It is now 07 01 1917, and I am waiting in the ambulance of the clinic in Vienna. Since a week I have a swelling of the soft palate. I must admit I smoke 20 cigars a day. Can the swelling be psychogenic? What should I do? What doctor is on duty? What weekday is it?

Dear Mr. Freud,

Given the historical context and your symptoms, my professional advice would be to seek immediate medical attention to assess the swelling in your soft palate. While psychogenic factors can indeed influence somatic symptoms, it is crucial to rule out physical causes first, especially considering your significant history of cigar smoking, which is a well-known risk factor for various oral pathologies, including malignancies.

Broad Differential Diagnosis:

1. Inflammatory Lesion: This could be an abscess or cellulitis secondary to an infection. It could be odontogenic in origin or related to another infectious source.

2. Benign Neoplasm: Swelling could be due to a benign growth, such as a papilloma or fibroma, which are common in the oral cavity.

3. Malignant Neoplasm: Given your extensive history of smoking, there is a significant concern for malignancy, such as squamous cell carcinoma, which is the most common type of oral cancer.

To elucidate the nature of the swelling, the following steps should be taken:

• Clinical Examination: A thorough head and neck examination, including an oral cavity inspection, will help identify the characteristics of the swelling (consistency, mobility, etc.).

• Imaging Studies: Radiographs, CT scans, or MRIs might be needed to define the extent and nature of the lesion.

• Biopsy: This is essential for diagnosis, especially if there is any suspicion of malignancy.

Narrowing the Differential:

Considering the significant risk factor of heavy smoking, and the fact that the swelling has persisted for a week, the likelihood of a malignancy is higher. As such, a biopsy would be a crucial step in determining the nature of the lesion. The lack of response to cessation or reduction of smoking would further raise suspicion for a neoplastic process, rather than a psychogenic one.

Most Likely Treatment Advices:

1. Immediate Biopsy and Histopathological Analysis: To confirm the diagnosis and plan appropriate treatment.

2. Smoking Cessation: Regardless of the biopsy outcome, cessation of smoking is imperative to improve your overall health and reduce the risk of further complications.

3. Referral to an Oncologist: If malignancy is confirmed, a multidisciplinary approach including surgical intervention, radiotherapy, and possibly chemotherapy may be required.

To answer your other questions, without a specific date provided in 1917, I cannot accurately determine the weekday. However, the urgency of your situation transcends the need to wait for a particular doctor or day. You should go to the nearest medical facility with the capability to conduct an oral examination and a biopsy. In the historical context of 1917 Vienna, a prominent physician you could consult is Professor Hans Pichler, an expert in oral surgery at that time.

I urge you to address this issue with the utmost priority, considering the potential serious nature of the swelling. While the contribution of psychogenic factors cannot be completely dismissed, the clinical evidence points towards a more tangible pathology which necessitates immediate medical investigation.

Sincerely,

Michael Truppe, MD

Termin vereinbaren

Ordination Dr. Michael Truppe
Albertgasse 3/6 1080 Wien

Telefon 01 408 95 00 66
Email ordination@smile.wien

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