EDITORIAL

 

Fistula-in-ano and Stephen Eisenhammer (1906-1995): Putting the record straight

 

 

Cedric Bremner^{I, II}

^IEmeritus Professor of Surgery, University of the Witwatersrand
^IIEmeritus Professor of Surgery, University of Southern California

Correspondence

 

 

Stephen Eisenhammer (Figure 1) was born in Middelburg in the Cape province in South Africa. His parents were of Viennese descent. He grew up on a farm in southern Rhodesia (now Zimbabwe), and studied medicine at the University of Cape Town and in Edinburgh in Scotland, where he graduated with a MBBCh in 1930. He was a house surgeon and surgical registrar at St Mark's Hospital for Diseases of the Rectum and Colon, London. He joined the London Emergency Medical War Services at the outbreak of war, and returned to South Africa in 1942. He then joined the South African Medical Corps and served in Madagascar.

 

 

In 1944, he started a private practice in Johannesburg, where most of his procedures were performed in his rooms under local anaesthesia. The author had occasion to visit him and to observe a procedure. On a later occasion, he was invited to my unit at Baragwanath Hospital to operate on a complicated anal fistula. His understanding of the anatomy was remarkable, and the patient was cured of a serious disease. Eisenhammer later became a part-time consultant at Coronation Hospital in Johannesburg.

He made significant contributions to the understanding of haemorrhoids, anal fistulae and abscesses, and internal anal sphincterotomy. His background at St Mark's Hospital obviously stimulated his interest in this area, and his first publication in 1951 was on the surgical correction of anal contractures.² His articles at that time were of such significance that they were usually long. Three articles published in Diseases of the Colon & Rectum were 15, 17 and 29 pages long.^3-5

Eisenhammer published his first article in the South African Medical Journal,¹ and reproduced the diagram of the transverse section of the anal canal, first described by Milligan and Morgan in 1934.¹ In 1956, he described the relationship of an anorectal abscess to the anatomy of the internal anal sphincter.⁶ This article introduced an understanding of the anatomical sites of anorectal abscesses and fistulae, which allowed the surgeon a safe and effective approach to the management of these conditions. Eisenhammer used the terms "acute" and "chronic" anorectal fistulous abscess because the origin of the fistula was the end result of the acute untreated abscess. In 1951, he published an article in the Journal of Surgery on the management of anal fissure by sphincterotomy.⁷

His articles on anorectal abscess and fistula, published in 1956, 1957, 1958 and 1966,^6,8-10 in which he clearly described the anatomy and management of these conditions, were of particular importance. His 1978 article on The final evaluation and classification of the surgical treatment of the primary anorectal cryptoglandular intermuscular (intersphincteric) fistulous abscess and fistula¹¹ was a culmination of his understanding and treatment of the condition.

Eisenhammer confided in me that he had spent many hours in the dissection hall in order to understand the configuration of this anatomy. On a visit to his old colleagues at St Mark's Hospital, he corrected their understanding of anal sphincterotomy. The St Mark's team was adamant that anal sphincterotomy was a division of the external sphincter, and argued with Stephen on this point. "Go and dissect the anal musculature in the anatomy laboratory as I did, and you will confirm that you are dividing the internal sphincter," he advised. His point of view was later accepted.

It was roughly 10 years later that Sir Alan Parks, who became President of the Royal College of Surgeons in England, also wrote articles on anorectal abscesses.^12,13 His anatomical diagrams and the concept of the origin of these abscesses were similar to Eisenhammer's, and he referenced the latter's classical articles. Eisenhammer confided to me that he was somewhat surprised and disappointed that Parks had not specifically mentioned that the concept was Eisenhammer's. On a later visit to London, he met Parks and mentioned the publication. Parks was a gentleman and apologised for not referencing Eisenhammer, and sensing Eisenhammer's disappointment, made him an honorary member of the British Colorectal Society.

 

REFERENCES

1. Eisenhammer S. The internal anal sphincter; its surgical importance. S Afr Med J. 1953;27(13):266-270.         [ Links ]

2. Eisenhammer S. The surgical correction of chronic internal anal (sphincteric) contracture. S Afr Med J. 1951;25(28):486-488.         [ Links ]

3. Eisenhammer S. Proper principles and practices in the surgical management of hemorrhoids. Dis Colon Rectum. 1969;12(4):288-305.         [ Links ]

4. Eisenhammer S. Total skin conservation approach to the surgery of the anorectal cryptoglandular intermuscular fistulous abscess and fistula with special reference to the "plastic saucerisation (marsupialisation) operation of the ischiorectal fossa. S Afr J Surg. 1972;10(1):5-19.         [ Links ]

5. Eisenhammer S. The surgery of the internal anal sphincter. New Orleans: American Proctologic Society Congress, 1974.         [ Links ]

6. Eisenhammer S. The internal anal sphincter and the anorectal abscess. Surg Gynecol Obstet. 1956;103(4):501-506.         [ Links ]

7. Eisenhammer S. The anorectal and anovulval fistulous abscess. Surg Gynecol Obstet.1961;113:519-520.         [ Links ]

8. Eisenhammer S. A new approach to the anorectal fistulous abscess based on the high intermuscular lesion. Surg Gynecol Obstet.1958;106(5):595-599.         [ Links ]

9. Eisenhammer S. The evaluation of the internal anal sphincterotomy operation with special reference to anal fistulae. Surg Gynecol Obstet. 1959;109:583-590.         [ Links ]

10. Eisenhammer S. The anorectal fistulous abscess and fistula. Dis Colon Rectum. 1966;9(2):91-106.         [ Links ]

11. Eisenhammer S. The final evaluation and classification of the surgical treatment of the primary anorectal cryptoglandular intermuscular (intersphincteric) fistulous abscess and fistula. Dis Colon Rectum. 1978;21(4):237-254.         [ Links ]

12. Parks AG. Pathogenesis and treatment of fistula-in-ano. Br Med J. 1961;1(5224):463-469.         [ Links ]

13. Parks AG, Stitz RW. The treatment of high fistula-in-ano. Dis Col Rectum. 1976;19(6):487-499.         [ Links ]

 

 

Correspondence:
Cedric Bremner
bremnersa@mweb.co.za