Sectional
page 11rIrg

Proceedings of the. RoyalD Society
Sceyoof Medicine
e~Vol. 46
425

Section of Paediatrics
President-D. W. WINNICOTT, M.A., F.R.C.P., M.R.C.S.

[November 28, 1952]

A Two-Year-Old Goes to Hospital
A Film Shown By
JoiHN BOWLBY, M.D., and JAMES ROBERTSON
Tavistock Clinic
Dr. John Bowlby: The theme of this film is a very commonplace one-simply the story of a childof 2i years who spends eight days in hospital for a minor operation and who frets a good deal ofthis time. It may be asked why bother to make and show a film of something so commonplace?
The reason is that we believe that fretting should no longer be looked upon as an unavoidable
inconvenience but as something of serious importance and worthy of scientific study. There is now
evidence that prolonged periods of maternal deprivation in very young children can, in some cases,
give rise to extremely serious psychiatric disturbances. There has been a succession of papers andmonographs on this subject during the last fifteen years and two years ago WHO published a reviewof this evidence (Bowlby, 1951). Furthermore, it is becoming fairly well known that the majority ofchildren under 4 years old who have spent only a brief period in hospital, or otherwise away from theirmothers, show emotional upsets of shorter or longer duration.
Since the existence of the problem is no longer in doubt, the Research Team investigating it at theTavistock Clinic is concentrating its attention on the psychological processes which lead to theseadverse effects. We are giving special attention to the emotional responses of very young children
during the first days and weeks following separation from their mothers. After a number of semisystematic studies we decided eighteen months ago to attempt as full a coverage as possible of one
child throughout her stay in hospital. It was during this pilot study that this film was made.
It is because we believe it permits of an objective examination of what actually happens when ayoung child has this experience that we think it may be of value in furthering our understanding offretting and the emotional disturbances to which it can lead. We believe that it is only on the basisof this knowledge that improved methods of care can be developed.
REFERENCEBOWLBY, E. J. M. (1951) Maternal Care and Mental Health. WHO Mono. Ser. No. 2. Geneva.

Mr. James Robertson: There are special difficulties in the way of getting objective data on themeaning of separation to children under 4. They can tell little in words, so that understanding has tobe sought largely through interpreting their behaviour. As fieldworker I discovered that there wereoften limits to the agreement to be had in discussion with nurses and paediatricians not only about
the meaning of behaviour in certain young patients but also about the actual facts of that behaviour.
There was a gap in observation and interpretation which could not be bridged. It seemed that emotional
factors in the peediatricians, nurses, and myself were suspect. I was thought at times to be diminishedin my objectivity by becoming over-identified with the children; I in turn considered that a contrary
phenomenon tended to occur in hospital staffs, namely that defences had built up in them against thepainful recognition of the extent to which young patients are unhappy-not only in the initial phaseof overt fretting but in later, stages of being "settled in".
In the film I have tried to provide a record which will be accepted as objective, and which has themerit that the behaviour can be viewed as often as desired in discussion between interested groups.
Thus I hope our mutual interest in discovering what is true will be advanced. Objectivity was sought
JUNE-PAEDIAT. 1

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Proceedtngs of the Royal Society of Medicine

