What Do Babies Need to Thrive? Changing Interpretations of ‘Hospitalism’ in an International Context, 1900–1945

What Do Babies Need to Thrive? Changing Interpretations of ‘Hospitalism’ in an International... Abstract In 1945, the émigré psychoanalyst René Spitz published a landmark article in which he suggested that babies cared for in institutions commonly suffered from ‘hospitalism’ and failed to thrive. According to Spitz this was the case because such babies were deprived of ‘maternal care, maternal stimulation, and maternal love.’ Historical interest in separation research and the development of the concept of maternal deprivation has tended to focus on the 1940s and 50s. The term ‘hospitalism’, however, was coined at the end of the nineteenth century and by 1945 the question of whether or not babies could be cared for in institutions had already been debated for a number of decades by an international community of paediatricians and developmental psychologists, later joined by psychoanalysts. Criss-crossing national boundaries and exploring debates over the nature, causes, and prevention of ‘hospitalism’, this article elucidates the changing understandings of the impact on babies of living in institutions. hospitalism, separation research, infant hospitals, foundling homes, paediatrics, child psychology, psychoanalysis In 1945, the émigré psychoanalyst René Spitz published a landmark article in which he suggested that babies cared for in institutions commonly suffered from a condition called ‘hospitalism’ and failed to thrive.1 Spitz reported that babies he observed in a foundling hospital became withdrawn, lost weight, suffered from severe developmental decline and many of them died. The causes of this, according to Spitz, were to be found in the fact that the babies were deprived of ‘maternal care, maternal stimulation, and maternal love’.2 He subsequently distilled his views on the catastrophic consequences of institutional care of babies in a harrowing short film released in 1947, entitled Grief: A Peril in Infancy. Spitz was to become one of the principal spokespersons of the dangers of maternal separation in the United States in the post-war period.3 His observations also influenced the British psychoanalyst John Bowlby, who in 1951, having been commissioned by the World Health Organisation to explore the plight of homeless children, published his influential report on Maternal Care and Mental Health. In it he formulated his theory of maternal deprivation, suggesting that young children needed continuous and responsive mothering or faced the risk of long-term damage. Recent historical interest in separation research and the development of the concept of maternal deprivation has paid much attention to the 1940s and 1950s. There has been a particular focus on the impact of such ideas on the gradual implementation of unrestricted parental visiting to children’s hospital wards from the 1950s onwards.4 So far, however, this research has overlooked the fact that by mid-century there was already a long-standing interest in the welfare of babies who had been separated from their families and the potential adverse effects that might arise from their care in institutions such as infant hospitals or foundling homes. Indeed, while the concept of ‘hospitalism’ is commonly associated with Spitz’s work, the term was in fact coined at the end of the nineteenth century.5 By the time Spitz’s article was published at the end of the Second World War, the question of whether or not babies could be appropriately cared for in institutions had already been debated over a number of decades by paediatricians and developmental psychologists, later joined by psychoanalysts. The answer had not always been negative; indeed, in the early twentieth century there were many paediatricians who thought that it depended on the nature of the institution; if run on modern principles, institutions could avoid the problem of hospitalism and provide as good an environment as any for raising babies. On the other hand, however, the contention that babies fared badly in institutions because they lacked the attention of mothers was not formulated in the 1940s for the first time; such ideas had been articulated before the First World War. This article, by tracing the history of the concept of hospitalism and exploring debates over its nature, causes and prevention from the end of the nineteenth to the mid-twentieth century, seeks to elucidate the changing understandings of the impact on babies of being separated from families. To achieve this, it disentangles the varied approaches of paediatricians, child psychologists and psychoanalysts, which were rooted in their diverse, though overlapping, views on infancy. Research into this has hitherto been patchy. Historians have paid considerable attention to the development of notions of infantile subjectivity in psychoanalytic theories, but they have not yet fully explored conceptualisations of infancy promoted by paediatricians since the late nineteenth century.6 Yet the psychoanalyst Melanie Klein in 1936 made the point that her understanding of infancy refuted paediatricians’ ideas on babyhood.7 In addition, the interwar theories of developmental psychologists on babies have hitherto received little attention, even though the school of child psychology that developed in interwar Vienna adopted an equally critical attitude to paediatricians’ theories, while simultaneously distancing itself from psychoanalytic ideas on the nature of infancy. These different conceptualisations of babyhood underpinned evolving interpretations of the phenomenon of hospitalism. The process of retracing the history of the concept of hospitalism in this article has also necessitated tracking developments as they criss-crossed national boundaries, calling into question the adequacy of nation-based frameworks which often characterise historical scholarship on changing ideas of childhood. The following sections of the article explore the formulation of and engagement with the diagnosis of hospitalism by paediatricians in Germany from the end of the nineteenth century to the Weimar Republic. It then moves on to examine how the concept was taken up and reformulated by a group of child psychologists in interwar Vienna. The rise of the Nazis and ensuing emigration of Jewish intellectuals meant that in the late 1930s, Viennese research parameters on hospitalism were brought to the United States, where its causes were profoundly reformulated by the psychoanalyst René Spitz, working in collaboration with Viennese child psychologist Katherine Wolf. Finally, the article focuses on developments in Britain, exploring how the theory of hospitalism informed the formulation of the influential theory of maternal deprivation, elaborated by the British psychoanalyst John Bowlby in the immediate post-war era. Paediatricians Conceptualise the Problem of ‘Hospitalism’, 1890s–1918 The term ‘hospitalism’ was first used in Britain during the late 1860s to indicate the problem of hospitals supposedly gradually absorbing the poisons of infection, creating an atmosphere of rot and decay.8 At the end of the nineteenth century, however, physicians came to use it to denote adverse effects of institutional stays specifically on babies. In 1897, an editorial by Floyd Crandall in the American Archives of Pediatrics used the term to denote the ‘excessive’ morality rate of patients under a year old in the newly multiplying hospitals for infants.9 Preoccupation with the effects of residing in institutions on babies grew in the context of emerging specialised hospitals for infants, increasing admissions of babies—who had previously been excluded from them—to children’s hospitals, and the appearance of new orphanages and residential institutions for babies. The multiplication of these infant institutions was part of a developing welfare effort to reduce the infant mortality rate and the consolidation of paediatrics as a separate specialism. Paediatricians played an influential role in the infant welfare movement, a process that was closely intertwined with the increasing importance of population policy and a preoccupation with the health of the body politic.10 Yet, as was soon noted, the infant mortality rate in these institutions was often shockingly high. However, it was not the existence of such institutions that was called into question by child health experts. Indeed, it came to be commonly thought that the problem lay with the institutions and how they were run, fuelling a search for medicalised solutions to make residential care safe for babies. Physicians in France, pioneers in infant welfare, were amongst the first to draw attention to the problem. Joseph Marie Jules Parrot and Victor Hutinel, physicians at the Hospice des Enfants-Assistés in Paris became particularly associated with reforms that sought to reduce the infant mortality rate there in the late nineteenth century.11 In the early twentieth century, however, Germany became the centre for a hospital-based and university-located paediatrics, a process that was accompanied by a wide-ranging engagement with the problems of hospitalism.12 In 1895, the paediatrician Hugo Neumann suggested that ‘one day’ medical progress might mean that babies could be looked after successfully in hospitals. By the first decade of the twentieth century, however, many paediatricians considered it to be ‘one of the greatest successes of clinical paediatrics’ that infant institutions had become instruments of reducing the infant morality rate.13 When in the late1890s and early 1900s paediatricians in Germany first addressed the problem of hospitalism—conceived as the high mortality rate in infant hospital wards and other institutions—they replicated the findings of physicians in France who had concluded that the key to the problem lay in containing the spread of germs.14 This was particularly true for paediatricians in Berlin, who were influenced by Robert Koch’s bacteriological discoveries. The first professor of paediatrics in Germany and director of the children’s wing of the Charité in Berlin, Otto Heubner (1843–1926) and his student Heinrich Finkelstein (1865–1942), who in 1901 became chief physician at the newly established Berlin Kinderasyl for infants, were amongst the first to consider the issue. Infections, spread by nurses and feeding equipment, were responsible for hospitalism. The introduction of hygienic measures was seen as the way to reduce the risks to babies posed by institutional stays.15 First elaborated in relation to hospitals, these conclusions were soon extended to babies in foundling homes.16 Koch’s influence also underlay an optimistic attitude to the possibility of providing uncontaminated substitute foods to babies in institutions. Both Heubner and Finkelstein were convinced that babies could thrive on artificial nutrition.17 All in all, it was possible to achieve excellent results in terms of the infant mortality rate in institutions, if there were sufficient hygienic measures to prevent new infections.18 The assumption that babies could thrive on substitute foods was, however, strongly questioned by others.19 Hospitalism became a problem not only of infection, but also of nutrition. As such, it could not be fought without human milk. Foremost here was the work of Arthur Schlossmann (1867–1932), a paediatrician based first in Dresden and then in Düsseldorf. Schlossmann quickly became one of the principal authorities on hospitalism in the early twentieth century. By then, doctors had documented an ongoing decrease in the breastfeeding rate, while at the same time establishing an inverse correlation between breastfeeding and infant mortality. Breastfeeding became, in the words of Larry Frohman, the ‘the axis around which all infant welfare programs in Germany pivoted’.20 Arthur Schlossmann saw breastfeeding as the basis of infant health and the prime factor in improving the chances of infant survival, which strongly shaped the way he understood the nature of hospitalism. Schlossmann trained as a paediatrician in Berlin, but in 1893 moved to Dresden, the capital of Saxony, which then had the highest infant mortality rate in the German Empire—in 1895 it stood at 28 per cent. In 1898, he opened the first ‘hospital for sucklings’, the Dresdener Säuglingsheim, which became the model for other such hospitals in the German Empire. In 1906, he moved to Düsseldorf, where he took over the infants’ wing in the local orphanage and also established an infant hospital.21 A prolific and frequently cited contributor to the discussion of institutional care for infants, Schlossmann based his arguments on his experiences of running infant hospitals in Dresden and Düsseldorf. As he repeatedly pointed out, under his direction both institutions did well when it came to the infant mortality rate, and indeed much better than the Berlin Charité. By 1900/1901, the mortality rate of the Säuglingsheim in Dresden was below average for the region at 27 per cent.22 In Düsseldorf, the fall in the mortality rate was dramatic: when Schlossmann first arrived there, the local orphanage had an infant mortality rate of 71.5 per cent. Between 1907 and 1912, the infant hospital that Schlossmann established, which also took in ill foundlings, had a mortality rate of 16.8 per cent.23 Schlossmann endorsed the need of aseptic care to prevent the spread of infectious diseases, declaring that ‘I consider every single child to be potentially infectious and subject to infection on any part of its body’.24 He also, however, consistently rejected colleagues’ search for and use of substitute foods in the care of young babies.25 Breast milk was not only a form of nutrition, but also a form of medicine.26 Without it he was convinced, ‘one cannot feed ill infants with a view to a successful outcome’.27 He accordingly established extensive on-site wet-nursing systems in his hospitals. According to Schlossmann, the combination of aseptic care and the provision of breast milk through wet nursing meant that babies could be safely looked after in institutions for long periods. He thus declared: the problem of the institutional care of infants has been solved, to at least the same extent for foundling homes as for infirmaries. It does not cause the slightest difficulty to set up a home for infants, in which they will be impeccably cared for, thrive, and rarely fall ill, if the necessary means and staff are available.28 The understanding that hospitalism need not blight infant institutions depended on and reinforced a particular conceptualisation of infancy. Under the influence of the child study movement and evolutionary theory, there had emerged in the late nineteenth century an understanding by which young babies were seen to be unable yet to engage with and make sense of their environment. Young babies could feel pleasure and displeasure (the latter initially predominating over the former), and from there the capacity to experience more differentiated emotions gradually developed.29 Paediatricians commonly did not think of babies as socially competent and tied into or dependent on emotional relationships. This meant that mothers’ care was replaceable by medical experts. Indeed, while mothers could be obliged to be involved in babies’ initial care in foundling homes, this was to ensure the health benefits of breastfeeding, conceived in terms of the nutritional value of human milk. In hospitals, however, mothers (as much as other relatives) were to be kept away, as they were perceived to be sources of potential infection. Ideally, relatives were to visit their babies once a week from behind a glass window.30 While not suggesting that institutions could or should replace the family, if babies found themselves in one, physicians, nurses and wet-nurses could provide the necessary care of infants.31 Arthur Schlossmann thus provided a telling description of his infant hospital in 1906: All our visitors notice how quiet it is here, how little the children cry. A well looked after child lies quietly in its cot and it is not unusual to spend more than an hour in a room with fifteen children without hearing a sound.32 According to Schlossmann, such quietness was an expression of content. Physically well-looked after babies did not experience significant discontent and would thus lie quietly in their cots for lengthy periods of time. The well-being of babies in institutions was solely dependent on how these institutions were run. In Infant Homes, Germs Receive More Attention Than Babies … The growing number of institutions for infants were run on principles that centralised babies’ physical well-being well into the twentieth century. Nonetheless, while paediatric concerns predominantly centred on babies’ bodily health, ideas about their emotional interiority and need to enter into an affective relationship with their mothers were also formulated in the first decade of the century. Commentators soon pointed out that the focus on the prevention of infection meant that in infant homes germs received more attention than the babies.33 To some, this was detrimental to babies’ welfare. Hospitalism thus conceptualised arose from the lack of the particular stimulations provided by maternal care. This position was most notably formulated by the Austrian colleague of Arthur Schlossmann, the paediatrician Meinhard von Pfaundler (1872–1947). Educated in Innsbruck and Graz, Pfaundler spent most of his career as the director of the University Children’s Hospital in Munich, where he played a prominent role in establishing the city as a centre of paediatric research. Pfaundler collaborated with Arthur Schlossmann in editing an influential textbook on children’s diseases in 1906.34 Soon after, however, he began to contest Schlossmann’s understanding of hospitalism and how to avoid it. According to Pfaundler, hospitalism could not be reduced to problems of nutrition and asepsis. Pfaundler began to question some of the cornerstones of his profession’s advice on infant care in the late 1890s.35 He soon formulated a conceptualisation of ‘natural infant care’ as the appropriate way of looking after babies. This, so Pfaundler said, was evident from observing mammals and ‘natural peoples’: ‘To be looked after by the mother, cared for, and protected is an instinctive wish of every mammal baby, which, like the human infant, comes into the world without