Ralph Ger (1921–2012)

Ralph Ger (Fig. 1) was born in Cape Town, South Africa on February 20, 1921 and died peacefully at home in Great Neck, New York on April 9, 2012 forty-nine days past his 91st birthday. Ralph was a rare and special man to clinical anatomists around the world not only because he played the major role in the creation of the American Association of Clinical Anatomists (AACA) but also because he touched, inspired, and was a guide to everyone who met him professionally and came to know him personally during his life. Ralph Ger, July 17, 2009, 26th Annual Meeting of the American Association of Clinical Anatomists, Cleveland, Ohio. Photo by Samuel A. Scott. Starting from almost his first school days as a child, Ralph excelled in his studies with one fortuitous exception. Luckily, the one subject where he dawdled was Afrikaans. His resistance to learning this language was indeed fortunate for the world of clinical anatomy and his future patients because this deficiency would in later years be his undoing as he pursued his childhood ambition to become a veterinarian. There was only one veterinary school in South Africa, and it was located in Pretoria almost a 1,000 miles from Cape Town. However, more significant than its distance from Ralph's home was the fact that instruction, at that time, was entirely in Afrikaans and not in English as was the case at Cape Town's university. With some sadness, he took this reality to heart and refocused his career ambitions on going to medical school and caring for bipeds rather than quadrupeds. Ralph finished school and started university at the precociously ripe age of 15! As one of over one hundred and fifty-first year medical students at the University of Cape Town, he took zoology, botany, chemistry, and physics. He earned one of the highest scores in his exams and was among the select group, of about one hundred students, admitted to the second year of medical school in 1938. It was there that his ardor for anatomy blossomed in the dissection room. Based upon continued stellar exam performances, Ralph was honored at the beginning of his third year with the distinction of being appointed Demonstrator of Anatomy at the age of 17. Ralph joined the South African Medical Corps upon receipt of his M.B., Ch.B degree in 1943 and served in the Corps for the remainder of World War II. Following his 1946 discharge, he returned to Cape Town to pursue a career in surgery and resumed his anatomy training as a postgraduate student. In 1948, Ralph decided that he needed to travel to England for further training and to complete the fellowship exams at the Royal College of Surgeons. During his five-year journey to pass these exams, one of the two catalytic events that would catapult Ralph further down the path of clinical anatomy occurred. He met the consultant surgeon Alfred M. Abrahams, the father of our Honored Member Peter Abrahams, while working at Walton Hospital in Liverpool. The seeds for clinical anatomy, which Ralph had planted in Cape Town while learning anatomy and practicing medicine, were skillfully cultivated and stimulated by Mr. Abrahams. Ralph told of a hiking trip they took to the beautiful Lake District during which they pondered the surgical anatomical adventure of kidney transplantation over half a decade before the first such operation was performed in Boston in 1954. Clinicians would come to know Ralph as a surgeon whose anatomical creativeness in the service of his patients was equally matched by his technical skill and courage born from his knowledge of the body. Ralph pioneered the use of muscle flaps to promote wound closure (Ger, 1966) and performed the first human laparoscopic hernia repair (Ger, 2003). As such, Ralph joined the 20th century giants in innovative minimally invasive surgery who forever changed the practice of surgery and the character and philosophy of surgical education. He was also a prodigious inventor of surgical devices. He developed and patented one of the first laparoscopic staplers as well as a mechanical device—the Proxiderm™—to promote treatment of chronic wounds using traction (Ger, 1995, 2012). Ralph's first five years in England and Scotland were arduous. The pressing demands of clinical work and studying for the surgical fellowship exams weighed heavily on his time and energy but he would eventually complete these exams in London and Edinburgh in 1953 to qualify as FRCS and FRCS (Ed). He returned to South Africa in 1955 after working two more years in England, one of which was in Birkenhead in Merseyside where Alfred Abrahams had relocated his practice. Returning to South Africa, Ralph was appointed an Assistant Surgeon at the University of Witwatersrand's Baragwanath Hospital, which at the time was the largest hospital in the world with a huge volume of trauma patients who needed surgery. Taking this position in Johannesburg was also significant because, at Baragwanath Hospital, he met an occupational therapist, Dorrit Neumann. They married in 1958 and started a family which, eventually included Amanda (1959), Michael (1960), and Kevin (1964). Ralph's stay in the Johannesburg, while eventful, was brief as he was quickly recruited back to Cape Town. From 1957 through 1966, he practiced and taught at the University of Cape Town where he rose to the positions of Surgical Attending at the Groote Schuur Hospital and Lecturer (=Assistant Professor) in Anatomy at the medical school. In 1966, persecution by the racist apartheid government, which had identified him as a subversive, resulted in Ralph losing