Par Xavier Riaud
Résumé
De 1919 à sa mort, Sigmund Freud est soigné d’un cancer du maxillaire par deux chirurgiens exceptionnels, l’Autrichien, Hans Pichler, et l’Américain, Varaztad Kazanjian. Fuyant le régime nazi, il s’exile en Angleterre où il en meurt, après de multiples récidives de la maladie.
Summary
From 1919 to his death, Sigmund Freud was treated for a maxillary jawbone cancer by two exceptional surgeons, the Austrian, Hans Pichler, and the American, Varaztad Kazanjian. Escaping the Nazi regime, he went into exile in England where he died after numerous recurrences of the disease.
A brief account on Sigmund Freud (1856-1939)…
As main theorist of psychoanalysis, he rethought the psychic apparatus and processes, and in the first place the concepts of the unconscious, dream and neurosis. Then, he proposed treatment techniques and psychoanalytic therapy. Freud gathered a generation of psychotherapists who progressively created psychoanalysis everywhere. Despite internal divisions and criticism coming from some psychiatrists as well as the outbreak of World War II, psychoanalysis appeared as a new discipline of social studies from 1920. In 1938, as he was threatened by the Nazi regime, Freud left Vienna to go into exile in London where he died of cancer in 1939.
Freud’s cancer
In 1919, Sigmund Freud was first seen by Hans Pichler (1877-1949), an Austrian stomatologist who was considered as one of the best maxillofacial surgeons in Europe, for a painful swelling of the left palate and of the maxillary tuberosity which persisted for a week [Romm & Luce, 1984, pp. 31-32].
From 1923 to 1938, Pichler operated on the philosopher, who was a great smoker, around twenty-five times on the right side of the soft palate, hard palate, palatoglossal arch, oral mucous membrane and of the rear mucus menbrane of the mandible. On October 4 and 11, he excised a part of the higher jawbone and of the right palate. Then he bound the right external carotid artery and removed the submandibular and cervical lymph nodes. On November 12 1923, he carried out the resection of the pterygoid process and a part of the soft palate. The operations were a great success. His recovery was difficult and Freud only started working again on January 1924 [Krémer, no date, pp. 1-3]. As his first prosthesis was fitted in 1923, he also had made his fifth palatal obturator in 1928.
On his seventieth birthday, he assured: “I hate my mechanical jaw”. About his new prosthesis, he did not hesistate to draw a parallel: “Fitting a new prosthesis is like the quest for happiness. You think you have reached it and then, you soon realize that everything has to be done again [Deranian, 2007, pp. 165-170].” When he was asked to speak French, he refused saying that : “My prosthesis does not speak French.”
In a letter dating back to 23 April 1923, Freud wrote: “Two months ago, I noticed a leucoplasia lump on my maxilla and on my right palate which had already been removed. I still cannot work and swallow. I am certain of its non-malignancy but as you know it, you can never be totally sure. According to my personal diagnosis, it may be an epithelioma but my colleagues did not confirm it. Tobacco may be the cause.” Freud had started smoking when he was 24 years old and soon had started to exclusively smoke cigars.
In 1930, Freud stayed twice in Berlin where Dr Hermann Schroeder, the head of the Dental Institute of the University of Berlin placed a first prosthesis in his mouth. Those trips to the capital exhausted the patient. As a result, during a very short period of time, a dentist from Vienna, Dr Joseph Weinmann, undertook to take care of him. In any case, Freud suffered a lot and did not stand the prostheses.
In 1931, Dr Brunswick, Freud’s close colleague decided to help him. Without Freud’s knowledge, he called upon professor Varaztad Kazanjian (1879-1974), an eminent Armenian American dentist and the 20th century’s forerunner of maxillofacial surgery to come to Vienna in order to design the philosopher’s new prostheses.
Passing through Europe for congresses in London and Paris in 1931, Kazanjian refused at first. Brunswick consequently asked for Princess Maria of Greece’s help and she agreed. Kazanjian finally accepted and made a detour through Vienna on July 31 and August 1. He saw the philosopher during those two days at Pichler’s dental office. On August 3, Freud wrote in his diary: “Something unbelievable happened! Within a day and a half, the magician made a prosthesis which is less intrusive and heavy than all the others and with which I can chew, talk and smoke like before [Deranian, 2007, pp. 165-170].”
With his own hands, he made in Pichler’s laboratory three prostheses with the supplies that Princess Maria had sent him. Freud knew that Kazanjian could hardly help him more [Hardt, no date, pp. 6-9]. Later, Kazanjian said to one of his colleagues that there was forlorn hope for the prosthesis to be successful. Kaznajian left Vienna on August 29. On August 30 1931, Freud wrote: “The magician left yesterday. I do not feel as great as before but I can speak more easily. It seems difficult to do more for me [Deranian, 2007, pp. 165-170].”
