FREUD: WILL AND DEPENDENCE
School of Dentistry, Faculty of Medicine, Departmen of Surgery, University of Salamanca, Spain; corresponding author, Clínica Odontológica, C/ Alfonso X El Sabio, S/N,CampusMiguelde Unamuno, Salamanca 37007, Spain.
The neurologist Sigmund Freud, one of the most relevant figures in the twentieth century, and the creator of psychoanalysis, had a squamous cell carcinoma in his soft palate stemming to his strong addiction to tobacco. The poor surgical praxis of some of the surgeons who operated on him during the first stages of the illness and the patient’s refusal to stop smoking, together with his conception of cocaine as an analgesic to mitigate his pain, converted the last 20 years of his life into a true Calvary, and he underwent 33 operations aimed at resolving his tumoral pathology-
Psychoanalysis, Squamous cell carcinoma, Tobacco, Cocaine.
Sigismund Scholomo Freud , a neurologist and creator and founder of the bases of psychoanalysis, is considered to be one of the most important intellectuals of the last century (Britannica Concise Encyclopedia 2006).
At the age of 17 he began his medical studies at the University of Vienna, gaining his degree in 1881 at the age of 25 (Gay P, 2010).
He was a pioneer in proposing the use of cocaine as a local anaesthetic, together with the ophthalmologist Carl Soller, a peer at the Neuroanatomy Laboratory of the Viena General Hospital, publishing “Über Coca” in 1884, where he expressed his enthusiasm about the use of the drug as an anaesthetic and analgesic, and declared himself to be a fervent user of the substance in oral solution as the treatment of choice in addictions to alcohol and morphine (Freud S, 1884) .
ADDICTION TO TOBACCO
Freud’s addiction to tobacco started when he was about 24. On 13 February 1929, in a questionnaire about tobacco, he answered “I began to smoke when I was 24, first cigarettes and then only cigars; I continue to smoke today at the age of 72, and I am horrified at the thought of depriving myself of this pleasure (Ernest J, 2003).
He smoked about 20 cigars of a select brand (“Don Pedro”) daily which were extraordinarily strong. “Cigars have served me for 50 years as protection and a weapon for life’s struggles and strife… To cigars I owe a huge intensification of my work capacity and an improvement in self-control” (Jones E, 1981).
Before dying on his brother’s birthday, Freud made him a present of his most valuable collection, his whole reserve of cigars, asking his brother to use them in the same way as Freud himself had done (Mangan G & Golding J,1984).
FREUD AND COCAINE
In 1883, A German military physicist, Dr. Theodor Aschenbrandt, managed to get hold of a supply of pure cocaine that he distributed among the Bavarian soldiers in the course of some military exercises, describing the experience as an increase in their physical capacity and resistance to pain (Aschenbrandt T, 1883).
In April 1884, Freud wrote to his fiancée: “I have read Aschenbrandt’s reports and was impressed…” (Freud S, 1973), and he began to experiment with the drug on himself and shortly afterwards, about two months later, he began to treat his friend Ernst von Fleischl-Marxow with cocaine for the latter’s addiction to morphine. In July 1884, he wrote “Über Coca”, a passionate paper about the drug in which there were some indications pointing to its analgesic properties, mentioning its use by his hospital colleague, the ophthalmologist Carl Koller, to anaesthetize corneas in his ophthalmological surgery (Freud S, 1980; Lovell J, 1993; Ball C, 2003).
FREUD’S ORAL PATHOLOGY
The first references to the lesion on Freud’s palate date back to 1917, when he was 61, Freud himself describing it as “an inflammatory and extremely painful lesion on the palate” (Schávelzon J, 1983).
In February 1923, this discomfort he was feeling worsened considerably, possibly due to ulceration of the lesion, and Freud went to see his personal physician Dr. Felix Deutch and his dermatologist friend Maxi Steiner. Both agreed that this was a cancerous lesion located on the right side of Freud’s palate (Deutsch F, 1956).