all of his hospital privileges. At this bleak time for the Ger family, there appeared the second catalytic individual who would play a very significant role in Ralph's surgical career, his passion for clinical anatomy, and ultimately in the creation of the AACA. This individual was Gershon “Effie” Efron. Effie was a Cape Town medical school graduate who had become a surgical resident and worked at the same hospital as Ralph. After finishing his residency, he too journeyed to England for additional training and to complete the Royal College of Surgeons fellowship exams. After three years of postgraduate surgical training and passing his exams, Effie had a chance encounter in London with a visiting professor of orthopedic surgery from New York's Albert Einstein College of Medicine who invited him to come to the United States to interview for a position at the relatively new medical college. Effie, who was then looking for a job, flew to New York and within the week was hired. Before moving to New York, Effie—who would subsequently become one of the Founding Members of the AACA—decided to make what he describes as a “possibly last visit” to Cape Town to visit family and friends. He arrived in South Africa shortly after the authorities had stripped Ralph of all his hospital privileges and appointments. Rejecting the advice of friends to stay away and not visit his former colleague and family who were being “watched,” Effie went to see Ralph and Dorrit to tell them about the job opportunities in the United States. Several months after Effie left Cape Town for New York, Ralph made his own trip to New York City where, not surprisingly, he too secured a surgery position at Einstein. Ralph returned to South Africa to collect the Ger family and emigrate to the United States. At Einstein, Ralph's abilities and potential were almost immediately appreciated and he was promoted to Chief of Surgery at Weiler Hospital located on the college's campus. With this relocation, Ralph gained, as he had in Cape Town, convenient access to a dissection laboratory where he could explore and teach anatomy with the goal of improving surgical outcomes and training. Ralph's surgical career at Einstein lasted until 1987 when he departed to become the Chair of the Department of Surgery at Winthrop University Hospital and to have a much shorter drive from his home on Long Island. Turning to Ralph's educational activities, Ralph and Effie emerged in 1968 as major figures charged with reshaping Einstein's anatomy course to emphasize the importance of anatomy in clinical practice and surgery. Two years later, Ralph was named the course director. Ralph and Effie continued to share many ideas about teaching applied or clinical anatomy. They were appalled at the increasingly woeful anatomical knowledge displayed by first year surgical residents, and motivated by what they saw as the need for more medically qualified faculty to teach anatomy. Under Ralph's direction these ideas were liberally incorporated into Einstein's anatomy course and eventually made their way into Ralph's textbook Essentials of Clinical Anatomy (Ger and Abrahams, 1986). The textbook was based upon Ralph's lecture notes and benefited significantly from the editing and input of his coauthor, the aforementioned, Peter Abrahams. Since Ralph's departure from Liverpool in 1955, Peter had grown up to become a practicing physician as well as a Senior Lecturer (Associate Professor) in Anatomy at The Middlesex Hospital Medical School in London. A second edition of Ralph's textbook was published in 1996 (Ger et al., 1996). Ralph's departure from Einstein's hospital in 1986 did not diminish his commitment to its anatomy course. When I arrived at Einstein in 1989 as the new course director, Ralph was a very active and omnipresent legend. He continued as the principle lecturer for the next 20 years and retired from teaching in 2009 when he gave his last lecture on the abdominal wall and herniae at the age of 88. Any one who attended even one of his lectures would remember his colorful chalkboard drawings (he only showed projection slides during the last 5–10 min of each lecture), his witty sayings and striking accent, and the way he made improving patient care the focus for each of his clinical anatomy lectures. Needless to say, Ralph received every teaching award offered by the medical college. Finally, what about Ralph's role in the creation of the AACA? After arriving in New York, Ralph regularly attended national and international surgical meetings. At these meetings, he found many likeminded surgeons who shared both his vision for teaching clinically oriented anatomy and his concerns about diminished anatomical training and its ultimate impact on the care of current and future surgical patients. Three such surgeons, frequently cited by Ralph, played central and critical roles in the events prior to his calling for the creation of the AACA in 1982. One was N. Alan Green from Norwich, England who would become a Founding Member of the AACA as well as one of our Honored Members. Alan was one of the founders and an early President of the British Association of Clinical Anatomists (BACA) that was established in 1977 to promote a stronger relationship between clinicians and anatomists (McDonald, 2003). Alan is currently writing a much more comprehensive account of Ralph for the Royal College of Surgeons (England) series: Plarr's Lives of the Fellows that can be accessed online by the public when it is published (Green, in prep., Online. URL: http://livesonline. rcseng.ac.uk/biogs/E002545b.htm [accessed September 2012]). The two other prominent surgeons who encouraged Ralph and lent their early and strong support were Oliver H. Beahrs (Ger, 2006) and Robert A. Chase who together with Ralph would serve as the first three Presidents of the AACA. Together, they also coauthored the only article, Gross Anatomy in Medical Education (Beahrs et al., 1986), cited by the late David Dawson in his omnibus history of AACA's first five years (Dawson, 1988). What is not covered in Dawson's excellent account of the AACA's origins, Ralph covers in his own words in an Editorial (Ger, 2004). While there were many individuals, listed in the official rooster of the 84 Founding Members (Dawson, 1988), who played seminal roles in founding the AACA in 1983, Ralph Ger stands apart as deserving our recognition as The Founding Father. Ralph, or “Sir Ralph” as he came to be known, would have generously spread a great deal of the initial credit upon other worthy individuals but history points to him as the key player. He was the person who, after several years of preparation and collaboration with many of the invitees, would call the inaugural organization meeting for February 18, 1983. According to Effie Efron, who was one of the 18 invitees present at this gathering, Ralph chaired and, with a creator's hand, orchestrated its proceedings. As a direct consequence of the formative decisions made at this meeting, the AACA was officially born on October 17 in Atlanta at the 1983 meeting of the American College of Surgeons. Oliver Beahrs was selected as the first president and Ralph the vice president. Several years later, Ralph was the driving force, along with several others, in the Association's decision to sever its relationship with The American Surgeon and to embark upon the creation of its own journal, Clinical Anatomy. Ralph was also a single and immutable clarion for Clinical Anatomy becoming a joint publication with the British association BACA. Influenced by his skillful guidance and enthusiasm, BACA decided to unite with us in this new venture. Ray Scothorne from Glasgow was named to join Ralph as Clinical Anatomy's first Editors (Ger and Scothorne, 1988). Ralph held this position through 1991 and the printing of the journal's fourth volume. Finally, Ralph's unique and special standing amongst the many who have contributed so much to creating and building the AACA and its journal is evidenced by the fact that he was the first member to receive both the Association's Honored Member in 1991 and the R. Benton Adkins Distinguished Service Awards in 2007. Only two other members, Keith Moore and Art Dalley, have been so honored in AACA's 30-year history. Art was one of the many who wrote to the Association upon learning of Ralph's death. I think his remarks speak—well beyond what I write here—for the many who shared their dismay and sadness at the news we would not see Ralph again. “Ralph Ger was a personal hero to me almost from the moment of our acquaintance. Ralph was as resolute in his stand for human rights in opposing apartheid as he was in his concern for the pain and suffering of patients. Ralph demonstrated great innovation in the surgical theater by applying anatomical principles to restore near normal function. Similarly, he demonstrated exceptional scholarship in his desire to see that his and his colleagues' experiences were shared with other clinicians and anatomists for their benefit, analysis, and criticism. Yet, his self-deprecating humor and stories would bring tears to my eyes as he painted himself as ideally-intentioned, yet as vulnerable to catastrophic situations as a Chevy Chase character.” Arthur F. Dalley, Ph.D. Nashville, TN Ralph taught me almost everything I know and appreciate about clinical anatomy. The most important of his lessons was that he cared for his patients by using his anatomical knowledge and creativity to solve problems that diminished his patients as fully functional human beings. Ralph did not treat patients. He cared for them. This is the soul of clinical anatomy as well as the man who was one of the founders and ardent promoters of this discipline. As consequential as Ralph's role in AACA may seem to us, the clinical ground upon which he walked is far loftier and now less traveled. Ralph was a true and unique pioneer, a revolutionary clinical innovator, encouraging mentor in the operating room, and a courageous surgeon. While most of us felt rewarded and stimulated from our acquaintance with him as a clinical anatomist, there are many more who knew him much more dearly and gratefully. They are the thousands of patients who appreciated him because, in so many instances, he surgically created for them a life and quality of existence that would not exist if Ralph Ger had not been their surgeon. The bottom line for Ralph was always that clinical anatomy is all about improving patient care! Ralph was a valued and influential mentor because he appreciated that the greatest teachers were those who continued to learn in spite of their vast experience. Front row center is where Ralph liked to sit during our meetings where he joined with us as a peer who was more eager to ask questions than to expound or pontificate. He definitely had his own strong opinions but he was always approachable with an inviting smile, sparkling blue eyes, and a charming greeting. Ralph cared about clinical anatomy and our association. Front row center in each of our hearts is where the man, we all came to know and love, will be remembered. Sir Ralph, gone but never to be forgotten.