Introduction


 

Summary Tables
Photo Album

Huge pleomorphic adenoma of the parotid gland, circa 1851.

Inflammatory
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Inflammatory
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Inflammatory
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Inflammatory
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Inflammatory
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Inflammatory
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Tables of first lesion reports

Early dental surgeons frequently reported nonmalignant soft tissue and bony masses, but inadequate descriptions make exact identification difficult, if not impossible. Tables 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.

Simon P. and the gum boil

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

They did root canal treatment too!

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. Initially, the seal was suggested to prevent toxins from entering the tooth from the bone, thereby causing the death of the pulp.

Chronic hyperplastic pulpitis...a mushroom in a tooth

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? or scurvy?), 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

Pericoronitis

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, a new idea at the time, 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

Pyogenic granuloma and the uterus connection

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 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 (Figure 2) reported just after the Golden Age but still several decades prior to the first skin lesion report.⁴⁴

Trouble with dentures

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. The epulis fissuratum (denture injury tumor) was first reported as a "mamillated epulis in 1858.²¹

Peripheral giant cell granuloma

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. He did so in an 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, one of the four founders of modern dentistry.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.

Peripheral ossifying fibroma

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 The lesion was later described by Birkett⁴⁷ as an "epulis with bony ingrowth" (Figure 3). Peripheral ossifying fibroma was, paradoxically, not formally differentiated from other fibromas until a century later and is much less common than the irritation fibroma.⁴⁸ Perhaps this very uniqueness was responsible for its being reported, albeit without an appropriate name, before the more common counterparts of oral fibrous hyperplasia.

The lowly fibroma

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.⁴⁹ But the first cases of oral irritation fibroma were not reported in the dental literature until 1845, under the diagnosis of "fibrous epulis."^15,50 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.⁵¹

Gingival enlargements

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 dedicated to 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,⁵² the first person described in print as a "Dental Pathologist,"¹ removed 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 4).^3,52-54 Sailors were especially prone to this disorder, as illustrated by one of the best know American travel journals, Two years before the mast:⁵⁵

"his gums swelled until he could not open his mouth. His breath, too, became very offensive; he lost all strength and spirit; could eat nothing; grew worse every day; and, in fact, unless something was done for him, would be a dead man in a week."

Scurvy was attributed to "salt provisions, want of cleanliness, and the free use of grease and fat (it was common on whaling ships), and laziness." Even at this early time, however, the sailors knew that the best treatment was "fresh provisions and terra firma." Since reported scorbutic gingivitis cases were sometimes associated with fatal outcomes, it is impossible today to differentiate such cases from leukemic gingivitis.

Sinus stuff

Thackston⁵⁶ 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 suggested for such contemporary problems as maggots and "worms" of the sinuses.^3,9,56-58

^{Soft Tissue Masses}                         

 
Bloodgood's plea

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 in light of the high prevalence of benign oral masses but, of course, scattered reports had been published on this topic long before his appeal.^60,61

Vascular tumors

Chapin Harris,²² for example, 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 an 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.⁶² It should be mentioned that Parmentier²⁰ referenced a 1795 French report of a "sanguinous" 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.^{63
Fat tumors}

Fat tumors

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.⁶⁴

Nerve tumors

No obvious neural tumors were reported as such during the Golden Age, but a case of probable traumatic neuroma was published in 1858 and cases of neurofibromatosis with oral involvement were reported shortly thereafter (Figure 5).^35,65

Bony Masses                 

Benign
Bony
Enlargements
 

Benign
Bony
Enlargements
 

Benign
Bony
Enlargements
 

Osteoma v. exostosis v. torus

An osteoma was reported by Harris⁹ on the lateral wall of the maxillary sinus in 1842. That 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.⁶⁶ 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, even though they were discussed in medical journals (Figure 6).^20,24 In fact, during that time the term exostosis was much more often applied in the dental literature 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

Cancer in the jaws? An obvious misunderstanding

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 7).¹ Numerous cases of true osseous malignancy were also reported and are discussed below.
Fibrous Dysplasia

Fibrosis of the marrow spaces

The first reported fibrous dysplasia case was described in 1845 in the mandible of a 14-year old girl.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. An earlier and more obvious case of fibrous dysplasia was reported in 1836 as "true exostosis" of the facial bones, but not in the dental literature.⁶⁹ 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 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 of bony "hypertrophy" in a child may have been an early example of cherubism.³⁰

Cartilage tumors and the mysterious giant cell granuloma

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.

