The Psychoanalytic Study of the Child

ISSN: 0079-7308 (Print) 2474-3356 (Online) Journal homepage: https://www.tandfonline.com/loi/upsc20

Hospitalism

René A. Spitz

To cite this article: René A. Spitz (1946) Hospitalism, The Psychoanalytic Study of the Child, 2:1,
113-117, DOI: 10.1080/00797308.1946.11823540

To link to this article: https://doi.org/10.1080/00797308.1946.11823540

Published online: 13 Feb 2017.

Submit your article to this journal

Article views: 3

Citing articles: 23 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=upsc20
 HOSPITALISM
A Follow-up Report on Investigation Described in Volume I, 1945
By RENE A. SPITZ, M.D. (New York)

1.
The striking picture of the infants studied in Foundling Home
encouraged us to make every effort to get whatever information we
could on the further development of the individual children. Distance
made it impossible for the author to attend to this personally. The
investigator who assisted in the original study was therefore directed
to ascertain, at regular intervals, certain objectively observable facts
on all those infants who were still available. He visited Foundling
Home during the two years following our own study, at four-monthly
intervals. On these occasions, equipped with a questionnaire prepared
by the author, he asked the nursing personnel a series of questions.
He observed each child's general behavior, and tried to make contact
with each. He took some motion pictures of them, and a set of stills at
the end of the two years, Finally, some bodily measurements, namely,
weight, height, and occipital circumference, were taken.
The questions referred to three principal sectors of personality:
1) Bodily performance: the gross indicator used was whether the
child could sit, stand, or walk.
2) Intellectual capacity to handle materials: the gross indicator
used was whether the child was capable of eating food alone with the
help of a spoon, and whether he could dress alone.
3) Social relations: these were explored by ascertaining the
number of words spoken by each child, and by finding out whether
he was toilet trained.
We are only too well aware that the resulting information is
inadequate for a thorough study. As will be seen, however, even this
inadequate follow-up yields a number of instructive data.
As is usually the case in follow-up investigations, only a rela-

113
114 RENE A. SPITZ

tively small number of the children originally seen could be checked

on. Two years ago, when we first visited the ward reserved for the
children from birth to one-and-a-hal£ years, and the ward for children
from one-and-a-half to three years, a total of 91 children were present.
In 'the course of the first year, 27 of these died of various causes,
among which were an epidemic of measles, intercurrent sickness, and
cachexia; by the end of the second year, another 7 of those originally
seen had died; this represents a total mortality of over 37 per cent
in a period of two years.
Thirty-six children could not be learned about because: 23 had
been taken back to theic families; 7 had been adopted (mostly by their
own illegitimate parents) ; 2 had been placed in children's institutions;
and 4 could not be accounted for.
At the time of this writing1 21 children of those originally seen
are still at the institution. Of these the youngest is two years of age,
the oldest four years and one month. The data on their development
are as follows:
1) Bodily development:
Incapable of any locomotion: S
Sit up unassisted (without walking): 3
Walk assisted: 8
Walk unassisted: 5
Total 21
2) Handling materials:
Cannot eat alone with spoon: 12
Eat alone with spoon: 9
Total 21
Cannot dress alone: 20
Dresses alone: 1
Total 21
3) Adaptation to demands of environment:
Not toilet trained in any way: 6
Toilet trained, partially:2 IS
Total 21

1. June 12, 1946.

2. These children are trained "to a certain extent". According to my observer
many of the so-called "toilet trained" children were found to soil in their beds; their
training appears to be limited to their making use of the toilet when put on it.
 HOSPITAUSM 115

4) Speech development:
Cannot talk at all:
Vocabulary: 2 words: ,
6
Vocabulary: 3 to 5 words: 8
Vocabulary: a dozen words: 1
Uses sentences: 1

