Clinical Anatomy 4:310-312
(1991)
Oliver H. Beahrs
EDITORIAL
Gross Anatomy in Medicine
Anatomy is the language of medicine because all of medicine relates to the
human body and the function of its various parts and systems. Human anatomy is,
in fact, one of the earliest sciences and traces its origin to the early Greek civilization. T h e Greek term for anatomy-anatome-means
“taking apart.” T h e Latin
t e r m d i s s e c a r t L i s for dissection. Anatomy in ancient times was expressed in
sculpture and art. As knowledge of gross anatomy increased, it gave rise to many of
the other basic sciences of medicine-pathology (morbid anatomy), embryology
(developmental anatomy), histology and cytology (microscopic anatomy), physiology (functional anatomy), physical anthropology, and others. Furthermore, many
of the terms used in medicine relating to the human body originated in anatomic
parts and their function, such as anterior-posterior, palmar-plantar, proximal-distal,
external-internal, abduction-adduction, elevation-depression, protraction-retraction, and others.
Thus, anatomy must be considered the most basic science of medicine. I t forms
the trunk of the tree from which all other medical sciences stem. As the body of
knowledge increases, the branches spread in many directions and the tree grows.
How then can a student of medicine not know anatomy and claim to understand
the language of medicine, let alone the other sciences related to the human body?
If a mechanic does not know the parts of the machine-automobile or television
set-that h e is repairing it is unlikely that it will work in the end. So physicians,
regardless of their specialty, must know and appreciate gross anatomy.
Unfortunately, in the recent past, the explosion of medical knowledge has put
pressure on the subjects within the medical curriculum, resulting in a decrease in
emphasis on subjects whose current clinical applications were not appreciated.
This resulted in a critical period for anatomy. So much so that a formal course in the
subject was dropped from the curriculum, and anatomy then taught as part of the
clinical subject-such as cardiac anatomy along with cardiology. It soon became
apparent that the graduate from medical school was lacking in knowledge of this
most basic subject of medicine. Now the pendulum is swinging back, and the
importance of an in-depth study of anatomy is once again gaining importance in
medical education. I t is difficult to understand why, irrespective of clinical specialty-surgery or psychiatry-a physician should not know the parts, the function,
and the language of anatomy.
Admittedly, to the young student, anatomy can be a “cold” subject requiring
memorizing terminology. Without clinical implications, students can easily lose
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interest in the subject. It need not be so. An anatomy teacher can easily be
innovative, creative, and make the subject interesting. However, gross anatomy to
somc tcachcrs of anatomy has been a “chore” because they are unprepared and are
trained in new fields of anatomy such as cellular biology. This, in part, led a group
of interested physicians and scientists to form the American Association of Clinical
Anatomists in 1983 to once again stimulate interest in teaching and clinical applications of human anatomy.
To better understand anatomy, knowledge of embryology is essential. I t is best
taught along with anatomy so the student understands the development of the
human body. Also, from the clinical standpoint, especially in surgery, congenital
abnormalities must be understood for successful treatment. An example of this is in
cervical exploration for hyperparathyroidism. If parathyroid glands are not found in
their usual positions, by knowing the avenue of descent of the glands in developmental anatomy and extending the surgical exploration appropriately, one can
almost always find the glands in predictable ectopic positions. With this information in mind, expensive localizing tests are not necessary.
T h e following are examples of how small bits of information are of value to the
surgeon. In doing an operation in the pelvis requiring freeing the rectum, bleeding
from the hollow of the sacrum is said to be a great hazard. However, considering that
there are no collateral vessels between the presacral vessels and those of the
rectum, bleeding from the dissection has to be considered iatrogenic. With knowledge of anatomy and using proper technique, bleeding can be prevented. If the
surgeon knows the detailed anatomy of the facial nerve and its relationship to bony
parts, parotidectomy becomes safe and the nerve easily dissected.
Although gross anatomy should be known to all physicians, it is basic to a
surgeon and the surgical specialty that h e practices. Surgeons should know the
anatomy so thoroughly that at no time in the course of dissection should they have
undue concern as to where specific structures are located or any question as to the
identity of a structure. Lack of knowledge or hesitancy too often leads to disaster.
