2025/04/30 by John Bunni · 1 voice
Medicine · #Colorectal Cancer Surgical Treatments #Congenital gastrointestinal and neural anomalies #Stoma care and complications
paper · pdf · doi:10.1093/bjs/znaf062
openalex publication_date 2025/04/30 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
The rectoprostatic fascia or, more comprehensively, the ‘rectogenital septum’ is arguably the most important fascia to the colorectal surgeon. Its importance in rectal cancer surgery cannot be overstated. There have been many debates regarding the correct plane of dissection in total mesorectal excision with regards to this fascia, be it in front of or immediately behind it, most famously between Bill Head and Neil Mortensen, and even its very existence in female patients has been called into question. The eponym has been attributed to Charles-Pierre Denonvilliers (1808–1872), the Parisian anatomist and plastic surgeon. This was following his report to the Société Anatomique in 1836 when he described a ‘prostato-peritoneal membrane’, and not fascia, (‘l’aponévrose prostato-péritonéale’) between the rectum and seminal vesicles, and this later formed his dissertation in 1837. In actual fact, however, the fascia was first described by the Scottish anatomist and surgeon Granville Sharp Pattison (1791–1851) some 16 years earlier in 1820, in his ‘Experimental observations on the Operation of Lithotomy with the description of a fascia of the prostate gland (which appears to explain anatomically the cause of urine infiltrations, and consequent death)’. Herein the author looks at three aspects of this single structure: its history, anatomy and embryology, and finally surgical application. This trilogy has an important message behind it—authors, no matter how complex they may be as individuals, ought not be prejudiced or penalized for their work. The author suggests giving due credit to Pattison and thus renaming the structure as the ‘Pattison-Denonvilliers fascia’. Medical eponyms are much beloved by medical students and clinicians alike. They offer a rich insight into the history and evolution of medicine. As is often the case with the passage of time, further light is shed upon both the key actors and others who are less in the limelight, yet who have equally contributed, and for whatever reason have failed to be recognized. These reasons vary and can occasionally be nefarious, such as in the case of Asa Yancey in the pull-through procedure1, or simply be due to ignorance, omission, or accident (‘Hanlon’s razor’). It is important that, as further discoveries are made or brought to light, they are done so in the spirit of fairness, scientific advance, and pursuit of knowledge and truth, rather than for any unsavoury or aggrandizing purpose. Hence whenever attempts are made to rename or rewrite the past, a healthy dose of scepticism and a thorough and robust examination of the evidence should be employed, being forever mindful of the (Orwellian warned) danger of revising history. The rectoprostatic fascia or, more comprehensively, the ‘rectogenital septum’ is a trapezoidal septum of connective tissue that lies between the rectum and seminal vesicles in males and rectum and vagina in females. The widespread account in the literature is that this structure was first described by Charles-Pierre Denonvilliers (1808–1872), the Parisian anatomist and plastic surgeon, in 18362–4 following his anatomical dissections of male cadaveric perinea. Denonvilliers (Fig. 1)3 was a highly decorated surgeon and doyen who became ‘Professeur Agrégé’ in 1839, a highly respected and much revered role, having finished his doctoral thesis 2 years earlier entitled ‘Propositions et observations d’anatomie, de physiologie et de pathologie’ (Fig. 2) Charles-Pierre Denonvilliers (1808–1872) Denonvilliers’ thesis In 1840 he became a surgeon at the main hospital in Paris and in 1841 he became head of the Department of Anatomical Studies. In 1843 he and other prominent colleagues founded the Société de Chirurgie de Paris, of which he was the first chairman. He was prolific in his work both in anatomy and surgery and was widely published in both fields. Unbeknownst to most modern colorectal surgeons, Denonvilliers was particularly innovative in the field of reconstructive plastic surgery. Based on this work, Denonvilliers became Professor of Anatomy at the University of Paris in 1849. He continued in educational roles until 1864 following the premature death of his son from which he is said to have never fully recovered. He sadly died following a stroke in 1872. A further probing of the literature reveals that in actual fact this anatomical entity was described some 16 years earlier by the Scotsman Granville Sharp Pattison (1791–1851)5. Pattison (Fig. 3)5 had led a rather colourful life and was no stranger to controversy5–12. Born in 1791, Pattison was named after Granville Sharp (1735–1813), the famous British campaigner for the abolition of slavery. In his early years at Glasgow Grammar School, Pattison was not a particularly high-achieving student and was very clear about his likes and dislikes. Nonetheless he underwent private tutoring and later enrolled at the University of Glasgow Medical School from 1806 to 1812. There he was inspired by the eminent anatomists James Jeffray and Allan Burns, and developed a burning passion for