Mrs. Hitler and her doctor

Unfortunately, as we have been dreading for the last four months or so since her relapse was diagnosed, my mother-in-law passed away from breast cancer in hospice. She died peacefully, with my wife and the rest of her family at her side. As you might expect, I do not much feel like blogging, and even if I did my wife needs me more. Because I foresaw this coming, however, I do have a series of "Best of" reposts lined up. If you've been reading less than a year or two, they're new to you. If not, I hope you enjoy them again. I don't know when I'll be back, other than maybe a brief update or two. It could be a couple of days; it could be a couple of weeks. Right now I just don't know. This post appeared in February 2006.

In 1907, Adolf Hitler's mother Klara died of breast cancer at age 47, when Hitler was only 18. The young Hitler was devastated by her death. Indeed, in Mein Kampf, Hitler described her death thusly:

These were the happiest days of my life and seemed to me almost a dream; and a mere dream it was to remain. Two years later, the death of my mother put a sudden end to all my highflown plans.

It was the conclusion of a long and painful illness which from the beginning left little hope of recovery. Yet it was a dreadful blow, particularly for me. I had honored my father, but my mother I had loved.

Dr. Eduard Bloch, the family physician who diagnosed and treated Klara Hitler's breast cancer was, through an odd quirk of fate, Jewish. Consequently it is not surprising that some, such as Rudolf Binion, have speculated that a hatred of Dr. Bloch for "failing" to save his mother might have been one factor behind Hitler's later violent anti-Semitism and even may have resulted in the Holocaust. Some of the treatments that Bloch used to treat Klara Hitler have been described as some as poor medical care or even quackery. That is why I found a recent article by Sandy Macleod in Australian Psychology to be of interest. It is argued that, contrary to the criticisms that were later leveled against Bloch, that Dr. Bloch actually performed his treatments competently according to the prevailing medical standards of the time. MacCleod describes Klara's initial presentation thusly:

Mrs Hitler saw Dr Bloch on 14 January 1907 complaining of a chest pain, 'so severe it interrupted sleep'. She was described by her doctor as 'a simple, modest, kindly woman, tall with brownish hair which she kept neatly plaited, and a long oval face with beautifully expressive grey-blue eyes'. Quiet, pious and maternal, three of her children had died as infants and another had died aged 6 in 1900. She devoted herself to her surviving children, Adolf and Paula. Klara was the third wife of Alois Hitler, a gruff and opinionated provincial civil servant, who had died in 1903. Adolf had despised his father and his father's way of life. Dr Bloch had never witnessed a 'closer attachment' between a mother and a son. Sadly, the doctor's examination revealed a fungating carcinoma of the breast.

These days, such presentations of breast cancer are uncommon. I've seen a few and even blogged about one case of an almost fungating cancer, but for the most part breast cancer is usually diagnosed before it can grow through the skin (fungate), leaving a bleeding and sometimes stinking mess. We refer to such tumors as locally advanced, and now the treatment is either estrogen blockade with Tamoxifen or an aromatase inhibitor and/or chemotherapy before any surgery is undertaken. The results of surgery alone on such locally advanced tumors are poor, because such tumors are inevitably already invading skin and the underlying muscle, meaning that surgical removal of all detectable tumor is impossible. However, we must remember that surgery alone was all that was available in 1907 to treat breast cancer. There was no chemotherapy or radiation therapy. Also, because mammography didn't exist and there was little knowledge of breast cancer among the general population 100 years ago, most breast cancer patients at that time presented with either large breast masses or, as Klara Hitler did, when the mass started eating through the skin of the breast.

Appropriately, Dr. Bloch referred Klara Hitler to an unnamed Linz surgeon, who presumably performed an operation that was the standard of care at the time for breast cancer, a radical mastectomy as popularized by the great surgeon William Halsted in the 1880's. Unfortunately and not unexpectedly, Klara Hitler's tumor rapidly recurred on her chest wall by September 1907. Recurrences on the chest wall can be one of the most difficult clinical situations to deal with in breast cancer, particularly a local recurrence that keeps growing, fungating, and bleeding. These days, we would treat very small localized recurrences with wide excision and radiation, but this is a rather uncommon situation, as most recurrences are in the form of numerous little tumor nodules in the skin. Larger recurrences, particularly if there are many tumor nodules (the more common situation), are treated with radiation alone. Indeed, one of the most difficult clinical situations in breast cancer is when the only site of disease is extensive involvement of chest wall, with no evidence of distant metastases. The suffering of such patients from the bleeding, sometimes rotting, sometimes painful tumor deposits can be horrible to see, and, if radiation can't control the growth of the tumor or if the patient has already had radiation, we still face the occasional case where even modern medicine can't offer much. Because these situations usually occur after adjuvant chemotherapy has been given, there is often not even a good chemotherapeutic option to try. And, of course, in 1907, there was no radiation, chemotherapy or hormonal therapy, leaving surgery or local wound care as the only options. Presumably surgery wasn't offered because the recurrence was too large.