sufficient means to live independently’.36 What he called ‘rational infant care’, on the other hand, was harmful to babies’ health, as well as their emotional well-being, their seelisches Gleichgewicht. This was evidenced, according to Pfaundler, by the phenomenon of hospitalism in institutions where extreme forms of rational care prevailed.37 Like the influential educationalist Friedrich Fröbel, Pfaundler suggested that a mother’s role encompassed providing stimulation for her child from early infancy. Pfaundler made this argument by invoking the theories of the Russian behaviourist Ivan Pavlov, whose disciple, the paediatrician Nicolai Krasnogorski, had spent time working in Berlin.38 Suggesting that babies’ development depended on stimuli and the emotions they provoked, Pfaundler contended that mothers entered a close relationship with their children in the early weeks, and that being subject to the wealth of stimuli that emanated from this relationship was important for the mental and physical well-being of the infant. Babies looked after en masse by nurses in homes grew up bereft of these stimuli.39 The quietness of the ward, cited by Schlossmann, was not the expression of content, but of the learned experience of institutionalised babies that their expressions were futile, leading to a reduction in reaction to external stimuli.40 To Pfaundler, therefore, institutions could not fulfil babies’ needs. Hospitalism in the Weimar Republic: Babies’ Mental and Physical Development Meinhard von Pfaundler’s ideas on babies’ need to enter into a relationship with their mothers were largely ignored by the contemporary medical world. The question of the lack of stimulation experienced by infants in institutions, however, became more pertinent after the First World War. In 1918 the Kaiserliche Gesundheitsamt issued guidelines for the establishment of infant homes (Säuglingsheime), which were an important feature of Weimar infant welfare provisions. There continued to be much medical interest in hospitalism, but the terms of debate shifted. It was widely accepted that the infant mortality rate could be kept relatively low in institutions, including for lengthy residencies. However, more and more questions were raised about more subtle effects of institutional care on babies. It was increasingly suggested that babies in institutions did not follow the expected developmental stages; they lagged behind physically and mentally when compared to babies growing up in families.41 Delay in physical development was associated with an increased frequency of experiencing infectious diseases. In 1925, a student of Meinhard von Pfaundler, Zaida Eriksson (1895–1974), published her dissertation on hospitalism (as a result of which she had become the fifth woman to be medically qualified in Finland). Based on the study of babies in a variety of institutions in Munich, she concluded that compared to babies raised in families, those raised in institutions suffered from decreased resistance to infections and grew more slowly.42 Lagging behind in mental development on the other hand was linked to the fact that babies in institutions received scant individual attention and thus lacked stimulation. Hilde Müller thus established that young children in institutions lagged behind in their intellectual development.43 Erna Eckstein-Schlossmann (1895–1998), Arthur Schlossmann’s daughter and like her father a paediatrician, came to the conclusion that the original optimism accompanying the establishment of infant homes had been replaced in paediatric circles with a sense that, for the care of healthy babies, the focus should be on foster placements in families. As for babies in hospitals, even in well-run institutions a ‘certain mental hospitalism’ could not be avoided. Engaging babies in activities could contain it, but their mental development still commonly lagged behind that of babies in families.44 By the later 1920s, the view that institutional care had an impact on babies’ mental and physical development became closely entwined with the increasing convergence of social and racial hygiene, in which the impact of infants’ adverse living conditions were seen to have a detrimental effect on the ‘race’ as a whole.45 It was Meinhard von Pfaundler who thus reframed his approach to babies in institutions most clearly. He continued to assert that institutions were not appropriate environments for infants, but now claimed that babies in institutions were in all likelihood already of ‘inferior inheritance’, born to ‘unmarried, ill, … , alcoholic, feeble-minded and morally inferior’ parents. Institutional upbringing was now undesirable to Pfaundler, because it further aggravated constitutional damage, to the detriment of future generations.46 Hospitalism at the Vienna Psychological Institute During the late 1920s and early 1930s, the shift of focus away from the infant mortality rate to the impact of institutional care on babies’ development was taken further by a new research centre: the Psychological Institute in Vienna. There, child psychologists established tests to measure infant and child development and a number of researchers made the application of these tests to infants in institutions the focus of their work. Amongst them was Käthe Wolf, who went on to closely collaborate with the psychoanalyst René Spitz in his research on hospitalism, which he developed after having spent time at the Institute in the mid-1930s, learning the methods of infant observation developed there. Research at the Psychological Institute was to provide a bridge from early paediatric research to later psychoanalytic interpretations of hospitalism through the development of baby observation techniques. In the 1920s and early 1930s Vienna was at the centre of developments in child psychology that foregrounded infants’ and children’s internal worlds and it became the ‘capital of child analysis’.47 As early as 1913, the analyst Hermine Hug-Hellmuth had published a psychoanalytically informed observational study of early child development.48 In the 1920s, Anna Freud organised the Kinderseminar, a group exploring the emerging field of child psychoanalysis.49 In 1925, one of its members, August Aichorn, provided a psychoanalytic account of ‘juvenile delinquents’ in residential care.50 Another member of the Kinderseminar, Sigfried Bernfeld, best remembered for his work on the link between psychoanalysis and progressive educational theory and his activism in socialist and Zionist youth movements, wrote in the same year The Psychology of the Infant, which, once translated, was considered by the psychologist and psychoanalyst Susan Isaacs to be ‘one of the most important books on child psychology’.51 Around this time, a research group developed at the Vienna Psychological Institute that focused on babies’ development, including their affective expressions and social development. The Psychological Institute, however, retained its distance from the Vienna Psychoanalytic Society. Alfred Adler’s individual psychology was tolerated, primarily because of its impact on educational theory and child guidance, but the relationship of the Psychological Institute to psychoanalysis was ‘predominantly negative’.52 Indeed, the one-time assistant at the Psychological Institute, Ilse Hellman, who later worked with Anna Freud in the Hampstead War Nurseries, recalled that the child psychologist ‘Charlotte Bühler was completely anti-psychoanalytic. All of us assistants were forbidden to go and listen to Anna Freud or to attend her seminars.’ She also suggested, however, that ‘quite a few people … went to them secretly’.53 The two institutes worked separately, but nonetheless there were students and researchers who were engaged with both groups. The convergence of these different approaches to child psychology were to underlie René Spitz’s re-interpretation of the nature and causes of hospitalism. The Viennese School of Child Psychology developed under the leadership of Charlotte Bühler (née Malachowski, 1893–1974). Bühler spent the academic year of 1924–1925 at Columbia University studying American research on child psychology. There, in discussion particularly with Arnold Gesell, she formulated the notion of developmental stages in infancy and sought to elaborate a method for the observation of the ‘entire behaviour of the child’.54 After her return from the USA, the Social-Democratic Viennese city government agreed to let Bühler and her team use the Children’s Reception Centre (Kinderübernahmestelle) for research. Opened in 1925, the Reception Centre was a quarantine station, which housed babies, children and youths who had come under municipal care for two to three weeks before they were transferred to foster places, children’s homes, reformatories or back to their parents. The Centre offered an ideal set-up to observe babies: they were housed in glass cubicles in groups of five or six, with a corridor running along the outside, where researchers recorded their observations. These observations constituted the foundation of Viennese, or Hetzer–Bühler Tests, for children from birth to the age of six.55 The tests aimed to quantitatively evaluate a child’s development of perception; body mastery; engagement with inanimate objects; social behaviour and mental production; as much as overall development.56 Babies’ development in these areas was seen to follow a predictable course that depended on internal processes of maturation. The Viennese tests informed child psychologists’ research into the effects of institutional care on babies, as well as René Spitz’s subsequent psychoanalytic re-orientation of hospitalism. Child psychologists writing on hospitalism took issue with the preoccupation with hygiene and physical health determining the institutional care of babies. While recognising that recommendations on these aspects had played an important role in reducing the mortality rate associated with institutional stays, developmental psychologists made a strong case for the view that the problem of adverse effects of institutional care on babies had not been solved. Indeed, it had been a ‘crass error’ for physicians to be in charge of the running of infant institutions, as this had led to neglect of the psychological dimension of infant development.57 Even if the dangers of ‘physical hospitalism’ had been reined in, there was still a need to engage with the problem of ‘psychological hospitalism’.58 The Viennese Baby Tests provided these researchers with a means to quantify the impact of institutional care on babies’ development. The resulting engagement with the phenomenon of hospitalism concluded that environmental factors had a significant impact on infant development. In 1929, Charlotte Bühler’s assistant, Hildegard Hetzer (1899–1991) published a book on Childhood and Poverty, which proved to be influential in subsequent research on hospitalism. Equating poverty with neglect, Hetzer claimed babies in well-off families had their needs met ‘five-times more’ than babies in poor families. Poor children, she said, could thus be called ‘neglected’ children and those from well-off backgrounds ‘cared for’ children. Hetzer suggested that there were clear developmental differences between ‘neglected’ and ‘cared-for’ infants. She thus implicitly called into question, without developing this, the notion underlying the Hetzer–Bühler Tests of development as consisting of endogenous processes of maturation.59 Hetzer’s work inspired a number of doctoral theses on the impact of institutional care on infant development. Some of the resulting research suggested that institutions were inherently damaging for babies and young children.60 But perhaps the most wide-ranging and complex study on the issue concluded that ‘institutions can be designed and changed in such a way that psychological hospitalism can also be fought successfully’, although the authors recognised that their ideal institution was utopian.61 The study was published in 1933–34 in the Zeitschrift für Kinderheilkunde. Co-authored by the American Hildegard Durfee (née Diechmann, 1896–1989) and the Viennese Käthe (later Katherine) Wolf (1907–1957), the article was largely based on the research of Durfee’s doctoral thesis.62 Durfee, who was born in Berlin, but emigrated as a child to the USA, was one of several American students who came to study at the Vienna Psychological Institute.63 Käthe Wolf studied philosophy at the University of Vienna, becoming a close collaborator of Charlotte Bühler and her husband Karl. She wrote her thesis on the developmental tests and was instrumental in drawing up tests for the first year of life.64 According to Durfee and Wolf, babies were susceptible to their environment from an early age. Rejecting Alfred Adler’s ‘extreme inference’ that environmental influences were at the root of character formation, the authors also refuted the notion that inheritance determined personality. Rather, environmental influences played an important, but not exclusive, role in infant development.65 Using the Viennese Baby Tests, the authors measured the physical, mental and social development of infants under a year old in a number of institutions with different approaches to how and by whom the babies were cared for. They concluded that institutions run on paediatric principles posed particular problems. Paying close attention to the rules of hygiene led to a monotonous life and little interaction with toys or people. But according to the authors, child development depended on mental stimulation and social interaction. Those institutions where mothers were present provided the best outcomes. Through the joint efforts of mothers, physicians and nurses, babies experienced all the advantages of maternal care, but avoided the potential dangers of ‘ignorant’ maternal caretaking.66 Durfee and Wolf concluded that for appropriate development, babies needed mental stimulation (through, for instance, colourful walls and pictures, and access to toys). But most affected by environmental influences was social development, babies needed to experience ‘love and interest’.67 On balance, maternal care was preferable to that of other caregivers. While providing the health advantages of breast milk, mothers were of even greater psychological importance: their engagement with their babies was characterised by ease and spontaneity that depended on a ‘certain degree of love’.68 The mother, to Durfee and Wolf, was therefore the most obvious person to foster babies’ social development. However, they also thought that trained specialists—that is expert nurses who would be responsible for the emotional well-being of the baby—could turn institutions into viable environments for infants.69 According to Durfee and Wolf’s writing on hospitalism in the early 1930s then, babies from a very early age were complex and their development was dependent on physical, mental and social stimulation and emotional care.70 Social engagement and emotional care were crucially important, but could be delivered by a range of individuals. The developmental studies undertaken by Charlotte Bühler’s team of researchers formed part of a programme of radical social reform, bridging, as Edward Timms has pointed out, a gap between theory and practice in the setting up of ‘Red Vienna’s’ child welfare programme.71 However, as one of the associates of the Psychological Institute, Lotte Schenk-Danziger, was to reflect, the research of the Vienna Psychological Institute on hospitalism did not lead to major reforms, unlike subsequent work discussed below.72 In 1938, the Anschluss heralded the end of the Vienna Psychological and Psychoanalytic Institutes. Some of its Jewish members were able to emigrate to England (including Anna and Sigmund Freud) or the USA (including Charlotte Bühler, Katherine Wolf and René Spitz); others were persecuted and perished in the Holocaust. The exploration of the involvement of emotions in infant development was cut short—the Nazi ideological focus was on racial and hereditary purity and physical health. ‘Foundling Home does not give the child a mother, nor even a substitute mother, but only an eighth of a nurse …’ The concept of hospitalism saw a reinterpretation in the 1940s in the work of René Spitz, a psychoanalyst who had spent time in Vienna in the 1930s before emigrating to the USA. During the 1930s and 1940s in the United States and Britain, institutional care for children came under growing criticism. There, the spectre of Nazism and the Second World War brought to the fore anxieties about human nature that, in the words of Mathew Thomson, ‘found a vehicle for expression in the figure of the psychologically damaged and vulnerable child’.73 A heightened concern for children to experience emotional security coincided with a growing preoccupation that the creation of democratic citizens started in the cradle.74 These developments underlay an increasing focus on the potentially emotionally damaging effects of institutional care on babies due to a lack of maternal care. Studies appeared that proposed that spending time in institutions was not only detrimental to babies’ health and development, but that the lack of maternal care was injurious to psychological well-being. In 1942, Harry Bakwin, chief paediatrician at the Bellevue Hospital in New York, thus questioned early twentieth-century German paediatricians’ conjecture that repeated infection led to hospitalism. This misconception meant that measures taken to avoid cross-infection had led to a situation where the large open ward of the past has been replaced by small cubicled rooms in which masked, hooded and scrubbed nurses and physicians move about cautiously, so as not to stir up bacteria. Visiting parents are strictly excluded and the infants receive a minimum of handling by the staff.75 Such measures to prevent infection were harmful, as hospitalised babies suffered from ‘loneliness’. Yet, the ‘young infant is dependent on the environment for gratification of his psychological needs just as he is for the satisfaction of his nutritional needs’.76 He reported that in his ward, parents were invited to visit their children freely and nurses were encouraged to handle and cuddle the babies at any opportunity. According to Bakwin, despite the greater possibility of cross-infection, this had led to a fall in the mortality rate at the hospital.77 Bakwin’s article was frequently referred to in the