Arpad G Gerster, MD, and the First Photographic Surgical Textbook

APE

PtpibcitdPoAbpp

FGHSldwafjciuwiesps

C

RFCUA

©P

rpad G Gerster, MD, and the Firsthotographic Surgical Textbook

lise B Halajian, T Adrian Wheat, MD, David A Bloom, MD, FACS

sdmsepdb

dMytdioliEVr1omytrop1

EAkuhtca

hotography became a key part of surgical education inhe latter part of the 19th century, a pivotal time in theractice and teaching of surgery. During this era, detailed

llustrations and photographs in medical journals and text-ooks began to complement the written words of physi-ians. These publications disseminated new discoveries,deas, and techniques allowing wide and rapid vetting inhe medical community. The photograph had been intro-uced as a practical tool by Louis Daguerre in 1838. Hisarisian street scene might have been the first photographf a human professional service—in that case, a shoeshine.1

half century later, Arpad Geyza (Charles) Gerster’s text-ook, The Rules of Aseptic and Antiseptic Surgery, broughthotography squarely into the teaching of a far more com-lex professional service, surgical practice (Fig. 1).2

AMILY AND CHILDHOODerster was born on December 22, 1848, in Kassa,ungary, the third of eight children of Caroline

chmidt-Sándy and Nicholas Gerster. As a child, Arpadearned the importance of respect, love, and education,escribing his family life as “like that on a shipboard,here everybody knows the business of everyone else,

nd order and punctuality are indispensable.”3 Arpad’sather, Nicholas Gerster, was a master chandler who hadoined the liberal party in 1847 and consequently be-ame heavily involved in Hungarian political affairs dur-ng the mid-1800s. As an identified rebel, he was keptnder police surveillance until 1854, when martial lawas eradicated in Hungary and the commonplace polit-

cal executions came to an end. Nicholas Gerster was anducated man, one of few Kassa inhabitants to speakcholastic Latin, and he became a well-respected androminent citizen. Arpad’s mother, Caroline, was de-cribed in Gerster’s autobiography as intelligent, deci-

ompeting Interests Declared: None.

eceived February 16, 2006; Accepted March 1, 2006.rom the Department of Urology, University of Michigan, Ann Arbor, MI.orrespondence address: David A Bloom, MD, Department of Urology,niversity of Michigan, 1500 E Medical Center Dr, 3875 Taubman Center,

fnn Arbor, MI 48109-0330. email: [email protected]

1162006 by the American College of Surgeons

ublished by Elsevier Inc.

ive, and independent.3 In addition to raising eight chil-ren, Caroline Gerster assumed an integral role in theanagement of her husband’s business. Gerster and his

iblings learned the value of education and independ-nce from their parents. He reflected, “My parents wereartners in every sense of the word. Love and respect areistinct entities: the first is a free gift, and the second muste earned by a series of successful tests.”3

The eight children of Nicholas and Caroline were aiverse and extraordinary lot. The two oldest sisters,ary and Constance, were followed by Arpad and his

ounger brother, Béla. After school in Kassa, Béla at-ended the Polytechnic Institute in Vienna and achievedegrees in engineering and architecture. He played a role

n the construction of the Canal of Corinth, whichpened in August 1893. Berta and Etelka were next inine, described by Gerster as “the musicians of the fam-ly.”3 Berta passed away in 1873 after a brief illness.telka studied voice and music at the Conservatory ofienna. She was esteemed by audiences throughout Eu-

ope and the United States and retired from the stage in890. Anna and Nicholas were the youngest. Anna tookn the role of mentor for her younger brother, Nicholas,arried well, and passed away in 1889. Nicholas, the

oungest child, became assistant to the chair of chemis-ry after graduation from the Polytechnic School of Zu-ich. He was well known for organic chemistry researchn ethereal oils and industrial chemistry and earned ap-ointment as royal inspector of chemical industries in892. Nicholas died in 1916.

DUCATIONrpad Gerster began school at 5 years of age, havingnown the alphabet since age 3. He passed examinationssually completed at the end of the fourth year just afteris third year in primary school. Rendered a year youngerhan his secondary schoolmates, Gerster found the olderhildren did not approve of his intrusion into their class,lthough in time he gained acceptance.

