Resumen por el autor, A. W. Meyer. El metodo de 10s casos clinicos y problemas en la Neurologia anat6mica. 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 ('ni THE CASE AND PROBLEIM METHOD IN ANATOMIC NEUROLOGY ARTHUR WILLIAM MEYER 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 351 T H E AN4T OY IC A L HECQRD. VOL 18, NO. 4 ,, 352 ARTHUR WILLIAM MEYER 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 CASE AND PROBLEM METHOD'IN NEUROLOGY 353 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 354 ARTHUR WILLIAM MEYER 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.