense, D.D.S.: Director, Atlanta Biopsy Associates, Atlanta, GA; Associate Director, The Maxillofacial Center for Diagnostics and Research, Morgantown, West Virginia

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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 oral pathology, the publication of the first textbook dedicated to oral pathology/oral medicine as we know it today, and the first review of oral pathology cases in medical journals.^1-4 It also included the initial reports, in the 28 dental journals then in print, of many of today's well-established oral lesions.

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

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. 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 text are taken directly from the terminology in use during the Golden Age. All lesions reported from 1839 through 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. 

 Inflammatory Oral Masses

Early dental surgeons frequently reported nonmalignant soft tissue and bony masses, but inadequate descriptions make exact identification difficult, if not impossible. Table 1 and Table 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 therapy then became extraction or endodontic treatment of the offending tooth rather than 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 profusely with each menses, a phenomenon known then as "vicarious menstruation." 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

The pyogenic granuloma was putatively first defined on the skin in 1897 but an oral pregnancy tumor was clearly described as early as 1844 (Figure 1).^10,41 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.^10,42 The first pyogenic granuloma outside pregnancy was probably reported by Chapin Harris⁴³ in 1846 from the maxillary antrum, although Wiserman of London may have discussed a gingival case as early as 1672.⁴³ 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.⁴⁴

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 in 1848 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 somewhat later in the same year 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 second and most ambitious attempt at continuing education in print, after the phenomenal lectures by Harris.²² The need for such education was emphasized by a contemporary article reporting another probable case of peripheral giant cell granuloma associated with a retained root or "embedded fang" in an elderly female.⁴⁵ 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. She recovered nicely after surgery.

A probable peripheral ossifying fibroma, arising from a recent extraction site, was described in 1844 and Arnott⁴⁶ later described two lesions in such microscopic detail that there can be no doubt of their ossifying fibroma diagnosis.¹³ Peripheral ossifying fibroma was, paradoxically, not formally differentiated from other fibromas until a century later and is much less common than the irritation fibroma.⁴⁷ Perhaps this very uniqueness was responsible for its being reported, albeit without an appropriate name, before the more common counterparts of oral fibrous hyperplasia.

Harris⁴ 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.⁴⁸ But the first cases of oral irritation fibroma were not reported in the dental literature until 1845, under the diagnosis of "fibrous epulis."^15,49 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.⁵⁰

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. In his long, rambling 1842 dissertation of diseases of the maxillary sinus, Harris⁴ emphasized that gingival tissues are strongly influenced by systemic as well as local factors. In the process he became the first to discuss generalized gingival hyperplasia in the dental literature. Leonard Koecker,⁵¹ the first person described in print as a "Dental Pathologist,"¹ discussed gingival hyperplasia as if it were a common phenomenon, suggesting the removal of all hyperplastic tissue in one sitting "with a strong scissors" and, apparently, 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 and contemporary dental surgeons were aware of the fact that generalized edematous gingival enlargement with ulceration and hemorrhage was a typical presentation for scorbutic gingivitis (Figure 2).^3,51-53 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 hyperplasia and was likely a familial or idiopathic form of fibrous hyperplasia.

Thackston⁵⁴ described an antral polyp extending into the oral cavity via an antra-oral fistula 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 engaged in professional publication were usually physicians and reported extensively on sinus diseases and therapies. Procedures for hemimaxillectomy were first reported during this time period, and treatments were discussed for such contemporary problems as maggots and "worms" of the sinuses.^3,9,54-56

In 1915 Bloodgood,⁵⁷ 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, but it is nevertheless surprising in light of more recent epidemiologic investigations reporting a very high prevalence rate (1/30 adults) for benign oral masses in the population.^58,59

Chapin Harris²² reported the first benign nonodontogenic oral neoplasm, an 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 a aneurysmal bone cyst or arteriovenous malformation but was described in an elderly patient and was neither cystic nor pulsatile. 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.⁶⁰ It should be mentioned that Parmentier²⁰ referenced a 1795 French report of a "sanguineous" tumor of the palate.