Gerster completed secondary school and graduated
rom the Kassa Gymnasium at 17 years of age. His initial
ISSN 1072-7515/06/$32.00doi:10.1016/j.jamcollsurg.2006.03.001

cnmiUrUam1mH1sgsK

GGu

faFtVtpgG1Bbyob

safhpY(HlRscrL““lfHbsditsycsicM

Fo

117Vol. 203, No. 1, July 2006 Halajian et al First Photographic Surgical Textbook

areer inclinations were toward maritime endeavors andatural sciences. Influenced by childhood friend andentor, Robert Ultzmann, Gerster turned to medicine

n 1864. Ultzmann had begun medical training at theniversity of Vienna in 1862, but returned to Kassa

egularly for vacations and visits with Gerster. In 1885,ltzmann was appointed to a professorship of surgery

nd urology at the University of Vienna. Joining Ultz-ann at Vienna, Gerster began medical training in

866. Gerster received his degree as doctor of medicine,aster of obstetrics, and doctor of surgery 7 years later.e entered the Austro-Hungarian Army in October of

872 under the universal military service plan and sub-equently served as a second lieutenant and assistant sur-eon in two units. Released in September of 1873, Ger-ter became the head of the Pathology Department atassa City Hospital.

ERSTER IN AMERICAerster was attracted to America, perhaps inspired by an

igure 1. Arpad G Gerster, MD. (Courtesy of the Mount Sinai Schoolf Medicine Archives.)

ncle in Brooklyn, NY. Despite the disapproval of H

riends, who perceived the notion of settling in Americas “incomparably foolish,” Gerster left Hungary in earlyebruary 1874.4 On the way to the United Stateshrough Bremen, Germany, he visited Alfred Wilhelmolkman’s clinic in Halle and observed the new Lis-

erian techniques; Lister had published his seminal pa-er, “On the Antiseptic Principle in the Practice of Sur-ery,” only 7 years earlier in the British Medical Journal.5

erster sailed to the United States on February 21,874, on board the S.S. Donau, where he met Annaarnard Wynne, an American from Cincinnati who hadeen studying music in Stuttgart. They married nearly 2ears later on December 14, 1875. Of their three sons,nly one reached maturity,6 this was John CA Gerster,orn on November 27, 1881.After arriving in New York on March 9, 1874, Gerster

ettled in Brooklyn and took over the general practice ofGerman physician who was returning home.7 Two new

riends, Dr Ernst Krackowizer and Dr Frederick Zinsser,elped Gerster get started in his first week by referringatients and making introductions to different Nework hospitals. Gerster visited the German Hospitallater Lenox Hill), the recently completed Rooseveltospital, St Luke’s Hospital, and the Long Island Col-

ege Hospital. The conditions at the newly constructedoosevelt Hospital in particular contrasted to those Ger-

ter had experienced in Austrian hospitals. The order,leanliness, and modern furnishings from the operatingooms to the patient quarters impressed him, althoughisterian method was lacking. With his introduction tomedical men and students,” Gerster observed thatphysicians in America were more concerned with estab-ishing a feeling of confidence and trust, hence of com-ort, in patients, than were [their] colleagues abroad.”3

e attributed this difference to the contrast in statusetween American physicians and those abroad. Gersteraid he had come from a country where “the medicalegree per se invested the physician with a social stand-

ng and authority unknown in America, where, in 1874,he meager educational requirements made it easy toecure a diploma after ‘two sessions of so many weeks aear.’”3 Here, Gerster was referring to the usual medicalurriculum of a yearly series of lectures repeated over aecond year and an apprenticeship as the standard Amer-can medical degree requirements in the 1870s. Gersterommented, years later, in an article entitled “Asepticethods of the Present Day in the Field and in the
ospital with a Retrospect,” on his early impressions of

ALoaic

vGPhmYa

thHagpana1mhwiruiiogppra

Rtvcmssn

(hThoMpf

LGpeSnUbrepaifttmSnaaogaSMs

mopgwtmo

d

118 Halajian et al First Photographic Surgical Textbook J Am Coll Surg

merican medicine and the incorporation of the newisterian techniques: “I reached New York in the monthf March, 1874, and visiting the hospitals of New Yorknd Brooklyn, found hardly a trace of serious endeavorn the new direction.” He added that many older physi-ians refused to accept the new methods.8