As the open wounds worsened, Dr. Bloch chose local wound care with daily applications of iodoform-embedded gauze to the fungating chest wound. These treatments were painful and went on for six weeks prior to Klara Hitler's death on December 21, 1907, as described by Macleod:

The caring and conscientious Dr Bloch was by now visiting daily to apply iodoform directly to the fungating chest wound. Mrs Hitler was reported as bear these stinging treatments well over the subsequent 6 weeks to her death. Her son agonized over every moment of her suffering. Albert von Mosetig-Moorhof, a Viennese surgeon, had made a name for himself with his paper published
in 1880 entitled 'Experiments with iodoform as wound dressing compound after operations for fungus
processes'. This was undoubtedly the scientific rationale for Mrs Hitler's painful treatment. Iodine is one of the oldest antiseptics. Tincture of iodine had been used extensively during the American Civil War and Mosetig-Moorhof had a background in military medicine. Iodine preparations have an unpleasant odour, stain clothes, are expensive and are relatively feeble antiseptics. Yet, they survive today as povidine-iodine (Betadine) and bismuth iodoform paraffin paste (BIPP), a saviour in World War I, and still considered the gold standard packing in ear surgery. Ironically, Dr Mosetig-Moorhof committed
suicide in the same year, 1907, perceiving his academic career had been an unsuccessful one. It is not recorded how effective an antifungal therapy iodoform was for Dr Bloch's patient, who died peacefully a few days before Christmas. Dr Bloch later recalled that he had 'never seen anyone as prostrate with grief as Adolf Hitler'.

Consequently, despite claims later, it could be convincingly argued that Dr. Bloch's use of topical iodophor was not unreasonable, based on the medical standards of the time, even though today we know that it is, as Binion characterized it, "utterly ineffective" in the case of recurrent breast cancer in the chest wall. Today, even for infected wounds, we don't use topical iodophor that often. It is viewed as too dessicating and thus too damaging to tissue, particularly since there are newer, better topical antimicrobials available. Today, its main users tend to be orthopedic surgeons dealing with open fractures with highly contaminated wound, where they usually only pack with iodophor gauze for a short period of time until the would is adequately debrided and cleaned up. However, in 1907, iodophor was thought to be one of the best topical antimicrobials available. Based on the data available in 1907, it was not unreasonable to use it to try to prevent suppuration of Klara Hitler's open chest wound, as sepsis was a common cause of death in such cases, and there were no antibiotics at that time either.

Macleod points out that some scholars, such as the psychoanalyst Gertude Kurth, proposed that Klara's suffering was the origin of Hitler's anti-Semitism. Kurth proposed that Hitler had "experienced a father-transference to the doctor" and ended up attributing "all positive traits to the doctor and . . . negative ones to the Jew," suggesting that Dr Bloch was responsible (in Hitler's mind) for the brutal assault (with iodoform) and mutilation (by surgery) of his dear mother. One historian in particular more than any other, Rudoph Binion, made much of the demise of Hitler's mother while being treated by a Jewish doctor. In the 1970's, Dr. Bloch's casebook became available, and in it were Dr. Bloch's notes regarding the treatment of Hitler's mother. From a rather convoluted analysis of this casebook, Binion concluded that Dr. Bloch had used too much iodophor packing and inadvertently poisoned Klara Hitler. As detailed in Ron Rosenbaum's excellent book, Explaining Hitler: The Search for the Origins of His Evil, his thesis, although presented in a more complex manner, could be reasonably summarized somewhat simplistically but not unreasonably as:

In 1907, a Jewish doctor poisoned Hitler's mother while treating her for breast cancer.

In 1918, Hitler was himself hospitalized for gas poisoning in the War and hallucinated a summons from on high to reverse Germany's defeat.

In 1941, Hitler personally ordered the removal of "the Jewish cancer" from the breast of Germany through the use of poison gas. Six million Jews died as a result.

Binion based his assertion that Bloch had used too much iodophor and thus hastened Klara Hitler's end, needlessly causing her pain in the interim on a detailed and very difficult to follow analysis of how much iodophor gauze Dr. Bloch had ordered, using figures he had obtained from the Austrian pharmaceutical registry listing how much gauze Dr. Bloch had purchased in the time period during which he was treating Klara Hitler (forty packages). However, the key flaw with Dr. Bloch's hypothesis is, as pointed out by Macleod:

Iodoform poisoning was first reported in 1903, the typical clinical features being headache and a delirium from metabolic acidosis, hypernatraemia and hyperchloraemia. Systemic absorption of topical iodine is more likely if it is applied to large areas of dermal breakdown, or with the protracted use of iodoform and BIPP gauze packing of otolaryngological wounds. Although a possible influence on Mrs Hitler's demise, from a medical perspective, Binion's proposition of poisoning would seem unconvincing. Mrs Hitler survived 6 weeks of daily iodoform, and the course of her illness appeared typical of that of terminal malignancy.