The first lymphangioma, sometimes referred to as "chronic clustered vesicles," was reported in 1850, although not pictured microscopically until the report of a fatal congenital case in 1872.^27,46 All vascular lesions were treated by surgical removal, ligation of feeder vessels, 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.⁶¹

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 and a discussion in the Bond³ text of 1848.²⁵ It was seldom reported thereafter, however, even though it is now and probably always has been the most common mesenchymal neoplasm in humans.⁶²

No obvious 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 were reported shortly thereafter (Figure 3).^35,63

Benign Bony Masses

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, during that time the term exostosis was much more often applied to apical cementum hyperplasia (hypercementosis) than to bony masses.¹ A report shortly after the period, however, did describe "alveolar exostosis" (buccal exostosis), as did the 1848 text by Bond.³

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 sometimes (often?) performed without anesthesia. Most of these now appear to be cases of large, often infected odontogenic cysts which were at the time considered by many health professionals to be malignancies, called "cystic carcinomas," and were treated radically (Figure 4).¹ Numerous cases of true osseous malignancy were also reported and are discussed below.

The first apparent report of fibrous dysplasia was a case in a 14-year old girl, described 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 rather obvious case of fibrous dysplasia was reported in 1836 as "true exostosis" of the facial bones.⁶⁶ This bosselated mass deformed the entire right side of the face and palate of a 24 year old man, and had been slowly enlarging for nine years (Figure 5). 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 of bony "hypertrophy" in a child and may have been an early example of cherubism rather than fibrous dysplasia.³⁰

The only other obvious intraosseous benign bony lesions 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.

Benign Epithelial Masses

Another seemingly well-established but seldom reported entity, the squamous papilloma, was first reported as a gingival mass by Tomes¹⁷ 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.⁶⁷

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 6).⁴⁴ This different biological behavior is still acknowledged and essentially unexplained today, although differing strains of human papillomavirus may be associated with each site.⁶⁸

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.⁶⁹ The first dental journal report was, in fact, not an oral lesion at all – it was a three-inch long horn from the temple of an 84 year old woman.²⁶

Salivary Masses

"Analysis of saliva" was a common diagnostic tool for physicians long before the nineteenth century, but the first salivary gland mass reported in a dental journal was a sialolith or "salivary calculus" offered in 1843 as an example of "earthy deposition" within the submandibular gland duct.⁷⁰ This entity had earlier been assumed to be simply another form of dental calculus or "tartar," but Dwinelle⁷¹ 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 vice versa.

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 third molar, a diagnosis of simple cellulitis cannot be absolutely ruled out, but the author specifically mentioned involvement of the parotid gland.

The first mucocele reported in a dental journal was, ironically, not from the mouth but from the maxillary sinus. It appears to have been a true mucus-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. Figure 7 offers a clinical depiction of mucocele of the lower lip.

The first reported ranula was considered to be a salivary infection but had a long history of intermittent enlargement and diminution.¹⁶ Although seldom mentioned, it is clear from the tone of published reports that the ranula was being routinely encountered in dental practice, and Bryant⁶⁷ calculated that it represented approximately 2% of all oral and pharyngeal surgical cases treated at Guy’s Hospital of London during the 1850s.^73,73b Walton and Bond,^3,73b who is perhaps the "Father of Oral Pathology," both suggested marsupialization as the primary treatment, with the surgical removal of the offending gland performed only after marsupialization had failed.¹ As early as 1547 a priest-physician to Henry VIII of England suspected that ranula, or "impostume," resulted from "too much humidity flowing to the place where the impostume is."⁷⁴

Few true salivary neoplasms were reported during the Golden Age. The earliest acceptable case was a massive pleomorphic adenoma or "fibro-cartilaginous tumor" of the parotid gland with a radical treatment in 1852 which included hemimaxillectomy.³⁰ Bond³ had earlier reported a long-standing salivary tumor the size of the patient's head, but his case lacked histologic description; another example is provided in Figure 8. Microscopic drawings of a parotid "enchondroma" were first printed in 1857 (Figure 9) in the earliest published series on salivary tumors.⁷⁶ 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. In contrast to the dental journal experience, parotid tumors were a common topic in the medical journals of the time.^75,77

Soft Tissue Cysts

Several nonodontogenic cysts were reported during the Golden Age (Table 2), beginning with 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" (Figure 10). By 1858 microscopic analysis had determined that such a cyst possessed the "elements of cancer," that is, epithelium, but was not really cancerous because it possessed a "distinct capsule."^78,79 Bond³ considered these "wens" to be common to the periorbital skin but rare in the mouth.

