Given the historical context and the clinical timeline of Sigmund Freud’s oral health, it appears that Freud suffered from a form of oral carcinoma, likely squamous cell carcinoma (SCC), which is the most common type of oral cancer. This diagnosis is supported by the description of a crater-shaped ulcer in the posterior aspect of the right maxillary tuberosity and the recurrence noted after initial surgical interventions. The extensive use of cigars would have significantly increased Freud’s risk for this type of carcinoma.
Initial Analysis:
Based on the details provided, the following three potential diagnoses were considered:
- Squamous cell carcinoma (SCC) of the oral cavity: This is a malignant tumor that arises from the lining of the mouth and throat. It is often associated with tobacco and alcohol use.
- Verrucous carcinoma: A less common and less aggressive variant of SCC that may present with a similar appearance.
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Minor salivary gland carcinoma: Given the involvement of the maxillary tuberosity, one could consider a neoplasm of the minor salivary glands, such as adenoid cystic carcinoma or mucoepidermoid carcinoma.
Differential Diagnosis:
Upon further analysis, we can narrow down the diagnosis:
- Squamous cell carcinoma (SCC): The patient’s heavy cigar use, the presence of a recurrent ulcerative lesion, and the need for repeated surgeries are all consistent with SCC. SCC often requires radical surgery and may recur if not completely excised, as was seen in Freud’s case.
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Verrucous carcinoma: This slower-growing form of SCC could have been a possibility; however, it is less likely given the aggressive nature and recurrence after the initial surgeries.
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Minor salivary gland carcinoma: Although these can occur in the maxillary tuberosity, the aggressive nature of the lesion, the ulcerative presentation, and the association with smoking make SCC a more likely diagnosis than a minor salivary gland tumor.
Treatment Recommendation:
The most probable diagnosis for Freud would have been squamous cell carcinoma (SCC) of the oral cavity. The treatment during his lifetime focused on surgical intervention, prosthetic rehabilitation, and late-stage radiotherapy. However, the surgical techniques and prosthetics used during Freud’s time were limited in comparison to current standards.
Literature from Freud’s era (late 19th to early 20th century) was rudimentary in understanding and treating cancer. The modern understanding of cancer biology, genetics, and treatment options has evolved tremendously since then.
Differences in Knowledge and Treatment: 1938 vs. 2024
- Surgery: In 1938, surgeries were performed with significant morbidity and without the precise imaging and navigation systems available in 2024. Current surgeries can be less invasive with microvascular reconstruction techniques to optimize functional and cosmetic outcomes.
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Radiation Therapy: In Freud’s era, radiotherapy was not as advanced and often caused significant side effects. Today, we have intensity-modulated radiation therapy (IMRT) and proton therapy, which are highly precise, sparing normal tissues and minimizing side effects.
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Chemotherapy: Systemic chemotherapy was not available in Freud’s time. In 2024, we have targeted therapies and immunotherapies that can significantly improve outcomes in many cancers.
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Palliative Care: While Freud received morphine for palliation, modern palliative care encompasses a holistic approach to symptom management, psychological support, and quality-of-life considerations.
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Genetics and Personalized Medicine: Our understanding of genetic mutations and their role in cancer has led to personalized medicine strategies that target specific pathways involved in tumor growth.
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Prosthetics: Today, maxillofacial prosthetics are highly advanced, using digital design and materials that provide better function and aesthetics.
Given the historical context, Freud’s care seemed comprehensive for that era. Today, treatment would likely include a multidisciplinary approach with advanced surgical techniques, adjuvant radiotherapy and/or chemotherapy, and carefully planned reconstructive surgery, followed by long-term surveillance for recurrence.
Citations:
– Rivera, C. (2015). Essentials of oral cancer. International journal of clinical and experimental pathology, 8(9), 11884.
– Neville, B. W., & Day, T. A. (2002). Oral cancer and precancerous lesions. CA: a cancer journal for clinicians, 52(4), 195-215.
– Dissanayaka, W. L., Pitiyage, G., Kumarasiri, P. V. R., Liyanage, R. L. P. J., Dias, K. D., & Tilakaratne, W. M. (2012). Clinical and histopathologic parameters in survival of oral squamous cell carcinoma. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 113(4), 518-525.
Signature:
Michael Truppe, MD
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