The Missed Diagnosis of Sigmund Freud’s Maxilla Osteoradionecrosis

Osteoradionecrosis (ORN) of the maxilla or mandible is a complication of radiotherapy (RT) associated with the management of head and neck malignancies. It is defined as exposed radiated bone that fails to heal over a period of 3 months without any evidence of persisting tumor. ¹ Various theories regarding the pathophysiology have been proposed. These include the radiation, trauma, vascular, and infection theory. ² Marked pain is the primary symptom, secondarly appears exposed devitalized bone, fistula, ulceration of the mucous membrane, hemorrhage, and trismus. ¹ Numerous factors that may be associated with the risk of ORN include total RT dose (authors estimated a dose superior of 60 Gy), patient-related variables (such as deep parodontitis, preirradiation bone surgery, bad oral hygiene, alcohol and tobacco abuse, bone inflammation, dental extraction after RT, cardiovascular diseases), and tumor-related factors (tumor size or stage, proximity of the tumor to bone, anatomic tumor site).^3,4 Sigmund Freud has cancer of the right maxilla (Figure 1A). He was diagnosed in 1923. The study of Dr Pichler’s notes, who treated Freud for the last 16 years until his death in 1939, suggests that he was having ORN. ⁵ This disease was first described by Regaud in 1922, but it was only defined as “radiation osteitis” in 1926 by Eiving. ⁶ This disease was therefore little known at the time, and it was not until the 1970s that it was fully understand and physiopathologically described. ⁶ The number of instances that each risk factor for ORN appeared in Dr Pichler’s notes is designated as “n.” Between 1923 and 1939, Sigmund Freud received numerous treatments by X-ray RT (n = 6) and radium in local application (n = 12). The dangers of RT have been slow to make themselves known, the doses employed in Freud’s time were far greater, resulting in an increase in complication rates. ⁷ It is therefore likely that he received more than 60 gray, especially since certain toxic effects of the rays are described (loss of hearing, trismus, pain, chronic mucositis, multiple dental lesions, migraines, and deterioration of the general state during the sessions). In addition, he suffered numerous local traumas: changes and adjustments of his prosthetic shutter due to pain (n = 52), local electrocoagulation to eliminate buds whose cancerous nature was not always proven (n = 28), local surgical revision (n = 23), and extractions and dental care (n = 8). Added to this is the iterative use of many irritating local topicals: cocaine, tetracaine, trichloroacetic acid, silver nitrate. The hypovascularization of the maxilla bone was favored by his bad cardiovascular terrain (angina pectoris), the ligation of his ipsilateral external carotid at the beginning of his treatment in 1923, ⁸ his chronic nonweaned smoking and the use of cocaine. During its treatment, many biopsies were made to treat recurrences, histological reports often mention uncertain diagnosis (n = 5). Eiving states that in 1926 many pathologists made mistakes and cannot recognize the histological signs of ORN. ⁶ In the last 2 years of his life, Freud’s doctors came to the appearance of painful and smelly bone sequestration without the diagnosis of cancer being proven. The practitioners decided to remove them and continue the treatment using a local application of radium. By treating “evil with evil” they have made the situation worse. We reviewed plain film X-ray (n = 12) performed during his last 2 years of life: they put to light multiple dental roots and dental crowns treatments, osteolysis secondary to periodontal disease (Figure 1B), and right mandible bone heterogeneity, suggestive of osteonecrosis bone (Figure 1C).

Figure 1.

A, Portrait-style photographs of Sigmund Freud dating from 1938 which were taken after a number of surgeries of his right maxilla tumor. B, Plain film X-ray of Freud’s head (oblic incidence), taken on February 28, 1939: multiple dental treatments (dental roots and dental crowns), osteolysis secondary to periodontal disease: possible promoting factor of osteonecrosis. Freud Museum-London (England). C, Plain film X-ray of Freud’s head (anteroposterior incidence). Right upper maxillar surgery stigmas (bone defect). Right mandible bone heterogeneity, suggestive of osteonecrosis bone. Freud Museum-London (England).

A cutaneous fistula finally appeared in August 1939. During the last decade of Freud’s life, Max Shur was his personal physician and a close friend. Facing his extreme suffering, Freud expressly asked Shur to “stop his martyr” and died on September 23, 1939, after Shur assisted suicide with a high dose of morphine. The proofreading of his medical file proves to us that there is uncertainty about the origin of the aggravation of his symptomatology at the end of life, the doctors of the time having concluded to a recurrence of the cancer, but we cannot eliminate the hypothesis of an advanced ORN of its remaining right maxilla that also involved the mandible.