Lisa Appignanesi

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Asperger’s Chil­dren: The Ori­gins of Autism in Nazi Vienna by Edith Sheffer

Asperger’s Chil­dren: The Ori­gins of Autism in Nazi Vienna by Edith Sheffer. Nor­ton, 317 pp., $27.95

Long-de­ceased Vi­en­nese doc­tors, un­less they’re called Freud, rarely make news­pa­per head­lines. But one has re­cently done so on both sides of the At­lantic. On April 19, the aca­demic open-ac­cess jour­nal Molec­u­lar Autism pub­lished a de­tailed ar­ti­cle by the Aus­trian med­i­cal his­to­rian Her­wig Czech about Hans Asperger, the Vi­en­nese pe­di­a­tri­cian whose name has since the 1980s des­ig­nated a syn­drome that forms part of the wider autism spec­trum. Like many prom­i­nent Aus­trian med­i­cal fig­ures of his gen­er­a­tion, Asperger’s wartime record of in­volve­ment in some of the dead­li­est as­pects of Nazi med­i­cal prac­tice had long re­mained un­ques­tioned or was glossed over. Now he stood ex­posed as hav­ing been far from an op­po­nent of Nazi think­ing; racial hy­giene was, in fact, at the cen­ter of his be­liefs.

The his­to­rian Edith Sheffer’s book Asperger’s Chil­dren was pub­lished a month af­ter Czech’s ex­posé. Her re­search was con­tem­po­ra­ne­ous with his and draws on the same archival sources, but books take longer. Hers is an im­pas­sioned in­dict­ment, one that glows with the heat of a pros­e­cu­tion mo­ti­vated by an eth­i­cal im­per­a­tive. She charges Asperger with a heinous med­i­cal crime: send­ing at least thirty-seven of his child pa­tients to their deaths. Herta Schreiber, who had suf­fered menin­gi­tis and diph­the­ria, was just short of three when her de facto death cer­tifi­cate was signed, in part on the grounds that she was “an un­bear­able bur­den to the mother.”

Ac­cused with Asperger is the whole of the Nazi ide­o­log­i­cal ap­pa­ra­tus that con­verted a di­ag­no­sis—a highly per­sonal form of hu­man as­sess­ment—into the first rung of a rou­tine killing ma­chine. Fi­nally, Sheffer wants to in­dict the en­tire ca­pa­cious cat­e­gory of autism, which she ar­gues in­cludes too many dif­fer­ent kinds of peo­ple along­side the high-func­tion­ing, of­ten ta­lented, but some­what re­la­tion­ally chal­lenged peo­ple who have been given the di­ag­no­sis of Asperger’s—a di­ag­no­sis that for the US has now been shifted, in the most re­cent Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders (DSM), into the broader autism spec­trum.

The term “autis­tic” orig­i­nated with the ta­lented Eu­gen Bleuler, di­rec­tor of the Burghöl­zli, the pi­o­neer­ing psy­chi­atric hos­pi­tal in Zurich. In the early part of the twen­ti­eth cen­tury some of Europe and Amer­ica’s best physi­cians spent at least a sea­son there. Bleuler val­ued Freud’s in­sights and took a cue from psy­cho­anal­y­sis in his ef­forts to at­tend to un­con­scious men­tal pro­cesses and lis­ten to pa­tients’ words. Among the staff was Carl Jung, whose pa­tient Sabina Spiel­rein also be­came a well­known psy­cho­an­a­lytic prac­ti­tioner and the teacher of the fa­mous psy­chol­o­gist Jean Pi­aget. Pa­tients were seen in­di­vid­u­ally twice a day: doc­tors were in­structed to write down ev­ery­thing they said, whether or not it sounded like non­sense.

In the de­tailed de­scrip­tion of the group of schizophre­nias he in­cluded in a 1911 book, Bleuler coined the term “autis­tic” to char­ac­ter­ize think­ing— some­thing that, un­like many, he was cer­tain was go­ing on in his pa­tients— and feel­ing that were more than usu­ally in­tro­verted, self-ab­sorbed, and lashed with fan­tasies. He said he owed the term to Freud’s “au­to­ero­tism,” which de­scribed an in­fant’s in­ner fan­tasy life prior to any en­gage­ment with the ex­ter­nal world. Autis­tic think­ing took place “in sym­bols, in analo­gies, in frag­men­tary con­cepts . . . in crude of­fenses against logic and pro­pri­ety.”1 In Bleuler’s un­der­stand­ing, schiz­o­phrenic pa­tients suf­fered from a break­down in the re­la­tion be­tween thoughts, feel­ings, and ac­tions; from am­biva­lence (an­other new term, which Freud picked up from him), as well as from delu­sions and hal­lu­ci­na­tions. Freud folded the idea of autis­tic think­ing into his own the­ory of the nar­cis­sis­tic state of ear­li­est in­fancy, when in­ner and outer life were not dis­tin­guish­able.