Krackowizer, cofounder of the German Hospital, in-ited Gerster to assist him at operative procedures.3,7

erster was shortly thereafter appointed surgeon at Steter’s Hospital in a new outpatient department,7 wheree was one of the first in America to use the Listerianethod regularly during operations. A few of his New

ork colleagues had also picked up the Listerian methodfter traveling to Europe.3

In 1877, Gerster moved from Brooklyn to Manhat-an, where he practiced surgery exclusively for the rest ofis life. He became attending surgeon at the Germanospital in 1878 and just 2 years later, received a similar

ppointment at Mount Sinai Hospital, one of very fewentiles so distinguished at the time.4 Gerster partici-ated vigorously in the New York medical communitynd became surgeon and professor of surgery at theewly established New York Polyclinic Medical Schoolnd Hospital in 1882, remaining chairperson until894. This organization, “the first school of graduates inedicine independent of an undergraduate college,”7

ad been founded by John Wyeth, a prominent surgeonho recognized the need for practical postgraduate med-

cal education. The Polyclinic was “an amalgam of Eu-ope’s short clinical courses and America’s ubiquitousrban dispensaries . . . [and] what made [this school] so

nfluential was that the wide variety of courses, especiallyn the surgical specialties, helped make up for the dearthf other clinical educational opportunities.”9 Under-raduate medical education at that time did little torepare its graduates for the practicalities of clinicalractice, and postgraduate schools filled a niche thatesidency training programs would subsume a few dec-des later.

At the Polyclinic, Gerster taught the Mayo brothers ofochester, MN, who came for special instruction during

he 1880s. William Mayo, an 1883 graduate of the Uni-ersity of Michigan Medical School, took a postgraduateourse at the Polyclinic in the fall of 1885. “Mayo re-embered Gerster as ‘a physician first, and a surgeon

econd, for he regarded the patient from the broadtandpoint of general medicine rather than from the
arrower standpoint of surgery.’”7 Charles Mayo d
Northwestern School of Medicine, 1888) later joinedis brother at Gerster’s clinics in 1888, 1889, and 1890.he Mayo brothers and Gerster held one another in theighest regard—the Mayos respected Gerster for hisutstanding leadership and Gerster appreciated theayos’ interest in and “preference for fundamental

athologic facts, a knowledge of which is the only basisor sound therapy.”10

ATER CAREERerster’s reputation grew locally and abroad. He becameresident of the New York Surgical Society in 1891,meritus professor at New York Polyclinic Medicalchool and Hospital in 1894, and 2 years later wasamed consulting surgeon at the German Hospital. Theniversity of Budapest offered him a chair in surgery,ut he turned it down, noting “where my name andeputation were made, there I proposed to serve to thend of my allotted time.”3 For most of his 40 years ofractice until retirement in 1914, because of mandatedge limitations, Gerster was a central figure in the med-cal community at Mount Sinai. He headed one of itsour surgical staffs in 1882 and dedicated much time tohe reorganization of surgical services. A major restruc-uring was again necessitated in 1904 when the hospitaloved from Lexington Avenue between 66th and 67th

treets to One Gustave L Levy Place at 1190 Fifth Ave-ue. As consultant at this time, Gerster was influential indministrative decisions.11 He managed hospital spacessignments, encouraged the installation of additionalperating rooms, and enhanced the training of the sur-ical nursing staff. Gerster served as Medical Counselornd Honorary Director for the Mount Sinai Trainingchool for Nurses,12 and, in 1896, he stood before theedical Board at Mount Sinai to stress the value of

killed nurses in operating rooms.13

Gerster wrote well in English and published over 80edical papers during his lifetime.6 His paper in 1885

n the surgical dissemination of cancer is a good exam-le, describing the case of a woman with a plantarrowth that might have been melanoma. Local resectionas followed by spread, above-the-knee amputation,

hen cranial metastases and suicide. EL Keyes, MD, aajor figure in the New York medical community, was

ne of the commentators on this case.14

One intern of Gerster’s at Mount Sinai from 1899escribed Gerster as “. . . a great surgeon, but a very
ifficult man. He was by temperament and background,

abakdcc

ctiACCtt1atabtsac1AcppYAtf

olHscJSthCcemdtfllhas

GGAdtstdcfgapEcGcttmmmos

F(


n overbearing European, Hungarian by birth, whorowbeat his assistants, nurses, and doctors to prove hisuthority.”15 Another colleague noted, “Gerster had aindly sympathy for the frailties of humankind, a won-erful sense of humor which took the sting out of hisritical remarks and made of him a gentle and lovableompanion.”16