Nowhere was there presented any evidence that Klara Hitler suffered the symptoms of iodophorm poisoning, even though sepsis could cause similar symptoms. Macleod further continues:

These fierce indictments upon Dr Bloch's care are surely unfair. He was practising the accepted medical care of the time for advanced cancer - what the doctor did not know, though he astutely sensed it, was that his patient's son, and key carer, was a very disturbed young man.

Also, such indictments of Dr. Bloch's care as the cause of Hitler's later murderous anti-Semitism are difficult to reconcile with Hitler's profuse thanking of Dr. Bloch for his efforts shortly after his mother's death, in which he said to Dr. Bloch, "I shall be grateful to you forever"; his sending of self-painted postcards to Dr. Bloch from Vienna, where he went to live after his mother's death; and, in 1938, five years after his attainment of power and after he had begun the persecution of Jews that ultimately led to the Holocaust, Hitler's personal intervention to get Dr. Bloch the necessary travel permits and visa to allow him to emigrate from Austria to the safety of the U.S. after the Anschluss. No other of the doomed Austrian Jews received such a boon from the German dictator. Also, as Ian Kershaw convincingly argues in the first volume of his two-volume biography of Hitler that his immersion in the virulent anti-Semitism common in Vienna during the years he lived there (1908 to 1913) was a more powerful influence leading to Hitler's hatred for Jews. Indeed, a friend of Hitler from 1909 to 1910, Reinhold Hanisch, has been quoted as saying, "In those days, Hitler was by no means a Jew hater. He became one afterward."

Of course, in looking for the cause of Hitler's anti-Semitism, the death of Hitler's mother of a fatal cancer while being treated by a Jewish doctor is an irresistable turning point in Hitler's life. It happened mere months after his failure to be admitted to the Academy of Fine Arts in Vienna, and it also led to an abrupt transition from safety and relative comfort to a much more precarious life. As Ian Kershaw himself put it:

His failure to enter the Academy and his mother's death, both occurring within four months in late 1907, amounted to a crushing double blow for the young Hitler. He had been abruptly jolted from his dream of an effortless path to the fame of a great artist; and the sole person upon whom he depended emotionally had been lost to him at almost the same time. (Ian Kershaw, Hitler 1889-1936: Hubris, p. 26)

Indeed.

I don't buy a fair amount of the psychoanalytical explanations Macleod interjects as some potential explnations for Hitler's anti-Semitism, such as his regression after the loss of his idealized mother and perhaps his developing some degree of transference with Dr. Bloch. However, it is of value to consider Macleod's rather interesting comparison between Dr. Bloch and another doctor who has been largely unfairly maligned for his treatment of a notorious historical person:

Medical history should view Dr Bloch in a similar vein to Dr Mudd. 'Your name isMud(d)' is the derogatory phrase referring to Dr Mudd, the doctor who attended the assassin of Abraham Lincoln. John Wilkes Booth fractured his left leg jumping onto the stage at Ford's Theatre after shooting the President. Booth presented himself later that night to a rural doctor along the route of his escape. Even if these events were known to Dr Mudd, and they were not, his Hippocratic Oath should not have deprived Booth of having his leg set. Dr Mudd was sentenced to a long term of brutal imprisonment for performing his duty.

The doctors of these infamous figures of history performed their professional duties with competency and practised with the medical knowledge appropriate to the period. Psychohistorians have been unreasonably critical of Dr Bloch. Proposing that the professional relationship between the Jewish GP and the Hitler family could somehow explain the subsequent evil perpetrated by Adolf Hitler, was based on misinterpretations of the medical facts and gross extrapolation of psychoanalytic theory. Dr. Mudd was innocent of his 'crime' of attending an injured man. These doctors each had the misfortunes to attend sinister patients.

Of course, Klara Hitler was by no means a "sinister" patient (John Wilkes Booth, at least, had shown up late at night in a manner that would have led most people to wonder if he were in some sort of trouble), and, at the time that Dr. Bloch treated her, Adolf Hitler was nothing but a rather strange and effete young man with what seemed to Dr. Bloch to be a rather exaggerated and unhealthy attachment to his mother. There was absolutely no way in 1907 that Dr. Bloch or anyone else could have predicted what this strange young man would become. As Ron Rosenbaum examines in great detail in his book, historians have been looking for the cause for Hitler's murderous hatred of Jews since before the end of World War II. It is likely that no one event in Hitler's life is an adequate explanation, even the death of his mother.