Autism as a sep­a­rate di­ag­nos­tic cat­e­gory did not ex­ist for Bleuler, Freud, or in­deed for any doc­tor un­til 1943. What brought it into be­ing was the birth of a new field: child psy­chi­a­try, with its close ob­ser­va­tion of be­hav­ior and its mea­sure­ments and as­sess­ments car­ried out in schools, hos­pi­tals, or in­sti­tu­tions. Bleuler’s pa­tients were all adults. Chil­dren, if they were seen to be men­tally ill or con­sid­ered “de­fi­cient” in some way, were put in the care of hos­pi­tal neu­rol­o­gists (as Freud had been, in his ear­li­est med­i­cal po­si­tion) or in­sti­tu­tions. Then, through­out the 1920s, psy­cho­an­a­lytic thinkers like Me­lanie Klein and Anna Freud turned their at­ten­tion to the in­ner life of the in­fant and child. The­o­ries of child de­vel­op­ment soon arose, many of them based on the close ob­ser­va­tion of be­hav­ior. It was this lat­ter em­pha­sis on be­hav­ior rather than on in­ner life that tilted the bal­ance to­ward the kinds of cat­e­gories to­day’s DSM uses to clas­sify men­tal dis­or­ders.

A stand-alone cat­e­gory of early in­fan­tile autism didn’t come into use un­til 1943, when the psy­chi­a­trist Leo Kan­ner pub­lished his “Autis­tic Dis­tur­bances of Af­fec­tive Con­tact” in the jour­nal Ner­vous Child. The ar­ti­cle, heav­ily en­debted to his Aus­trian col­leagues Georg Frankl and Anni Weiss’s work in Vienna’s Cu­ra­tive Ed­u­ca­tion Clinic, con­cen­trated on eleven young pa­tients, eight boys and three girls, who had been ob­served and as­sessed by a va­ri­ety of di­ag­nos­tic tests, plus parental re­ports. Kan­ner ar­gued that de­spite the bor­row­ing of Bleuler’s term, these chil­dren’s pro­files were not pre­cur­sors of adult schizophre­nia. What they had in com­mon was an “ex­treme alone­ness.” They had no in­ter­est in oth­ers and had not es­tab­lished re­la­tion­ships with their par­ents or other chil­dren. They had, how­ever, a good re­la­tion­ship to ob­jects that didn’t change in ap­pear­ance and po­si­tion. Their speech was dis­turbed in var­i­ous ways; they had an anx­ious and ob­ses­sive de­sire for same­ness that man­i­fested it­self in re­peated acts and speech. They also had ex­cel­lent rote mem­ory. Kan­ner’s chil­dren all had pro­fes­sion­ally suc­cess­ful par­ents, who he noted were not warmly af­fec­tion­ate to­ward their off­spring: this led him to the rather un­happy later hy­poth­e­sis that “re­frig­er­a­tor moth­ers” might have some­thing to do with his small pa­tients’ autism.

In Ger­many as well as Aus­tria dur­ing the Nazi pe­riod, death, as Sheffer notes in her book, was of­ten “a treat­ment op­tion” for doc­tors. With the aim of pu­ri­fy­ing the state, Nazis des­ig­nated not only Jews, Roma, and ho­mo­sex­u­als as toxic sub­jects—the first two slated for elim­i­na­tion—but also the dis­abled, those of “in­fe­rior hered­i­tary ma­te­rial,” pa­tients in men­tal in­sti­tu­tions, and chil­dren who were judged likely to be­come an on­go­ing drain on the public purse. Young peo­ple who didn’t or couldn’t con­form, who were not gemein­schafts­fähig—able to demon­strate what Sheffer trans­lates as “com­mu­nity com­pe­tence”—reg­u­larly ended up in the so-called T4 euthana­sia pro­gram, named af­ter its head­quar­ters, Tier­garten­strasse 4 in Berlin, home of the Char­i­ta­ble Foun­da­tion for Cu­ra­tive and In­sti­tu­tional Care.

