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The case and problem method in anatomic neurology.

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Resumen por el autor, A. W. Meyer.
El metodo de 10s casos clinicos y problemas en la Neurologia
Puesto que el estudio de la complicada anatomia del sistema
nervioso central por 10s estudiantes se reduce casi por completo
a aprender de memoria, el autoT indica que en la enseiianza de
esta materia se debiera recurrir, con mucha mas frecuencia que
hasta el presente, a la exposici6n de casos clinicos reales e hipotbticos. Tal procedimiento no solamente haria la tarea del
estudiante menos complicada y mas interesante sin0 que tambien
dirigirfa su atenci6n sobre la existencia de muchas relaciones
oscuras. El objeto de este metodo no es restringir la atenci6n
del alumno a consideraciones priicticas, ni tampoco anticipar su
trabajo clinico, sin0 el usar casos concretos con el prop6sito de
revelar las relaci6nes complejas y fijarlas en la mente de un
mod0 mas permanente. Este metodo estA particularmente
justificado en Neurologia, porque el estudio objetivo del sistenia
nervioso central solo puede ser parcial aim cuando se lleve a
cabo en las mejores condiciones.
'rrandation Ly JoaG F. Noriidez
tiwie Institution of Wnshington
Department of A n a t o m y of the Stanford Uniaersitv Medical School
Seers and prophets of old frequently taught by parable. This
is essentially the interpretation of a particular set of circumstances by the case method. Revered teachers of medicine of
the past also used hypothetic and actual cases to illustrate some
general principle. A fitting illustration often can illumine what
otherwise would remain obscure, and, because of its efficiency,
objective teaching no doubt dates back far in hunian history.
Although we of to-day do not claim t o be either seers or prophets,
we nevertheless have abundant opportunity to extend the applications of the case method in our teaching not only in anatomy,
but in physiology and in psychology of the abnormal as well.
Among the various educational subjects, medicine particularly
has had.the distinction of long making free use of the living
individual. This is true especially in clinical teaching, and a
more extensive application of the case and problem method in
the teaching of anatomy not only would seem possible, but
highly commendable. It should be found especially advantageous for illustrating obscure structural relations, such as vascular
anastomoses, sympathetic connections, and above all certain
features in the anatomy of the central nervous system. Even
with the best of equipment it long will remain difficult not only
for the student t o realize the existence of tracts, the extent of
which he cannot demonstrate and which he can examine only
here and there throughout their entire complicated course.
Anatomic neurology still remains such a bugbear to the student
largely because of the nature of the things themselves. The
structural relationships of the central nervous system are so
intricate and an examination of them in continuity naturally
18, NO. 4
must remain impossible. Hence much must be left to imagination and memory, and many a physician will recall with what
relief he, as a student, turned from the anatomic to physiologic
and cli,nical neurology. This common experience justifies the
emphasis recently placed by certain neurologists upon the socalled methods of functional neurology, for the association of
structure and function, although often impossible, nevertheless
makes a necessarily difficult task far less tedious and meaningless.
Under the exigencies of the situation, a long list of clinical
cases selected from the literature not only would furnish a welcome relief to the student, but would teach him much regarding
the structure and function of the nervous system. To select
such a list admittedly would be a considerable task to anyone
except a practicing neurologist of wide experience, but it would
be worth while. Some good examples could be gleaned from
text-books on clinical neurology, and medical literature is replete
with material of this kind. Moreover, the literature of the great
war has added many illustrations of the effects of lesions of the
nervous mechanism. It no doubt would be very difficult to
get a large series of clean-cut cases, but many of them could be
used in part in ordep to illustrate some particular feature which
it is desired to emphasize. This would save the student from
confusion and postpone consideration of associated phenomena.