Gerster furthered his involvement in the medicalommunity at home and abroad with memberships inhe German Association of Surgeons (Berlin), the Med-cal Society of the County of New York, the Hungarianssociation of New York (president, 1895), and theharaka Club. Gerster was admitted into the eliteharaka Club after giving an anniversary address enti-

led “The American System of Hospital Economy” tohe New York Academy of Medicine on November 2,905.3 The Charaka Club provided an outlet for Gersternd other prominent physicians to explore cultural in-erests in relation to medicine, such as music, art, poetry,nd history. Members were primarily from New York,ut included others from St Louis, Brooklyn, Washing-on, Philadelphia, Boston, Baltimore, and Oxford. Ger-ter achieved an additional distinguished appointments professor of clinical studies at the College of Physi-ians and Surgeons, Columbia University, from 1910 to914. He was elected president of the American Surgicalssociation from 1911 to 1912. In 1916, Gerster be-ame a trustee of the New York Academy of Medicine, aosition he retained until dying at age 74 of anginaectoris at his home and office (34 E 75th Street in Nework City) on March 11, 1923.17 He was buried in thedirondack Mountains, a place he especially favored

hroughout his adult life, having been a strong advocate

igure 2. The Adirondack Mountains. Sketch by Arpad Gerster.Courtesy of the Mount Sinai School of Medicine Archives.)

or environmental conservation (Fig. 2).18 w

Gerster’s son, John, had an influential surgical careerf his own after graduating from medical school at Co-umbia University in 1905 and training at Mount Sinai

ospital through 1908. He remained on the surgicaltaff at Mount Sinai and became president of the Asso-iated Alumni of The Mount Sinai Hospital in 1929.19

ohn was distinguished as a founder of the Americanociety for the Control of Cancer (which later becamehe American Cancer Society), a group that first met inis home in 1913. Appointed chairman of the New Yorkity Cancer Committee in 1926, John Gerster was a

entral figure in the establishment of a public cancerducation program. Throughout John Gerster’s chair-anship and especially during the late 1940s, “a tremen-

ous change took place in the attitude of the publicoward cancer and its control. Influential leaders in allields of endeavor began to take an active interest andend active support to the movement.”20 John Gersterived to age 92 and died of cancer in the same house asis father. A son of John Gerster, John Wynne Gerster,lso became a surgeon and served as the senior attendingurgeon at Greenwich (CT) Hospital.21

ERSTER AND PHOTOGRAPHYerster’s contribution was his textbook, The Rules ofseptic and Antiseptic Surgery, in 1890.2 This book wasoubly remarkable. It was the premier American surgicalext on sterile technique and was also the first majorurgical book to incorporate many photographs. Gersterook the photographs himself and William Kurtz repro-uced the plates using a halftone process. Halftone pro-essing involves printing a photographic image in theorm of dots. Different tone densities from the photo-raph are represented by dots of various sizes. Kurtz waspioneer in the field of photography and “was the first toerfect the color halftone printing process.”22 Boston’sngraver and Printer published one of Kurtz’s first suc-essful color halftone prints in March 1893.22 Beforeerster’s book, the use of photography in medical edu-

ation had been minimal and his innovative incorpora-ion of halftone prints was a giant step. The influentialextbook cycled through three editions. This “was theost talked-of book of its time in medical circles, anday well have been the strongest single factor in pro-oting the spread of the practice of antisepsis.”10 The

riginal manuscripts of both the surgical text and Ger-ter’s autobiography, Recollections of a New York Surgeon,
ere donated to the New York Academy of Medicine for

pGB

PTdosfdwJpbari

lom1cp1oapfamsciwmasp“tDJuttp

pptsmas1ippipmfssapdlsrpwwbs(so

pBeiHiprmlppma


reservation by Mrs Arpad Gerster and Dr John CAerster in 1931, where they remain today in the Rareooks Library.3

