Charles N. was brought by his mother on February 2, 1943, at 4½ years of age, with the chief complaint, “The thing that upsets me most is that I can’t reach my baby.”She introduced her report by saying: “I am trying hard not to govern my remarks by professional knowledge which has intruded in my own way of thinking by now.” 
As a baby, the was inactive, “slow and phlegmatic.”He would liein the crib, just staring. He would act almost as if hypnotized.He seemedto concentrate on doing one thing at a time. Hypothyroidism was suspected, and he was given thyroid extrct, without any change of the general condition. 
His enjoyment and appreciation of music encouraged me to play records, When he was 1½ years old, he colud discriminate between eighteen symphonies. He recognized the composer as soon as the first movement started. He wolud say “Beethoven.”At about the same age, he began to spin toys and lids of bottles and jars by the hour. He had a lot of manual dexterity in ability to spin cylinders. He would watch it and get severely excited and jump up and down in ecstasy. Now he is interested in reflecting light from mirrors and catching reflections. When he is interested in a thing, you cannot change it. He would pay no attention to me and show no recognition of me if I enter the room... 
The most impressive thing is his detachment and his inaccessibilitiry.He walks as if he is in a shadow, lives in a world of his own where he cannot be reached. No sense of relationship to persons. He went through a period of quoting another person; never offers anything himself. His entire conversation is a replica of whatever has been said to him. He used to speak of himself in the second person, mow he uses the third person at times; he would  say, “He wants”-never “I want.” 
He is destructive; the furniture in his roo looks like it has hunks out of it. He will break a purple crayon into two parts and say, “You had a beautiful purple crayon and now it’s two pieces. Look what you did.” 
He developed an obsession about feces, would hide it anywhere ( for instance, in drawers), would tease me if I walked into the room: “You soiled  your pants, now you can’t have your crayons!” 
As a result, he is still not toilet trained. He never soils himself in the nursery school, always does it when he comes home. the same is true of wetting. He proud of wetting, jumps up and down with ecstasy, says, “Look at the big puddle he made” 
When he is with other people, he doesn’t look up at them. Last July, we had a group of people. When Charles came in it was just like a foal who’d been let out an enclosure. He did not pay attention to them but their presence was felt. He will mimic a voice and he sings and some people would not notice any abnormality in the child. At school, he never envelops himself in a group, he is detached from the rest of the children, except when he is in the assembly; if there is music, he will go to the front row and sing. 
He has a wonderful memory for words. Vocabulary is good, except for pronouns. He never initiates conversation, and conversation is limited, extensive only as far as objects go. 
Charles was born normally, a planned and wanted child. He sat up at 6 months and walked at less than 15 months-”just stood up and walked one day-no preliminary creeping.”He has had none of the usual children’s diseases. 
Charles is the oldest of theree children. The father, a high-school graduate and a clothing merchant, is described as a “self-made, gentle. calm, and placid person.”The mother has “a successful business record, theatrical booking office in New York, of remarkable equanimity.”The other two children were 28 and 14 months old at the time of Charles’visit to the Clinic. The maternal grandmother, “very dynamic, forceful, hyperactive, almost hypomanic,”has done some writing and composing. A maternal aunt, “psychoneurotic, very brilliant, given to hysterics,”has written poems and songs. Another aunt was referred to as “the amazon of the family.”A maternal uncle, a psychiatrist, has considerable musical talent. The paternal relatives are described as “ordinary simple people.” 
Charles was a well-developed, intelligent-looking boy, who was in good physical health. He woreglasses. When he entered the office, he paid not the slightest attention to the people present (three physicians, his mother, and his uncle). Without looking at anyone, he said, “Give me a pencil!”and took a piece of paper from the desk and wrote something resembling a figure 2 ( a large desk calendar prominently displayed a figure 2; the day was February 2). He had brought with him a copy o Readers Digest and was fascinated by a picture of a baby. He said, “Look at the funny baby,”innumerable times, occasionally adding, “Is he not funny? Is he not sweet? 
When the book was taken away from him, he struggled with the hand that held it, without looking at the person who had taken the book. When he was with a pin, he said, “What’s this?”and answered his own question: “It is a needle.” 
He looked timidly at the pin, sharnk from further pricks, but at no time did he seem to connect the pricking with the person who held the pin. when the Readers digest was taken from him and thrown on the floor and a foot placed over it, he tried to remove the foot as if it were another detached and interfering object, again with no concern for the persn to whom the foot belonged. He once turned to his mother and excitedly said, “Give it to you!” 
When confronted with the Seguin form board, he was mainly interested in the names of the forms, before putting them into their appropriate holes. He  often spun the forms around, jumping up and down excitedly while they were in motion. the whole performance was very repetitious. He never used language as a means of communicating with people. He remembered names, such as “octagon,” “diamond,” “oblong bolck,”but nevertheless kept askeing, “What is this?” 
He did not respond to being called and dis not look at his mother when she spoke to him. when the blocks were removed, he screamed, stamped his feet, and cried, “I’ll give it to you!”( meaning “You give it to me”). He was very skillful in his movements. 
Charles was placed at the Devereux schools. 