Kazanjian demanded 5 000 dollars for his work which were paid to him. During his stay, Kazanjian only stayed in Pichler’s laboratory. He did not see anything of Vienna. He worked night and day and the patient sometimes saw him from three to four hours a day. After a short twenty-day stay, Kazanjian could not go back to Vienna for he had to return to his family [Deranian, 2007, pp. 165-170]. Kazanjian’s prostheses had helped the famous psychoanalyst for three years.
Besides, the Austrian dentist saw Freud 143 times between 1923 and 1924, and 122 times from 1926 to 1928 [Hardt, 2007, pp. 6-9]. He was said to have treated him 16 times in 1923, 74 times in 1924 and 94 times in 1932 [Deranian, 2007, pp. 165-170]. In 1938, Pichler examined Freud one last time before his departure for Austria for he was afraid of the Nazis. He also examined him on September 7 1938 in London and observed a recurrence of his carcinoma [Hardt, 2007, pp. 6-9]. Freud died of a verrucous carcinoma (also known as Ackerman tumor) in 1939 when he was 83 years old. With his daughter’s agreement, Anna Freud, he was said to have asked his personal Austrian doctor, Max Schur, to inject him a – lethal? – dose of morphin from 1928 to 1938. Max Schur (1897-1969), a doctor who also practiced psychoanalysis and who was trained in Vienna, was Freud’s close friend. So much so that he followed Freud when he left to England to escape from the Hitlerian regime. Sigmund Freud never stopped smoking despite his illness. As for Pichler and Kazanjian, they remained friends and never ceased to communicate [Deranian, 2007, pp. 165-170].
Verrucous carcinoma (also known as Ackerman tumor)
It is a rare histological form of carcinoma, actually known as a clinical and independent histopathological entity. It can grow at all membrane levels located in the upper aerodigestive tract, oral cavities being where it is the most frequently affected, followed by laryngeal membranes. Described for the first time in 1948, by Lauren V. Ackerman (1905-1993), a prestigious American doctor and pathologist who enhanced cancerous surgery, it represents from 1 to 3 % of the laryngeal carcinomas and from 2 to 12 % of the oral carcinomas. The average age when it is generally diagnosed is 69 years old. There is an unquestionable correlation with the consumption of tobacco and poor oral hygiene. It is a leucoplasic, papillomatous, exophytic and locally aggressive lesion [Montjean & al., 2004, p. 173].
Hans Pichler (1877-1949)
The son of a dentist, Hans Pichler was born in Vienna, in 1877. As he was always ending first in all sports activities, both when he was a teenager and an adult, he gradually gained respect from his peers. Always proving his physical resistance, he excelled in numerous sports, including skiing and alpinism. All his life he would keep a distinctive taste for any kinds of physical challenges [Romm & Luce, 1984, pp. 31-32]. After the gymnasium, he started to study medicine in Vienna, Fribourg and Prague. On August 10 1900, he attended the meeting of the nine founders of the international dental federation (IDF). The next day, due to illness, he could not attend the first meeting of the executive council of the IDF which took place within the Dental School of Paris [Ennis, 1967, pp. 1, 8].
On that year, he chose to follow a surgical career at the Anton Eiselsberg’s clinic. Eiselsberg (1860-1939) was an eminent surgeon from Vienna. Suffering from eczema following the use of an antiseptic to desinfect his hands before each operation, he turned towards dental surgery and attended lectures at the Dental School of Northwestern University in Chicago, in 1902. Green Valdimar Black (1836-1915), author of the classification of carious lesions, father of the equally well-known “prophylactic extension” and first dean of the dental school of the university in 1897 was his tutor. At the beginning, Hans attended his American lectures with perplexity. Then, pushed by his scientific pragmatism, he graduated in dentistry at the end of that year. He always defended his positions and expressed his opinions which were qualities expected in the best clinicians [Romm & Luce, 1984, pp. 31-32]. The year after, Pichler went back to Vienna where he settled. As professor, he led the Dental Institute of the University of Vienna. There, he taught the principles of dental art and oral surgery, and advocated the implementation of a curriculum for Austrian dentists which would end up with a diploma.