medical press in Britain. In the spring of 1944, controversy erupted in the letter pages of The British Medical Journal about the design of the babies’ ward in the new Children’s Hospital in Birmingham. As babies were to be kept in small cubicles to avoid the risk of cross-infection, an exasperated reader suggested that the practice of putting ‘babies into glass cages’ where they would be ‘isolated from friend or foe’ was bound to lead to immediate misery and long-term consequences to mental health for the babies in question.78 The accusation did not go unopposed. Another correspondent, directly referencing Bakwin’s study, responded that ‘compared with the paramount importance of infection’ the ‘problem of “loneliness” is a minor one’ and that the ‘majority of patients in babies’ wards are not yet at a sociable age’.79 A doctor at the hospital for his part declared that the original letter had not provided ‘a shred of evidence of the results, good or bad, upon their mental health’.80 A further contributor to the discussion, however, pointed out that the Pirquet Hospital in Vienna had abandoned the practice of housing babies in cubicles, as babies became ‘lonely, frightened, and lost weight when nursed in them’.81 The exchange of readers’ letters went to the heart of questions about babies in hospitals and other institutions in the early 1940s. How important was the risk of cross-infection, and how should it be contained? Were infants already sociable beings? If so, how much and what kind of social engagement did they need? Who could provide it? And could lessons be learned from other countries? In 1945, René Spitz (1887–1974) provided answers in his influential intervention on hospitalism, published in the newly founded Psychoanalytic Study of the Child and subsequently visually reinforced in a short film entitled Grief: A Peril in Infancy. Born in Vienna in 1887 to Jewish Hungarian parents, Spitz studied medicine in Budapest and graduated in 1910. He subsequently frequented lectures by the psychoanalyst Sandor Ferenczi and upon his instigation underwent analysis with Sigmund Freud for a period in 1910–1911.82 Historians of psychoanalysis have stressed the pioneering influence of Ferenczi and the Budapest school in focusing on the maternal role in psychoanalytic theory.83 In his Clinical Diary, Ferenczi wrote in 1932 that during analysis one must probe deep, ‘right down to the mothers’. In 1929, in ‘The Unwelcome Child and His Death Instinct’, Ferenczi suggested emotional rejection by mothers could lead to unconscious self-destructive tendencies.84 René Spitz was to place the mother–child dyad at the centre of his understanding of hospitalism. Maternal absence in institutions lead to illness and possibly infant death. The infant cannot ‘enact a suicide’, he was to explain, ‘but it is striking that these cases [of motherless institutionalised babies] one and all show a great susceptibility to intercurrent sickness’ and experienced a mortality rate above average.85 Spitz resided in Vienna from 1935 to 1936. There, he was one of the younger generation of psychoanalysts who gathered around Anna Freud and attended her Kinderseminar. But he also spent the year studying and working with Charlotte Bühler at the Psychological Institute, where, as Ilse Hellman was to recall later, ‘he was so very interested in baby observation’.86 Later in life, Spitz suggested that he first conceived of his project on infants in institutions in 1936 and that was also when he started to supplement written observations with filming babies.87 Fleeing the Nazis, Spitz emigrated in 1938 to the United States, where he spent some years in New York (he later moved to Denver). It was while in New York that he set up his own research project on infants in institutions. He decided to involve a child psychologist in the project, and turned to Katherine (Käthe) Wolf.88 Wolf, a previous associate of the Vienna Psychological Institute, had written her doctoral thesis on the baby tests, co-authored an article with Hildegard Durfee on infants in institutions, and arrived in New York in 1941. She collaborated with René Spitz for many years on projects that were based on infant observations. At the time of her death in 1957, she was an associate professor in the Child Study Centre and Department of Psychology at Yale, working on infant observations in her home. She died before publishing her findings and the materials she left behind were unfortunately indecipherable to others.89 Spitz set out to discover how infants in a foundling hospital (in Mexico) fared in comparison to a group of babies in a prison nursery (in upstate New York) who had access to their mothers, and then compared these with two control groups of babies growing up in families—one group in an impoverished fishing village, the other in professional urban homes.90 He quantified how the babies developed in these different circumstances by applying the Viennese Baby Tests, which Katherine Wolf had helped to develop. The full nature of Wolf’s involvement with Spitz’ project is not known, but it is clear that she helped with the observations and with statistically interpreting the data gathered by means of the Baby Tests. While the first two articles on hospitalism were published under Spitz’s name only, the third was published as a co-authored article.91 Spitz (and Wolf) found that the children in the foundling home ‘showed all the manifestations of hospitalism, both physical and mental’ and that the development quotient of the children ‘spectacularly deteriorated’ over time. And although conditions were impeccably hygienic, the babies showed an extreme susceptibility to infection and illness, and their mortality rate was well above that of the other babies.92 Spitz thus re-introduced the concern that the mortality rate of babies in foundling homes was considerably higher than average, suggested that the developmental impact was more pronounced than others had so far feared, and stressed that the effects of institutional care could have long-term, irreversible consequences. According to Spitz, babies fared so badly because they were deprived of their mothers. The fact that unlike the foundling hospital babies, the prison nursery babies had access to toys, other perceptual stimuli, and more opportunity to move around was of little consequence in understanding their development. Instead, he explained that A progressive development of emotional interchange with the mother provides the child with perceptive experiences of its environment. The child learns to grasp by nursing at the mother’s breast and by combining the emotional satisfaction of that experience of its environment. He learns to distinguish animate objects from inanimate ones by the spectacle provided by the mother’s face in situations fraught with emotional satisfaction. The interchange between mother and child is loaded with emotional factors and it is in this interchange that the child learns to play. He becomes acquainted with his surroundings through the mother carrying him around; through her help he learns security in locomotion as well as in every other aspect. This security is reinforced by her being at his beck and call.93 The significance of the mother–child relationship for the development of the child during the first year meant that ‘deprivations in other fields, such as perceptual and locomotor radius can all be compensated by adequate mother–child relations’.94 The absence of the mother, however, caused a ‘complete restriction of psychic capacity by the end of the first year’ and the damage inflicted by the deprivation of maternal care for more than three months, without provision of a ‘good love substitute’, was irreparable.95 Without an affective mother–infant relationship, babies—emotionally fragile, psychologically complex and in need of a sense of security—could not undergo healthy and normal development. ‘With the best will in the world a residential nursery cannot provide a satisfactory emotional environment for infants and young children’ With the help of his film Grief: A Peril in Infancy, Spitz’s message about the problems of institutional care for babies was distributed and listened to far beyond psychoanalytic circles.96 His and Wolf’s interpretation of hospitalism also fed into the elaboration of the tremendously influential theory of maternal deprivation by the British psychoanalyst John Bowlby in the post-war period. As extensive scholarship has established, there were multiple influences on the formulation of Bowlby’s theory.97 The events of war-time and its effects certainly informed the development of theories of the affective needs of children and the problems associated with residential care. This was most clearly evident in the work of Anna Freud, who with her friend Dorothy Burlingham in 1941 opened the Hampstead War Nurseries caring for children from several weeks to 10-years-old, and came to conclude that the greatest danger to children’s well-being was not the war, but separation from the mother and the manner in which it took place.98 But what has been overlooked so far amongst the influences on Bowlby, is the long-standing tradition of research into the adverse effects of institutional care on babies, or hospitalism, recently reformulated to foreground the detrimental impact of the lack of maternal care on such babies. Commissioned by the WHO, Bowlby published a report in 1951 on the fate of homeless children, entitled Maternal Care and Mental Health. In preparing the report, Bowlby spent five weeks travelling in the USA. There he found much support and substantiation for his developing theory of maternal deprivation: there was David Levy who was writing about adopted children who were deceitful and detached; Lauretta Bender who headed the new child psychiatric unit at the Bellevue Hospital and wrote about children who had been first raised in foundling homes; and William Goldfarb, who worked with the Foster Home Bureau of the New York Association for Jewish Children and studied children who had first been reared in institutions and moved to foster care at the age of three, comparing them to children immediately placed in foster care.99 Bowlby also met René Spitz and Katherine Wolf. While Bowlby was impressed with Katherine Wolf, it seems the two men did not get on well on a personal level.100 But Spitz’s and Wolf’s work dovetailed with and informed aspects of Bowlby’s developing theory. Bowlby was to cite Hildegard Durfee and Wolf’s 1933 article on hospitalism, as well as Spitz and Wolf’s subsequent work in the WHO report. And he credited their work and discussions with them for the revision of his understanding that maternal separation was pathogenic only after the age of six months and particularly after 12 months. Instead, he came to agree that separation at a much younger age already was damaging.101 In the report, Bowlby went on to declare that ‘with the best will in the world, a residential nursery cannot provide a satisfactory emotional environment for infants and young children’, as it could not provide ‘mothering of an adequate and continuous kind’.102 With this, he voiced his disappointment with the Curtis Report of 1946 on the care of homeless children, which was to form the basis of the Children Act of 1948. The report, although critical of residential care for older children, had advocated residential nurseries for children aged up to 12 months.103 To Bowlby, this was the ‘most serious shortcoming in an otherwise progressive report’.104 He looked forward to the day that ‘residential nurseries, except for the most temporary emergency case, will be commonly recognised as incompatible with sound national policies of mental hygiene’.105 Conclusion There were fundamental changes in how the diagnosis of hospitalism was conceptualised between the end of the nineteenth and the middle of the twentieth century. International connections, fostered both through engagement with other experts’ work across borders and through the intellectual migration of the 1930s, emerge as important in shaping these developments. The changing meanings attributed to the figure of the baby quietly lying in its cot in an institution, invoked by the paediatrician Arthur Schlossmann before the First World War, exemplify shifts in conceptualising hospitalism. Over the following decades, this baby was interpreted and re-interpreted by changing groups of experts. Physicians, child psychologists and psychoanalysts provided different explanations of how to see this baby: as a contented baby who had all his or her needs met and stood a good chance of survival; as a baby who lagged behind in development through inheritance and lack of mental and physical stimulation and thus purportedly posed a threat to the hereditary make-up of the population; or as a baby who had not experienced love and interest and had thus fallen behind in social behaviour. As the article has discussed, the question of the meaning of the absence of maternal care was always present in discussions on hospitalism. While in the early twentieth century many paediatricians viewed maternal care as replaceable by medical experts, it is also important to note that there was not a neat shift of focus at mid-century from babies’ bodily welfare to their emotional welfare. The view that the mother–infant relationship was central to infant well-being was already formulated before the First World War, although it was only at mid-century that this understanding became increasingly influential. In the German speaking-world, the early twentieth-century matrix of competing and intertwining theories that centred on the bodies, minds and emotions of babies gave way with the rise of Nazism to a focus on the physical health and racial and hereditary purity of babies. In the USA and Britain, however, the spectre of Nazism and the Second World War gave greater voice and impact to theories on the emotional interiority of babies and elevated the relationship between infant and mother to key importance in laying the foundations not only to physical, but also to future emotional health. In the British context, the development of new approaches to infantile subjectivity as a consequence of the intellectual migration to the country in the 1930s has been well documented: it set off the ‘controversial discussions’ between Anna Freudians and Kleinians that were to divide the British Psycho-Analytic Society.106 Exploring the influence of research on babies by the Vienna Psychological Institute adds a further dimension to our understanding of mid-twentieth century formulations of infantile subjectivity. René Spitz developed his interpretation of the impact of institutional care in the USA based upon Viennese baby observation techniques. Influenced by the Budapest school of psychoanalysis and writing at a time of unprecedented separations and losses, for Spitz the absence of the mother made residential care profoundly damaging, as measured by applying the Baby Tests. Yet, as this article has shown, the concept of hospitalism did not originate with Spitz. The profound changes in conceptualising the causes and nature of hospitalism in babies from the end of the nineteenth to the mid-twentieth century provide insights into how infant institutions, once associated with welfare endeavours to lower the infant mortality rate, from this new perspective could never fulfil the fundamental requirements of raising babies. Rather than resting contendedly, the quiet baby of the institutional ward came to be seen as deeply traumatised and bereft, languishing in the emotional vacuum of maternal absence. Acknowledgements I am grateful to Shaul Bar-Haim, Till Kössler, Mathew Thomson, my writing group: Lucy Bland, Clare Midgley, Alison Oram, Krisztina Robert, Cornelie Usborne, and the anonymous reviewers for their comments on earlier versions of this article. This work was supported by the Wellcome Trust. Footnotes 1 René A. Spitz, ‘Hospitalism: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood’, The Psychoanalytic Study of the Child, 1945, 1, 53–74. 2 René A. Spitz, ‘Hospitalism: A Follow-Up Report’, The Psychoanalytic Study of the Child, 1946, 2, 115. 3 Robert Karen, Becoming Attached: First Relationships and How They Shape our Capacity to Love (Oxford: Oxford University Press, 1998), 25; Marga Vicedo, The Nature and Nurture of Love: From Imprinting to Attachment in Cold War America (Chicago: University of Chicago Press, 2013), 29–30. 4 See, for instance, Frank C. P. van der Horst and René van der Veer, ‘Changing Attitudes to the Care of Children in Hospital: A New Assessment of the Influence of the Work of Bowlby and Robertson in the UK, 1940–1970’, Attachment & Human Development, 2009, 11, 119–42; Bican Polat, ‘Before Attachment Theory: Separation Research at the Tavistock Clinic, 1948–1956’, Journal of the History of Behavioral Sciences, 2017, 53, 48–70; Harry Hendrick, ‘Children’s Emotional Well-Being and Mental Health in Early Post-Second World War Britain: The Case of Unrestricted Hospital Visiting’, in Marijke Gijswijt-Hofstra and Hilary Marland, eds, Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 213–42; Roy Kozlovsky, The Architectures of Childhood: Children, Modern Architecture and Reconstruction in Postwar England (London: Routledge, 2013), ch. 4. 5 See, for instance, Kozlovsky, Architectures, 150; Frank C. P. van der Horst, John Bowlby—From Psychoanalysis to Ethology: Unravelling the Roots of Attachment Theory (Oxford: Wiley-Blackwell, 2011), 46; Michal Shapira, The War Inside: Psychoanalysis, Total War, and the Making of the Democratic Self in Postwar Britain (Cambridge: Cambridge University Press, 2013), 204. 6 For psychoanalytic theories of infantile subjectivity, see Michal Shapira, ‘Psychoanalysts on the Radio: Domestic Citizenship and Motherhood in Postwar Britain,’ in Bonnie Smith and Joanna Regulska, eds, Women and Gender in Postwar Europe (New York: Routledge, 2011), 71–86; Shapira, The War Inside; Cathy Urwin and Elaine Sharland, ‘From Bodies to Minds in Childcare Literature: Advice to Parents in Inter-War Britain’, in Roger Cooter, ed., In the Name of the Child: Health and Welfare, 1880–1940 (London and New York: Routledge, 1992), 174–99; Michael Roper, ‘From Shell-Shocked Soldier to the Nervous Child: Psychoanalysis in the Aftermath of the First World War’, Psychoanalysis and History, 2016, 18, 39–69. 