Case 10 

John F. was first seen on February 13, 1940, at 2 years, 4 months of age. 
The father said: “The main thing that worries me is the difficulty in feeding. That is the essential thing, and secondly his slowness in development. During the first days of life he did not take the breast satisfactorily. After fifteen days he was changet from breast to bottle but did not take the bottle satisfactorily. There is a long story of trying to get food down. We have tried everything under the sun. He has been immature all along. at 20 months he first started to walk. He sucks his thumb and grinds his teeth quite frequently and rolls from sid to side before sleeping. If we dom’t do what he want’s, he will scream and yell.” 
John was born September 19, 1937; his birth weight was 7½ pounds. There were frequent hospitalizations because of the feeding problem. No physical disorder was ever found, except that the anterior fontanelle did not close until he was 2½ years of age. He suffered from repeated colds and otitis media, which necessitated bilateral myringotomy. 
John was an only child until February, 1943. The father, a psychiatrist, is “a very calm, placid, emotionally stable person, who is the soothing element in the family.”The mother, a higt school graduate, worked as secretary in a pathology laboratory before marriage-  “a hypomanic type of person; sees everything as a pathological specimen rather than well; throughout the pregnancy she was very apprehensive, afraid she would not livethrough the labor.”The paternal grandmother is “obsessive about religion and washer her hands every few minutes.”The maternal grandfather was an accountant. 
John was brought to the office by  both parents. He wandered aboput the room constantly and aimlessly. Except for spontaneous scribbling, he never brought two objects into relation to each other. He did not respond to the simplest commands, except that his parents with much difficulty elicited bye-bye, pat-a-cake, and peek-a-boo gestures, performed clumsily. His typical attitude toward objects was to throw them on the floor. 
Three months later, his vocabulary showed remarkable improvement, though his articulation was defective. Mild obsessive trends were reported, such as pushing aside the first spoonful of every dish. His excursions about the office were slightly more purposeful. 
At the end of his fourth year, he was able to form a very limited kind of affective contact, and even that only with a very limited number of people. Once such a relationship had been established, it had to continue in exactly the same channels. He was capable of forming elaborate and grammatically correct sentences, but he used the pronoun of the second person when referring to himself. He used language not as a means of communication but mainly as a repetition of things he had heard, without alteration of the personal pronoun. There was very marked obsessiveness. Daily routine must be adhered to rigidly; any slightest change of the pattern called forth outbursts of panic. There was endless repetition of sentences. He had an  excellent rote memory and colud recite many prayers, nursery rhymes, and songs “in different languages”; the mother did a great deal of stuffing in this respect and was very proud of these “achievements”: “He can tell victrola records by their color and if one side of the record is identified, he remembers what is on the other side.” 
At 4½ years, he began gradually to use pronouns adequately. Even though his direct interest was in objects only, he took great pains in attracting the attention of the examiner ( Dr. Hilde Bruch) and in gaining her praise. 
However, he never addressed her directly spontaneously. He wanted to make sure of the sameness of the environment literally by keeping doors and windows closed. When his mother opened the door “to pierce through his obsession,”he became violent in closing it again and finally, when again interfered with, burst helplessly into tears, utterly frustrated. 
He was extremely upset upon seeing anything broken or incomplete. He noticed two dolls to which he had paid no attention before. He saw that one of them had no hat and became very much agitated, wandering about the room to look for the hat. When the hat was retrieved from another room, he instantly lost all interest in the dolls. 
At 5½ years, he had good mastery of the use of pronouns. He had begun to feed himself satisfactorily. He saw a group photograph in the office and asked his father, “When are they coming out of the picture and coming in here:” 
He was very serious about this. His father said somethig about the pictures they have at home on the wall. This disturbed John somewhat. he corrected his father: “We have them near the wall”( “on”apparently meaning to him “above”or “on top”). 
When he saw a penny, he said, “Penny. That’s where you play tempins.”He had been given pennies when he knocked over tenpins while playing with his father at home. 
He saw a dictionary and said to his father, “That’s where you left the money?” 
Once his father had left some money in a dictionary and asked John to tell his mother about it. 
His father whistled a tune and John and correctly identified it as “Mendelssohn’s violin concerto.”Thogh he could speak of things as big or pretty, he was utterly incapable of making comparisons (“Which is the bigger line? Prettier face?”etc.). 
In December, 1942, and January, 1943, he had two series of predominantly right-sided convulsions, with conjugate deviation of the eyes to the right and transient paresis of the right arm. Neurologic examination showed no abnormalities. His eyegrounds were normal. an electoencephalogram indicated “focal disturbance in the left occipital region, “but “a part of the record colud not be read because of the continuous marked artefacts due to the child’s lack of cooperation.” 

Case 11, discussion and comment