HOTOGRAPHY AND PRINTING IN 1887he capture of an accurate image on a permanent me-ium must have seemed an improbable dream through-ut most of human history. This fantasy began to showome promise with the camera obscura, wherein lightrom a subject enters a pinhole opening in the wall of aark room and casts an inverted image on the oppositeall. Painters such as Albrecht Durer (1471�1528) and

an Vermeer (1632�1675) used variants of this princi-le for their work, and by the 17th century small portableoxes with lenses at the aperture allowed artists to tracen image on thin paper placed over a glass plate.23 Theepresentations still amounted only to imitations ofmages.

Thomas Wedgewood made actual images formed byight and the subject itself when he produced sun printsn paper and other substrates. Joseph Nicephore Niepceade negatives with his heliograph process by 1816. In

827, he met the stage-set painter Louis Daguerre, aorrespondence ensued, and the two signed articles ofartnership in 1829. Niepce died 4 years later and by837, Daguerre had developed the process to the pointf producing the immodestly named daguerreotype, onsilver-plated 6.5 � 8.5-inch copper sheet. The coatedlate was made light-sensitive by contact with iodineumes, exposed to an image formed by a camera obscura,nd the latent depiction was developed through heatedercury. Henry Fox Talbot, an English scientist, had

omewhat independently developed a similar image-apturing system. His idea arose while traveling in Italyn 1833 “on the lovely shores of Lake Como,” when heas sketching with a camera lucida and he thought itight be possible to fix a vision on sensitive paper usingcamera obscura. By 1835, Talbot was making inch-

quare glass negatives, and early in 1839 he presented aaper on his method to the Royal Society of London:Some Account of the Art of Photogenic Drawing, or,he Process by Which Natural Objects May Be Made toelineate Themselves Without the Aid of a Pencil.” Sir

ohn FW Herschel improved on Daguerre and Talbot bysing sodium thiosulfate (“hypo”) to permanently fixhe image, thereby precluding additional changes fromhe effect of continued light exposure. Additionally, he
roposed the term photography, which replaced Talbot’s
hotogenic drawing. In 1841, Talbot described an im-roved process, which he called the calotype (or talbot-ype), wherein he developed a latent negative image inilver iodide papers. From the negative he could makeany copies. Frederick Scott Archer in 1851 developedcollodion wet-plate process and the daguerreotype

oon became obsolete.The new wet plates required up to0 seconds of exposure (necessarily on a tripod) andmmediate processing. During the Civil War years, fieldhotographers such as Matthew Brady took their wet-late apparatus to the scenes of action. Ensuing technicalmprovements permitted wider application of photogra-hy through the next half of the 19th century, such thatuch of human life and the natural world were soon

ixed in images. Richard Leach Maddox, an English phy-ician and amateur photographer, could not stand themell of the ether necessary for the wet collodion platesnd experimented with dry emulsions. In 1871, he re-orted favorable experience with gelatin dry plates (“theriest of the dry”), permitting excellent negatives that no

onger required immediate processing.24 Initial expo-ures required 30 to 90 seconds, but his method waseproducible and technical improvements in his drylates soon permitted exposures as brief as 1

25 a secondith hand-held cameras. By the 1880s, photographersere capturing motion as evidenced by Eadweard Muy-ridge’s galloping horse (1878), fencer (1890), and head-pringer (1885) and Thomas Eakins’s double jumper1884). By this time dry plates, flexible films, and inexpen-ive portable cameras brought photography into the homesf amateurs.

The incorporation of photography into mass-producedrinted works was an interest of Niepce as early as 1826.y 1839, Alfred Donne in Paris and Josef Berres of Vi-nna in 1840 were converting daguerreotype plates intontaglio plates that could make impressions on paper.