In Vienna, whose pop­u­la­tion en­thu­si­as­ti­cally wel­comed the Nazis, such chil­dren were sent to be mur­dered at the no­to­ri­ous Spiegel­grund, part of the Stein­hof men­tal hos­pi­tal com­plex in the Vienna Woods. Iron­i­cally, the Stein­hof it­self had been de­signed by the great ar­chi­tect of the Vienna Se­ces­sion, Otto Wag­ner, in the re­form­ing first decades of the cen­tury, when it had been seen as a pi­o­neer­ing project to im­prove the lives of the ill. “The child euthana­sia pro­gram re­veals an in­ti­mate di­men­sion to ex­ter­mi­na­tion,” Sheffer writes:

Doc­tors per­son­ally ex­am­ined the chil­dren they con­demned. Nurses per­son­ally fed and changed the sheets of chil­dren they killed. They knew the chil­dren’s names, voices, faces, and per­son­al­i­ties. Killings were typ­i­cally done in the chil­dren’s own beds. Death came slowly, painfully, as chil­dren would be starved or given over­doses of bar­bi­tu­rates un­til they grew ill and died, usu­ally of pneu­mo­nia.

Some­times their brains or other body parts found their way into re­search jars—a fact only dis­closed in the late 1990s.

Asperger was part of the as­sess­ment ap­pa­ra­tus that de­ter­mined the fate of such chil­dren. Though no death war­rants signed in his name ex­ist, and though he claimed, like so many of his countrymen did af­ter the war—de­spite prior vo­cal en­thu­si­asm or fel­low-trav­el­ing—never to have been a Nazi sym­pa­thizer, it is clear from the archival ev­i­dence Sheffer ex­pertly amasses that he knew he was sign­ing off on chil­dren’s fates. Cru­cially, too, his no­tions of what con­sti­tuted “autis­tic psy­chopa­thy” in child­hood, which he de­scribed most fully in his 1944 trea­tise of the same name, were deeply in­flu­enced by Nazi ide­ol­ogy.

Ear­lier re­searchers, like the sci­ence jour­nal­ist Steve Sil­ber­man in Neu­rotribes: The Legacy of Autism and the Fu­ture of Neu­ro­di­ver­sity (2015), have claimed that Asperger—who lauded his autists’ spe­cial, if ec­cen­tric, tal­ents—was nei­ther a Nazi sym­pa­thizer nor a par­tic­i­pant in the euthana­sia pro­gram. Sil­ber­man, like many in the field, may have been re­ly­ing on the re­doubtable Ger­man de­vel­op­men­tal psy­chol­o­gist Uta Frith, who spread Asperger’s fame from her base in the UK and re­mained will­fully blind to his im­pli­ca­tion in Nazi ideas and prac­tices. Per­haps the pho­to­graphs of him have counted in his fa­vor. They show a tall, fair man of im­pec­ca­ble bear­ing who would look good in the short trousers of the Wan­der­vo­gel, the boy-scout-like groups he and the Nazis fa­vored. Asperger did use some pos­i­tive lan­guage about the more ed­u­ca­ble chil­dren in his care, but Sheffer’s anal­y­sis clearly tilts the bal­ance against him.

Born near Vienna in 1906, Asperger trained at the city’s univer­sity dur­ing the 1920s. It was a time when an ex­per­i­men­tal chil­dren’s clinic, fo­cus­ing on Heilpäd­a­gogik—which Shef-

fer trans­lates not as “ther­a­peu­tic” but as “cu­ra­tive” ed­u­ca­tion—flour­ished un­der Er­win Lazar. Like many other doc­tors and psy­chol­o­gists across Europe and in the US af­ter World War I, Lazar was in­ter­ested in “dis­so­cial” youths and in dis­tin­guish­ing be­tween the so­cial, phys­i­cal, and psy­chi­atric rea­sons for their dif­fi­cul­ties or crim­i­nal be­hav­ior. Ideas of ther­a­peu­tic ed­u­ca­tion abounded. Au­gust Aich­horn, who was per­suaded by Anna Freud to run a child guid­ance cen­ter for delin­quents along­side the Vienna Psy­cho­an­a­lytic So­ci­ety, used these cases as the ba­sis for his fa­mous book Way­ward Youth (1925). It was trans­lated into many lan­guages and re­viewed in the UK by Don­ald Win­ni­cott, the pi­o­neer­ing pe­di­a­tri­cian and an­a­lyst.