anatomy. After graduation, Pattison took up a teaching post in anatomy at College Street Medical School and bonded with the founder and surgery professor, Dr John Burns, who was Allan’s brother7,10. Granville Sharp Pattison (1791–1851) His predilection for conflict was present throughout his life; so much so that Pattison kept a pair of pistols on his desk at all times7,9,10. Early on in his career he was accused and tried for grave robbing in the High Court of Justiciary in Edinburgh, albeit receiving a ‘not guilty’ verdict. At that time it was only legal to use the bodies of hanged criminals for medical science, yet a shortage of these resulted in the very unscrupulous practice of grave robbing. One famous case was that of Mrs Janet McAllaster; the very public trial generated so much anger that, despite Pattison being found not guilty, he was pelted with stones and almost lynched. Despite his tempestuous personal life, he remained an excellent teacher of anatomy and in 1818 was appointed Chair of Anatomy and Surgery at Anderson’s Institute in Glasgow. Things worsened when he was named as the lover of the wife of a colleague (Dr Andrew Ure) during the colleague’s divorce proceedings and at a similar time was engaged in numerous bitter rows both in Europe and later America with colleagues, most famously Hugh Miller, attending surgeon and director at the Glasgow Royal Infirmary9. So rowdy and unruly was Pattison that he was described by the late and great William Osler as ‘that vivacious and pugnacious Scot’!12 Mired with scandal he moved to the USA to start anew in 1819, given that he was told that his ‘private character at present lies under a stigma and employing you, our own good name would be abused’. He travelled to Philadelphia and not long after found conflict with Dr Nathaniel Chapman. He subsequently became Chair of Anatomy, Physiology, and Surgery at the University of Maryland in Baltimore. Further conflict ensued that resulted in trips back and forth between the UK and America. He was founding Professor of Anatomy at the University of London in 1826 and travelled back to the USA in 1832. He died in 1851 following the effects of chronic cholecystitis and was buried back in Scotland the following year. It was in 1820 in Baltimore, Maryland that Pattison described the ‘fascia of the prostate gland’ in his ‘Experimental observations on the Operation of Lithotomy with the description of a fascia of the prostate gland (which appears to explain anatomically the cause of urine infiltrations, and consequent death)’ (Fig. 4)5. This was a frequently performed procedure in those days for bladder stones and Pattison believed that the intraoperative damage of this fascia and subsequent urine extravasation was the main reason for the high mortality rate of this procedure. At the time, many believed that haemorrhage was the leading cause of death from this operation, but it was Pattison who postulated that it was sepsis due to violation of this anatomical barrier, resulting in urine extravasation, inflammation, and subsequently infection: ‘If I have, in the first part of my essay, proven by unquestionable facts, that in almost every case of death after lithotomy, this event occurs from infiltrated urine, producing gangrenous suppuration. betwixt the bladder and rectum; surely, upon the safety of this fascia, rests the safety of our patient’5. Pattison’s famous paper describing the rectogenital fascia Despite his tempestuous life, he was well recognized as a remarkable anatomist and pioneering surgeon. It is likely down to the work of Hugh Hampton Young (1870–1945) that Denonvilliers’ name was given to this fascia8. Young, the ‘Father of American Urology’ is credited as the pioneer of radical perineal prostatectomy in conjunction with William Halstead (although some believe the procedure was performed earlier still by George Goodfellow in 1891). Young had intensively studied the rectogenital fascia and employed the eponym ‘Denonvilliers’ fascia’ and hence appeared to be oblivious to Pattison’s work8. Young’s work also led to the embryological study conducted by Wesson in 1922 (which commenced at the Brady Urological Institute, Johns Hopkins, Baltimore, but was completed in the Department of Urology at the University of California)13. Wesson’s publication includes a thorough background history, citing Cunéo and Veau, Proust, Zuckerandl, Dixon, Henle, Moullin, and Waldeyer and Richardson, yet makes no mention whatsoever of Pattison13. What is truly astonishing is that Young and Wesson had both worked at Johns Hopkins in Baltimore where Pattison himself published his work in 1820 less than 40 miles away whilst at the University of Maryland. Patrick Walsh, also from Johns Hopkins in Baltimore, who first identified the neurovascular bundles in 1981 (which still bear his name) and subsequently performed the first nerve-sparing prostatectomy in 1982, also failed to recognize the original description of this fascia as coming from Pattison. The historical evidence put forward makes it crystal clear that this structure was first described by Granville Sharp Pattison. Therefore, the author suggests giving him due credit and renaming the rectogenital septum (at least in males) as the Pattison-Denonvilliers fascia. The author has no funding to declare. The author declares no conflict of interest.