T h e surgeon must be aware of anatomic variations, since this knowledge is crucial
to the success of the operation.
To learn basic anatomic information by trial and error at the expense of a patient
undergoing an elective or emergency operation is morally wrong. Anatomy must be
learned, first, with the aid of texts, by memorizing nomenclature and differentiating anatomic relationships. Second, the student must further study anatomy by
dissecting cadavers in order to acquire an even greater understanding of the threedimensional inter-relationships of structures. Third, the surgical residents should
supplement their detailed knowledge of live anatomy by assisting and learning
from more experienced surgeons at the operating table. By the time residents are
seniors or chiefs, they should not only be responsible surgeons, but experts in
anatomy. From this time onward, an operation should be carried out in an organized
manner, with dispatch and, in many respects, performed as “a song and a dance.”
Certain technical aspects in handling tissues in the course of an operation must
be recognized. Proper tension on tissues frequently will make them separate along
tissue planes. Blunt dissection can, at times, be carried out more safely than sharp
dissection. T h e use of traction and countertraction will not only facilitate separation
of tissues, but along with pressure, aid in controlling bleeding. Major vessels
should be ligated early so major blood loss will not occur.
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Following resection of tissues in an operation, remaining structures in the
anatomic site should be reconstructed in such a way as to re-establish anatomic
relationships. In re-establishing bowel continuity after a resection, preferably an
anastomosis should accurately approximate anatomic layers of the bowel wall. All
techniques do not do this.
With new imaging technology available in clinical practice, a detailed knowledge
of anatomy becomes even more important. With computerized axial tomography
( C T scan), magnetic resonance imaging (MRI), and ultrasound, cross-sectional
anatomy must be known and anatomic relationships appreciated by the diagnostician as well as the surgeon. Endoscopic procedures require greater appreciation of
anatomy viewed in a different perspective. T h e recent and rapid acceptance of
laparoscopic cholecystectomy is an excellent example of how new technology is
leading to a greater appreciation of anatomy.
T h e need for detailed knowledge of anatomy has significantly increased over the
past several decades. Intracardiac surgery 50 years ago first emphasized the need
for understanding the detailed anatomy of the heart. Organ and tissue transplantation or transfer has increased the need for accurate knowledge of blood supply to
tissues. Earlier surgical procedures required only information for excisional removal
of tissues protecting blood supply to remaining structures. Microsurgery is being
done today in the transfer of a section of small bowel to bridge a gap in the
esophagus. To anastornose the alimentary tract parts, it is necessary to carefully
join blood vessels to assure blood supply to them. A kidney transplant requires not
only restoring blood supply to the kidney but also re-establishing urinary tract
drainage. Coronary artery bypass or revascularization requires knowledge of arterial
anatomy not previously needed.
T h e approach to intracranial procedures is possible today because of imaging
procedures to more clearly identify the lesions and anatomy involved. This permits
operations not previously possible. Even ultrasound imaging has led to identification of congenital defects before birth, permitting repair of these by fetal surgery.
Also, massive body defects caused by excisional removal of tumors or trauma can
be reconstructed by transfer of tissue, resulting in restored function or repair of the
cosmetic defect.
T h e increasing technology and improvement of techniques of microsurgery will
continue to make possible in the future surgical procedures not previously thought
possible. These will require increased knowledge of detailed anatomy.
Although the importance of gross anatomy in the medical curriculum waxes and
wanes, it will always remain the most basic science in all of medicine. A few years
ago, the interest in the subject was at a low point. However, in recent years,
anatomy is regaining its rightful place in the medical curriculum and new technology and other advances in medicine are leading to added recognition of the
importance of anatomy in the clinical practice of medicine.
(Editor’s note: Dr. Beahrs served as first president of the Academy of Clinical
Anatomy, and recent past president of the American College of Su7geons.)
Oliver H. Beahrs
Mayo C h i c
Rochester, ,Minnesota 55905