7 Melanie Klein, ‘Weaning (1936)’, in Love, Guilt and Reparation and Other Works 1921–1945 (London: Vintage, 1998), 297. 8 Bill Bynum, ‘Hospitalism’, The Lancet, 28 April 2001, 357, 1372. 9 Floyd M. Crandall, ‘Editorial: Hospitalism’, Archives of Pediatrics, 1897, 14, 448–54. For another early use of the term see Adolf Baginsky, ‘Zur Kenntnis der Atrophie der Säuglinge’, Deutsche medizinische Wochenschrift, 1899, 25, 281–4. 10 H. Finkelstein and L. Ballin, Die Waisensäuglinge Berlins und ihre Verpflegung im städtischen Kinderasyl (Berlin: Urban & Schwarzberg, 1904), 4; H. Finkelstein, ‘Die Bedeutung städtischer Säuglingsasyle für die Herabsetzung der Sterblichkeit in der Waisenkostpflege, Zeitschrift für Säuglingsfürsorge, 1907, 1, 6; Edward Ross Dickinson, The Politics of German Child Welfare from the Empire to the Federal Republic (Cambridge, MA: Harvard University Press, 1996), 52; Silke Fehlemann, Armutsrisiko Mutterschaft: Mütter- und Säuglingsfürsorge im rheinisch-westfälischen Industriegebiet, 1890–1924 (Essen: Klartext, 2009), 147. 11 Rachel Fuchs, Abandoned Children: Foundlings and Child Welfare in Nineteenth-Century France (Albany: State University of New York Press, 1984), 139, 149; Walther Freund, ‘Über den “Hospitalismus” der Säuglinge’, Ergebnisse der inneren Medizin und Kinderheilkunde, 1910, 6, 339. 12 On hospital-based and university-located paediatrics, see Lawrence T. Weaver, ‘Kinderheilkunde and Continental Connections in Child Health: The “Glasgow School Revisited”—Again’, Journal of the History of Medicine and Allied Sciences, 2013, 68, 592. 13 Freund, ‘Über den “Hospitalismus”’, 337–8. 14 Freund, ‘Über den “Hospitalismus”’, 339–40. 15 Otto Heubner, ‘Ueber Säuglingsernährung und Säuglingsspitäler’, Berliner Klinische Wochenschrift, 1897, 21, 443; Heinrich Finkelstein, ‘Über Morbidität und Mortalität in Säuglingsspitälern und deren Ursachen’, Zeitschrift für Hygiene und Infektionskrankheiten, 1898, 20, 141, 148, 154. 16 Finkelsein and Ballin, Waisensäuglinge, 10. 17 Sigrid Stöckel, Säuglingsfürsorge zwischen sozialer Hygiene und Eugenik: Das Beispiel Berlins im Kaiserreich und in der Weimarer Republik (Berlin: Walter de Gruyter, 1996), 121–2; Finkelsein and Ballin, Waisensäuglinge, 39, 81; H. Finkelstein, ‘Bemerkungen zu dem Aufsatz des Herrn Szalardi: Die Sterblichkeit in den Säuglingsspitälern’, Jahrbuch für Kinderheilkunde, 1899, 69, 98–100. 18 Finkelstein, ‘Bemerkungen’, 98–100. 19 M. Szalárdi, ‘Die Sterblichkeit in den Säuglingsspitälern’, Jahrbuch für Kinderheilhunde, 1899, 69 90–1. 20 Larry Frohman, ‘Prevention, Welfare, and Citizenship: The War on Tuberculosis and Infant Mortality in Germany, 1900–1930’, Central European History, 2006, 39, 447. 21 M. Pfaundler, ‘Arthur Schlossmann’, Klinische Wochenschrift, 1932, 11, 1246–7; Eduard Seidler, ‘Arthur Schlossmann’, in JüdischeKinderärzte,1933–1945: entrechtet, geflohen, ermordet, 2nd rev. edn (Freiburg: S. Karger, 2007), 245–7. 22 Arthur Schlossmann, ‘Die Entwicklung der Versorgung kranker Säuglinge in Anstalten’, Ergebnisse der inneren Medizin, 1923, 24, 200. 23 Arthur Schlossmann, ‘Zur Frage der Säuglingssterblichkeit in Anstalten’, Münchener medizinische Wochenschrift, 1920, 67, 1319; Arthur Schlossmann, ‘Die Anstaltsversorgung von Kindern’, Zeitschrift für das gesamte Krankenhauswesen, 1927, 283. 24 Arthur Schlossmann, ‘Über Errichtung und Einrichtung von Säuglingskrankenanstalten’, Archiv für Kinderheilkunde, 1902, 219; Arthur Schlossmann, ‘Über die Fürsorge für kranke Säuglinge unter besonderer Berücksichtigung des neuen Dresdner Säuglingsheimes’, Archiv für Kinderheilkunde, 1906, 43, 57. 25 Schlossmann, ‘Die Entwicklung’, 197. 26 Schlossmann, ‘Die Entwicklung’, 193, 197. 27 Schlossmann, ‘Über die Fürsorge’, 22. 28 Schlossmann, ‘Die Entwicklung’, 207. See also Arthur Schlossmann, ‘Erfahrungen und Gedanken über Anstaltsbehandlung der Säuglinge’, Monatsschrift für Kinderheilkunde, 1913, 11, 545, 550; Arthur Schlossmann, ‘Zur Frage’, 1318. 29 Till Kössler, ‘Die Ordnung der Gefühle: Frühe Kinderpsychologie und das Problem kindlicher Emotionen (1880–1930)’, in Uffa Jensen and Daniel Morat, eds, Rationalisierung des Gefühls: Zum Verhältnis von Wissenschaft und Emotionen, 1880–1930 (München: Wilhelm Fink, 2008), 189–210; Jörg Heßling, Die Haltung zu Kindern in der deutschen Kinderheilkunde von 1877 bis 1980 (Herzogenrath: Murken-Altrogge, 1998), 56–66. See also Otto Heubner, ‘Über die Zeitfolge in der psychischen Entwicklung des Säuglings und des jungen Kindes’, Ergebnisse der inneren Medizin, 1919, 16, 1–31. 30 Schlossmann. ‘Die Entwicklung’, 206. See also Werner Gottstein, ‘Kinderkrankenhäuser’, in K. Biesalski, et al., Fachkrankenhäuser (Berlin: Julius Springer, 1930), 126. 31 For the suggestion that an institution might replace family, see Schlossmann, ‘Die Entwicklung’, 208–9. 32 Schlossmann, ‘Über die Fürsorge’, 62. 33 M. von Pfaundler, ‘Physiologie des Neugeborenen’, in A. Döderlein (ed.), Handbuch der Geburtshilfe, vol. 1 (Wiesbaden: J.F. Bergmann, 1915), 727; Adalbert Czerny, ‘Säugling, Arzt und Pflegerin’, in Festschrift zur Eröffnung des Kaiserin—Auguste Victoria-Hauses zur Bekämpfung der Säuglingssterblichkeit (Berlin: Georg Stilke, 1909), 61. 34 M. Pfaundler and Arthur Schlossmann, Handbuch der Kinderheilkunde, 4 vols (Leipzig: Vogel, 1906). 35 He was thus critical of feeding according to the clock, ignoring crying, and banning pacifiers, carrying and rocking. See Meinhard Pfaundler, ‘Ueber Saugen und Verdauen’, Wiener klinische Wochenschrift, 1899, 1012. 36 Meinhard Pfaundler, ‘Über natürliche und über rationelle Säuglingspflege’, Süddeutsche Monatshefte, 1909, 6, 316. See also Pfaundler, ‘Physiologie’, 730–1. 37 Pfaundler, ‘Über natürliche’, 317–18. 38 E. Seidler, ‘Die Kinderheilkunde in Deutschland’, in P. Schweier and E. Seidler, Lebendige Pädiatrie: Festschrift zur 100jährigen Geschichte der Kinderheilkunde (Munich: Walter de Gruyter, 1983), 63–4. 39 Pfaundler, ‘Physiologie’, 728. 40 Ibid., 729. 41 See Lotte Landé, ‘Entwicklung und Schicksal der im Kaiserin Auguste Victoria Haus geborenen Kinder’, Zeitschrift für Kinderheilkunde, 1919, 20, 57; Hilde Müller, ‘Muss es einen Hospitalismus in Säuglingsanstalten geben?’, Gesundheitsfürsorge für das Kindesalter, 1926/27, 2, 172. 42 Zaida Eriksson, ‘Über Anstaltsschaden der Kinder: ‘Hospitalismus’ in Kinderheimen’, Acta Paediatrica, Supplement 1925, 4, 64. 43 Hilde Müller, ‘Über Intelligenzprüfungen bei Anstaltskindern bis zum 3. Lebensjahre im Vergleich zu Kindern in der privaten Pflege’, Jahrbuch für Kinderheilkunde, 1925, 109, 345–51. 44 Erna Eckstein-Schlossmann, ‘Zur Frage des Hospitalismus in Säuglingsanstalten’, Zeitschrift für Kinderheilkunde, 1926, 42, 32, 38. 45 Sigrid Stöckel, ‘Infant Mortality and Concepts of Hygiene. Strategies and Consequences in the Kaiserreich and the Weimar Republic: The Example of Berlin’, History of the Family, 2002, 7, 613. 46 Meinhard von Pfaundler, ‘Klinik und Fürsorge’, Gesundheitsfürsorge für das Kindesalter, 1925/26, 1, 10, 17. 47 Lisa Appignanesi and John Forrester, Freud’s Women (London: Weidenfeld and Nichols, 1992), 287. 48 Hermine Hug-Hellmuth, Aus dem Seelenleben des Kindes: Eine psychoanalytische Studie (Leipzig: Deuticke, 1913). 49 For the development of child psychoanalysis see Claudine Geissmann and Pierre Geissmann, A History of Child Psychoanalysis (London: Routledge, 1998). See also Michael Roper, ‘From Shell-Shocked Soldier to the Nervous Child: Psychoanalysis in the Aftermath of the First World War’, Psychoanalysis and History, 2016, 18, 39–69 for developments in Britain. 50 August Aichhorn, Verwahrloste Jugend: Die Psychoanalyse der Führsorge Erziehung (Leipzig: Psychoanalytischer Verlag, 1925). 51 Siegfried Bernfeld, Psychologie des Säuglings (Vienna: Julius Springer, 1925). For Isaac’s assessment see Nick Midgley, ‘Anna Freud: The Hampstead War Nurseries and the Role of the Direct Observation of Children for Psychoanalysis’, International Journal of Psychoanalysis, 2007, 88, 940. 52 On the acceptance of Adler’s views, see Lotte Schenk-Danzinger, ‘Zur Geschichte der Kinderpsychologie: Das Wiener Institut’, Zeitschrift für Entwicklungspsychologie und pädagogische Psychologie, 1984, 16, 97. On the views of the Psychological Institute, see Charlotte Bühler in Ludwig J. Pongratz, Werner Traxel und Ernst G. Wehner, eds, Psychologie in Selbstdarstellungen (Bern: Hans Huber, 1972), 29. 53 Ilse Hellman, From War Babies to Grandmothers: Forty-Eight Years in Psychoanalysis (London: Karnac, 1990), 4. 54 Bühler in Pongratz et al., Psychologie in Selbstdarstellungen, 27. 55 Hildegard Hetzer and Käthe Wolf, ‘Babytests: Eine Testserie für das erste Lebensjahr’, Zeitschrift für Psychologie, 1928, 107, 62–104; Charlotte Bühler and Hildegard Hetzer, Kleinkindertests: Entwicklungstests für das erste bis sechste Lebensjahr (Leipzig: Hirzel, 1932). 56 For child psychology at the Vienna Psychological Institute see Mitchell G. Ash, ‘Psychology and Politics in Interwar Vienna: The Vienna Psychological Institute, 1922–1942’, in Mitchell G. Ash and William W. Woodward, eds, Psychology in Twentieth-Century Thought and Society (Cambridge: Cambridge University Press, 1987), 143–64; Gerhard Benetka, Psychologie in Wien: Sozial- und Theoriegeschichte des Wiener Psychologischen Instituts, 1922–1938 (Wien: WUV, 1995); and 'Gerhard Benetka and Thomas Slunecko, ‘Das Wiener Psychologische Institut und die Herausbildung der Entwicklungspsychologie’, in Liselotte Ahnert, ed., Charlotte Bühler und die Entwicklungspsychologie (Vienna: Vienna University Press, 2015), 9–18. 57 Durfee and Wolf, ‘Anstaltspflege’, 310, 314. 58 Hildegard Hetzer, ‘Die Entwicklung des Kindes in der Anstalt’, in Adolf Busemann, ed., Handbuch der pädagogischen Milieukunde (Halle: Hermann Schroedel, 1932), 160. Hildegard Durfee and Käthe Wolf, ‘Anstaltspflege und Entwicklung im Ersten Lebensjahr’, Zeitschrift für Kinderforschung, 1933–1934, 42, 274; Irmgard Gindl, Hildegard Hildegard and Martha Sturm, ‘Unangemessenheit der Anstalt als Lebensraum für das Kleinkind’, Zeitschrift für angewandte Psychologie und Characterkunde, 1937, 52, 313. 59 Benteka, Psychologie, 190. Hetzer’s own interpretations of child development increasingly changed in the 1930s and 1940s. In 1931, she was offered a teaching job in Berlin, which she lost in 1934 under the Law for the Restoration of the Professional Civil Service, probably due to her work with the Jewish Charlotte Bühler and her provenance from ‘Red Vienna’. In the years that followed, Hetzer increasingly incorporated Nazi terminology in her publications. Having become a member of the National Socialist People’s Welfare Organization in 1936, she started to work for the organization at the beginning of the war. In 1940, she suggested that the Hetzer–Bühler Tests constituted a useful aid for the implementation of the Law for the Prevention of Offspring with Hereditary Diseases. In March 1942, Hetzer took up a position for two and a half months near Poznań in the ‘Reichsgau Warthenau’ in a children’s home where she provided psychological profiles of children selected for Germanisation. Hetzer later claimed that she believed that the children were neglected German, not Polish children, a claim upon which Theo Herrmann has cast doubt. Hetzer left that position in May 1942, but continued to work until the end of 1944 in occupied Poland. The details of what she did in those years are not known yet. After the war, Hetzer established a successful career in West Germany, receiving, amongst other accolades, the Bundestverdienstkreuz Erster Klasse in 1972. See Gerhard Benetka, ‘Hetzer, Hildegard’, in Brigitta Keintzel and Ilse Korotin, eds, Wissenschaftlerinnen in und aus Österreich (Vienna: Böhlau, 2002), 285–8; Gisela Bruns und Siegfried Grubitzsch, ‘Hildegard Hetzer—Pionierin der Entwicklungsverfahren’, Psychologie & Gesellschaftskritik, 1992, 16, 83–95; Theo Herrmann, ‘Hildegard Hetzer als NSV Psychologin im okkupierten Polen (1942–1944)’, in Theo Hermann and Włodek Zeidler, eds, Psychologen in autoritären Systemen (Frankfurt a.M.: Peter Lang, 2012), 129–63. 60 Hetzer, ‘Die Entwicklung’, 162, 169–70; Gindl, Hetzer and Sturm, ‘Unangemessenheit’, 338. 61 Durfee and Wolf, ‘Anstaltspflege’, 307, 319. 62 Hildegard Durfee, ‘Analyse der auf der geistigen Entwicklung des Säuglings wirksamen Anstaltsfaktoren’ (Dissertation, Wiener, 1932). 63 ‘Hildegard Durfee, World Citizen and Psychologist, Dies’, Brattleboro Reformer (29 November 1989). I am grateful to Charles Butterfield and Jeanne M. Walsh for locating the obituary and sending it to me. 64 Katharina Wolf, ‘Die grundlegenden Prinzipien des Entwicklungstests und die Möglichkeit ihrer Realisierung’ (Dissertation, Wien, 1930); Hetzer and Wolf, ‘Babytests’; Liselottl Frank and Käthe Wolf, ‘Die Testreihen für das erste Lebensjahr’, in Bühler and Hetzer, Kleinkindertests. 65 Durfee and Wolf, ‘Anstaltspflege’, 306. 66 Ibid., 299, 310, 314. 67 Ibid., 309–10, 314, 318. 68 Ibid., 311–12, 320. 69 Ibid., 319. 70 While Durfee and Wolf believed that differences in development only started to be measurable after four months of age, they thought that an institutional stay at an earlier age already had effects on subsequent development (Ibid., 276, 294). 71 Edward Timms, ‘New Approaches to Child Psychology: From Red Vienna to the Hampstead Nursery’, in Edward Timms and Jon Hughes, eds, Intellectual Migration and Cultural Transformation: Refugees from National Socialism in the English-Speaking World (Vienna: Springer, 2003), 224. 72 Lotte Schenk-Danzinger, ‘Zur Geschichte der Kinderpsychologie: Das Wiener Institut’, Zeitschrift für Entwicklungspsychologie und Pädagogische Psychologie, 1984, 16, 97. 73 Mathew Thomson, Lost Freedom: The Landscape of the Child and the British Post-War Settlement (Oxford: Oxford University Press, 2013), 77. 74 Cathy Urwin and Elaine Sharland, ‘From Bodies to Minds in Childcare Literature: Advice to Parents in Inter-War Britain’, in Roger Cooter, ed., In the Name of the Child: Health and Welfare, 1880–1940 (London and New York: Routledge, 1992), 192. See also Shapira, The War Inside. 75 Harry Bakwin, ‘Loneliness in Infants’, American Journal of Diseases of Children, 1942, 63, 31. 76 Ibid., 38. 77 Ibid., 39–40. 78 H. C. Scott, ‘Babies in Glass Cages’, British Medical Journal, 19 February 1944, 266–7. The design of the ward allowed for the presence only of breast-feeding mothers in a separate ‘hostel’. These mothers were given access to their babies at feeding times, and fed their babies while dressed in a sterile gown and a face mask. See ‘Babies Hospital’, Mother and Child, 1944, xv, 10 and Scott, ‘Babies in Glass Cages’. 79 H. S. Baar, ‘Babies in Glass Cages’, The British Medical Journal, 8 April 1944, 505. 80 See Leonard G. Parson, ‘Babies in Glass Cages’, British Medical Journal, 4 March 1944, 336. 81 Clifford Allen, ‘Babies in Glass Cages’, British Medical Journal, 18 March 1944, 404. 82 Judit Meszaros, Ferenczi and Beyond: Exile of the Budapest School and Solidarity in the Psychoanalytic Movement during the Nazi Years (London: Karnac, 2014), 189. 83 Shaul Bar-Haim, ‘The Maternalizing Movement: Psychoanalysis, Motherhood and the British Welfare State c. 1920–1950’ (PhD thesis, University of London, 2015), introduction and ch. 1. I am grateful to Shaul Bar-Haim for drawing my attention to the connection between Ferenczi and René Spitz. 84 Judit Mészáros, ‘Ferenczi in Our Contemporary World’, in Adrienne Harris and Steven Kuchuk, eds, The Legacy of Sándor Ferenczi: From Ghost to Ancestor (London: Routledge, 2015), 23. For an exploration of the role of the maternal in the Budapest School of Psychoanalysis see, for instance, Bar-Haim, ‘The Maternalizing Movement’. 85 René A. Spitz and Katherine M. Wolf, ‘Anaclitic Depression: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood’, Psychoanalytic Study of the Child, 1946, 2, 319; Spitz, ‘Hospitalism’, 1945, 59. 86 Hellman, ‘Professional Life’, 5. 87 René Spitz Papers, Box M2111, Folder No. 7, Archives of the History of American Psychology, The Centre for the History of Psychology, The University of Akron. 88 René Spitz Papers, Box M2111, Folder No. 16, Archives of the History of American Psychology, The Centre for the History of Psychology, The University of Akron. 89 ‘Katherine M. Wolf—In Memorian’, The Staff of the Child Study Association of America. Child Study: A Quarterly Journal of Parent Education, 1957–1958, 2–3; Robert Karen, Becoming Attached: First Relationships and How They Shape our Capacity to Love (Oxford: Oxford University Press, 1998), 144. 90 Spitz, ‘Hospitalism’, 1945, 58. 91 Ibid., footnote 7. See Spitz and Wolf, ‘Anaclitic Depression’, 313–42. 92 Spitz, ‘Hospitalism’, 1945, 59. 93 Spitz, ‘Hospitalism’, 1945, 68. 94 Ibid., 70. 95 Ibid., 68; Spitz and Wolf, ‘Anaclitic Depression’, 335; Spitz, ‘Hospitalism’, 1946, 115. 96 John Bowlby, A Secure Base: Clinical Applications of Attachment Theory (London: Routlege, 1988), 24. See also Lisa Cartwright, ‘“Emergencies of Survival”“: Moral Spectatorship and the “New Vision of the Child” in Postwar Child Psychoanalysis’, Journal of Visual Culture, 2004, 3, 40; Karen, Becoming Attached, 23. 97 See, for instance, Denise Riley, War in the Nursery: Theories of the Child and Mother (London: Virago, 1983); Suzan van Dijken, John Bowlby—His Early Life: A Biographical Journey into the Roots of Attachment Theory (London: Free Association, 1998); van der Horst, John Bowlby; Vicedo, Nature and Nurture. 98 Shapira, The War Inside, 66ff. 99 19 March 1950, John Bowlby Papers, PP/BOW/B.1/12, Archives and Manuscripts, Wellcome Library. 100 29 March 1950, John Bowlby Papers, PP/BOW/B.1/12, Archives and Manuscripts Wellcome Library. 101 John Bowlby, Maternal Care and Mental Health (Geneva: World Health Organization, 1951), 48; ‘Notebook 2 USA’, John Bowlby Papers, PP/BOW/D4/8, Archives and Manuscripts, Wellcome Library. 102 Bowlby, Maternal Care, 132–3. 103 Report of the Care of Children Committee (London: HSMO, 1946), 160. 104 Bowlby, Maternal Care, 132. 105 Ibid., 134. 106 Pearl King and Riccardo Steiner, eds, The Freud-Klein Controversies 1941–45 (London: Routledge, 1991); Riccardo Steiner, Tradition, Change, Creativity: Repercussions of the New Diaspora on Aspects of British Psychoanalysis (London: Karnac, 2000). © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social History of Medicine Oxford University Press

What Do Babies Need to Thrive? Changing Interpretations of ‘Hospitalism’ in an International Context, 1900–1945