No one pretends to be sure that the whole anatomy of the
nervous or any other system can thus be illustrated. Besides
many symptoms or signs exhibited by these cases or case histories
would be wholly inexplicable at present, but there would be a
lesson and a stimulus in all this to both student and teacher,
and the medical student later would approach the patient more
understandingly than is otherwise likely. If one began with
simple cases of peripheral injuries resulting in simple disturbances
in function and followed these by a series of more proximal
lesions and, finally, by a considerable group of cases illustrating
the effects of lesions in various segments of the cord, medulla,
and the rest of the brain, the student would be confronted with
a most interesting series of problems and conditions, the interpretation of which not only would require clear thinking, but would
fix in his memory structural relations and physiologic conceptions
which otherwise are easily forgotten or even overlooked.
Anyone who has ever tried the case method in anatomy knows
with what delight it is hailed by the student. This is due not
merely to its direct human appeal, but to the eloquence with
which accident and disease often reveal obscure structural relationships. Next to a thorough examination of the structures
themselves, I know of no better way to impress certain anatomic
relations upon students than to consider the effects of displacements, pressures, and injuries upon them and adjacent organs.
One cannot, for example, properly consider the effects of air or
fluid in the pleura or pericardial cavities without emphasizing
many anatomic facts and referring to interrelationships otherwise
easily overlooked.
I n suggesting the wider application of the case and problem
method, especially in anatomic neurology, I am fully aware of
the limitations imposed by both time and method. Nor would
I rely solely upon this method, or even try to anticipate clinical
neurology. That would be both futile and unwise, and although
the collection of a large and excellent series of cases will require
much time, I am certain that the histories of a select list of
clinical cases can greatly enrich our anatomic instruction and
add meaning and interest to purely morphologic considerations.
The extent to which the method can be used is a matter of minor
importance only.
Since physiologists have left the field of muscular movements
to the anatomists, it would seem that the latter no longer should
neglect this opportunity to use the case and problem method for
the demonstration of muscular actions. Even the best of our
text-books of systematic anatomy merely tabulate what has
come to be regarded as the most obvious or conspicuous action
of particular muscles, without giving the student any idea of
the intricate relationships and the splendid coordination illustrated by muscular movements. Anatomists seldom consider
muscular movements as such, and physiologists usually take
up only certain special groups of movements, such as those of
respiration, deglutition, coughing, sneezing, and sometimes a few
others, and with these considerations a very interesting and
important subjcct is usually dismissed. I mention this not, to
be sure, as an indictment or accusation, but merely to call attention to the situation.
Our text-books of systematic anatomy also assign actions t o
muscles which they undoubtedly do not perform, and a thoroughgoing discussion of muscular movements long has waited upon
some anatomist with physiologic training and practical experience, or a physiologist with considerable anatomic knowledge
and clinical interest. How incomplete our knowledge of muscular movements is, a neurologic patiknt occasionally illustrates
to the student. At present there are but a few small volumes
which consider muscular movements. other than more or less
incidentally. A thoroughgoing modern discussion of this subject
would be a great boon to both the student and the anatomist.
Let, us hope that English neurologists who have contributed so
much to the subject soon will answer this need.
I n making these brief suggestions, 1 am aware of the fact that
pedagogic reflections coming from a laboratory worker are regarded as tirnc ill spent by many of us. Nor is this difficult to
understand. Yet most of us spend a large part of our lives in
formal teaching and only a few fortunate or exceptional individuals could retain their positions in public or quasi-public educat,ional institutions on a purely investigational basis. Deny it
though we may, we are where we are, and are doing what we are,
because we are expected to teach, not merely by example, but
by very word and deed. Hence it would seem that under these
circumstances an intolerant attitude toward improvement and
change in method is discreditable, whatever else it may not be.
To spend a lifetime in a teaching position, and, in fact, to make
a livelihood-such as it is-by teaching, and then entertain an
inhospitable attitude toward considerations upon the methods
by which that livelihood is made does justice to nothing save the
inadequate and immutable salaries characteristic of institutions
of higher education.
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problems, neurology, method, case, anatomical
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