Total 21

As seen from these data, the mental development of these 21

children is extraordinarily retarded, compared to that of normal
children between the ages of two and four, who move, climb, and
babble all day long, and who conform to or struggle against the
educational demands of the environment. This retardation, which
amounts to a deterioration, is borne out by the weights and heights
of these children, as well as by their pictures.
Normal children, by the end of the second year weigh, on the
average, 26~ pounds, and the length is 33~ inches. At the time of
this writing, 12 of the children in Foundling Home range in age
between 2.4 and 2.8; 4, between 2.8 and 3.2; and 5, between 3.2 and
4.1. But of all of ehese children, only 3 fall into the weight range
of a normal two-year-old child, and only 2 have attained the length
of a normal child of that age. All others fall below the normal two-
year-level-in one case, as much as 45 per cent in weight and 5 ihches
in length. In other words, the physical picture of these children im-
presses the casual observer as that of children half their age.
In our previous article on the subject (in Volume I) we ex-
pressed the suspicion that the damage inflicted on the infants in
Foundling Home by their being deprived of maternal care, maternal
stimulation, and maternal 'love, as well as by their being completely
isolated, is irreparable. Our follow-up' confirms this assumption.
After their fifteenth month, these children were put into more.favor-
able environmental conditions than before, i.e., in the ward for the
older children.. This is a large room, sunny, without the partitions
which in the ward for the younger children isolated the infants from
each other and from every environmental stimulus. Three to five
nurses are constantly ~ the room, and they chat with each other and
with the children. The children are also taken out of their cots and
placed on the floor. Thus they have infinitely more active stimulation
than they previously experienced in the ward for younger children.
Notwithstanding this improvement in environmental conditions, the
process of deterioration has proved to be progressive. It would seem
116 RENE A. SPITZ

that the developmental imbalance.caused by the unfavorable environ-

mental conditions during the children's first year produces a psycho-
somatic damage that cannot be repaired by normal measures. Whether
it can be repaired by therapeutic measures remains to be investigated.
We have advisedly spoken of psychosomatic damage. From the
figures given above it can be seen that quite apart from the inade-
quate psychic and physical development, all these children showed a
seriously decreased resistance to disease, and an appalling mortality.
Those who survived were all far below the age-adequate weight
reached by normal children of comparable age.

II.
In view of these findings we once again examined the data on
Nursery, the institution compared to Foundling Home in our previous
article. The organization of Nursery did not permit a follow-up
extended to the fifth year, as did that of Foundling Home. As a rule
children leave Nursery when they are a full year old. However, a
certain number of exceptions are made in this rule, and in the course
of our study of Nursery, which now covers-a. period of three-and-a-
half years, 29 'children were found who stayed Ionger fhan a year.
The age at which these left varied from the thirteenth to the eighteenth
month (1.1 to 1.6). This means that the oldest of them was half-a-year
younger than the youngest child in our follow-up in Foundling Home,
and two-and-a-half years younger than the oldest. In spite of this
enormous difference in age, the Nursery children all ran lustily around
on the floor; some of them dressed and undressed themselves; they
fed themselves with a spoon; nearly all spoke a few words; they
understood commands and obeyed them; and the older ones showed
a certain consciousness of toilet requirements. All of them played
lively social games with each other and with the observers. The
more advanced ones imitated the activities of the nurses, sweeping
the floor, carrying and distributing diapers, etc. In all these children,
tests showed that the developmental quotients which in the eleventh
and twelfth months had receded somewhat.f not only came up to
the normal age level, but in most cases surpassed it by far.
But the gross physical picture alone, as expressed by the figures
on morbidity and mortality of the children in Nursery, is sufficiently
3. See this Annual, I, p. 69. The average retardation in the developmental quotient
was approximately 12 points during the eleventh and twelfth month; to be discussed
in a later publication.
 HOSPITALISM 117

striking. During the three-and-a-hal£ years of our study of Nursery

we had occasion to follow 122 infants, each for approximately a full
year:' During this time not a single child died. The institution was
visited by no epidemic. Intercurrent sickness was limited, on the
whole, to seasonal colds, which in a moderate number developed into
mild respiratory involvement; there was comparatively little intestinal
disturbance; the most disturbing illness was eczema. The unusually
high level of health maintained in Nursery impelled us to look into
its past record. We investigated the files of Nursery for ten years prior
to the beginning of our work there. We found that during the whole
of the last fourteen years a total of three children have died: one
of pneumonia at the age of three months; and two of pyloric stenosis,
the first at the age of one month, the second after several operations
at the age of nine months.
It is in the light of these findings, which show what can be
achieved in an institution under favorable circumstances and adequate
organization, that the consequences of the methods used in Foundling
Home should be evaluated.

4. Exceptions to this are 6 children who because of circumstances in their families

left before their tenth month. This is more than counterbalanced by the group of
29 children who stayed longer than one year.