Freud put himself into the hands of the Professor of laryngology of the University of Vienna, Markus Hajek, who operated on him under local anaesthesia on 20 April of that year, performing an incomplete resection of part of the palate and jaw using a technically incorrect surgical technique. Hajek’s histological diagnosis was squamous cell carcinoma and he recommended that the surgical treatment be complemented with radiation therapy. The radiological treatment was directed by Professor Guido Holzknecht, the Chief of the X-ray laboratory at the Vienna General Hospital (Romm S, 1983; Schur M, 1972).
The next surgeon to treat Freud’s oral carcinoma was Hans Pichler, a Viennese physician and a pioneer in maxillofacial interventions, who performed a second operation in two phases. In the first, he ligated the right external carotid artery and removed the cervical adenopathy, and in the second he performed a broad resection of the palate, thus managing to reduce the haemorrhaging in this second phase (Davenport JC, 1993).
As a result of these interventions, Freud entered a dramatic period of his life, during which he underwent a total of 33 operations.
Pichler built the first prosthesis to cover the large defect during the palate resection, which Freud referred to as “the monster” or “the necessary evil” (Schur M, 1972) .
For a time, Freud tolerated the prosthesis made by Pichler acceptably well, but later found that the discomfort was of such magnitude that he decided to go to Berlin, where a famous prosthetist, Dr. Schoroeder, built him a new piece made of vulcanized rubber (vulcanite) and gold to cover the defect (Tainmont J, 2007).
Around 1931, he again complained of the discomfort due to his prosthesis. It was precisely in that year that Varastad Kazanjian, a plastic surgeon at the University of Harvard (Cambridge, Massachusetts, USA), went to Berlin to a professional meeting, asking Pichler to make a new obturating prosthesis, for which he was to charge $ 6000 (Gay P, 1989). His last two prostheses can still be seen at the museum-house in London and the first one made by Pichler is in the house-museum of Vienna (Fig. 1B).
In 1936 Freud retired to London, where Pichler asked a series of English oral surgeons to monitor and look after his lesion. In 1939, Pichler himself went to London to operate on Freud again, and this time too recommended radiation therapy.
After considerable physical deterioration, Freud asked his personal physician and friend Felix Schur to end his life, which he did with the administration of a lethal dose of morphine on 23 September 1939 (Jones E, 1981 Schur M, 1972; Adeyemo WL, 2004).
Freud’s ashes rest at the crematorium of Golder’s Green (London).
Since Markus Hajek diagnosed the lesion taken from Freud’s mouth on 20 April as a squamous cell carcinoma, the incompetence and poor praxis of the various surgeons attending him (Schur M, 1965) and the complementary treatments with radiation therapy to control the lesion by means of an obturating prosthesis containing a radium capsule hindered the complete healing of the edges of the lesion, giving rise to constant ulcers and setbacks in his illness (Tainmont J, 2007).
The attempts by his physician and friend Felix Deutch and the surgeon Pichler to convince Freud to stop smoking were unfruitful. The pathologist of the University of Vienna Jakob Erheim, who had diagnosed the lesion removed by Pichler also failed to convince Freud to give up tobacco. Freud’s stubbornness in this matter, refusing to even cut down his consumption, was a further aggravating element in the situation (Romm S, 1987; Mangan G & Golding J, 1984).
However, to this must be added something that both physicians and biographers have overlooked. In his youth Freud was a passionate investigator of defender of cocaine. In his work “Über Coca” he defines the drug as “something that calms hunger and pain” (Freud S, 1884).
When Freud’s discomfort, which was almost unsupportable, began, as from 1939 he found refuge in the drug and its anaesthetic effects, using mouth washes and frequent nasal infiltrations of the aqueous solutions that his maestro Josef Breuer had taught him about, managing to achieve a transient anaesthesia of the oral mucosa in his attempt to mitigate the pain (López-Valverde, 2009; Lovell J, 1993; Schur M, 1972; Wittenberg C, 2002).
This kind of anaesthesia used by the patient helped to aggravate his lesion owing to the tremendous vasoconstrictor effect (of cocaine and indeed of tobacco) on the whole of the oral mucosa, especially at the edges of the surgical wound, which considerably hindered the healing process and was possibly the reason for the frequent relapses Freud underwent.
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