Epithelial Masses                          

The ubiquitous papilloma

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.⁵¹

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 9).⁴⁴ This different biological behavior is still acknowledged and essentially unexplained today, although differing strains of human papillomavirus may be involved.⁷⁰

The devil's horn

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.⁷¹ 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 A smaller horn from the lower lip was depicted shortly after the Golden Age (Figure 10).⁷²

Salivary                   

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.⁷³ This entity had earlier been assumed to be simply another form of dental calculus or "tartar," but Dwinelle⁷⁴ 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.⁹ It appears to have been a true mucus-producing lesion rather than an antral pseudocyst. That a sinus mucocele should be reported long before the first labial example, published in 1857,²⁰ is another reminder of the strong interest shown in maxillary sinus pathology by early dental surgeons. Figure 11 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 reported, it is obvious from the tone of the 1858 report by Walton⁷⁴ 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. Walton⁷⁵ and Bond,³ who is perhaps the "Father of Oral Pathology,"¹ both suggested marsupialization as the primary treatment, with surgical removal of the offending gland performed only after marsupialization had failed. 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."⁷⁶

Few true salivary neoplasms were reported during the Golden Age. The earliest acceptable case was an 1852 report of 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 massive example is provided in Figure 12. Microscopic drawings of a parotid "enchondroma" were first printed in 1857 (Figure 13) 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.^47,78

^Cysts         

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 14). 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."^79,80 Bond³ considered these "wens" to be common to the periorbital skin but rare in the mouth.

Bryant⁵¹ 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 Coleman⁸¹ 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

Precancers                      

Sir James' ichthyosis

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,⁸² 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.⁸³ In this light it is perhaps also important to note that, as early as 1806, at least some investigators, albeit not dental investigators, were of the opinion that there was "an alteration in the structure of a part...preceding that more obvious change which is called cancer."⁸⁴

^{Oral Cancer}                 

A misunderstood tumor

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. The first reported examples are listed in Table 3. 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 dialogue of the heretofore verboten topic and it helped to create the interest and speculation which eventually became the foundation of future research investigation. Ironically, there was much more emphasis on such serious pathologic entities in the old dental journals than in our modern journals of general dentistry.

A cancer has a life of its own

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.⁸⁴ 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, 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.^84,85 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.⁸⁴

The classification of Cartier

Toward the end of the Golden Age, Cartier⁸⁶ 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. Taft⁸⁷ 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."

It has already been mentioned that the 1842 Thackston⁵⁶ report of maxillary sinus carcinoma ("fungus haematodes") was the first unequivocal dental journal account 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, Thackston⁵⁶ and Harris⁹ independently reported the first cases of sarcoma, maxillary osteosarcoma, under the diagnostic headings of "fungus exostosis" and "osteo-sarcoma" (Figure 15). A report of this disease was also the first attempt to subclassify orofacial cancers according to their clinical appearance and biologic behavior.⁸⁹ Chondrosarcoma of the maxilla was first discussed by Bond³ in 1848 and the disease was most dramatically illustrated by Holmes (Figure 16).⁹⁰

The first oral carcinoma

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.⁹¹ 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 Broders⁹² for his tumor-grading research because he considered it to be among the worst of human cancers.

The first follow-up study

Of 175 oral and pharyngeal surgical cases reported in 1861 by Bryant,⁵¹ 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.

Basal cell carcinoma, the rodent ulcer

The relentless progression of orofacial malignancy was well illustrated in the 1850s by a huge basal cell carcinoma of the midface (Figure 17) and by the case of a young woman who died of her disease (Figure 18). The former malignancy was thought to be a form of necrotizing "folliculitis" and the latter was probably a fibrosarcoma, although histologic detail is lacking.

Treatment (treatment!?!)

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 19).^94-98 Eve⁹⁷ 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.).⁹⁹ 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, from the treatment.¹⁰⁰

Despite this 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 well summarized by a direct quote from the waning days of the Golden Age. Choppin¹⁰¹ reported "a case of removal of the tongue, for cancer, with the écraseur." 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.

