Human anatomy refers specifically to the consideration of the various structures that make up the human body. This can be separated into systematic or regional anatomy sections; the first describing certain characteristics for instance osteology; focusing on the human skeleton, and angiology; looking at the vascular system. The latter description, regional anatomy, takes into account all of the individual systems and notes how they interact and function together in a certain region e.g. the lower limb, or the thorax. In addition to this anatomy encompasses both adult and embryological anatomy, as well as applied and clinical anatomy; the direct application of the pathological conditions which may occur, and a practical application of anatomy [1].

There is no doubt that gross anatomy is one of the preclinical cornerstones of medical education [2, 3]. Every doctor must grasp the concepts of anatomy to aid in appropriate diagnosis and management of their patient, as well as communication with peers and patients, and it comes as no surprise that anatomy and surgical practice must be inter-related.

Doctors need to have a firm understanding of anatomy and this should be based on a theoretical knowledge, a practical 3D application of this knowledge, as well as an appropriate bedside or clinical application on the patient [4].

Current perception is that anatomy knowledge in inadequate, with a belief amongst senior surgical program directors in the UK feeling that knowledge of anatomy was lacking, or in need of a refresher course, in a total of 91% of new doctors. This was further supplemented with 52% feeling that anatomical knowledge was significantly less in new graduates than those graduating 10 years ago [3].

Likewise, there has been an increase in anatomical competence related claims with both avoidable death and morbidity seen as a consequence [5-7].

The desire to understand the human body dates back to written records, with the Egyptians noted first to show interest in the body’s make up. The Edwin Smith Surgical Papyrus dates back to 1500BC and describes vessels emanating from drawn organs, symbolizing the heart, liver, spleen, kidney and bladder, which carry air, mucus, the ‘breath of life’ and the ‘breath of death.’ Other Egyptian records show an understanding that the heart is the centre of the blood supply, and vessels to the major members of the body are required [8].

Anatomy methods and nomenclature can be dated more specifically to the time of the Greek physicians [9]. Animal dissection was used predominately, but around 480BC the optic nerve and Eustachian tubes were identified, with Empedocles stating the human heart was the primary organ involved in both the vascular sense and for distributing the ‘breath’ around the body.

Comparative anatomy, mainly due to animal dissections, was described by Aristotle in the 4^th century BC, with Praxagoras credited for defining arteries and veins.

Ptolemy I allowed the first studies of dead bodies in 300 BC, with the Greek physicians Herophilos and Erasistratus noted for their dissections on dead criminals in Alexandria, Egypt [10, 11]. The former, often called the founder of anatomy, was later accused of performing his dissections on live criminals [12].

Hippocrates, the ‘Father of Medicine,’ continued anatomical studies in 460 BC.

The 2^nd century saw Galen write his two works on anatomy; On anatomical procedure and On the uses of the parts of the body of man. These would become the main sources of anatomical teaching until the 16^th century and were based on his findings through animal dissection, his work as a gladiatorial physician and a compilation of the works of previous writers [9, 10].

His writings include the first description of seven pairs of cranial nerves, and the passage of blood rather than the precluding opinion of air and mucus in the blood vessels.

The period between the 8^th and 15^th centuries was of poor input to anatomy. This time was of profound Christian belief, and scientific enquiry was not promoted. For this time, Galen’s commentary became the accepted.

The 13^th century saw several anatomists allowed to dissect human cadavers with Mondino de Luzzi, Alessandro Achillini and Antonio Benivieni amongst those noted for their work [13-15].

Leonardo da Vinci, dissected over 30 human specimens during his life. These are depicted in a wide range of his drawings, found in the anatomical Manuscript B, dating back to 1489.

The 16^th century saw Andreas Vesalius challenge the teachings of Galen. His widespread travels in search of condemned men, and dissection of them after death, allowed a more detailed study of human anatomy, allowing a challenge to be made between these new findings and those previously ‘known’ after comparative dissection in animals by Galen. It was at this time anatomy was noted to be significant to the discipline of medicine, with Vesalius stating that anatomy could only be taught by dissection. In 1543, Vesalius would publish his great work De humani corporis fabrica, or ‘the structure of the human body,’ and from this human anatomical studies would stride forward [16].

Vesalius pupil, MR Columbus would go onto describe accurately the anatomy of bones, the cavities of the heart, as well as comment on the larynx and brain.

The hepatic vessels, lymphatic system and left to right ventricle flow of the heart were soon described, with Italy becoming a centre for anatomy teaching and vivisection.

These teachings would take place from 1490 in anatomical theatres, such as in Padau [17], where hired hands would dissect a cadaver whilst professors educated those sat in the amphitheaters on the parts being dissected. This way of teaching, not only for those in medicine, would continue until the 19^th century where cadaveric teaching would move to the classroom.