Poverty, a des­per­ate home life, and parental pre­da­tions be­gan to be seen as shap­ing these chil­dren’s psy­cho­log­i­cal and men­tal lives and con­tribut­ing to their delin­quency. Yet once the so­cial, the psy­cho­log­i­cal, and the med­i­cal were con­flated, it made a dif­fer­ence whether they were be­ing as­sessed from the po­lit­i­cal left or the po­lit­i­cal right. For those in the lat­ter group, a “way­ward,” re­bel­lious youth who didn’t fit into the nor­mal co­hort could land in a gen­eral cat­e­gory of un­de­sir­abil­ity— those “de­fec­tive” in­di­vid­u­als who were, ac­cord­ing to right-wing politi­cians, a bur­den on the na­tion and, ac­cord­ing to eu­geni­cists, harm­ful to what we would now call the gene pool.

In Aus­tria and Ger­many, as in the rest of the West since the nine­teenth cen­tury, eu­genic think­ing was pop­u­lar. In Bri­tain—where it was launched in the 1880s by the statis­ti­cian Fran­cis Gal­ton, Dar­win’s half cousin, who was much in­flu­enced by his Ori­gin of Species—the em­pha­sis of such think­ing lay largely on pos­i­tive eu­gen­ics. Re­form­ers both on the left and on the right sup­ported in­tel­li­gence test­ing and “breed­ing for the best,” in the hope that the gen­eral “stan­dard” of the pop­u­la­tion would be raised. In Scan­di­navia, and par­tic­u­larly in Nazi Ger­many and Aus­tria but also in the US, the em­pha­sis was on neg­a­tive eu­gen­ics. Forced ster­il­iza­tion pro­grams for “un­de­sir­ables” of all kinds per­sisted af­ter World War II. North Carolina con­tin­ued its en­forced ster­il­iza­tion pro­gram of the “men­tally de­fec­tive or fee­ble-minded” un­til 1977. Five thousand of the 7,686 peo­ple ster­il­ized there were black. In­deed, the wide ac­cep­tance of ster­il­iza­tion in var­i­ous coun­tries may be one rea­son that the Nurem­berg Tri­als paid lit­tle at­ten­tion to this heinous as­pect of Nazi pu­rifi­ca­tion pol­icy, which com­pounded ster­il­iza­tion with euthana­sia.

Hans Asperger was a self-pro­claimed eu­geni­cist and a right-wing Catholic. He worked briefly with the staff of the pro­gres­sive clinic that Er­win Lazar, a stu­dent of Bleuler’s, had led. It was in this clinic that many of the ear­li­est ideas on autism orig­i­nated, in par­tic­u­lar with two of its ta­lented staff who would soon em­i­grate to Amer­ica. The Nazi sym­pa­thizer Franz Chvostek, who ran the so-called swastika clinic at the Univer­sity of Vienna, be­came his ally, and he was abet­ted in his climb through the ranks when the Vienna Chil­dren’s Hos­pi­tal was taken over by Franz Ham­burger, an ally of Chvostek’s. Both men were known eu­geni­cists and be­lieved in mass ster­il­iza­tion. Ham­burger fired most of the hos­pi­tal’s Jewish staff, and in 1931 Asperger, aged twenty-five, be­came one of his early ap­pointees.

In 1934 he was made head of the Cu­ra­tive Ed­u­ca­tion Clinic, where he worked along­side the no­to­ri­ous Er­win Jeke­lius, an early SA mem­ber. With Ham­burger, Asperger took part in the “Mo­tor­ized Mother Ad­vis­ing” unit, trav­el­ing the Aus­trian coun­try­side to pro­vide med­i­cal ad­vice to par­ents, but also cre­at­ing a regis­ter of “hered­i­tary fee­ble­mind­ed­ness,” among other ills. Af­ter the An­schluss, Sheffer writes, Asperger’s other pro­fes­sional com­rade, Jeke­lius, be­came “the most prom­i­nent fig­ure in child and adult euthana­sia in Vienna, di­rect­ing the killing cen­ters of Spiegel­grund and Stein­hof.”