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Abstract

Abstract In 1945, the émigré psychoanalyst René Spitz published a landmark article in which he suggested that babies cared for in institutions commonly suffered from ‘hospitalism’ and failed to thrive. According to Spitz this was the case because such babies were deprived of ‘maternal care, maternal stimulation, and maternal love.’ Historical interest in separation research and the development of the concept of maternal deprivation has tended to focus on the 1940s and 50s. The term ‘hospitalism’, however, was coined at the end of the nineteenth century and by 1945 the question of whether or not babies could be cared for in institutions had already been debated for a number of decades by an international community of paediatricians and developmental psychologists, later joined by psychoanalysts. Criss-crossing national boundaries and exploring debates over the nature, causes, and prevention of ‘hospitalism’, this article elucidates the changing understandings of the impact on babies of living in institutions. hospitalism, separation research, infant hospitals, foundling homes, paediatrics, child psychology, psychoanalysis In 1945, the émigré psychoanalyst René Spitz published a landmark article in which he suggested that babies cared for in institutions commonly suffered from a condition called ‘hospitalism’ and failed to thrive.1 Spitz reported that babies he observed in a foundling hospital became withdrawn, lost weight, suffered from severe developmental decline and many of them died. The causes of this, according to Spitz, were to be found in the fact that the babies were deprived of ‘maternal care, maternal stimulation, and maternal love’.2 He subsequently distilled his views on the catastrophic consequences of institutional care of babies in a harrowing short film released in 1947, entitled Grief: A Peril in Infancy. Spitz was to become one of the principal spokespersons of the dangers of maternal separation in the United States in the post-war period.3 His observations also influenced the British psychoanalyst John Bowlby, who in 1951, having been commissioned by the World Health Organisation to explore the plight of homeless children, published his influential report on Maternal Care and Mental Health. In it he formulated his theory of maternal deprivation, suggesting that young children needed continuous and responsive mothering or faced the risk of long-term damage. Recent historical interest in separation research and the development of the concept of maternal deprivation has paid much attention to the 1940s and 1950s. There has been a particular focus on the impact of such ideas on the gradual implementation of unrestricted parental visiting to children’s hospital wards from the 1950s onwards.4 So far, however, this research has overlooked the fact that by mid-century there was already a long-standing interest in the welfare of babies who had been separated from their families and the potential adverse effects that might arise from their care in institutions such as infant hospitals or foundling homes. Indeed, while the concept of ‘hospitalism’ is commonly associated with Spitz’s work, the term was in fact coined at the end of the nineteenth century.5 By the time Spitz’s article was published at the end of the Second World War, the question of whether or not babies could be appropriately cared for in institutions had already been debated over a number of decades by paediatricians and developmental psychologists, later joined by psychoanalysts. The answer had not always been negative; indeed, in the early twentieth century there were many paediatricians who thought that it depended on the nature of the institution; if run on modern principles, institutions could avoid the problem of hospitalism and provide as good an environment as any for raising babies. On the other hand, however, the contention that babies fared badly in institutions because they lacked the attention of mothers was not formulated in the 1940s for the first time; such ideas had been articulated before the First World War. This article, by tracing the history of the concept of hospitalism and exploring debates over its nature, causes and prevention from the end of the nineteenth to the mid-twentieth century, seeks to elucidate the changing understandings of the impact on babies of being separated from families. To achieve this, it disentangles the varied approaches of paediatricians, child psychologists and psychoanalysts, which were rooted in their diverse, though overlapping, views on infancy. Research into this has hitherto been patchy. Historians have paid considerable attention to the development of notions of infantile subjectivity in psychoanalytic theories, but they have not yet fully explored conceptualisations of infancy promoted by paediatricians since the late nineteenth century.6 Yet the psychoanalyst Melanie Klein in 1936 made the point that her understanding of infancy refuted paediatricians’ ideas on babyhood.7 In addition, the interwar theories of developmental psychologists on babies have hitherto received little attention, even though the school of child psychology that developed in interwar Vienna adopted an equally critical attitude to paediatricians’ theories, while simultaneously distancing itself from psychoanalytic ideas on the nature of infancy. These different conceptualisations of babyhood underpinned evolving interpretations of the phenomenon of hospitalism. The process of retracing the history of the concept of hospitalism in this article has also necessitated tracking developments as they criss-crossed national boundaries, calling into question the adequacy of nation-based frameworks which often characterise historical scholarship on changing ideas of childhood. The following sections of the article explore the formulation of and engagement with the diagnosis of hospitalism by paediatricians in Germany from the end of the nineteenth century to the Weimar Republic. It then moves on to examine how the concept was taken up and reformulated by a group of child psychologists in interwar Vienna. The rise of the Nazis and ensuing emigration of Jewish intellectuals meant that in the late 1930s, Viennese research parameters on hospitalism were brought to the United States, where its causes were profoundly reformulated by the psychoanalyst René Spitz, working in collaboration with Viennese child psychologist Katherine Wolf. Finally, the article focuses on developments in Britain, exploring how the theory of hospitalism informed the formulation of the influential theory of maternal deprivation, elaborated by the British psychoanalyst John Bowlby in the immediate post-war era. Paediatricians Conceptualise the Problem of ‘Hospitalism’, 1890s–1918 The term ‘hospitalism’ was first used in Britain during the late 1860s to indicate the problem of hospitals supposedly gradually absorbing the poisons of infection, creating an atmosphere of rot and decay.8 At the end of the nineteenth century, however, physicians came to use it to denote adverse effects of institutional stays specifically on babies. In 1897, an editorial by Floyd Crandall in the American Archives of Pediatrics used the term to denote the ‘excessive’ morality rate of patients under a year old in the newly multiplying hospitals for infants.9 Preoccupation with the effects of residing in institutions on babies grew in the context of emerging specialised hospitals for infants, increasing admissions of babies—who had previously been excluded from them—to children’s hospitals, and the appearance of new orphanages and residential institutions for babies. The multiplication of these infant institutions was part of a developing welfare effort to reduce the infant mortality rate and the consolidation of paediatrics as a separate specialism. Paediatricians played an influential role in the infant welfare movement, a process that was closely intertwined with the increasing importance of population policy and a preoccupation with the health of the body politic.10 Yet, as was soon noted, the infant mortality rate in these institutions was often shockingly high. However, it was not the existence of such institutions that was called into question by child health experts. Indeed, it came to be commonly thought that the problem lay with the institutions and how they were run, fuelling a search for medicalised solutions to make residential care safe for babies. Physicians in France, pioneers in infant welfare, were amongst the first to draw attention to the problem. Joseph Marie Jules Parrot and Victor Hutinel, physicians at the Hospice des Enfants-Assistés in Paris became particularly associated with reforms that sought to reduce the infant mortality rate there in the late nineteenth century.11 In the early twentieth century, however, Germany became the centre for a hospital-based and university-located paediatrics, a process that was accompanied by a wide-ranging engagement with the problems of hospitalism.12 In 1895, the paediatrician Hugo Neumann suggested that ‘one day’ medical progress might mean that babies could be looked after successfully in hospitals. By the first decade of the twentieth century, however, many paediatricians considered it to be ‘one of the greatest successes of clinical paediatrics’ that infant institutions had become instruments of reducing the infant morality rate.13 When in the late1890s and early 1900s paediatricians in Germany first addressed the problem of hospitalism—conceived as the high mortality rate in infant hospital wards and other institutions—they replicated the findings of physicians in France who had concluded that the key to the problem lay in containing the spread of germs.14 This was particularly true for paediatricians in Berlin, who were influenced by Robert Koch’s bacteriological discoveries. The first professor of paediatrics in Germany and director of the children’s wing of the Charité in Berlin, Otto Heubner (1843–1926) and his student Heinrich Finkelstein (1865–1942), who in 1901 became chief physician at the newly established Berlin Kinderasyl for infants, were amongst the first to consider the issue. Infections, spread by nurses and feeding equipment, were responsible for hospitalism. The introduction of hygienic measures was seen as the way to reduce the risks to babies posed by institutional stays.15 First elaborated in relation to hospitals, these conclusions were soon extended to babies in foundling homes.16 Koch’s influence also underlay an optimistic attitude to the possibility of providing uncontaminated substitute foods to babies in institutions. Both Heubner and Finkelstein were convinced that babies could thrive on artificial nutrition.17 All in all, it was possible to achieve excellent results in terms of the infant mortality rate in institutions, if there were sufficient hygienic measures to prevent new infections.18 The assumption that babies could thrive on substitute foods was, however, strongly questioned by others.19 Hospitalism became a problem not only of infection, but also of nutrition. As such, it could not be fought without human milk. Foremost here was the work of Arthur Schlossmann (1867–1932), a paediatrician based first in Dresden and then in Düsseldorf. Schlossmann quickly became one of the principal authorities on hospitalism in the early twentieth century. By then, doctors had documented an ongoing decrease in the breastfeeding rate, while at the same time establishing an inverse correlation between breastfeeding and infant mortality. Breastfeeding became, in the words of Larry Frohman, the ‘the axis around which all infant welfare programs in Germany pivoted’.20 Arthur Schlossmann saw breastfeeding as the basis of infant health and the prime factor in improving the chances of infant survival, which strongly shaped the way he understood the nature of hospitalism. Schlossmann trained as a paediatrician in Berlin, but in 1893 moved to Dresden, the capital of Saxony, which then had the highest infant mortality rate in the German Empire—in 1895 it stood at 28 per cent. In 1898, he opened the first ‘hospital for sucklings’, the Dresdener Säuglingsheim, which became the model for other such hospitals in the German Empire. In 1906, he moved to Düsseldorf, where he took over the infants’ wing in the local orphanage and also established an infant hospital.21 A prolific and frequently cited contributor to the discussion of institutional care for infants, Schlossmann based his arguments on his experiences of running infant hospitals in Dresden and Düsseldorf. As he repeatedly pointed out, under his direction both institutions did well when it came to the infant mortality rate, and indeed much better than the Berlin Charité. By 1900/1901, the mortality rate of the Säuglingsheim in Dresden was below average for the region at 27 per cent.22 In Düsseldorf, the fall in the mortality rate was dramatic: when Schlossmann first arrived there, the local orphanage had an infant mortality rate of 71.5 per cent. Between 1907 and 1912, the infant hospital that Schlossmann established, which also took in ill foundlings, had a mortality rate of 16.8 per cent.23 Schlossmann endorsed the need of aseptic care to prevent the spread of infectious diseases, declaring that ‘I consider every single child to be potentially infectious and subject to infection on any part of its body’.24 He also, however, consistently rejected colleagues’ search for and use of substitute foods in the care of young babies.25 Breast milk was not only a form of nutrition, but also a form of medicine.26 Without it he was convinced, ‘one cannot feed ill infants with a view to a successful outcome’.27 He accordingly established extensive on-site wet-nursing systems in his hospitals. According to Schlossmann, the combination of aseptic care and the provision of breast milk through wet nursing meant that babies could be safely looked after in institutions for long periods. He thus declared: the problem of the institutional care of infants has been solved, to at least the same extent for foundling homes as for infirmaries. It does not cause the slightest difficulty to set up a home for infants, in which they will be impeccably cared for, thrive, and rarely fall ill, if the necessary means and staff are available.28 The understanding that hospitalism need not blight infant institutions depended on and reinforced a particular conceptualisation of infancy. Under the influence of the child study movement and evolutionary theory, there had emerged in the late nineteenth century an understanding by which young babies were seen to be unable yet to engage with and make sense of their environment. Young babies could feel pleasure and displeasure (the latter initially predominating over the former), and from there the capacity to experience more differentiated emotions gradually developed.29 Paediatricians commonly did not think of babies as socially competent and tied into or dependent on emotional relationships. This meant that mothers’ care was replaceable by medical experts. Indeed, while mothers could be obliged to be involved in babies’ initial care in foundling homes, this was to ensure the health benefits of breastfeeding, conceived in terms of the nutritional value of human milk. In hospitals, however, mothers (as much as other relatives) were to be kept away, as they were perceived to be sources of potential infection. Ideally, relatives were to visit their babies once a week from behind a glass window.30 While not suggesting that institutions could or should replace the family, if babies found themselves in one, physicians, nurses and wet-nurses could provide the necessary care of infants.31 Arthur Schlossmann thus provided a telling description of his infant hospital in 1906: All our visitors notice how quiet it is here, how little the children cry. A well looked after child lies quietly in its cot and it is not unusual to spend more than an hour in a room with fifteen children without hearing a sound.32 According to Schlossmann, such quietness was an expression of content. Physically well-looked after babies did not experience significant discontent and would thus lie quietly in their cots for lengthy periods of time. The well-being of babies in institutions was solely dependent on how these institutions were run. In Infant Homes, Germs Receive More Attention Than Babies … The growing number of institutions for infants were run on principles that centralised babies’ physical well-being well into the twentieth century. Nonetheless, while paediatric concerns predominantly centred on babies’ bodily health, ideas about their emotional interiority and need to enter into an affective relationship with their mothers were also formulated in the first decade of the century. Commentators soon pointed out that the focus on the prevention of infection meant that in infant homes germs received more attention than the babies.33 To some, this was detrimental to babies’ welfare. Hospitalism thus conceptualised arose from the lack of the particular stimulations provided by maternal care. This position was most notably formulated by the Austrian colleague of Arthur Schlossmann, the paediatrician Meinhard von Pfaundler (1872–1947). Educated in Innsbruck and Graz, Pfaundler spent most of his career as the director of the University Children’s Hospital in Munich, where he played a prominent role in establishing the city as a centre of paediatric research. Pfaundler collaborated with Arthur Schlossmann in editing an influential textbook on children’s diseases in 1906.34 Soon after, however, he began to contest Schlossmann’s understanding of hospitalism and how to avoid it. According to Pfaundler, hospitalism could not be reduced to problems of nutrition and asepsis. Pfaundler began to question some of the cornerstones of his profession’s advice on infant care in the late 1890s.35 He soon formulated a conceptualisation of ‘natural infant care’ as the appropriate way of looking after babies. This, so Pfaundler said, was evident from observing mammals and ‘natural peoples’: ‘To be looked after by the mother, cared for, and protected is an instinctive wish of every mammal baby, which, like the human infant, comes into the world without sufficient means to live independently’.36 What he called ‘rational infant care’, on the other hand, was harmful to babies’ health, as well as their emotional well-being, their seelisches Gleichgewicht. This was evidenced, according to Pfaundler, by the phenomenon of hospitalism in institutions where extreme forms of rational care prevailed.37 Like the influential educationalist Friedrich Fröbel, Pfaundler suggested that a mother’s role encompassed providing stimulation for her child from early infancy. Pfaundler made this argument by invoking the theories of the Russian behaviourist Ivan Pavlov, whose disciple, the paediatrician Nicolai Krasnogorski, had spent time working in Berlin.38 Suggesting that babies’ development depended on stimuli and the emotions they provoked, Pfaundler contended that mothers entered a close relationship with their children in the early weeks, and that being subject to the wealth of stimuli that emanated from this relationship was important for the mental and physical well-being of the infant. Babies looked after en masse by nurses in homes grew up bereft of these stimuli.39 The quietness of the ward, cited by Schlossmann, was not the expression of content, but of the learned experience of institutionalised babies that their expressions were futile, leading to a reduction in reaction to external stimuli.40 To Pfaundler, therefore, institutions could not fulfil babies’ needs. Hospitalism in the Weimar Republic: Babies’ Mental and Physical Development Meinhard von Pfaundler’s ideas on babies’ need to enter into a relationship with their mothers were largely ignored by the contemporary medical world. The question of the lack of stimulation experienced by infants in institutions, however, became more pertinent after the First World War. In 1918 the Kaiserliche Gesundheitsamt issued guidelines for the establishment of infant homes (Säuglingsheime), which were an important feature of Weimar infant welfare provisions. There continued to be much medical interest in hospitalism, but the terms of debate shifted. It was widely accepted that the infant mortality rate could be kept relatively low in institutions, including for lengthy residencies. However, more and more questions were raised about more subtle effects of institutional care on babies. It was increasingly suggested that babies in institutions did not follow the expected developmental stages; they lagged behind physically and mentally when compared to babies growing up in families.41 Delay in physical development was associated with an increased frequency of experiencing infectious diseases. In 1925, a student of Meinhard von Pfaundler, Zaida Eriksson (1895–1974), published her dissertation on hospitalism (as a result of which she had become the fifth woman to be medically qualified in Finland). Based on the study of babies in a variety of institutions in Munich, she concluded that compared to babies raised in families, those raised in institutions suffered from decreased resistance to infections and grew more slowly.42 Lagging behind in mental development on the other hand was linked to the fact that babies in institutions received scant individual attention and thus lacked stimulation. Hilde Müller thus established that young children in institutions lagged behind in their intellectual development.43 Erna Eckstein-Schlossmann (1895–1998), Arthur Schlossmann’s daughter and like her father a paediatrician, came to the conclusion that the original optimism accompanying the establishment of infant homes had been replaced in paediatric circles with a sense that, for the care of healthy babies, the focus should be on foster placements in families. As for babies in hospitals, even in well-run institutions a ‘certain mental hospitalism’ could not be avoided. Engaging babies in activities could contain it, but their mental development still commonly lagged behind that of babies in families.44 By the later 1920s, the view that institutional care had an impact on babies’ mental and physical development became closely entwined with the increasing convergence of social and racial hygiene, in which the impact of infants’ adverse living conditions were seen to have a detrimental effect on the ‘race’ as a whole.45 It was Meinhard von Pfaundler who thus reframed his approach to babies in institutions most clearly. He continued to assert that institutions were not appropriate environments for infants, but now claimed that babies in institutions were in all likelihood already of ‘inferior inheritance’, born to ‘unmarried, ill, … , alcoholic, feeble-minded and morally inferior’ parents. Institutional upbringing was now undesirable to Pfaundler, because it further aggravated constitutional damage, to the detriment of future generations.46 Hospitalism at the Vienna Psychological Institute During the late 1920s and early 1930s, the shift of focus away from the infant mortality rate to the impact of institutional care on babies’ development was taken further by a new research centre: the Psychological Institute in Vienna. There, child psychologists established tests to measure infant and child development and a number of researchers made the application of these tests to infants in institutions the focus of their work. Amongst them was Käthe Wolf, who went on to closely collaborate with the psychoanalyst René Spitz in his research on hospitalism, which he developed after having spent time at the Institute in the mid-1930s, learning the methods of infant observation developed there. Research at the Psychological Institute was to provide a bridge from early paediatric research to later psychoanalytic interpretations of hospitalism through the development of baby observation techniques. In the 1920s and early 1930s Vienna was at the centre of developments in child psychology that foregrounded infants’ and children’s internal worlds and it became the ‘capital of child analysis’.47 As early as 1913, the analyst Hermine Hug-Hellmuth had published a psychoanalytically informed observational study of early child development.48 In the 1920s, Anna Freud organised the Kinderseminar, a group exploring the emerging field of child psychoanalysis.49 In 1925, one of its members, August Aichorn, provided a psychoanalytic account of ‘juvenile delinquents’ in residential care.50 Another member of the Kinderseminar, Sigfried Bernfeld, best remembered for his work on the link between psychoanalysis and progressive educational theory and his activism in socialist and Zionist youth movements, wrote in the same year The Psychology of the Infant, which, once translated, was considered by the psychologist and psychoanalyst Susan Isaacs to be ‘one of the most important books on child psychology’.51 Around this time, a research group developed at the Vienna Psychological Institute that focused on babies’ development, including their affective expressions and social development. The Psychological Institute, however, retained its distance from the Vienna Psychoanalytic Society. Alfred Adler’s individual psychology was tolerated, primarily because of its impact on educational theory and child guidance, but the relationship of the Psychological Institute to psychoanalysis was ‘predominantly negative’.52 Indeed, the one-time assistant at the Psychological Institute, Ilse Hellman, who later worked with Anna Freud in the Hampstead War Nurseries, recalled that the child psychologist ‘Charlotte Bühler was completely anti-psychoanalytic. All of us assistants were forbidden to go and listen to Anna Freud or to attend her seminars.’ She also suggested, however, that ‘quite a few people … went to them secretly’.53 The two institutes worked separately, but nonetheless there were students and researchers who were engaged with both groups. The convergence of these different approaches to child psychology were to underlie René Spitz’s re-interpretation of the nature and causes of hospitalism. The Viennese School of Child Psychology developed under the leadership of Charlotte Bühler (née Malachowski, 1893–1974). Bühler spent the academic year of 1924–1925 at Columbia University studying American research on child psychology. There, in discussion particularly with Arnold Gesell, she formulated the notion of developmental stages in infancy and sought to elaborate a method for the observation of the ‘entire behaviour of the child’.54 After her return from the USA, the Social-Democratic Viennese city government agreed to let Bühler and her team use the Children’s Reception Centre (Kinderübernahmestelle) for research. Opened in 1925, the Reception Centre was a quarantine station, which housed babies, children and youths who had come under municipal care for two to three weeks before they were transferred to foster places, children’s homes, reformatories or back to their parents. The Centre offered an ideal set-up to observe babies: they were housed in glass cubicles in groups of five or six, with a corridor running along the outside, where researchers recorded their observations. These observations constituted the foundation of Viennese, or Hetzer–Bühler Tests, for children from birth to the age of six.55 The tests aimed to quantitatively evaluate a child’s development of perception; body mastery; engagement with inanimate objects; social behaviour and mental production; as much as overall development.56 Babies’ development in these areas was seen to follow a predictable course that depended on internal processes of maturation. The Viennese tests informed child psychologists’ research into the effects of institutional care on babies, as well as René Spitz’s subsequent psychoanalytic re-orientation of hospitalism. Child psychologists writing on hospitalism took issue with the preoccupation with hygiene and physical health determining the institutional care of babies. While recognising that recommendations on these aspects had played an important role in reducing the mortality rate associated with institutional stays, developmental psychologists made a strong case for the view that the problem of adverse effects of institutional care on babies had not been solved. Indeed, it had been a ‘crass error’ for physicians to be in charge of the running of infant institutions, as this had led to neglect of the psychological dimension of infant development.57 Even if the dangers of ‘physical hospitalism’ had been reined in, there was still a need to engage with the problem of ‘psychological hospitalism’.58 The Viennese Baby Tests provided these researchers with a means to quantify the impact of institutional care on babies’ development. The resulting engagement with the phenomenon of hospitalism concluded that environmental factors had a significant impact on infant development. In 1929, Charlotte Bühler’s assistant, Hildegard Hetzer (1899–1991) published a book on Childhood and Poverty, which proved to be influential in subsequent research on hospitalism. Equating poverty with neglect, Hetzer claimed babies in well-off families had their needs met ‘five-times more’ than babies in poor families. Poor children, she said, could thus be called ‘neglected’ children and those from well-off backgrounds ‘cared for’ children. Hetzer suggested that there were clear developmental differences between ‘neglected’ and ‘cared-for’ infants. She thus implicitly called into question, without developing this, the notion underlying the Hetzer–Bühler Tests of development as consisting of endogenous processes of maturation.59 Hetzer’s work inspired a number of doctoral theses on the impact of institutional care on infant development. Some of the resulting research suggested that institutions were inherently damaging for babies and young children.60 But perhaps the most wide-ranging and complex study on the issue concluded that ‘institutions can be designed and changed in such a way that psychological hospitalism can also be fought successfully’, although the authors recognised that their ideal institution was utopian.61 The study was published in 1933–34 in the Zeitschrift für Kinderheilkunde. Co-authored by the American Hildegard Durfee (née Diechmann, 1896–1989) and the Viennese Käthe (later Katherine) Wolf (1907–1957), the article was largely based on the research of Durfee’s doctoral thesis.62 Durfee, who was born in Berlin, but emigrated as a child to the USA, was one of several American students who came to study at the Vienna Psychological Institute.63 Käthe Wolf studied philosophy at the University of Vienna, becoming a close collaborator of Charlotte Bühler and her husband Karl. She wrote her thesis on the developmental tests and was instrumental in drawing up tests for the first year of life.64 According to Durfee and Wolf, babies were susceptible to their environment from an early age. Rejecting Alfred Adler’s ‘extreme inference’ that environmental influences were at the root of character formation, the authors also refuted the notion that inheritance determined personality. Rather, environmental influences played an important, but not exclusive, role in infant development.65 Using the Viennese Baby Tests, the authors measured the physical, mental and social development of infants under a year old in a number of institutions with different approaches to how and by whom the babies were cared for. They concluded that institutions run on paediatric principles posed particular problems. Paying close attention to the rules of hygiene led to a monotonous life and little interaction with toys or people. But according to the authors, child development depended on mental stimulation and social interaction. Those institutions where mothers were present provided the best outcomes. Through the joint efforts of mothers, physicians and nurses, babies experienced all the advantages of maternal care, but avoided the potential dangers of ‘ignorant’ maternal caretaking.66 Durfee and Wolf concluded that for appropriate development, babies needed mental stimulation (through, for instance, colourful walls and pictures, and access to toys). But most affected by environmental influences was social development, babies needed to experience ‘love and interest’.67 On balance, maternal care was preferable to that of other caregivers. While providing the health advantages of breast milk, mothers were of even greater psychological importance: their engagement with their babies was characterised by ease and spontaneity that depended on a ‘certain degree of love’.68 The mother, to Durfee and Wolf, was therefore the most obvious person to foster babies’ social development. However, they also thought that trained specialists—that is expert nurses who would be responsible for the emotional well-being of the baby—could turn institutions into viable environments for infants.69 According to Durfee and Wolf’s writing on hospitalism in the early 1930s then, babies from a very early age were complex and their development was dependent on physical, mental and social stimulation and emotional care.70 Social engagement and emotional care were crucially important, but could be delivered by a range of individuals. The developmental studies undertaken by Charlotte Bühler’s team of researchers formed part of a programme of radical social reform, bridging, as Edward Timms has pointed out, a gap between theory and practice in the setting up of ‘Red Vienna’s’ child welfare programme.71 However, as one of the associates of the Psychological Institute, Lotte Schenk-Danziger, was to reflect, the research of the Vienna Psychological Institute on hospitalism did not lead to major reforms, unlike subsequent work discussed below.72 In 1938, the Anschluss heralded the end of the Vienna Psychological and Psychoanalytic Institutes. Some of its Jewish members were able to emigrate to England (including Anna and Sigmund Freud) or the USA (including Charlotte Bühler, Katherine Wolf and René Spitz); others were persecuted and perished in the Holocaust. The exploration of the involvement of emotions in infant development was cut short—the Nazi ideological focus was on racial and hereditary purity and physical health. ‘Foundling Home does not give the child a mother, nor even a substitute mother, but only an eighth of a nurse …’ The concept of hospitalism saw a reinterpretation in the 1940s in the work of René Spitz, a psychoanalyst who had spent time in Vienna in the 1930s before emigrating to the USA. During the 1930s and 1940s in the United States and Britain, institutional care for children came under growing criticism. There, the spectre of Nazism and the Second World War brought to the fore anxieties about human nature that, in the words of Mathew Thomson, ‘found a vehicle for expression in the figure of the psychologically damaged and vulnerable child’.73 A heightened concern for children to experience emotional security coincided with a growing preoccupation that the creation of democratic citizens started in the cradle.74 These developments underlay an increasing focus on the potentially emotionally damaging effects of institutional care on babies due to a lack of maternal care. Studies appeared that proposed that spending time in institutions was not only detrimental to babies’ health and development, but that the lack of maternal care was injurious to psychological well-being. In 1942, Harry Bakwin, chief paediatrician at the Bellevue Hospital in New York, thus questioned early twentieth-century German paediatricians’ conjecture that repeated infection led to hospitalism. This misconception meant that measures taken to avoid cross-infection had led to a situation where the large open ward of the past has been replaced by small cubicled rooms in which masked, hooded and scrubbed nurses and physicians move about cautiously, so as not to stir up bacteria. Visiting parents are strictly excluded and the infants receive a minimum of handling by the staff.75 Such measures to prevent infection were harmful, as hospitalised babies suffered from ‘loneliness’. Yet, the ‘young infant is dependent on the environment for gratification of his psychological needs just as he is for the satisfaction of his nutritional needs’.76 He reported that in his ward, parents were invited to visit their children freely and nurses were encouraged to handle and cuddle the babies at any opportunity. According to Bakwin, despite the greater possibility of cross-infection, this had led to a fall in the mortality rate at the hospital.77 Bakwin’s article was frequently referred to in the medical press in Britain. In the spring of 1944, controversy erupted in the letter pages of The British Medical Journal