ippolyte Louis Fizeau improved photographic print-ng by applying the electrolyte process to the etchinghase and granulating the plate so that inking couldeflect halftone densities. In 1852, Talbot patented aethod with steel plates using multiple dots to fill in

arge areas (the photoglyphic engraving, later known ashotogravure). Photolithography, the product of Al-honse Louis Poitevin in 1855, depended on bichro-ate colloids to preferentially accept ink in unexposed

reas.
None of these processes was applicable to rapid large-

sptetcwotp

GGpssHpHtai

ucgiggttrisapt

ttseebkhus

“tldp

apph

deembcweip

hCaa


cale printing on a printing press and it was the halftonelate that allowed this critical jump in the 1880s. Here,he photograph is converted to varying-sized dots forach part of an image according to the tones. By 1890,he year of Gerster’s book, amateur photography wasommonplace and large-scale halftone printing allowedide dissemination of photographs in books and peri-dicals.25 One year later, George Eastman introducedhe Kodak camera and its gelatin-bromide emulsion in aaper roll.26

ERSTER’S EXTRAORDINARY BOOKerster was not the first physician to see the inflectionoint of photography. Oliver Wendell Holmes in 1863tudied stereoscopic pictures of people walking on thetreets of Paris and New York to model limb prostheses.e published his observations in The Atlantic Monthly, a

eriodical he helped found.27 The Medical and Surgicalistory of the War of the Rebellion was published in mul-

iple volumes from 1870 to 1888 and included somelbumin prints affixed to the pages, although all of thellustrations in the text were woodcuts.

Gerster saw the value of photography in medical ed-cation well before most of his contemporaries. It is ouronjecture that he must have been an amateur photo-raphic enthusiast before he professionalized his hobbyn the textbook of 1887. He had the necessary photo-raphic skills insofar as he could take pictures and makelass plates, noting in the first edition preface that “Greatechnical difficulties, inherent to the unfavorable season,he small space and inadequate lighting of the operating-ooms of the mentioned hospitals, had to be overcomen exposing the sensitive plates. The matter was renderedtill more difficult by the circumstance that operatingnd photographing were done by one and the same set ofersons, and that the welfare and interests of the patientshemselves had constantly to be sedulously considered.”2

The unfavorable season probably referred to the au-umn and winter months, implying that the lighting inhe operating room was largely a result of sunlight. Edi-on’s incandescent lamp of 1880 and generalized urbanlectrification were unlikely features of most hospitalsven in 1887. Gerster modestly stated that he alone wasoth surgeon and photographer. Gerster had sufficientnowledge of halftone processes and expertise such thate obtained the services of William Kurtz, who cleanedp the photographic plates taken in imperfect circum-
tances and translated them into printed pages in a book: t
In view of the defective character of many of the au-hor’s negatives, the greatest praise belongs to Mr Wil-iam Kurtz, to whose artistic taste, skill, and versatility isue their excellent reproduction by phototypographicrocess.”2

The book was “respectfully dedicated to the father ofntiparasitic surgery, Sir Joseph Lister, Bart.”2 Gersterroduced three editions in only a few years. His finalreface tells much, including how the text derived fromis Polyclinic lectures.

The necessity of issuing within two years a third edi-tion of this work may be a sign of the spread ofantiseptic doctrine and practice among the membersof the medical profession in this country. The generaloutlines and scope of the book, being based on thecourse of lectures yearly delivered by the author to abody consisting of practicing physicians, have re-tained their practical character. Principal accentua-tion was placed on the points showing importantdivergence from older methods.

Additional new matter was introduced in the chap-ters on Herniotomy, Haemorrhoids, Appendicitis,and the Surgery of the Kidney. As in the former edi-tions, statistical material was brought in only whenthe typical and uniform character of the operationspertaining to one subject permitted its safe use as agauge of the value of aseptic or antiseptic methods.The additional experience of 2 years’ work was uti-lized in widening the basis of the conclusions drawnfrom the computation of numbers.2

Gerster’s cautionary reliance on statistical methods toiscern value was unusual for his time. The third editionncompassed 365 pages, including a good index, 252ngravings, and 3 chromolithographic plates. The fiveain sections of the book were Asepsis, Antisepsis, Tu-

erculosis, Gonorrhea, and Syphilis. He discussed spe-ific operative procedures within each section. Patientsere respectfully identified by name and when postop-

rative results were shown, they posed with dignity and,n some photographs, with what can be discerned asride in their results.Gerster’s book “featured aseptic instruments, many of

is own design, made by Tiemann & Co.”28 New Yorkity seems to have been the epicenter for the American

ntiseptic surgery, as this was both Tiemann’s locationnd the site of the first public demonstrations of Lis-
erian antiseptic surgery in 1876 by Robert F Weir and