Bryant⁶⁷ 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. In a similar fashion, the 1863 review of cystic lesions by Coleman⁵⁰ made it clear that the dermoid or teratoid cyst was well understood to contain multiple tissue types when he stated that "there is hardly a structure that has not been found" within it.

A small and semitranslucent oral lymphoepithelial cyst was reported from the lingual tonsil as an "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 should be mentioned that the white premalignant lesion, leukoplakia, was not reported 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,⁸⁰ 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," probably an example of syphilitic glossitis. The term "leukoplakia" was not coined until 1877 and the disease was not generally discussed in dental journals until the late nineteenth century.⁸¹ 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."⁸²

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.

While little of the cancer reportage was substantiated by clinical or basic research, its value was nevertheless considerable in that it opened a public discussion of the heretofore verboten 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 our modern journals of general dentistry.

From the beginning of the nineteenth century cancer began to be characterized as a disease with an "independent existence," a concept which was considerably different from all earlier theories.⁸² 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 Burns and Pattison published, in 1843, the first textbook of head and neck cancer, and 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.^82,83 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 could be considerably different for cancers of different anatomic parts.⁸²

Toward the end of the Golden Age, Cartier⁸⁴ reviewed 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 unusual. 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 distinctions between the biological behavior 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 in his expectations that the dental professional be knowledgeable about oral pathology and oral cancer. Taft⁸⁵ 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 the 1842 Thackston⁵⁴ report of maxillary sinus carcinoma ("fungus haematodes") was the first unequivocal dental journal account of a head and neck cancer (Table 3). 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, Thackston⁵⁴ and Harris⁹ independently reported the first cases of sarcoma, maxillary osteosarcoma, under the diagnostic headings of "fungus exostosis" and "osteo-sarcoma" (Figure 11). A report of this disease was also the first attempt to subclassify orofacial cancers according to their clinical appearance and biologic behavior.⁸⁷ Chondrosarcoma of the maxilla was first discussed by Bond³ in 1848 and the disease was most dramatically illustrated by Holmes (Figure 12).⁸⁸

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.⁸⁹ 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 is , in itself, remarkable when one considers that lip carcinoma was deliberately selected as late as 1927 by Broders⁹⁰ 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 in 1861 by Bryant,⁶⁷ 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. His appears to be the first instance of a true follow-up study relating to oral cancer.

The relentless progression of orofacial malignancy was well illustrated in the 1850s by a huge basal cell carcinoma of the midface (Figure 13) and by the case of a young woman who died of her disease (Figure 14). The former malignancy was thought to be a form of "folliculitis" and the latter was probably a fibrosarcoma, although histologic detail is lacking.

Remarkable attempts were made toward surgical cure of maxillofacial malignancy during the Golden Age. Radical surgical excision was sometimes performed without anesthesia and only occasionally without failure (Figure 15).^92-96 Eve⁹⁵ 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.).⁹⁷ Shortly after the report by Eve the first report of chemotherapy for an oral cancer was published. A member reported 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.⁹⁸

Despite the interest in treatment, there was no systematic approach and little apparent concern for the well-being of the patient. In fact, the state of the art of oral cancer therapy is best summarized by a direct quote from the waning days of the Golden Age. Choppin⁹⁹ 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,^{3,17,50,100-103} 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 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."¹⁰⁴

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. Cartier⁸⁴ 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.

Bond³ appears to be the first to speculate in detail on the etiology of oral cancers. His assumption that they were produced by trauma from the teeth was reiterated by Liston,¹⁰⁵ who stated clearly that "malignant action may take place" from such trauma. This became the usual and standard etiologic theory throughout the Golden Age and did not lose popularity until the mid-twentieth century. Slightly after the Golden Age, Obre¹⁰⁶ 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.

Conclusion

The dental surgeons of the first Golden Age of Dentistry were obviously well aware of the basic clinical, and sometimes the basic microscopic characteristics of both benign and malignant tumors. Their interest is well demonstrated by the large number of articles published on the subject between 1839 and 1860. Those pertaining to the first reports of diseases in dental journals are summarized in the present literature review.