about the design of the babies’ ward in the new Children’s Hospital in Birmingham. As babies were to be kept in small cubicles to avoid the risk of cross-infection, an exasperated reader suggested that the practice of putting ‘babies into glass cages’ where they would be ‘isolated from friend or foe’ was bound to lead to immediate misery and long-term consequences to mental health for the babies in question.78 The accusation did not go unopposed. Another correspondent, directly referencing Bakwin’s study, responded that ‘compared with the paramount importance of infection’ the ‘problem of “loneliness” is a minor one’ and that the ‘majority of patients in babies’ wards are not yet at a sociable age’.79 A doctor at the hospital for his part declared that the original letter had not provided ‘a shred of evidence of the results, good or bad, upon their mental health’.80 A further contributor to the discussion, however, pointed out that the Pirquet Hospital in Vienna had abandoned the practice of housing babies in cubicles, as babies became ‘lonely, frightened, and lost weight when nursed in them’.81 The exchange of readers’ letters went to the heart of questions about babies in hospitals and other institutions in the early 1940s. How important was the risk of cross-infection, and how should it be contained? Were infants already sociable beings? If so, how much and what kind of social engagement did they need? Who could provide it? And could lessons be learned from other countries? In 1945, René Spitz (1887–1974) provided answers in his influential intervention on hospitalism, published in the newly founded Psychoanalytic Study of the Child and subsequently visually reinforced in a short film entitled Grief: A Peril in Infancy. Born in Vienna in 1887 to Jewish Hungarian parents, Spitz studied medicine in Budapest and graduated in 1910. He subsequently frequented lectures by the psychoanalyst Sandor Ferenczi and upon his instigation underwent analysis with Sigmund Freud for a period in 1910–1911.82 Historians of psychoanalysis have stressed the pioneering influence of Ferenczi and the Budapest school in focusing on the maternal role in psychoanalytic theory.83 In his Clinical Diary, Ferenczi wrote in 1932 that during analysis one must probe deep, ‘right down to the mothers’. In 1929, in ‘The Unwelcome Child and His Death Instinct’, Ferenczi suggested emotional rejection by mothers could lead to unconscious self-destructive tendencies.84 René Spitz was to place the mother–child dyad at the centre of his understanding of hospitalism. Maternal absence in institutions lead to illness and possibly infant death. The infant cannot ‘enact a suicide’, he was to explain, ‘but it is striking that these cases [of motherless institutionalised babies] one and all show a great susceptibility to intercurrent sickness’ and experienced a mortality rate above average.85 Spitz resided in Vienna from 1935 to 1936. There, he was one of the younger generation of psychoanalysts who gathered around Anna Freud and attended her Kinderseminar. But he also spent the year studying and working with Charlotte Bühler at the Psychological Institute, where, as Ilse Hellman was to recall later, ‘he was so very interested in baby observation’.86 Later in life, Spitz suggested that he first conceived of his project on infants in institutions in 1936 and that was also when he started to supplement written observations with filming babies.87 Fleeing the Nazis, Spitz emigrated in 1938 to the United States, where he spent some years in New York (he later moved to Denver). It was while in New York that he set up his own research project on infants in institutions. He decided to involve a child psychologist in the project, and turned to Katherine (Käthe) Wolf.88 Wolf, a previous associate of the Vienna Psychological Institute, had written her doctoral thesis on the baby tests, co-authored an article with Hildegard Durfee on infants in institutions, and arrived in New York in 1941. She collaborated with René Spitz for many years on projects that were based on infant observations. At the time of her death in 1957, she was an associate professor in the Child Study Centre and Department of Psychology at Yale, working on infant observations in her home. She died before publishing her findings and the materials she left behind were unfortunately indecipherable to others.89 Spitz set out to discover how infants in a foundling hospital (in Mexico) fared in comparison to a group of babies in a prison nursery (in upstate New York) who had access to their mothers, and then compared these with two control groups of babies growing up in families—one group in an impoverished fishing village, the other in professional urban homes.90 He quantified how the babies developed in these different circumstances by applying the Viennese Baby Tests, which Katherine Wolf had helped to develop. The full nature of Wolf’s involvement with Spitz’ project is not known, but it is clear that she helped with the observations and with statistically interpreting the data gathered by means of the Baby Tests. While the first two articles on hospitalism were published under Spitz’s name only, the third was published as a co-authored article.91 Spitz (and Wolf) found that the children in the foundling home ‘showed all the manifestations of hospitalism, both physical and mental’ and that the development quotient of the children ‘spectacularly deteriorated’ over time. And although conditions were impeccably hygienic, the babies showed an extreme susceptibility to infection and illness, and their mortality rate was well above that of the other babies.92 Spitz thus re-introduced the concern that the mortality rate of babies in foundling homes was considerably higher than average, suggested that the developmental impact was more pronounced than others had so far feared, and stressed that the effects of institutional care could have long-term, irreversible consequences. According to Spitz, babies fared so badly because they were deprived of their mothers. The fact that unlike the foundling hospital babies, the prison nursery babies had access to toys, other perceptual stimuli, and more opportunity to move around was of little consequence in understanding their development. Instead, he explained that A progressive development of emotional interchange with the mother provides the child with perceptive experiences of its environment. The child learns to grasp by nursing at the mother’s breast and by combining the emotional satisfaction of that experience of its environment. He learns to distinguish animate objects from inanimate ones by the spectacle provided by the mother’s face in situations fraught with emotional satisfaction. The interchange between mother and child is loaded with emotional factors and it is in this interchange that the child learns to play. He becomes acquainted with his surroundings through the mother carrying him around; through her help he learns security in locomotion as well as in every other aspect. This security is reinforced by her being at his beck and call.93 The significance of the mother–child relationship for the development of the child during the first year meant that ‘deprivations in other fields, such as perceptual and locomotor radius can all be compensated by adequate mother–child relations’.94 The absence of the mother, however, caused a ‘complete restriction of psychic capacity by the end of the first year’ and the damage inflicted by the deprivation of maternal care for more than three months, without provision of a ‘good love substitute’, was irreparable.95 Without an affective mother–infant relationship, babies—emotionally fragile, psychologically complex and in need of a sense of security—could not undergo healthy and normal development. ‘With the best will in the world a residential nursery cannot provide a satisfactory emotional environment for infants and young children’ With the help of his film Grief: A Peril in Infancy, Spitz’s message about the problems of institutional care for babies was distributed and listened to far beyond psychoanalytic circles.96 His and Wolf’s interpretation of hospitalism also fed into the elaboration of the tremendously influential theory of maternal deprivation by the British psychoanalyst John Bowlby in the post-war period. As extensive scholarship has established, there were multiple influences on the formulation of Bowlby’s theory.97 The events of war-time and its effects certainly informed the development of theories of the affective needs of children and the problems associated with residential care. This was most clearly evident in the work of Anna Freud, who with her friend Dorothy Burlingham in 1941 opened the Hampstead War Nurseries caring for children from several weeks to 10-years-old, and came to conclude that the greatest danger to children’s well-being was not the war, but separation from the mother and the manner in which it took place.98 But what has been overlooked so far amongst the influences on Bowlby, is the long-standing tradition of research into the adverse effects of institutional care on babies, or hospitalism, recently reformulated to foreground the detrimental impact of the lack of maternal care on such babies. Commissioned by the WHO, Bowlby published a report in 1951 on the fate of homeless children, entitled Maternal Care and Mental Health. In preparing the report, Bowlby spent five weeks travelling in the USA. There he found much support and substantiation for his developing theory of maternal deprivation: there was David Levy who was writing about adopted children who were deceitful and detached; Lauretta Bender who headed the new child psychiatric unit at the Bellevue Hospital and wrote about children who had been first raised in foundling homes; and William Goldfarb, who worked with the Foster Home Bureau of the New York Association for Jewish Children and studied children who had first been reared in institutions and moved to foster care at the age of three, comparing them to children immediately placed in foster care.99 Bowlby also met René Spitz and Katherine Wolf. While Bowlby was impressed with Katherine Wolf, it seems the two men did not get on well on a personal level.100 But Spitz’s and Wolf’s work dovetailed with and informed aspects of Bowlby’s developing theory. Bowlby was to cite Hildegard Durfee and Wolf’s 1933 article on hospitalism, as well as Spitz and Wolf’s subsequent work in the WHO report. And he credited their work and discussions with them for the revision of his understanding that maternal separation was pathogenic only after the age of six months and particularly after 12 months. Instead, he came to agree that separation at a much younger age already was damaging.101 In the report, Bowlby went on to declare that ‘with the best will in the world, a residential nursery cannot provide a satisfactory emotional environment for infants and young children’, as it could not provide ‘mothering of an adequate and continuous kind’.102 With this, he voiced his disappointment with the Curtis Report of 1946 on the care of homeless children, which was to form the basis of the Children Act of 1948. The report, although critical of residential care for older children, had advocated residential nurseries for children aged up to 12 months.103 To Bowlby, this was the ‘most serious shortcoming in an otherwise progressive report’.104 He looked forward to the day that ‘residential nurseries, except for the most temporary emergency case, will be commonly recognised as incompatible with sound national policies of mental hygiene’.105 Conclusion There were fundamental changes in how the diagnosis of hospitalism was conceptualised between the end of the nineteenth and the middle of the twentieth century. International connections, fostered both through engagement with other experts’ work across borders and through the intellectual migration of the 1930s, emerge as important in shaping these developments. The changing meanings attributed to the figure of the baby quietly lying in its cot in an institution, invoked by the paediatrician Arthur Schlossmann before the First World War, exemplify shifts in conceptualising hospitalism. Over the following decades, this baby was interpreted and re-interpreted by changing groups of experts. Physicians, child psychologists and psychoanalysts provided different explanations of how to see this baby: as a contented baby who had all his or her needs met and stood a good chance of survival; as a baby who lagged behind in development through inheritance and lack of mental and physical stimulation and thus purportedly posed a threat to the hereditary make-up of the population; or as a baby who had not experienced love and interest and had thus fallen behind in social behaviour. As the article has discussed, the question of the meaning of the absence of maternal care was always present in discussions on hospitalism. While in the early twentieth century many paediatricians viewed maternal care as replaceable by medical experts, it is also important to note that there was not a neat shift of focus at mid-century from babies’ bodily welfare to their emotional welfare. The view that the mother–infant relationship was central to infant well-being was already formulated before the First World War, although it was only at mid-century that this understanding became increasingly influential. In the German speaking-world, the early twentieth-century matrix of competing and intertwining theories that centred on the bodies, minds and emotions of babies gave way with the rise of Nazism to a focus on the physical health and racial and hereditary purity of babies. In the USA and Britain, however, the spectre of Nazism and the Second World War gave greater voice and impact to theories on the emotional interiority of babies and elevated the relationship between infant and mother to key importance in laying the foundations not only to physical, but also to future emotional health. In the British context, the development of new approaches to infantile subjectivity as a consequence of the intellectual migration to the country in the 1930s has been well documented: it set off the ‘controversial discussions’ between Anna Freudians and Kleinians that were to divide the British Psycho-Analytic Society.106 Exploring the influence of research on babies by the Vienna Psychological Institute adds a further dimension to our understanding of mid-twentieth century formulations of infantile subjectivity. René Spitz developed his interpretation of the impact of institutional care in the USA based upon Viennese baby observation techniques. Influenced by the Budapest school of psychoanalysis and writing at a time of unprecedented separations and losses, for Spitz the absence of the mother made residential care profoundly damaging, as measured by applying the Baby Tests. Yet, as this article has shown, the concept of hospitalism did not originate with Spitz. The profound changes in conceptualising the causes and nature of hospitalism in babies from the end of the nineteenth to the mid-twentieth century provide insights into how infant institutions, once associated with welfare endeavours to lower the infant mortality rate, from this new perspective could never fulfil the fundamental requirements of raising babies. Rather than resting contendedly, the quiet baby of the institutional ward came to be seen as deeply traumatised and bereft, languishing in the emotional vacuum of maternal absence. Acknowledgements I am grateful to Shaul Bar-Haim, Till Kössler, Mathew Thomson, my writing group: Lucy Bland, Clare Midgley, Alison Oram, Krisztina Robert, Cornelie Usborne, and the anonymous reviewers for their comments on earlier versions of this article. This work was supported by the Wellcome Trust. Footnotes 1 René A. Spitz, ‘Hospitalism: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood’, The Psychoanalytic Study of the Child, 1945, 1, 53–74. 2 René A. Spitz, ‘Hospitalism: A Follow-Up Report’, The Psychoanalytic Study of the Child, 1946, 2, 115. 3 Robert Karen, Becoming Attached: First Relationships and How They Shape our Capacity to Love (Oxford: Oxford University Press, 1998), 25; Marga Vicedo, The Nature and Nurture of Love: From Imprinting to Attachment in Cold War America (Chicago: University of Chicago Press, 2013), 29–30. 4 See, for instance, Frank C. P. van der Horst and René van der Veer, ‘Changing Attitudes to the Care of Children in Hospital: A New Assessment of the Influence of the Work of Bowlby and Robertson in the UK, 1940–1970’, Attachment & Human Development, 2009, 11, 119–42; Bican Polat, ‘Before Attachment Theory: Separation Research at the Tavistock Clinic, 1948–1956’, Journal of the History of Behavioral Sciences, 2017, 53, 48–70; Harry Hendrick, ‘Children’s Emotional Well-Being and Mental Health in Early Post-Second World War Britain: The Case of Unrestricted Hospital Visiting’, in Marijke Gijswijt-Hofstra and Hilary Marland, eds, Cultures of Child Health in Britain and the Netherlands in the Twentieth Century (Amsterdam: Rodopi, 2003), 213–42; Roy Kozlovsky, The Architectures of Childhood: Children, Modern Architecture and Reconstruction in Postwar England (London: Routledge, 2013), ch. 4. 5 See, for instance, Kozlovsky, Architectures, 150; Frank C. P. van der Horst, John Bowlby—From Psychoanalysis to Ethology: Unravelling the Roots of Attachment Theory (Oxford: Wiley-Blackwell, 2011), 46; Michal Shapira, The War Inside: Psychoanalysis, Total War, and the Making of the Democratic Self in Postwar Britain (Cambridge: Cambridge University Press, 2013), 204. 6 For psychoanalytic theories of infantile subjectivity, see Michal Shapira, ‘Psychoanalysts on the Radio: Domestic Citizenship and Motherhood in Postwar Britain,’ in Bonnie Smith and Joanna Regulska, eds, Women and Gender in Postwar Europe (New York: Routledge, 2011), 71–86; Shapira, The War Inside; Cathy Urwin and Elaine Sharland, ‘From Bodies to Minds in Childcare Literature: Advice to Parents in Inter-War Britain’, in Roger Cooter, ed., In the Name of the Child: Health and Welfare, 1880–1940 (London and New York: Routledge, 1992), 174–99; Michael Roper, ‘From Shell-Shocked Soldier to the Nervous Child: Psychoanalysis in the Aftermath of the First World War’, Psychoanalysis and History, 2016, 18, 39–69. 7 Melanie Klein, ‘Weaning (1936)’, in Love, Guilt and Reparation and Other Works 1921–1945 (London: Vintage, 1998), 297. 