12by several devices. A schedule of filming was agreed beforehand with the ward staff; it consists ofdocumentary record of main events such as admission, anesthetic, parents' visits-and a daily"time sample" covering the same period and at intervals determined by a clock which is seen in thefilm. The child was selected at random by a hospital clerk from the list of those awaiting operation forumbilical hemia. Filming was done by myself with a hand camera in natural lighting. There was noother apparatus to disturb the ward and the child was not segregated. The only departure from routine
was that a nurse was detailed to play with the child during the daily time sample.
SYNOPSIS OF FILM
Laura is 2 years 5 months old, a first child and so far an only one. She is intelligent, mature, and has unusual
control over the expression of feeling. She rarely cries. She is about to go into hospital for eight days to havea minor operation for umbilical hernia.
Although her parents had tried to prepare her for going into hospital, when she meets the admitting nurse
she is cheerful and friendly and clearly does not realize that her mother will leave her. Going through theward she seems less confident, and when she is undressed to be bathed she screams for her 'Mummy. Within
ten minutes, however, her unusual control over feeling asserts itself and she is apparently calm.
She is put in a cot and breaks down again when nurse takes her temperature "Don't like it. I want myMummy". A few minutes later her mother comes to say good-bye, and leaves for her consolation a piece ofblanket she has had since infancy and which she calls her "baby". Throughout her stay this "blanket baby"
and her Teddy make a link with home and are clung to when she is sad or frightened.
When alone she appears calm, but if a kindly person stops to talk with her her feelings appear. Sister comesto greet the new patient and Laura's face crumples "I want my Mummy". This occurred throughout her stay:and the camera shows that what may easily be taken for calmness is often a facade which contact with a friendly
person breaks down.
When the surgeon comes she clutches her Teddy and blanket "baby" for comfort, and despite his tact she isapprehensive and resistive. Occasionally during the day she asks quietly for her Mummy, but without insistence.
On the second day she looks strained and sad, and has difficulty in responding to the nurse who comes toplay with her. Then her feelings appear and she cries a little for her Mummy. But though she cries little throughout her stay she takes great interest in the children who cry as if they cry for her who is too controlled tocry. The rectal anesthetic is kindly administered, but the strange experience frightens her. Thirty minutesafter recovery from the anasthetic her parents visit. She is very distressed-"I want to go homes'-tries to getto her mother but has to be restrained because of the stitches, and rolls about on her pillow crying. As herparents leave she is subdued and seems perplexed. She waves slightly in response to their cheerful going.
On the third day she is seen quietly clutching her Teddy and blanket baby, not crying or demanding attention
and likely to seem "settled" to busy ward staff. But when a nurse comes to play with her she is at first withdrawn, then in contact with the friendly person her feelings break through again and she cries bitterly for her
Mummy. When the nurse leaves her control gradually reasserts itself. This cycle of withdrawal, breakdown,
and resumed control is repeated shortly afterwards when the nurse again plays with her. In the afternoon her
mother visits, but although Laura has been sitting up all morning and has wanted her mother she makes noattempt to get to her. Mother would like to take her in her arms but is deterred from doing so by what shebelieves to be hospital regulations. Ten minutes later a nurse sits her up, but it is fifteen minutes before Laurathaws out towards her mother. Then she becomes increasingly animated and friendly, and is transformed bya radiant smile seen for the first time in three days. When her mother says she has to leave Laura is immediately
anxious, and as her mother leaves she turns her head away. She does not cry, but shows her feeling clearly by
the change in her face and the restless movement of her hands. Although it is the middle of the afternoon she
asks to be tucked down with all her personal possessions tucked around her and forbids the nurse to remove
the chair on which her mother had been sitting.
On the fourth dav the record is brief and featureless. She is not visited.
On the fifth day her mother visits in the afternoon, and again there is a period of withdrawal before she
warms up to her mother. She asks to go on mother's lap, but when mother says she cannot she does not ask
again. When her mother has to go Laura is pained, cries a little, then quietly recovers and sits with pursed lips.
On the sixth day a new child is admitted who cries a lot, Laura, very controlled herself, watches him with atense face. (When she got up she went to him and said "You're crying because you want your Mummy. Don't
cry. She'll come to-morrow.")
On the sevenith day both parents visit and Laura is up for the occasion. Although she knows chairs are being
set out for them she shows no excitement, and when her mother comes she makes no attempt to go to her.
She remains subdued. When Daddy comes from the office ten minutes later he gets a warmer welcome. Daddy
leaves first and his going is apparently almost ignored. She asked to go with him but does not insist. Whenher mother leaves, Laura apparently ignores her going.
On the eighth morning she is shaken by sobs. Her mother had told her the previous evening that she would
be going home to-day and her control has given way. When her mother comes Laura remains cautious, however,and not until her outdoor shoes are produced does she accept that she is going home. She insists on taking allher possessions home with her, even a tattered old book she refused to leave behind. When she dropped thatbook on the way out and a nurse picked it up, she screamed in temper and snatched it away-the fiercest feelingshown during her whole stay. On the way out she is seen walking apart from her mother.
Dr. D. W. Winnicott (President of the Section) welcomed the film as a highly successful first effort. Here,as he saw it, was a normal child. She came into hospital and gradually became affected as a normal child must.
She was fortunately spared that phase of false recovery to which the child reaches if the break from the homelasts too long, and which may make the child cling to the nurse in fear when at last the mother or father comesto take the child home.

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The main comment Dr. Winnicott wished to make was that from long experience he could say that thisfilm was definitely about a real problem. The effect of separation of small children from their mothers was sooften serious, even producing irreversible changes, that every time when a child is to be taken into hospital
there ought to be a careful weighing up of the value on the physical side against the danger on the psychiatricside. This principle is not vitiated by the undoubted fact that in certain circumstances certain children (notyoung ones) derive benefit and even enrichment from a stay in hospital-perhaps because of the relief that thisaffords on account of a parent's anxiety state or depression mood.
It is interesting that the child who feels ill seems to be less harassed by being taken into hospital than thechild who feels well, but who is considered to need something done. A verbal explanation given to a young
child, whatever is said, is of no value as compared with the child's own feeling that help is needed. On feeling
better, however, the child begins to have an urgent need to go home.

[January 23, 1953]
Congenital Valves in the Posterior Urethra (Two Cases).-D. INNES WILLIAMS, M.D., M.Ch.
Case L-The child was first seen at the age of 4j months when he was admitted to the Hospital forSick Children, Great Ormond Street, under the care of Mr. Twistington Higgins. He had previously
been taken ill when 1 month old, with a high temperature, "pink" urine, and dribbling micturition;these symptoms had subsided rapidly with Chloromycetin, and he had not been referred for a urologicalopinion. The present attack commenced with abdominal pain and hlmaturia. The urine was infectedwith B. coli, and had a specific gravity of 1003. The blood urea was 51 mg./100 ml. The symptoms
again subsided with Chloromycetin, but the bladder was found to be chronically distended.
A micturating cystogram (Fig. 1) was performed and showed a grossly dilated and elongated posterior
urethra with reflux into an enormous right hydro-ureter. Intravenous pyelography showed no shadow
on the right, and only poor secretion from the left kidney.
Operative treatment was by the method of "perineal valvulotomy". The bulb of the urethra waslaid open and the membranous urethra dilated up. A miniature gorget was then passed in anteriorly,
and a flat retractor posteriorly (Fig. 2). By the use of a head-light and a sucker it was then possible

valve-FIG. l.-Micturating cystograim (Case I).

verumnontanum

FIG. 2.-The memnbranous urethra is dilated
up with sounds: a gorget is inserted anteriorly,
and a narrow flat retractor posteriorly. Thevenunontanum and valves are thus exposed:
the valves can be caught wyith a blunt hook anddestroyed with the diathermy.

to visualize the verumontanum, and the valvular folds descending from it. The folds were picked up
and destroyed with the diathermy. The bladder was then drained via the perineal urethrostomv.
A tender swelling appeared in the right l-oin and flank soon after the operation: it was clear thatthe right ureter had become kinked and acutely obstructed. Drainage of urine from the bladder