The importance of anatomy was noted by Giovanni Battisti Morgagni, consequently described as the father of modern autopsy, believing it to be key for diagnosis and treatment [18].

With an increase in interest into anatomy, growing numbers of medical trainees and a limit to the number of accessible cadavers, the 17^th and 18^th century saw the peak of grave-robbing, or body snatching, as well as people being murdered for the sale of their body to anatomy schools [19, 20].

The Anatomy Act was passed in Britain in 1832 which allowed both a legitimate and adequate source of corpses by allowing legal dissection on executed murderers, likewise dissection was only permitted to be carried out by physicians or barber surgeons [21].

The 19^th century saw an increase in anatomical research. This involved both developmental biology and histology studies, both allowed by the improvement in microscopy and research skills.

The continued development in technology has brought us to the modern day, where radiology has revolutionized the study of living tissues. In particular MRI and CT machines have allowed unprecedented details of both living and dead tissue, and interest has moved to function and evolution of anatomy as the macroscopic aspects of human anatomy have been largely noted.

Alongside a greater ability to view the human body, the preservation of its anatomical specimens has improved. Latex injection and plastination has allowed detailed alternatives to a deceased body, as has the vast improvement in photography and imaging [22, 23].

Clinical, or living, anatomy, with the use of living models, has also increased as our understanding of the relationship between the outside and inside of the body has improved, with many schools for instance advocating the use of ultrasound teaching, for instance in anatomy of the neck [24, 25] and heart [26].

A doctor’s anatomical knowledge begins in medical school and ultimately progresses throughout their career [27]. Following the General Medical Council’s (GMC) recommendations (1993) in ‘Tomorrows Doctor’s’, which stated that [28]:

• Too much emphasis in medical school was based on factual content and too little on clinically relevant content.
• An increased proportion of learning should be student-centered and self-directed.
• Medical schools must implement a curriculum that provides the skills, knowledge and attitudes required for students’ professional development.

Many medical schools were encouraged to restructure their medical curriculums, with many opting for a Problem Based Learning (PBL) course as it was felt that contextual learning helped retain knowledge [29]. The GMC offers no guidance on what is considered the minimum level of knowledge requirement in each medical subject [30]. Rather, medical schools have freedom to interpret and form their curricula [30]. In implementing these changes to the course structure and an ever increasing magnitude of skills and knowledge required in medicine there has been a general reduction in anatomy contact time in many medical schools [31]. Statistics show a reduction of as much as 60% in contact time since 1980 in some medical schools [32].

A generalised decline in dissection based anatomy teaching has been observed since the implementation of the new curricula, with a move towards new teaching methods to, in theory, save time with an ever increasing medical student population and improve retention of knowledge [33].

There are numerous methods of anatomy teaching currently available to the undergraduate and postgraduate trainee. The fierce debate will continue on regarding the effectiveness of each among traditionalists and liberalists.

Dissection has been the cornerstone of anatomy for centuries and we are now seeing a gradual move away from the tried and tested art.

Medical schools have limited their allocated teaching time for anatomy and have subsequently had to invent new innovative ways to teach the subject in a manner that saves time. However the quality of teaching provided and standard of anatomical knowledge of new graduates is often said to be lower than that of past medical graduates, leading to low confidence in new methods [73].

No doubt medical students and surgical trainees will chose a teaching method when selecting at which institution to study. Therefore medical schools and surgical trainee programs may have to adapt their courses in the future in order to appeal to the majority of students. However what is vital for future patient care is that anatomy teaching time must not be reduced further and if possible increased to improve the basic understanding of anatomy that underpins clinical practice.

In general, there is a need for research and external audit into the methods of teaching, specifically anatomy, with no common national core curriculum or agreement currently seen [74-76], although this is noted as an area requiring assessment [77].

It has been noted that a reduction in undergraduate teaching and anatomical knowledge is of concern to both the under and post graduate doctor, and this in combination with a change in basic surgical training has set up a system allowing the potentially anatomically naive doctor to become a surgeon [51, 74, 75, 78].

It should be noted that the modernized medical career may place detailed anatomical knowledge unnecessary for the majority of modern doctors, and other ‘core areas’ are deemed as important for the formation of a the generic doctor. For the surgeon, however, this is not appropriate and there needs to be a shift towards opportunity and exposure to learn detailed anatomy, but possibly at later stage of their training.

Robert Liston phrases this well with his quote:

The foundation of the study of the art of operating must be laid in the dissecting room.

Saying this there is something intrinsic to the majority of medical students regarding a fascination with human anatomy, and this is mirrored both in non medical staff and the general public. With this new innovations and ways of teaching anatomy will be developed and should be incorporated into the curricula of our trainees, but not at the complete abandonment of methods that have already stood the test of time.