8 Bill Bynum, ‘Hospitalism’, The Lancet, 28 April 2001, 357, 1372. 9 Floyd M. Crandall, ‘Editorial: Hospitalism’, Archives of Pediatrics, 1897, 14, 448–54. For another early use of the term see Adolf Baginsky, ‘Zur Kenntnis der Atrophie der Säuglinge’, Deutsche medizinische Wochenschrift, 1899, 25, 281–4. 10 H. Finkelstein and L. Ballin, Die Waisensäuglinge Berlins und ihre Verpflegung im städtischen Kinderasyl (Berlin: Urban & Schwarzberg, 1904), 4; H. Finkelstein, ‘Die Bedeutung städtischer Säuglingsasyle für die Herabsetzung der Sterblichkeit in der Waisenkostpflege, Zeitschrift für Säuglingsfürsorge, 1907, 1, 6; Edward Ross Dickinson, The Politics of German Child Welfare from the Empire to the Federal Republic (Cambridge, MA: Harvard University Press, 1996), 52; Silke Fehlemann, Armutsrisiko Mutterschaft: Mütter- und Säuglingsfürsorge im rheinisch-westfälischen Industriegebiet, 1890–1924 (Essen: Klartext, 2009), 147. 11 Rachel Fuchs, Abandoned Children: Foundlings and Child Welfare in Nineteenth-Century France (Albany: State University of New York Press, 1984), 139, 149; Walther Freund, ‘Über den “Hospitalismus” der Säuglinge’, Ergebnisse der inneren Medizin und Kinderheilkunde, 1910, 6, 339. 12 On hospital-based and university-located paediatrics, see Lawrence T. Weaver, ‘Kinderheilkunde and Continental Connections in Child Health: The “Glasgow School Revisited”—Again’, Journal of the History of Medicine and Allied Sciences, 2013, 68, 592. 13 Freund, ‘Über den “Hospitalismus”’, 337–8. 14 Freund, ‘Über den “Hospitalismus”’, 339–40. 15 Otto Heubner, ‘Ueber Säuglingsernährung und Säuglingsspitäler’, Berliner Klinische Wochenschrift, 1897, 21, 443; Heinrich Finkelstein, ‘Über Morbidität und Mortalität in Säuglingsspitälern und deren Ursachen’, Zeitschrift für Hygiene und Infektionskrankheiten, 1898, 20, 141, 148, 154. 16 Finkelsein and Ballin, Waisensäuglinge, 10. 17 Sigrid Stöckel, Säuglingsfürsorge zwischen sozialer Hygiene und Eugenik: Das Beispiel Berlins im Kaiserreich und in der Weimarer Republik (Berlin: Walter de Gruyter, 1996), 121–2; Finkelsein and Ballin, Waisensäuglinge, 39, 81; H. Finkelstein, ‘Bemerkungen zu dem Aufsatz des Herrn Szalardi: Die Sterblichkeit in den Säuglingsspitälern’, Jahrbuch für Kinderheilkunde, 1899, 69, 98–100. 18 Finkelstein, ‘Bemerkungen’, 98–100. 19 M. Szalárdi, ‘Die Sterblichkeit in den Säuglingsspitälern’, Jahrbuch für Kinderheilhunde, 1899, 69 90–1. 20 Larry Frohman, ‘Prevention, Welfare, and Citizenship: The War on Tuberculosis and Infant Mortality in Germany, 1900–1930’, Central European History, 2006, 39, 447. 21 M. Pfaundler, ‘Arthur Schlossmann’, Klinische Wochenschrift, 1932, 11, 1246–7; Eduard Seidler, ‘Arthur Schlossmann’, in JüdischeKinderärzte,1933–1945: entrechtet, geflohen, ermordet, 2nd rev. edn (Freiburg: S. Karger, 2007), 245–7. 22 Arthur Schlossmann, ‘Die Entwicklung der Versorgung kranker Säuglinge in Anstalten’, Ergebnisse der inneren Medizin, 1923, 24, 200. 23 Arthur Schlossmann, ‘Zur Frage der Säuglingssterblichkeit in Anstalten’, Münchener medizinische Wochenschrift, 1920, 67, 1319; Arthur Schlossmann, ‘Die Anstaltsversorgung von Kindern’, Zeitschrift für das gesamte Krankenhauswesen, 1927, 283. 24 Arthur Schlossmann, ‘Über Errichtung und Einrichtung von Säuglingskrankenanstalten’, Archiv für Kinderheilkunde, 1902, 219; Arthur Schlossmann, ‘Über die Fürsorge für kranke Säuglinge unter besonderer Berücksichtigung des neuen Dresdner Säuglingsheimes’, Archiv für Kinderheilkunde, 1906, 43, 57. 25 Schlossmann, ‘Die Entwicklung’, 197. 26 Schlossmann, ‘Die Entwicklung’, 193, 197. 27 Schlossmann, ‘Über die Fürsorge’, 22. 28 Schlossmann, ‘Die Entwicklung’, 207. See also Arthur Schlossmann, ‘Erfahrungen und Gedanken über Anstaltsbehandlung der Säuglinge’, Monatsschrift für Kinderheilkunde, 1913, 11, 545, 550; Arthur Schlossmann, ‘Zur Frage’, 1318. 29 Till Kössler, ‘Die Ordnung der Gefühle: Frühe Kinderpsychologie und das Problem kindlicher Emotionen (1880–1930)’, in Uffa Jensen and Daniel Morat, eds, Rationalisierung des Gefühls: Zum Verhältnis von Wissenschaft und Emotionen, 1880–1930 (München: Wilhelm Fink, 2008), 189–210; Jörg Heßling, Die Haltung zu Kindern in der deutschen Kinderheilkunde von 1877 bis 1980 (Herzogenrath: Murken-Altrogge, 1998), 56–66. See also Otto Heubner, ‘Über die Zeitfolge in der psychischen Entwicklung des Säuglings und des jungen Kindes’, Ergebnisse der inneren Medizin, 1919, 16, 1–31. 30 Schlossmann. ‘Die Entwicklung’, 206. See also Werner Gottstein, ‘Kinderkrankenhäuser’, in K. Biesalski, et al., Fachkrankenhäuser (Berlin: Julius Springer, 1930), 126. 31 For the suggestion that an institution might replace family, see Schlossmann, ‘Die Entwicklung’, 208–9. 32 Schlossmann, ‘Über die Fürsorge’, 62. 33 M. von Pfaundler, ‘Physiologie des Neugeborenen’, in A. Döderlein (ed.), Handbuch der Geburtshilfe, vol. 1 (Wiesbaden: J.F. Bergmann, 1915), 727; Adalbert Czerny, ‘Säugling, Arzt und Pflegerin’, in Festschrift zur Eröffnung des Kaiserin—Auguste Victoria-Hauses zur Bekämpfung der Säuglingssterblichkeit (Berlin: Georg Stilke, 1909), 61. 34 M. Pfaundler and Arthur Schlossmann, Handbuch der Kinderheilkunde, 4 vols (Leipzig: Vogel, 1906). 35 He was thus critical of feeding according to the clock, ignoring crying, and banning pacifiers, carrying and rocking. See Meinhard Pfaundler, ‘Ueber Saugen und Verdauen’, Wiener klinische Wochenschrift, 1899, 1012. 36 Meinhard Pfaundler, ‘Über natürliche und über rationelle Säuglingspflege’, Süddeutsche Monatshefte, 1909, 6, 316. See also Pfaundler, ‘Physiologie’, 730–1. 37 Pfaundler, ‘Über natürliche’, 317–18. 38 E. Seidler, ‘Die Kinderheilkunde in Deutschland’, in P. Schweier and E. Seidler, Lebendige Pädiatrie: Festschrift zur 100jährigen Geschichte der Kinderheilkunde (Munich: Walter de Gruyter, 1983), 63–4. 39 Pfaundler, ‘Physiologie’, 728. 40 Ibid., 729. 41 See Lotte Landé, ‘Entwicklung und Schicksal der im Kaiserin Auguste Victoria Haus geborenen Kinder’, Zeitschrift für Kinderheilkunde, 1919, 20, 57; Hilde Müller, ‘Muss es einen Hospitalismus in Säuglingsanstalten geben?’, Gesundheitsfürsorge für das Kindesalter, 1926/27, 2, 172. 42 Zaida Eriksson, ‘Über Anstaltsschaden der Kinder: ‘Hospitalismus’ in Kinderheimen’, Acta Paediatrica, Supplement 1925, 4, 64. 43 Hilde Müller, ‘Über Intelligenzprüfungen bei Anstaltskindern bis zum 3. Lebensjahre im Vergleich zu Kindern in der privaten Pflege’, Jahrbuch für Kinderheilkunde, 1925, 109, 345–51. 44 Erna Eckstein-Schlossmann, ‘Zur Frage des Hospitalismus in Säuglingsanstalten’, Zeitschrift für Kinderheilkunde, 1926, 42, 32, 38. 45 Sigrid Stöckel, ‘Infant Mortality and Concepts of Hygiene. Strategies and Consequences in the Kaiserreich and the Weimar Republic: The Example of Berlin’, History of the Family, 2002, 7, 613. 46 Meinhard von Pfaundler, ‘Klinik und Fürsorge’, Gesundheitsfürsorge für das Kindesalter, 1925/26, 1, 10, 17. 47 Lisa Appignanesi and John Forrester, Freud’s Women (London: Weidenfeld and Nichols, 1992), 287. 48 Hermine Hug-Hellmuth, Aus dem Seelenleben des Kindes: Eine psychoanalytische Studie (Leipzig: Deuticke, 1913). 49 For the development of child psychoanalysis see Claudine Geissmann and Pierre Geissmann, A History of Child Psychoanalysis (London: Routledge, 1998). See also Michael Roper, ‘From Shell-Shocked Soldier to the Nervous Child: Psychoanalysis in the Aftermath of the First World War’, Psychoanalysis and History, 2016, 18, 39–69 for developments in Britain. 50 August Aichhorn, Verwahrloste Jugend: Die Psychoanalyse der Führsorge Erziehung (Leipzig: Psychoanalytischer Verlag, 1925). 51 Siegfried Bernfeld, Psychologie des Säuglings (Vienna: Julius Springer, 1925). For Isaac’s assessment see Nick Midgley, ‘Anna Freud: The Hampstead War Nurseries and the Role of the Direct Observation of Children for Psychoanalysis’, International Journal of Psychoanalysis, 2007, 88, 940. 52 On the acceptance of Adler’s views, see Lotte Schenk-Danzinger, ‘Zur Geschichte der Kinderpsychologie: Das Wiener Institut’, Zeitschrift für Entwicklungspsychologie und pädagogische Psychologie, 1984, 16, 97. On the views of the Psychological Institute, see Charlotte Bühler in Ludwig J. Pongratz, Werner Traxel und Ernst G. Wehner, eds, Psychologie in Selbstdarstellungen (Bern: Hans Huber, 1972), 29. 53 Ilse Hellman, From War Babies to Grandmothers: Forty-Eight Years in Psychoanalysis (London: Karnac, 1990), 4. 54 Bühler in Pongratz et al., Psychologie in Selbstdarstellungen, 27. 55 Hildegard Hetzer and Käthe Wolf, ‘Babytests: Eine Testserie für das erste Lebensjahr’, Zeitschrift für Psychologie, 1928, 107, 62–104; Charlotte Bühler and Hildegard Hetzer, Kleinkindertests: Entwicklungstests für das erste bis sechste Lebensjahr (Leipzig: Hirzel, 1932). 56 For child psychology at the Vienna Psychological Institute see Mitchell G. Ash, ‘Psychology and Politics in Interwar Vienna: The Vienna Psychological Institute, 1922–1942’, in Mitchell G. Ash and William W. Woodward, eds, Psychology in Twentieth-Century Thought and Society (Cambridge: Cambridge University Press, 1987), 143–64; Gerhard Benetka, Psychologie in Wien: Sozial- und Theoriegeschichte des Wiener Psychologischen Instituts, 1922–1938 (Wien: WUV, 1995); and 'Gerhard Benetka and Thomas Slunecko, ‘Das Wiener Psychologische Institut und die Herausbildung der Entwicklungspsychologie’, in Liselotte Ahnert, ed., Charlotte Bühler und die Entwicklungspsychologie (Vienna: Vienna University Press, 2015), 9–18. 57 Durfee and Wolf, ‘Anstaltspflege’, 310, 314. 58 Hildegard Hetzer, ‘Die Entwicklung des Kindes in der Anstalt’, in Adolf Busemann, ed., Handbuch der pädagogischen Milieukunde (Halle: Hermann Schroedel, 1932), 160. Hildegard Durfee and Käthe Wolf, ‘Anstaltspflege und Entwicklung im Ersten Lebensjahr’, Zeitschrift für Kinderforschung, 1933–1934, 42, 274; Irmgard Gindl, Hildegard Hildegard and Martha Sturm, ‘Unangemessenheit der Anstalt als Lebensraum für das Kleinkind’, Zeitschrift für angewandte Psychologie und Characterkunde, 1937, 52, 313. 59 Benteka, Psychologie, 190. Hetzer’s own interpretations of child development increasingly changed in the 1930s and 1940s. In 1931, she was offered a teaching job in Berlin, which she lost in 1934 under the Law for the Restoration of the Professional Civil Service, probably due to her work with the Jewish Charlotte Bühler and her provenance from ‘Red Vienna’. In the years that followed, Hetzer increasingly incorporated Nazi terminology in her publications. Having become a member of the National Socialist People’s Welfare Organization in 1936, she started to work for the organization at the beginning of the war. In 1940, she suggested that the Hetzer–Bühler Tests constituted a useful aid for the implementation of the Law for the Prevention of Offspring with Hereditary Diseases. In March 1942, Hetzer took up a position for two and a half months near Poznań in the ‘Reichsgau Warthenau’ in a children’s home where she provided psychological profiles of children selected for Germanisation. Hetzer later claimed that she believed that the children were neglected German, not Polish children, a claim upon which Theo Herrmann has cast doubt. Hetzer left that position in May 1942, but continued to work until the end of 1944 in occupied Poland. The details of what she did in those years are not known yet. After the war, Hetzer established a successful career in West Germany, receiving, amongst other accolades, the Bundestverdienstkreuz Erster Klasse in 1972. See Gerhard Benetka, ‘Hetzer, Hildegard’, in Brigitta Keintzel and Ilse Korotin, eds, Wissenschaftlerinnen in und aus Österreich (Vienna: Böhlau, 2002), 285–8; Gisela Bruns und Siegfried Grubitzsch, ‘Hildegard Hetzer—Pionierin der Entwicklungsverfahren’, Psychologie & Gesellschaftskritik, 1992, 16, 83–95; Theo Herrmann, ‘Hildegard Hetzer als NSV Psychologin im okkupierten Polen (1942–1944)’, in Theo Hermann and Włodek Zeidler, eds, Psychologen in autoritären Systemen (Frankfurt a.M.: Peter Lang, 2012), 129–63. 60 Hetzer, ‘Die Entwicklung’, 162, 169–70; Gindl, Hetzer and Sturm, ‘Unangemessenheit’, 338. 61 Durfee and Wolf, ‘Anstaltspflege’, 307, 319. 62 Hildegard Durfee, ‘Analyse der auf der geistigen Entwicklung des Säuglings wirksamen Anstaltsfaktoren’ (Dissertation, Wiener, 1932). 63 ‘Hildegard Durfee, World Citizen and Psychologist, Dies’, Brattleboro Reformer (29 November 1989). I am grateful to Charles Butterfield and Jeanne M. Walsh for locating the obituary and sending it to me. 64 Katharina Wolf, ‘Die grundlegenden Prinzipien des Entwicklungstests und die Möglichkeit ihrer Realisierung’ (Dissertation, Wien, 1930); Hetzer and Wolf, ‘Babytests’; Liselottl Frank and Käthe Wolf, ‘Die Testreihen für das erste Lebensjahr’, in Bühler and Hetzer, Kleinkindertests. 65 Durfee and Wolf, ‘Anstaltspflege’, 306. 66 Ibid., 299, 310, 314. 67 Ibid., 309–10, 314, 318. 68 Ibid., 311–12, 320. 69 Ibid., 319. 70 While Durfee and Wolf believed that differences in development only started to be measurable after four months of age, they thought that an institutional stay at an earlier age already had effects on subsequent development (Ibid., 276, 294). 71 Edward Timms, ‘New Approaches to Child Psychology: From Red Vienna to the Hampstead Nursery’, in Edward Timms and Jon Hughes, eds, Intellectual Migration and Cultural Transformation: Refugees from National Socialism in the English-Speaking World (Vienna: Springer, 2003), 224. 72 Lotte Schenk-Danzinger, ‘Zur Geschichte der Kinderpsychologie: Das Wiener Institut’, Zeitschrift für Entwicklungspsychologie und Pädagogische Psychologie, 1984, 16, 97. 73 Mathew Thomson, Lost Freedom: The Landscape of the Child and the British Post-War Settlement (Oxford: Oxford University Press, 2013), 77. 74 Cathy Urwin and Elaine Sharland, ‘From Bodies to Minds in Childcare Literature: Advice to Parents in Inter-War Britain’, in Roger Cooter, ed., In the Name of the Child: Health and Welfare, 1880–1940 (London and New York: Routledge, 1992), 192. See also Shapira, The War Inside. 75 Harry Bakwin, ‘Loneliness in Infants’, American Journal of Diseases of Children, 1942, 63, 31. 76 Ibid., 38. 77 Ibid., 39–40. 78 H. C. Scott, ‘Babies in Glass Cages’, British Medical Journal, 19 February 1944, 266–7. The design of the ward allowed for the presence only of breast-feeding mothers in a separate ‘hostel’. These mothers were given access to their babies at feeding times, and fed their babies while dressed in a sterile gown and a face mask. See ‘Babies Hospital’, Mother and Child, 1944, xv, 10 and Scott, ‘Babies in Glass Cages’. 79 H. S. Baar, ‘Babies in Glass Cages’, The British Medical Journal, 8 April 1944, 505. 80 See Leonard G. Parson, ‘Babies in Glass Cages’, British Medical Journal, 4 March 1944, 336. 81 Clifford Allen, ‘Babies in Glass Cages’, British Medical Journal, 18 March 1944, 404. 82 Judit Meszaros, Ferenczi and Beyond: Exile of the Budapest School and Solidarity in the Psychoanalytic Movement during the Nazi Years (London: Karnac, 2014), 189. 83 Shaul Bar-Haim, ‘The Maternalizing Movement: Psychoanalysis, Motherhood and the British Welfare State c. 1920–1950’ (PhD thesis, University of London, 2015), introduction and ch. 1. I am grateful to Shaul Bar-Haim for drawing my attention to the connection between Ferenczi and René Spitz. 84 Judit Mészáros, ‘Ferenczi in Our Contemporary World’, in Adrienne Harris and Steven Kuchuk, eds, The Legacy of Sándor Ferenczi: From Ghost to Ancestor (London: Routledge, 2015), 23. For an exploration of the role of the maternal in the Budapest School of Psychoanalysis see, for instance, Bar-Haim, ‘The Maternalizing Movement’. 85 René A. Spitz and Katherine M. Wolf, ‘Anaclitic Depression: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood’, Psychoanalytic Study of the Child, 1946, 2, 319; Spitz, ‘Hospitalism’, 1945, 59. 86 Hellman, ‘Professional Life’, 5. 87 René Spitz Papers, Box M2111, Folder No. 7, Archives of the History of American Psychology, The Centre for the History of Psychology, The University of Akron. 88 René Spitz Papers, Box M2111, Folder No. 16, Archives of the History of American Psychology, The Centre for the History of Psychology, The University of Akron. 89 ‘Katherine M. Wolf—In Memorian’, The Staff of the Child Study Association of America. Child Study: A Quarterly Journal of Parent Education, 1957–1958, 2–3; Robert Karen, Becoming Attached: First Relationships and How They Shape our Capacity to Love (Oxford: Oxford University Press, 1998), 144. 90 Spitz, ‘Hospitalism’, 1945, 58. 91 Ibid., footnote 7. See Spitz and Wolf, ‘Anaclitic Depression’, 313–42. 92 Spitz, ‘Hospitalism’, 1945, 59. 93 Spitz, ‘Hospitalism’, 1945, 68. 94 Ibid., 70. 95 Ibid., 68; Spitz and Wolf, ‘Anaclitic Depression’, 335; Spitz, ‘Hospitalism’, 1946, 115. 96 John Bowlby, A Secure Base: Clinical Applications of Attachment Theory (London: Routlege, 1988), 24. See also Lisa Cartwright, ‘“Emergencies of Survival”“: Moral Spectatorship and the “New Vision of the Child” in Postwar Child Psychoanalysis’, Journal of Visual Culture, 2004, 3, 40; Karen, Becoming Attached, 23. 97 See, for instance, Denise Riley, War in the Nursery: Theories of the Child and Mother (London: Virago, 1983); Suzan van Dijken, John Bowlby—His Early Life: A Biographical Journey into the Roots of Attachment Theory (London: Free Association, 1998); van der Horst, John Bowlby; Vicedo, Nature and Nurture. 98 Shapira, The War Inside, 66ff. 99 19 March 1950, John Bowlby Papers, PP/BOW/B.1/12, Archives and Manuscripts, Wellcome Library. 100 29 March 1950, John Bowlby Papers, PP/BOW/B.1/12, Archives and Manuscripts Wellcome Library. 101 John Bowlby, Maternal Care and Mental Health (Geneva: World Health Organization, 1951), 48; ‘Notebook 2 USA’, John Bowlby Papers, PP/BOW/D4/8, Archives and Manuscripts, Wellcome Library. 102 Bowlby, Maternal Care, 132–3. 103 Report of the Care of Children Committee (London: HSMO, 1946), 160. 104 Bowlby, Maternal Care, 132. 105 Ibid., 134. 106 Pearl King and Riccardo Steiner, eds, The Freud-Klein Controversies 1941–45 (London: Routledge, 1991); Riccardo Steiner, Tradition, Change, Creativity: Repercussions of the New Diaspora on Aspects of British Psychoanalysis (London: Karnac, 2000). © The Author(s) 2018. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.

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Social History of MedicineOxford University Press

Published: Feb 5, 2018

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