Asperger first men­tioned “autis­tic psy­chopa­thy” in 1938, but it had al­ready been de­scribed by two ta­lented Jewish staff in the clinic ear­lier in the 1930s: Georg Frankl and his soon-tobe-wife, the psy­chol­o­gist Anni Weiss. In 1937 Frankl em­i­grated to the US with the help of Leo Kan­ner. At Johns Hop­kins he worked with Kan­ner and even­tu­ally Weiss, who had em­i­grated in 1934 and spent a few years at Columbia. In Vienna they had to­gether iden­ti­fied in high-func­tion­ing chil­dren “the dis­rup­tion of af­fec­tive con­tact” that be­came a clas­sic part of the autis­tic spec­trum. Asperger never cred­ited his Jewish com­pa­tri­ots in his speeches or writ­ings.

Sheffer probes Asperger’s affini­ties with Nazi psy­chi­a­try, par­tic­u­larly his use of the term for soul­ful be­long­ing, Gemüt, at once an as­sess­ment of char­ac­ter and of unity with the Volk. A fail­ure in Gemüt slipped into def­i­ni­tions of psy­chopa­thy: the term gemüt­losen Psy­chopa­then was ap­plied to chil­dren who were with­drawn, will­ful, iso­lated, whose “con­fine­ment of the self...led to a nar­row­ing of re­la­tions to their en­vi­ron­ment.” Not to con­form or fit into the state’s stereo­type of a healthy body and a healthy mind could mark one for elim­i­na­tion.

Chil­dren born out of wed­lock, teenage lon­ers, “delin­quents,” un­con­ven­tional ado­les­cent girls whose step­fa­thers and step­moth­ers wor­ried about their sex­u­al­ity—all such un­de­sir­ables could find them­selves with a fa­tal di­ag­no­sis. Killings in Spiegel­grund be­gan on Au­gust 25, 1940. By the end of the war, at least 789 chil­dren had per­ished un­der the euthana­sia pro­gram; some had phys­i­cal, some men­tal prob­lems, and oth­ers sim­ply didn’t con­form to the time’s def­i­ni­tion of “nor­mal” and couldn’t, ac­cord­ing to the doc­tors, be in­te­grated into the com­mu­nity.

Sheffer dra­mat­i­cally in­cor­po­rates the voices of the few chil­dren who sur­vived the sadis­tic ter­rors of the psy­chi­atric regime into her ac­count, as well as ex­tant case notes. This makes for an an­guish­ing text. It also gives one pause. How did Uta Frith—who taught many of the neu­ropsy­chol­o­gists and cog­ni­tive psy­chol­o­gists who now lead the field and, in 1991, made the first English trans­la­tion of Asperger’s text on autism—man­age to over­look his Nazi af­fil­i­a­tions? Sheffer tells us that Frith chose not to pub­lish Asperger’s pref­ace, which gives a clear in­di­ca­tion of his Nazi sym­pa­thies. But then the city of Vienna, ever slow to ac­knowl­edge its record of ac­tive col­lab­o­ra­tion while plead­ing its “oc­cu­pa­tion” un­der Nazi rule, only memo­ri­al­ized the chil­dren who had been killed at Spiegel­grund in 2002. One of its chief eu­th­a­niz­ing

medics, Hein­rich Gross, like Asperger him­self, went on to have a suc­cess­ful post­war ca­reer.