During the Great War, his work became successful and he subsequently acquired an uncommon and well known dexterity. Pichler’s scientific work was colossal. He covered numerous fields about dentistry. He wrote 125 articles and participated to many books. Focusing his research on maxillofacial surgery and preventive dentistry, he also enquired about the prostheses which were used after jaw resection, about the treatment of trigeminal neuralgia and about the management of facial fenestras. He soon became Victor Veau’s great friend. Veau (1871-1949) was a famous French surgeon [Romm & Luce, 1984, pp. 31-32]. In 1936, Hans presided over the 9th congress of the International Dental Federation in Vienna. Then professor, he stated with conviction: “We, Austrian men, want to stay in contact with medicine but we want to collaborate with dentists coming from the whole word towards a common objective.” The congress met great success which made Pichler proud in a country where the dentists were mainly stomatologists. During the meeting, two resolutions which were approved by Pichler were registered: the end of rivalry between stomatologists and dentists who had to work in perfect harmony, and the obligation for the dentists to follow appropriate medical training in universities [Ennis, 1967, pp. 110, 112]. Hans translated Black’s book in German and in 1948, he published his three-volume book entitled Surgery of the mouth and jaws (Chirurgie de la bouche et des mâchoires), a collection of his professional experiences [Deranian, 2007, pp. 165-170]. Pichler was a calm man but who had his own distinct temperament. He was a shy man which at first made him look like a reserved and modest person. He was an extremely meticulous man who paid attention to every single details. Very tactful, he knew how to comfort and give attention to his patients [Romm & Luce, 1984, pp. 31-32]. Hans Pichler died on February 3 1949 in Vienna [Riaud, 2010, pp. 119-122].
Professor Hans Pichler (1877-1949)
[© Osterreichische Nationalbibliotek, 2009].
Varaztad Hovhannes Kazanjian (1879-1974)
Varaztad was born on March 18, 1879, in Erzincan, in Turkish Armenia. He did most of his scholarship in the French Jesuit Mission of Sivas. In 1893, he moved to Samsun to live with and work for his older half-brother. Then, he later worked in the local post-office. [http://www.armeniapedia.org, 2006, pp. 1-3]. In 1895, he left for the United States where he arrived in October. He lived in the Armenian community of Worcester. He received correspondence courses before attending Worcester’s evening classes. On October 15 1915, he officially became a US citizen. In 1902, he attended the Boston English High School. In 1902, he entered the Boston English High School. He was admitted to Harvard School of Dental Medicine in 1902. He graduated on June 28 1905. He immediately established his own private dental practice in Boston [Deranian, 2007, pp. 200-202].
In 1906, he was appointed assistant in dental mechanic, then, assistant in dental prosthesis in 1907 and finally, demonstrator in dental prosthesis at Harvard School of Dental Medicine in 1909. In 1911, he began his second year of study in Boston University School of Medicine. In 1912, he was designated head of the Prosthetic Dentistry Department at Harvard School of Dental Medicine. On the same year, he left the Boston University School of Medicine. On December 21 1912, he married Sophie Augusta Cuendet in Boston. She died on August 10 1919.
During World War One, Kazanjian mainly practised as a dentist [Deranian, 2007, pp. 65- 102, 200-202]. In 1915, he was appointed Chief dental officer at the Harvard Medical Unit which was part of the British Expeditionary Forces. He served with the rank of honorary lieutenant. He officiated in Camiers, France at the general hospitals #20 and #22. In September, he met Dr Hayes in Paris at the Dental Department of the American Ambulance. He worked relentlessly at the hospital #22 where he treated no less than 22 casualties within a month. His prosthetic achievements were innovative and original. None were similar. By means of a great amount of dental ties, he immobilized and held together the bone fragments as part of maxillary fractures, and fixed them harmoniously to the original occlusion. On October, 1915, he returned to the USA. Then he went back to England along with a second unit coming from Harvard on November 17. On December 3, he visited Oxford. The same month, he was affected in the general hospital #20 which was under English command. When he would enter the main ward, the wounded would kiss his hand as a token of respect and gratitude. Kazanjian innovated so much that some newspapers wrote editorials about him. His original techniques became benchmark surgical procedures. In April 1916, he was the guest speaker of the American Society in Paris. In June, he was promoted Honorary Major of the Royal Army Medical Corps. On June 15, he released his article entitled “Immediate Treatment of Gunshot Fractures of the Jaws” to the British Dental Association. In his article, he gave a list of his treatment protocols as well as a classification of fractures. On November 7, 1917 and April 7, 1918, the Armenian doctor received two subpoenas signed by Churchill. Kazanjian led and worked with six dentists