Look-alike lesions

There was, fortunately, a clear understanding that not all destructive oral ulcerations were cancers. For example, cancrum oris, tuberculosis, osteomyelitis, and other similar diseases were well known and easily differentiated from malignancy,^{3,17,81,102-105} 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."¹⁰⁶

The mystery of metastasis

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. Cartier⁸⁶ 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.

What causes it?

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,¹⁰⁷ 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, Obre¹⁰⁸ 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.

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Today's Diagnosis

Year

Original Diagnostic Term(s)*

Pulp polyp⁶

1840

Nerve fungus; bluish excrescence; erectile tissue;
tumid pulp; polypus

Parulis^6,7

Gum boil; liquid tumor; abscess; fistula; tubercle; paroulis

Periodontal abscess⁸

Conjoined suppuration; pyorrhea

Pseudocyst of maxillary sinus⁹

Retention of mucus

Pyogenic granuloma¹⁰

Aneurism; epulis; fungous granulation; erectile tissue

Pregnancy gingivitis¹¹

Uterine irritation; positive inflammation of the gums

Pericoronitis¹²

1844

Painful affection

Peripheral ossifying fibroma¹³

1844

Osseous epulis; bony epulis; alveolar exostosis

Acute parotitis¹⁴

1844

Acute inflammation

Irritation fibroma¹⁵

1845

Fibrous epulis; fibroid; fibrous polyp; polypus

Ranula¹⁶ **

1848

Acute inflammation of gland; sublingual cyst

Peripheral giant cell granuloma¹⁷ **

1848

Fungus flesh; epulis

Gumma¹⁸

1848

Indurated knot (of syphilis)

Papillary hyperplasia, palate¹⁹

1851

Hyperplasia

Mucocele²⁰

1857

Salivary retention cyst; serous cyst

Epulis fissuratum²¹

1858

Mamillated epulis; simple epulis

Today’s Diagnosis

Year

Original Diagnostic Term(s) *

Hemangioma²²

Bluish excrescence; erectile tissue

Osteoma⁹

Exostosis; osteoid

Arteriovenous malformation²³

Anastomosing aneurism

Fibrous dysplasia¹⁵ **

Fibrous tumor of jaw

Teratoma (Ovarian)¹⁸

Encysted tumor; dermoid cyst

Exostosis²⁴

True exostosis

Papilloma¹⁷

Wart

Lipoma²⁵

Fatty tumor; yellow epulis; adipose tumor

Cutaneous horn²⁶

1849

Horny growth; horny tumor

Lymphangioma²⁷ **

1850

Chronic clustered vesicles

Warthin's tumor²⁸ **

1852

Enlarged lymphatic gland

Epidermoid cyst²⁹ **

1852

Painless abscess; wen; sublingual cyst

Cherubism³⁰ **

1852

Bony hypertrophy

Pleomorphic adenoma³⁰

1852

Fibro-cartilaginous tumor; soft enchondroma

Enchondroma³¹

1856

Chondroma

Parotid cyst³²

1856

Cyst in duct of Steno

Gingival fibromatosis³³

1856

Fungus excrescence; hypertrophied gums

Lymphoepithelial cyst²⁰ **

1857

Hydatid cyst

Torus palatinus²⁰

1857

Medio-palatine exostosis

Rhabdomyoblastoma³⁴

1858

Muscular hypertrophy

Cystic hygroma³⁵

1858

Hydrocele

Neuroma³⁵ **

1858

Neurofibroma

Central giant cell granuloma³⁵

1858

Myeloplaxes tumour

Teratoma, cervical³⁶

1860

Foetal inclusion

Today’s Diagnosis

Year

Original Diagnostic Term(s)

Carcinoma of maxillary sinus⁵⁶

1842

Fungus haematodes

Oral carcinoma⁹

1842

Cancerous ulcer; cancer; carcinoma

Osteosarcoma⁵⁶

1842

Osteo-sarcoma; fungus exostosis

Soft tissue sarcoma⁸⁹

1847

Fungus haematodes; sarcoma

Chondrosarcoma³

1848

Cartilage cancer

Adenocarcinoma³

1849

Glandular cancer

Lip vermilion carcinoma⁹¹

1849

Cancerous ulceration