References

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

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

3. Hayden HH. On conjoined suppuration of the gums and alveolus. Am J Dent Sc 1841; 2:214-297.

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

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

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

7. 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.

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

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

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

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

12. 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.

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

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

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

16. 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.

17. 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.

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

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

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

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

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

24. [1852, epid cyst (painless abscess)]

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

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

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

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Index of Tables of First Reports of Nonodontogenic Lesions *

[Click on the table number to view the table]

        * first reports in dental journals, 1839-1960

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

Today's Diagnosis	Year	Original Diagnostic Term(s)*
Pulp polyp1	1840	Nerve fungus; Bluish excrescence; Erectile tissue; Tumid pulp; Polypus
Parulis1,2	1840	Gum boil; Liquid tumor; Abscess; Fistula; Tubercle; Paroulis
Periodontal abscess3	1841	Conjoined suppuration; Pyorrhea
Pseudocyst of maxillary sinus4	1842	Retention of mucus
Pyogenic granuloma5	1844	Aneurism; Epulis; Fungous granulation; Erectile tissue
Pregnancy gingivitis6	1844	Uterine irritation; Positive inflammation of the gums
Pericoronitis7	1844	Painful affection
Peripheral ossifying fibroma8	1844	Osseous epulis; Bony epulis; Alveolar exostosis
Acute parotitis9	1844	Acute inflammation
Irritation fibroma10	1845	Fibrous epulis; Fibroid; Fibrous polyp; Polypus
Ranula11 **	1848	Acute inflammation of gland; Sublingual cyst
Peripheral giant cell granuloma12 **	1848	Fungus flesh; Epulis
Gumma13	1848	Indurated knot (of syphilis)
Papillary hyperplasia, palate14	1851	Hyperplasia
Mucocele15	1857	Salivary retention cyst; Serous cyst
Epulis fissuratum16	1858	Mamillated epulis; Simple epulis

 * 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.
                                               

TODAY'S DIAGNOSIS	YEAR	ORIGINAL DIAGNOSTIC TERM(S) *
Hemangioma17	1841	Bluish excrescence; Erectile tissue
Osteoma4	1842	Exostosis; Osteoid
Gingival fibromatosis4	1842	Fungus Excrescence; Hypertrophied Gums
Arteriovenous malformation18	1844	Anastomosing aneurism
Fibrous dysplasia10 **	1845	Fibrous tumor of jaw
Teratoma (Ovarian)18	1848	Encysted tumor; Dermoid cyst
Exostosis19	1848	True exostosis
Papilloma12	1848	Wart
Lipoma20	1849	Fatty tumor; Yellow epulis; Adipose tumor
Cutaneous horn21	1849	Horny growth; Horny tumor
Lymphangioma22 **	1850	Chronic clustered vesicles
Warthin's tumor23 **	1852	Enlarged lymphatic gland
Epidermoid cyst24 **	1852	Painless abscess; Wen; Sublingual cyst
Pleomorphic adenoma25	1852	Fibro-cartilaginous tumor; Soft enchondroma
Enchondroma26	1856	Chondroma
Parotid cyst27	1856	Cyst in duct of Steno
Lymphoepithelial cyst15 **	1857	Hydatid Cyst
Torus palatinus15	1857	Medio-palatine Exostosis
Rhabdomyoblastoma29	1858	Muscular Hypertrophy
Cystic hygroma30	1858	Hydrocele
Neuroma30 **	1858	Neurofibroma
Central giant cell granuloma30	1858	Myeloplaxes Tumour
Teratoma (Cervical)31	1860	Foetal Inclusion

* 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.

TODAY'S DIAGNOSIS	YEAR	ORIGINAL DIAGNOSTIC TERM(S)
Carcinoma of maxillary sinus32	1842	Fungus haematodes
Intraoral carcinoma9	1842	Cancerous ulcer; Cancer; Carcinoma
Soft tissue sarcoma33	1842	Fungus haematodes; Sarcoma
Osteosarcoma9,32	1842	Osteo-sarcoma; Fungus exostosis
Lip carcinoma34	1849	Cancerous ulceration
Chondrosarcoma3	1848	Cartilage cancer
Adenocarcinoma3	1849	Glandular cancer