The term autism was first introduced in 1908 by the Swiss psychiatrist Eugen Bleuler (1857-1939) to describe an atypical behavior observed in some schizophrenic patients. The etymology of the term “autism” stems from the Greek language: “autos”, meaning self, and “ism”, a suffix denoting a morbid action or state. The term thus denotes a behavior of “being in oneself”; a description of a person who, for any given reason, sequesters himself from others.  Bleuler observed clinical manifestations of autism in his schizophrenic patients when referring to the “remoteness” that they kept. Indeed, many of his patients lived in a socially withdrawn and inaccessible manner prompted by what he considered to be an infantile wish to avoid reality. With time, other authors interpreted the initial concept in different ways and by the mid1960’s and onwards narrowed autistic withdrawal to a world devoid of symbolic life.  Michael Rutter, the first professor of child psychiatry in the United Kingdom, claimed that “the autistic child has a deficiency of fantasy rather than excess” (for a review see Evans, 2013). This misguided assertion was cast without considering the level of functioning or competence of diagnosed children nor the complex relationship that symbolic play has with multiple developmental domains.

Bleuler attempted to integrate the concept of autistic behavior along with symptoms indicative of inappropriate affect, ambivalence, and a loosening of thought associations in the diagnostic criteria for schizophrenia.  His goal never materialized as autism is present only in a subset of schizophrenic individuals and is therefore not considered a central or core element of the condition.

Autism as applied to pervasive developmental disorders of childhood was probably first used by a medical professional in 1938 when Hans Asperger (1906-1980), a pediatrician at the Vienna University Hospital, used the terminology “autistic psychopaths” in a lecture which he advertised as dealing with “The Mentally Abnormal Child”.  Six years later, Asperger published his habilitation, or doctoral thesis, entitled “Autistic Psychopathy in Childhood”.  The patients were described as creatively intelligent but being isolated and having difficulties in social integration.  Other characteristics in the case histories included clumsiness, emotional poverty, special interests, stereotyped movements, and the use of elaborate and idiosyncratic language.  Unfortunately, the contribution of Asperger remained largely unknown outside of the German literature until Lorna Wing replaced the expression autistic psychopath with its eponym in 1981.  According to Shopler, “Asperger’s own publication did not inspire research, replication, or scientific interest prior to 1980. Instead, he laid the fertile groundwork for the diagnostic confusion that has grown since 1980” (Shopler et al., 1998, page 388).  A decade later, Uta Frith translated Asperger’s publication to English, and it became clear that some patients in Asperger series echoed clinical features of a medical disorder contemporaneously reported by Leo Kanner.

Leo Kanner (1894-1981), born Chaskel Leib Kanner, is rightfully considered the father of autism. Born in Klekotow, Austria, Kanner pursued his medical education in Berlin with specialty training in cardiology.  After emigrating to the United States in 1924, Kanner worked at the Yankton State Hospital in South Dakota (named Dakota Hospital for the Insane at its 1880 inauguration).  At Yankton State Hospital, Kanner studied and reported on the effects of tertiary syphilis among Native Americans and the fluctuations in blood pressure accrued to changing levels of adrenalin (epinephrine) in patients with functional psychosis.

It may have been that the harsh arctic conditions in South Dakota swayed the Kanner family to seek refuge in other parts of the United States.  Back then the most important item of a small home in the Dakotas was the stove which was used for both cooking and heating.  In the rural environment near major cities small homes had a rope leading to the outhouse to prevent getting lost and ultimately dying during a heavy snowfall.  It is therefore unsurprising that Kanner used his participation at medical congresses as a way of establishing professional contacts and garnering possible job offers.  In an American Academy of Psychiatry congress in Minneapolis, Kanner reached out to Adolf Meyer (1866-1950), the first psychiatrist-in-chief of the Johns Hopkins Hospital, asking for a job opportunity.

History turns on a dime. Four years after his arrival to the Yankton State Hospital, Kanner accepted a 3-year Commonwealth Fellowship at Johns Hopkins where he would reinvent himself as a psychiatrist.  Under Adolf Meyer’s influence Kanner’s diagnostic acumen would be refined by taking into account all possible biological, social and psychological factors of relevance to his patients. The copious notetaking required for this broad integrative diagnostic approach would be a strength in many of his future publications, a majority of which he wrote as sole or first author.

After finishing his fellowship, Meyer enlisted Kanner’s assistance in establishing the Children’s Psychiatry Service at the Harriet Lane Home for Invalid Children.  This happened as Dr. Edwards A. Park became the Pediatrician-in-Chief of Harriet Lane. Under Park’s long tenure Pediatrics expanded into multiple subspecialties, many of which would bring deserved fame to Hopkins.  In this way, Child Psychiatry flourished in the same environment that provided revolutionary advances, and established the world leaders, in pediatric endocrinology, surgery and cardiology.  The emphasis on psychobiology brought about by Adolf Meyer and Leo Kanner’s fell right in place with the scientific research and training being undertaken at Hopkins.