Start­ing in the 1960s, the num­bers of chil­dren with “autism syn­drome” di­ag­noses rose and rose. Nonpsy­cho­an­a­lytic re­searchers gained promi­nence in the field and re­jected Kan­ner’s the­o­ries about “re­frig­er­a­tor moth­ers.” In­stead they fa­vored mea­sur­ing be­hav­ior to abet epi­demi­o­log­i­cal re­search and the study of en­tire pop­u­la­tions. What we now call ev­i­dence-based medicine, which fo­cuses on sta­tis­tics rather than in­di­vid­u­als, was on its way. An epi­demi­o­log­i­cal study in Bri­tain by Vic­tor Lot­ter in 1966 showed that autism was to be found in 4.5 of ev­ery 10,000 mem­bers of the child pop­u­la­tion. This num­ber kept ris­ing as in­sti­tu­tions for the care of the men­tally ill were closed through­out the 1960s and at­tempts were made by gov­ern­ments to in­te­grate all chil­dren into the school sys­tem. The fig­ures also grew be­cause the def­i­ni­tion of autism syn­drome now stretched to in­clude chil­dren who had never ac­quired speech and might suf­fer from var­i­ous kinds of “re­tar­da­tion.” With this re­clas­si­fi­ca­tion, by 2006 the re­ported rate was 116.1 per 10,000. As the his­to­rian Bon­nie Evans has noted, in France, where in­sti­tu­tions for “re­tarded” chil­dren did not close, the num­bers of peo­ple di­ag­nosed with autism re­mained small.2 Mean­while Bri­tain and the US shared ex­perts and evolv­ing de­scrip­tive lan­guage for a range of be­hav­iors and con­di­tions that fell into the autism spec­trum. In the third edi­tion of the DSM, autism moved out of the di­ag­no­sis of adult schizophre­nia to be­come a sub­cat­e­gory of “per­va­sive de­vel­op­men­tal dis­or­ders” (PDD). By the time DSM-IV was pub­lished in 1994, the cri­te­ria for a di­ag­no­sis of autism were “a qual­i­ta­tive im­pair­ment in so­cial in­ter­ac­tion” and “com­mu­ni­ca­tion,” plus “re­stricted, repet­i­tive and stereo­typed pat­terns of be­hav­ior, in­ter­ests and ac­tiv­i­ties”—all set­ting in be­fore the age of three. The di­ag­no­sis also in­cluded a de­lay or ab­nor­mal func­tion­ing of sym­bolic or imag­i­na­tive play.

Asperger’s name first ap­peared in English-lan­guage medicine in 1981, when the Bri­tish psy­chi­a­trist Lorna Wing pub­lished an ac­count of a syn­drome she named af­ter him, draw­ing on his 1944 trea­tise on autis­tic psy­chopa­thy. In that pa­per, Asperger de­scribed chil­dren, some of them “lit­tle pro­fes­sors,” who lacked the abil­ity to in­ter­act with oth­ers. “Asperger’s dis­or­der,” a new sub­cat­e­gory of PDD in­cluded in DSM-IV, was dis­tin­guished by the fact that chil­dren showed no de­lay or deficit in in­tel­li­gence or cog­ni­tive abil­i­ties or ver­bal com­mu­ni­ca­tion, but like other autis­tic chil­dren ex­hib­ited im­pair­ments in so­cial in­ter­ac­tion and be­haved in repet­i­tive and rit­u­al­is­tic ways. Soon, Asperger’s be­came widely known as the high-func­tion­ing end of autism. In the pop­u­lar me­dia it was var­i­ously at­trib­uted to nearly all men and cer­tainly all nerdy men: bril­liant com­puter geeks, sci­en­tists, hus­bands who never ad­e­quately looked at or spoke with their wives.

It is un­clear whether this com­mon us­age con­trib­uted to Asperger’s dis­or­der dis­ap­pear­ing as a sep­a­rate di­ag­no­sis from (2013) and be­ing merged into an autism spec­trum dis­or­der. (Asperger’s re­mains in the In­ter­na­tional Clas­si­fi­ca­tion of Dis­eases, which is main­tained by the WHO.) We don’t know whether the autism spec­trum will even­tu­ally emerge as a sin­gle neu­rode­vel­op­men­tal dis­or­der with causes that sci­en­tists will track, whether the cur­rent pan­demic is linked to en­vi­ron­ment or genes, or whether it’s a sin­gle dis­ease at all (rather than a re­clas­si­fi­ca­tion of var­i­ous oth­ers).

What is clear is that by now the dis­parate co­hort who bear the di­ag­no­sis of autism has grown hugely, and that for many such peo­ple their di­ag­noses have had a pri­mary part in their self­def­i­ni­tion. For some, this med­i­cal iden­tity can urge them to­ward much-needed spe­cial care or spe­cial school­ing. It can also have, as Sheffer in­di­cates, a neg­a­tive ef­fect—per­haps like all group iden­ti­ties, which as­sume sim­i­lar­ity where there is sub­stan­tial dif­fer­ence. This book is ded­i­cated to her son, Eric, who she in­di­cates has suf­fered from the “act of clas­si­fi­ca­tion.”