LscTThte

TAVyiHCsevOat

wbofltcwsa

tac

GGcosgnisNssatiaeftvmmwgal

At


ewis A Stimson.29 Almost simultaneously, two otherurgeons in New York authored surgical textbooks advo-ating antiseptic technique and aseptic instruments (byiemann). These were Stephen Smith’s 1887 edition ofhe Principles and Practice of Operative Surgery30 (Smithad discussed Lister’s technique earlier in the 1879 edi-ion) and Wyeth’s A Text-Book on Surgery: General, Op-rative and Mechanical.31

HE ASEPSIS/ANTISEPSIS DISTINCTIONlthough Gerster’s aseptic technique came from theolkman demonstrations of Listerism followed by 13ears of personal experience in New York City, othernfluences had lent the concept support, including

olmes’s work on puerpural fever, Semmelweis, andivil War surgical experiences. Gerster viewed aseptic

urgery as operating in a sterile field. He practiced in anra where bacteriology was newly proved, but not uni-ersally understood in the world of medical practice.perative procedures were performed in street clothes

nd with bare hands. Gerster viewed the operative set-ing more stringently:

Supposing that the skin in the region to be operatedon be shaved, then energetically scrubbed in hot wa-ter with soap and a clean brush for five minutes, thenthe surgeon’s hands be scrubbed, likewise his knife,and now an incision be made through the skin: sup-posing that this happened in an atmos-phere free from particles of filth called dust: such awound could safely be termed a clean or aseptic one.All particles of filth adhering to skin, hands, andinstrument were removed by this simple process ofscrubbing, and no new particles could settle downout of the atmosphere, which we assume to be freefrom dust.2

Gerster described how even a large wound will healithout suppuration “first if its edges be approximatedy sutures made with a clean needle and clean wire, silk,r gut; and second, if the immunity from invasion ofilth be maintained until the bloody serum marking theine of union becomes dry.” He then applied asepticechniques to healing by secondary intention: “. . . wean vary our experiment and show that a wound can healithout suppuration even if contact of the walls of the

ame be imperfect or none.” He stated later that, “theseptic discipline is purely a preventive one.”2

Antiseptic surgery, he wrote, Y

. . . refers to such wounds as have become the seat ofinfection, causing inflammation, suppurations, orthe higher forms of sepsis—phlegmon and gangrene.The object of the antiseptic treatment is the limitingand elimination of established septic processes by drain-age and disinfection. It is also preventive, but in a nar-rower sense than the aseptic method. There all mischiefis prevented from the outset; here further extension ofpresent mischief is sought to be checked. The asepticmethod will generally preserve all the parts involved; theantiseptic method cannot restore the integrity of partsdestroyed by ulceration, suppuration, or gangrene.2

Gerster’s “aseptic and antiseptic method” is basicallyoday’s “sterile technique,” which might find renewedttention as antibiotic resistances increase in the 21st

entury.

ERSTER IN PERSPECTIVEerster was a risk-taker; he saw opportunities and took

hances on them well ahead of his peers. Early evidencef this trait was his emigration to America, despite rea-onable assurance of a successful life and career in Hun-ary. Whether by chance or deliberate intent, he wit-essed the early application of Listerism and recognized

ts value. This was most certainly a fine instance oferendipity—a balance of good fortune and sagacity.ot only did he incorporate Lister’s principles into his

urgical practice (which raised his stock as a successfulurgeon), but he also became a highly sought teacher ofseptic and antiseptic technique, bringing him to a cen-er stage in proximity with key figures of American med-cine. Human progress often results as new technologiesre purposefully integrated into an endeavor or knowl-dge domain. Medical education has benefited greatlyrom photography and saw its first grand implementa-ion in Gerster’s surgical textbook. Within a century, theisual aspect of instructional materials expanded intootion pictures, digitalized CDs, and Web-based for-ats. Photography has become integrated into therapyith real-time imaging in the operating room for radio-raphic, endoscopic, laparoscopic, and robotic surgery,s modern-day Gersters continue to recognize techno-ogical inflection points that change medicine.

cknowledgment: We would like to thank Barbara Niss ofhe Mount Sinai Hospital Archives, NY, NY; and the New
ork Academy of Medicine Library, NY, NY.