Sometime in 1942, Kanner was invited to be the guest editor for a special issue in a newly established journal named The Nervous Child. Having finished his training a few years before, the invitation may have been due, in part, to the professional networking capacity available to Hopkins faculty.  Ernest Harms, a clinical psychologist of European origin, served as the editor of The Nervous Child.  The home base of the publication was Baltimore, Maryland, making the proximity to Kanner ideally suited towards establishing a friendly dialogue.  Indeed, Kanner used Harms as a sounding board for his ideas.  “How about writing his special issue around the theme of Affective Contact of Children?”, Kanner asked Harms.  For his own endeavor, Kanner would collect a series of cases that had fascinated him for a number of years. The first case had been seen in 1935; a 3-and-a-half-year-old boy named David Speck, brought to Hopkins by his mother.  By 1942, Kanner had collected 8 children to which he added 3 more by the time of his publication.

It is noteworthy that the clinical series reported in Kanner’s article has maintained its relevance through the decades and according to Google scholar has been cited 11,376 times (as of 10/25/18) within the medical literature. The journal of The Nervous Child on which this influential article was published; however, perished, closing production in 1956. Despite the international recognition Kanner received from his research and publications, he remained an Associate Professor at Johns Hopkins until his promotion to full Professor in 1957 at the ripe age of 63.  Two years later, Kanner would retire and become an Emeritus Professor.

Kanner’s seminal article published in 1943 described a series of children (8 boys and 3 girls, all under 11 years of age) initially diagnosed with childhood schizophrenia and/or emotional problems but who also exhibited an autistic withdrawal as original conceived by Bleuler.  These children existed in autistic isolation, living in a shell, keeping an anxious and obsessive desire for sameness, and exhibiting language and verbal rituals plagued by meaningless repetitions (echolalia). Many of the children described by Kanner had been diagnosed as “mentally weak”, but curiously lacked any discernible cognitive impairment. Indeed, Kanner observed that his patients had an excellent use of vocabulary and an extraordinary memory for past events. Kanner concluded that the children were suffering from what he called “early childhood autism”.

Although Bleuler introduced the term autism for schizophrenic patients, Kanner thought that these conditions were intrinsically different. Childhood schizophrenia was a psychotic disorder with a period of relative normalcy preceding the beginning of the illness, and followed by a progressively deteriorating course.  Kanner recognized clinical antecedent descriptions of the condition in the published works of Sukhareva (Russia), Lutz and Tramer (Switzerland), and Despert (United States).  Thus, the symptoms were known, but whether these reflected the existence of a unique condition, deserving of an exclusive appellation, would have to wait for Kanner’s analysis.  Indeed, these antecedent reports failed to mention the term autism when describing the symptomatology.  It may be that in Kanner’s case the conceptualization of the autistic behavior he observed in his patients came from long discussions with some of the parents of his patients. One of the mothers of his patients was a Psychologist and another one a prominent Pediatrician, moreover, 4 of the fathers were Psychiatrists.  Many of them lived close by, in the state of Maryland, enabling the possibility of frequent visits to the clinics (a review of the different patients in Kanner’s series can be found in Olmsted and Blaxill, 2011).  It is noteworthy that one of the fathers was Wendell S. Muncie, a colleague of Kanner at the Phipps Psychiatric Clinics who also worked under the tutelage of Adolf Meyer.  Wendell Muncie would go on to author the popular textbook, Psychobiology and Psychiatry: A Textbook of Normal and Abnormal Human Behavior (foreword by Adolf Meyer), which underwent 19 printings between 1939 and 1948. In his book, Muncie agrees with Kanner’s reported observations, including the intelligence of the parents, alluding to the fact that one half of the families in the original series were represented in Who’s Who in America, or in American Men of Science.  Although autistic patients had been characterized as being unable to make intelligent decisions or judgements (feebleminded), Muncie believed that chronic acquaintance with them would disprove the claim.  Autism was different and distinguishable from any other type of mental deficiency as well as childhood schizophrenia.  According to Muncie, they looked intelligent and had, in some instances, phenomenal vocabulary and memory.  Muncie’s personal interest on the subject becomes clear when he cites observations from “unidentified parents” as to potential clinical findings for his medical textbook (e.g., the constancy of the autistic personality over the years).  It may be that many parents, who were health-related professionals, provided copious histories, had been keen observers to signs and symptoms of significance, made reference to the relevant literature, and may have guided the discussions with Kanner as to possible diagnoses.

Figure: Wendell Muncie, MD: An interview describing Dr. Muncie”s experiences at Johns Hopkins is available at the Hopkins Medical Archives.

References

Evans B. How autism became autism: the radical transformation of a central concept of child development in Britain. Hist Human Sci 26(3):3-31, 2013.

Muncie W. Psychobiology and psychiatry; a textbook of normal and abnormal human behavior. CV Mosby Company, St. Louis, 1948.

Olmsted D, Blaxill M. The Age of Autism: Mercury, Medicine, and a Man-Made Epidemic. St. Martin’s Griffin, New York, 2011.

Shopler et al., Asperger syndrome or high functioning autism? Current Issues in Autism. Plenum Press, Berlin, first ed, 1998.