The philoso­pher of sci­ence Ian Hack­ing has won­der­fully de­scribed the phe­nom­e­non of di­ag­nos­tic cat­e­gories “mak­ing up peo­ple.” A large set of so­cial fac­tors con­trib­ute to the pop­u­lar­ity of a di­ag­no­sis, which in turn cre­ates the lenses through which we see our­selves and oth­ers. The growth of the autism di­ag­no­sis has been set in mo­tion by pa­tient ac­tivism, sta­tis­ti­cal con­fla­tion, web­sites, blogs, and chat rooms, art ex­hi­bi­tions, pro­vi­sion of ser­vices specif­i­cally for that di­ag­no­sis, me­dia por­traits, Web and medico/po­lit­i­cal cam­paigns, books such as An­drew Solomon’s prize-win­ning Far From the Tree, and the at­ten­tion of ta­lented writer-doc­tors such as Oliver Sacks. All these com­bine to cre­ate a par­tic­u­lar kind of be­ing who, for bet­ter or worse, bears an iden­tity that is a med­i­cal di­ag­no­sis, most of­ten a psy­chi­atric one that at once stig­ma­tizes and des­tig­ma­tizes. In Rewrit­ing the Soul (1995), Hack­ing traced the noisy rise of Mul­ti­ple Per­son­al­ity Dis­or­der. That di­ag­no­sis has now all but dis­ap­peared. Sheffer clearly wishes the di­ag­no­sis that bears Hans Asperger’s name would dis­ap­pear, and in­deed any “to­tal­iz­ing la­bel based on vary­ing traits” rather than a set of phys­i­o­log­i­cal causes. Autism im­pris­ons chil­dren in a sin­gle clas­si­fi­ca­tion and af­fects their be­ing in the world and their treat­ment by oth­ers.

It may be that be­cause of Sheffer’s work, as well as Czech’s, Asperger’s name will dis­ap­pear from di­ag­nos­tic clas­si­fi­ca­tions and fade from the pop­u­lar con­scious­ness. Whether that will suf­fice to dis­man­tle the en­tire cat­e­gory of autism is doubt­ful. There are too many vested in­ter­ests in the cam­paign for greater recog­ni­tion, re­search funds, and ser­vices to suf­fer­ers. Cam­paign­ers, as well as many doc­tors and psy­chol­o­gists, are vo­cal in re­peat­ing that early di­ag­no­sis re­duces parental anx­i­ety and chil­dren’s lone­li­ness, pro­vides ac­cess to spe­cial schools, and helps chil­dren de­velop in the best pos­si­ble way. Un­til an­other set of clas­si­fi­ca­tions ar­rives to deal with the con­sid­er­able chal­lenges that now go un­der this name, autism will likely be with us. If I have one cavil with this im­pas­sioned book it is that Sheffer, in mak­ing her case against Asperger and Nazi men­tal health pol­icy, per­haps too read­ily and speed­ily folds the en­thu­si­as­tic and nec­es­sary re­forms of the 1920s wel­fare state—with its far-reach­ing hopes of im­prove­ment for an im­pov­er­ished class and hap­less chil­dren—into the vi­cious Nazi state. Of the tire­less med­i­cal re­former Er­win Lazar, she writes that while “seek­ing to im­prove the care of chil­dren,” he “ex­panded a sys­tem that in time would ul­ti­mately con­trol and con­demn ‘dis­so­cial’ chil­dren.” It is true that a state that pri­or­i­tizes so­ci­ety and the so­cial good may end up cre­at­ing an as­sess­ment ap­pa­ra­tus with norms of be­hav­ior that some­times lead to the os­tra­ciz­ing of those who are dif­fer­ent and lack Ge­mein­schafts­fähigkeit or “com­mu­nity com­pe­tence.” But this also hap­pens in many states that pri­or­i­tize in­di­vid­ual rights and lib­er­ties and have no wel­fare ap­pa­ra­tus what­ever. As many coun­tries af­ter World War II have shown, wel­fare ar­range­ments need not lead a state to do away with its own cit­i­zens.

Hans Asperger, bot­tom right, with the staff of the Vienna Chil­dren’s Hos­pi­tal, 1933

DSM-V Jo­hann K., who was killed un­der the Nazis at the Spiegel­grund chil­dren’s clinic, Vienna, 1943; draw­ing by Man­fred Bock­el­mann, 2012

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