Here, then, are a number of important points upon which the doctor may be called to give his opinion. It is he alone who is able, by his special knowledge, to enlighten the other members of the jury. If the mental condition is doubtful and requires further observation, it is for him to point it out. One will thus avoid the mistake of placing in a class for defectives a lunatic, or a child poisoned by alcohol, who would not find there the kind of care required. If the bodily condition discovered complicates or aggravates the mental deficiency, as adenoid vegetations may do, he will prescribe the proper treatment. If he suspects the coexistence of some neurosis, he will give directions by which the condition may be recognised, and consequently treated. The doctor therefore has to recognise the physical and mental ailments by which the defective may be affected. He makes this diagnosis for two reasons. In the first place, in order that mental deficiency may not be confounded with conditions of illness of a different kind; and, secondly, in order to relieve or cure if possible coexisting affections which may aggravate the condition of the children and interfere with the work of the school.
We shall conclude here what we have to say about the rôle of the doctor, since in this volume we are specially concerned with the recognition and segregation of the children. To discuss the rôle of the doctor quite fully would take us too far.
The details we have given show that the part of the doctor with regard to defectives is quite different from that of the teacher. It is not so much to determine the child's precise mental level as to diagnose the condition of his brain, and to discover, by analysis of all the symptoms, the original responsible agent. That, however, is the second part of the doctor's work, and is of scientific interest; whereas the first part, which consists in diagnosing the ailments which co-exist with the mental deficiency, is of immediate practical utility.
Let us note, in conclusion, the scientific trend of the present day. A large proportion of medical work is of scientific interest rather than of direct utility for the patient. A concrete example will explain our meaning. A severe shivering, a sudden elevation of the temperature, a dulness on one side of the chest, the presence in the same position of crepitant râles, a rusty, sticky expectoration—such is the syndrome by which a practitioner recognises an attack of acute pneumonia. He knows its duration; he knows the relief which will be produced by the application of poultices. To ideas such as these may be reduced all that is indispensable for the doctor to know in order to exercise his art. The post-mortem examination of the hepatised lung, its increase in density, the histological study of the engorged air cells and bronchioles, the researches upon the pneumococcus, its culture, its vitality—all this constitutes a search into etiology and pathogenesis, whose aim is quite different.
The same distinction may be made in the medical study of defective children. And from this point of view the results which at first seem of secondary importance reappear in the foreground. This is the case, for example, with the stigmata of degeneration. It would be unreasonable to attribute to them an individual value, and to utilise them for arranging children serially in the order of their mental deficiency; but in the work of synthesis they are decidedly significant, since their study leads one to consider them either as the effects of, and therefore as witnesses to, alterations in the nervous system, or as the consequences of causes sufficiently powerful to have modified that system.
One would not deny all practical bearing to such investigations of pathogenesis. It is a mistake of Tolstoy to regard them as the pastime of refined dilettantes. When the biological study of defectives leads to this idea, that the mental weakness of the defectives, like the peculiarities in the character of the ill-balanced, is the result of degeneration—the result, for instance, of the alcoholisation of a people—it will quickly result in measures of social hygiene.
The point is, however, that this second part of the work cannot, in our opinion, be carried out under the same conditions as the first. One would like to believe that, in making observations upon heredity and stigmata, the doctors are collecting, in their daily work, materials for a great scientific work which will be produced by degrees. No doubt all their schedules may some day be extracted from the drawers in the office where they will sleep for a long time; but with what object will they be taken out, if not to compile statistics of doubtful value? The truth is that scientific investigation cannot be carried on automatically and collectively. There is always a personal element which is independent of all administrative prescription. What use can be made of observations which are often merely a collection of paper? If we are some day to understand the rôle of heredity, of alcoholism, of insanity, of poverty, in the production of defective children, it will be necessary for someone, who wants to do a really good piece of work, to set aside all these equivocal documents, and go straight to the facts, collecting his information at first hand and in a critical spirit. Scientific work can be done in no other way. When it is done otherwise it is worth nothing.
We therefore suggest the following schedule for the medical examination of defective children. The schedule includes two parts—one part optional, because it is only of indirect interest; another part which is obligatory. None of the questions in this part should be left unanswered, and the doctor will also give the instructions which he thinks ought to be followed.