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In surveying the literature of recent years one finds several factors that are lacking and perhaps some that have received undue emphasis. Perhaps the greatest single deficiency in research has been in pathology. To be sure there have been many excellent studies made but the number of investigators have been few and the scope of their investigations have been quite circumscribed. At the meeting in Philadelphia last year Dr. Temple Fay suggested certain fields of pathological investigation that may have a profound bearing on the etiology of some cases that have been neglected or overlooked. I refer to his work on the size of the cranial foramena.

In investigating this subject one can work with living persons by means of X-ray studies of the cranium and comparing the sizes with known normals. Since the function of the brain cells is directly dependent upon adequate blood supply it is easy to understand the meaning of subnormal sizes of the foramena through which the blood vessels must pass. Here is a fertile field of investigation for every institution equipped with a Roentgen-Ray apparatus.

Dietary studies in mental deficiency have been made but the application of the newer knowledge of vitamin-therapy has not as yet been adequately studied when applied to the subnormal.

The use of endocrine products for mental defectives, particularly by physicians in private practice, has been overdone. They have been used as "shotgun prescriptions" with the hope that they might do some good. Inaccuracy of diagnosis leads to the indiscriminate use of endocrine therapy resulting in failure to improve the individual case with resultant waste of time, material and money. It is a rare case that needs endocrine therapy and such preparations should only be used when the diagnosis definitely points to endocrine deficiency.

There is great need for further intensive research into the etiology of obscure cases of mental retardation. Why for example, to cite a case with which I am familiar, should one member of an otherwise brilliant family be a nonsalvageable mental defective? W. M.'s parents were both superior types of individuals with excellent university training. His paternal grandfathers were on the one side a college president and on the other side a famous surgeon. His maternal grandparents were both endowed with more than average intelligence. No evidence of mental deficiency or other psychopathic conditions were to be found in a thorough search of the family tree. A sister was dean of women in a New England college; one brother a physician, one a lawyer and one a successful business man. The history of the gestation and birth were without clues as to the etiology. The history of the infancy and early childhood were likewise without factors which might cause retardation. Yet W.M. never progressed beyond the level of a low-grade moron. Why? That is a question with which we are frequently confronted and for which we have no definite answer. Such cases are indeed calamities for normal families to face. Medical science is perhaps remiss in not as yet having provided a definite answer.

Unfortunately it is families such as W.M.'s that become the victims of charlatans in the profession and also in some of the schools for retarded children. They spend small fortunes to find a cure and pay exorbitant fees to some of our schools for the retarded, only to learn by sad experience that there is no cure and they are faced with the problem of life-time care and support for the unfortunate member of the family.

Let us hope that research may be intensified toward the end of finding an adequate answer to such problems in etiology.

The application of the newer knowledge and newer techniques in surgery to mental defectives is definitely lagging. Dr. R. M. Klemme of St. Louis has developed a technique of brain surgery which he has applied largely to acquired motor disorders but which may find wide application in cases of birth injury. Most of the birth palsy cases are of normal intelligence and if surgery can offer them a marked degree of physical relief they should most certainly have the advantage of this new method of therapy. This is, of course, a highly specialized field of neuron surgery but it is one that has a practical application to a relatively large group of cases.

Out of the surgical advances during the war will undoubtedly come not a few techniques applicable to the physical defects found in mental defectives. We should be on the lookout for and be prepared to utilize such advances for the benefit of the children entrusted to our care.

I might go on further in the possibilities for medical research but I must touch upon other forms of investigation open to the institutions. In 1941 our Committee on Education and Training in cooperation with the United States Office of Education made a very intensive study of the educational programs in residential schools for the mentally deficient. This was a monumental piece of work and it has given the institutions a basis for comparing their facilities and curricula with others. This report contained a summary with some significant questions for study. A good deal of follow-up work along the line of this report has been done by the Committee on Education and Training. Perhaps the future will bring us a model outline.