who, despite their small number, tried to bring as much comfort as they could to the wounded soldiers. This was when Varaztad invented the Kazanjian clamp which controlled arterial hemorrhages, the Kazanjian Button which was used during the immobilization of the jawbones with dental rubber band and the Kazanjian splint for nasal fractures. On June 3, 1918, he was appointed “Companion of the Order of Saint Michael and Saint George”. His works became more and more famous. Gillies and Fry were his close friends and faithful allies. On the same year, he was appointed Professor of Military Oral Surgery at Harvard School of Dental Medicine [Deranian, 2007, pp. 65-102, 200-202]. In 1919, he was demobilised from the British Army after having treated around 3 000 patients. He received his decoration by King George V at Buckingham Palace in May. Upon his arrival to the USA, he was admitted as a third-year student at Harvard Medical School. He went back to office as professor of Military Oral Surgery at Harvard School of Dental Medicine [Deranian, 2007, pp. 200-202]. In 1921, he graduated in medicine. In Boston, he established a private practice specialised in facial plastic surgery, surgical prosthesis and oral surgery. On August 25, 1923, he remarried. In 1931, he was named head surgeon for plastic surgery operations at Massachusetts Eye and Ear Infirmary. At the same time, he became special consultant in plastic surgery at Massachusetts General Hospital. In 1932, he received an award from the Rhode Island Dental Society. In 1937, he presided over the American Academy of Dental Science and in 1940, the American Society of Plastic Surgeons. In 1943, he received the Alfred E. Fones Medal from the Connecticut State Dental Society. In 1947, he was appointed honorific lecturer at the University of Pennsylvania School of Medicine [Deranian, 2007, pp. 200-202]. In 1949, he published his first book co-authored with Dr John Marquis Converse, entitled The Surgical Treatment of Facial Injuries (Le traitement chirurgical des blessures de la face). In 1951, he was congratulated by the American Society of Plastic and Reconstructive Surgery for his leadership and devotion in the organization and development for the practice of plastic surgery. In 1952, Bowdoin College awarded him an Honorary degree of Science. In 1953, he was awarded the Honor Key Award of the Academy of Ophthalmology and Otolaryngology. In 1954, he received an award from the American Society of Oral Surgeons in 1954 and was made Honorary Member of the Chalmers J. Lyons Academy of Oral Surgery at the University of Michigan. In 1956, he received the Honorary Award from the American Society of Maxillofacial Surgeons. That same year, he was awarded the Leonard Wood Memorial Medal, Boston City Hospital Alumni Association and was also made Honorary Member of the Massachusetts Dental Society. In 1957, he was made Honorary Member and received an award from the New England Society of Oral Surgeons. On that same year, he was awarded Honorary Membership at the Worcester Dental Society. In 1959, he received an award from the American Association of Plastic Surgeons. The second edition of his book came out on the same year. In 1960, he served as the first President of the New England Society of Plastic Surgeons. In 1962, he received written congratulations from the chairman of New York University for his work [Deranian, 2007, pp. 200-202]. In 1964, he retired from his private practice and stopped his work. In 1966, he became Honorary Fellow of the British Association of Plastic Surgeons in London and in 1967, of the Royal College of Physicians and Surgeons in Glasgow. On that same year, he was honored with the Harvard Dental Centennial Award, an achievement illustrating a century of dentistry in Harvard. He died on October 19, 1974, at his home in Belmont, surrounded by his family [Deranian, 2007, pp. 200-202]. Kazanjian was a simple, humble and humanist man who was close to his family, faithful in friendship and passionate about his work, estimated by his students but also by his colleagues, enjoying nature and fishing above everything. Never denying his Armenian origins and serving his new American nation with all his spirit, Kazanjian is internationally known as the pioneer of maxillofacial surgery in the 20th century. Kazanjian was described by his patients and colleagues as a lancet virtuoso. Medical and media organizations kept paying tribute to Kazanjian and even more after he died. He released 154 publications in American, British, French (7), Spanish (2) and German (1) journals from 1911 to 1975, the last one being posthumous. Among them, there are 50 scientific collaborations. He worked in 18 clinics and hospitals. He taught orthodontia at Harvard Forsyth Post-graduate of Orthodontia (1919-1920), Otolaryngology at the Tufts College Medical School in 1944. He was professor of Oral Surgery at Harvard Medical School in 1922 and professor of plastic surgery at Harvard Medical School in 1941. He was appointed professor emeritus of plastic surgery at the Harvard Medical School in 1947 [Deranian, 2007, pp. 200-202 ; Riaud, 2010, pp. 71-78].
Professor Varaztad H. Kazanjian (1879-1974)
[© Francis A. Countway Library of Medicine, 2009].
Bibliography
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