R

1

1

1

1

1

1

1

1

1

1

22

2

2

2

2

2

2

2

2

3

3


EFERENCES

1. Newhall B. The history of photography. Boston, MA: LittleBrown & Co; 1982:17.

2. Gerster AG. The rules of aseptic and antiseptic surgery. 3rd ed.New York: D Appleton and Company; 1890.

3. Gerster AG. Recollections of a New York surgeon. New York:Paul B Hoeber; 1917:12, 16�17, 162, 165, 194, 240, 241.

4. Dictionary of American Biography. Vols 1�20. New York:Charles Scribner’s Sons; 1928–1936:229.

5. Lister J. On the antiseptic principle in the practice of surgery. BrMed J 1867;II:246.

6. The National Cyclopaedia of American Biography. Vol 26. NewYork: James T White & Co; 1937. Reprint. Vols 1–50. AnnArbor, MI: University Microfilms; 1967�1971:428.

7. American National Biography Online. American Council ofLearned Societies, Oxford University Press. Available at: http://www.anb.org/articles/12/12-0032.html. AccessedFebruary1,2000.

8. Gerster AG. Virginia Medical Semi-Monthly 1913–1914;18:21.

9. Rutkow IM. John Wyeth (1845�1922) and the postgraduateeducation and training of America’s surgeons. Arch Surg 2002;137:748–749.

0. Clapesattle H. The doctors Mayo. Minneapolis, MN: The Uni-versity of Minnesota Press; 1941:236.

1. Aufses AH Jr, Niss BJ. This house of noble deeds. New York:New York University Press; 2002:134.

2. Resolution of the death of Dr. Arpad G. Gerster. Annual reportfor the Mount Sinai Training School for Nurses for 1922, NewYork, NY.

3. Mount Sinai Archives Collection. Individual file: Arpad Gersterand the Mt Sinai training school for nurses.

4. Gerster AG. On the surgical dissemination of cancer. NY Med JWkly Rev Med 1885;VL:233–257.

5. Voorsanger WC. Medical memoirs. The reminiscences of Wil-

liam C Voorsanger, MD. San Francisco, CA: Lawton and AlfredKennedy; 1965:1.

6. Sachs B. Dr. Gerster: as man and scholar. The Proceedings ofThe Charaka Club. Vol VI. New York: Paul B Hoeber; 1925:40.

7. The Journal of the American Medical Association. GH Sim-mon, ed. Vol 80, Jan.–June 1923. Chicago: American MedicalAssociation; 1923, p 940.

8. Niss BJ. From the archives. Mount Sinai Levy Library News,May 1988.

9. Mount Sinai Alumni. http://www.mssm.edu/alumni/about/past_presidents.shtml. Accessed June 2004.

0. Personality spotlight. Cancer News, July 3, 1952, p 11.1. Mary Brennan, Bronxville Bride of John Gerster. The New York

Times, July 20, 1969.2. http://acad.bryant.edu/�ehu/h364proj/sprg_98/baker/people.

htm. Accessed October 2002.3. Newhall B. The history of photography. 5th ed. New York: Mu-

seum of Modern Art; 1997.4. Maddox RL. An experiment with gelatino-bromide. Br J Pho-

tography 1871;18:422–423.5. Bloom DA, Ferro F. Medical photography and genitourinary

surgery. Br J Urol 1998;82:325–330.6. Doty R. Photography in America. New York: Random House;

1974.7. Holmes OW. The human wheel, its spokes and felloes. Atlantic

Monthly 1863;XI:567–580.8. Edmonson JM, Hambrecht FT. American Armamentarium

Chircurgicum. George Tiemann & Co. 1889. The CentennialEdition. San Francisco: Norman Publishing; 1989:37.

9. Edmonson JM. American surgical instruments. San Francisco:Norman Publishing; 1997:167.

0. Smith S. The principles and practice of operative surgery. Phil-adelphia: Lea Brothers & Co; 1887.

1. Wyeth JA. A text-book on surgery: general, operative and me-
chanical. New York: D Appleton and Co; 1887.

Documents

Arpad G Gerster, MD, and the First Photographic Surgical Textbook