Sandy Macleod. Australasian Psychiatry. Volume 13, Issue 4, December 2005.
The professional relationship between the doctor and the patient is the cornerstone of clinical practice. The complexities and contortions of this relationship are well recognized in medical and medicolegal literature. Family members may also intervene sometimes with clarity and benefit, sometimes without. Rarely has this relationship had potentially such grave historical consequences as that between a general practitioner (GP) Dr Eduard Bloch, his patient Mrs Klara Hitler and her son Adolf. For pain and palliative care practitioners, this story has relevance, but also for psychiatrists.
Klara Hitler died of breast cancer, aged 47, on 21 December 1907. Her death, her son Adolf wrote in Mein Kampf, was ‘a dreadful blow, particularly for me’. The care provided to her by her Jewish family doctor has been proposed, by three generations of scholars, as a cause of the Holocaust. The somewhat preposterous assertion that (poor) medical care provoked such an evil reaction in Mrs Hitler’s son is, however, an intriguing tale of medical and psychoanalytic speculation.
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.
Rudolph Virchow (1821-1902), the ‘Pope of German Medicine’, had discovered in 1858 that all growth, including cancer formation, was dependent upon a process of continually dividing cells, ‘omnis cellula e cellula’ (all cells come from cells). The leading Viennese surgeon, Theodur Billroth (1829-1894), had started to apply this knowledge practically to the clinical management of cancer with aggressive surgery and the famous German surgeon, Richard Volkmann (1830-1889), had made it a rule to never perform a partial amputation of the breast, but to remove the entire organ even for the smallest tumour. William Halstead (1852-1922), an American surgeon who had trained in Germany and Austria, which were then the main centres of medical sophistication, was to subsequently popularize mastectomy. However, it was an unnamed Linz doctor who preformed this surgery on Mrs Hitler in early 1907. After a 21 day hospital stay, she was discharged home to the care of her disabled sister, her darling 18-year-old son and her 11-year-old daughter. The tall, sallow, frail-looking adolescent soon wrenched himself off to the Academy of Fine Arts in Vienna, only to fail, to his great consternation, the entrance examinations. But his mother’s health was rapidly deteriorating, as had been predicted by her medical attendants. Dr Bloch informed the family that her condition was now ‘hopeless’. Adolf then returned home and provided ‘indefatigable’ care for his dying mother, the doctor later recalled. Dr Bloch had clearly recognized that his palliative care concerned not only the patient, but also the distressed family.
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 baring 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’. Hitler dutifully thanked the doctor and settled the account. ‘I shall be grateful to you forever’, Hitler told the doctor. As expressions of gratitude, he sent the doctor self-painted postcards from Vienna where he went immediately after the funeral. In 1938, Hitler personally ensured that Dr Bloch received visa and travel permits allowing him to escape to the USA.
In 1947, Gertrud Kurth, a psychoanalyst, proposed that Hitler ‘experienced a father-transference to the doctor’ and suggested that this accounted for him attributing ‘all positive traits to the doctor and… negative ones to the Jew’. Dr Bloch, she maintained, was responsible (in Hitler’s mind) for the brutal assault (with iodoform) and mutilation (by surgery) of his dear mother. The Jew became his object of loathing. Rudolf Binion, an American historian, in the 1970s proposed, based on Dr Bloch’s medical casebook, that the doctor had overdosed Mrs Hitler on iodoform. Hence, the subconscious origin of Hitler’s hatred of the ‘Jewish cancer’ and the ‘Jewish poison’. 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.
James Olson in a recently published history of breast cancer speculates that ‘whilst Hitler contemplated the liquidation of millions of Jews… perhaps, in a warped inner vision, he remembered a Jew tormenting his mother’. 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. Dr Bloch would also have had some inkling that in the shrine of his medical world Sigmund Freud was exploring a psychological concept very pertinent to understanding the distortions and the magic of the doctor-patient relationship.
Freudian psychoanalysis, these days so maligned, provided a truly great intellectual legacy, that of the clinical concept of transference. How patients experience and perceive their doctor, and how doctors respond without conscious awareness towards their patients – transference and countertransference – are critical influences upon all medical care. Transference and countertransference may be sources of misunderstandings, and may create potentially very serious clinical hazards, yet these experiences and feelings are the heart of therapeutic opportunities. Freud recognized that narcissistic persons could not form an irrational transferential attachment without psychologically decompensating. In modern terminology, those with severe personality disorders (particularly borderline and narcissistic disorders) are not treatable by classical psychoanalytic psychotherapy. The effete and self-absorbed young Hitler was probably of such character. If there is merit in the contentions that Dr Bloch had a role in the cause of the Holocaust, one would suggest that Hitler psychologically regressed in reaction to the losing of his idealized mother, and evolved a manifestly disturbed transferential relationship with the doctor. This relationship was abruptly geographically terminated following the death of his mother. However, over the ensuing decades these distorted memories continued to trouble the aspiring Fuhrer.
Heinz Kohut, in the 1960s and 1970s, formulated clinical strategies allowing the possibility of successfully treating the malignant narcissism that the Freudians had found impenetrable. Such persons develop either ‘mirroring transferences’, in which they desperately and persistently seek the approval and affirmation of their ‘therapist’, or ‘idealizing transferences’, during which the therapist is perceived to be the perfect and omniscient ‘parent’. Hitler’s responses to Dr Bloch, including his allowing his emigration from Nazi Germany, suggest perhaps both forms of transference. Dr Bloch’s inaccessibility (in the USA) might have further enticed Hitler to project his aggression (felt towards his despised father) onto the religion of his mother’s doctor. But even with modern understandings, to blame Dr Bloch would seem an extraordinary extrapolation of psychoanalytical knowledge.
Rather similar psychodynamic influences might have been present for the instigator of World War I. Kaiser Wilhelm II was born with a withered arm and evolved a frail self-esteem. He idolized his father and grandmother (Queen Victoria). Yet, he was mercilessly bullied by his father and felt teased by his English relatives. His father reigned only 90 days before dying of carcinoma of the throat. English doctors, called in by his aloof mother, had unsuccessfully treated Kaiser Frederick III. Wilhelm blamed his mother and her English people for the death of his adored father. Probably, his father’s doctors were also a focus of his criticisms of the nation he dragged into the war of 1914-1918.
Medical history should view Dr Bloch in a similar vein to Dr Mudd. ‘Your name is Mud(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.