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The Virginia Apgar Papers

From Surgery to Anesthesiology, 1933-1937

[Virginia Apgar]. [December 1936].
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Virginia Apgar graduated fourth in her medical school class in 1933, and won a prestigious surgical internship at Presbyterian Hospital (currently New York-Presbyterian Hospital/Columbia University Medical Center), the teaching hospital of Columbia University College of Physicians and Surgeons (P & S). Although she excelled in surgery, after her first year, her mentor, Dr. Allen Whipple, recommended that she not pursue a career as a surgeon, but consider anesthesiology instead. Part of his reasoning was economic: in the middle of the Great Depression, Apgar had finished medical school $4000 in debt; she was self-supporting, with no family resources to draw upon. Surgery was a crowded specialty, and none of Whipple's earlier woman protégées had been financially successful.

However, Whipple, as head of the Department of Surgery, also saw a growing need for medically managed anesthesia. Successful surgical outcomes depended not only on the surgeon's skill, but on the ability to keep the patient both anesthetized (pain-free and/or unconscious) and physiologically stable during the operation. Nurse-anesthetists, working under the surgeons' direction, traditionally administered anesthesia in most operating rooms. As knowledge of physiology and pharmacology expanded in the early twentieth century, academic surgeons began developing better anesthetic agents and techniques. Increasingly, their use required deeper knowledge and more training than was typically given to nurses, yet few physicians specialized in this area. Whipple hoped to raise the level of anesthesia practice at Presbyterian, and believed that Apgar's intelligence and abilities could be applied to advantage in such a project. Accordingly, she wrote to Dr. Frank McMechan of the Associated Anesthetists of the United States and Canada to ask about training programs in anesthesia. There were then only thirteen such programs in the United States, with training ranging from two weeks to three years. Only two programs paid salaries to residents, and none had openings when Apgar sent her initial inquiries. For the short term, after finishing her surgical residency in November 1935, Apgar worked in the nurse-anesthetist training program at Presbyterian for a year. In late 1936 Dr. Ralph Waters at the University of Wisconsin offered her a visiting position in his anesthesia training program.

When Apgar joined Waters's training program in 1937, she also joined the first cohort of specialist physicians whose training, practice, and research was focused on anesthesia and analgesia (pain relief). Agents such as ether and chloroform, which quickly render patients unconscious, had been successfully used to ease childbirth and facilitate surgery from the 1840s; yet surgery (apart from amputations and minor procedures) did not become a routine part of medicine until the late 1800s, when antiseptic, then aseptic techniques were widely adopted. Prior to the acceptance and application of the germ theory of disease, infection often killed patients even when they survived the surgery. As longer and more complicated surgeries became possible, there was a corresponding need for better anesthetic agents and techniques. Most anesthetics are drugs that depress vital functions (respiration, heart action, etc.) and require careful handling to ensure patient safety, especially with longer operations. By 1900 a few practitioners began to focus their attention on better understanding of the physiology of anesthesia. However, the administration of anesthesia was viewed as menial work by many surgeons, and was often relegated to nurses or novice medical trainees. As late as 1911, the American Medical Association had rejected a request for an anesthesia section in that organization.

Ralph Waters had established a general practice in Iowa in 1912, but soon limited his practice to obstetrics and anesthesia, and later to anesthesia alone. He carried out as much research as he could, and published over a dozen papers on anesthesiology, focusing on the scientific fundamentals, such as the role of carbon dioxide levels in respiration. In 1927 he left private practice to join the medical school faculty at the University of Wisconsin, where he taught anesthesia practice, did cooperative research with scientific colleagues such as Chauncey Leake (pharmacology) and Arthur S. Loevenhart (physiology), and established the first graduate training program in anesthesiology. His stated intent for the program was "to teach doctors who would go out to teach other doctors the scientific basis for safe practice of clinical anesthesia." As one of Waters's original trainees between 1933 and 1942, Apgar was a charter member (and first woman member) of the "Aqualumni" (as they dubbed themselves, playing on Waters's name), a cohesive group that pledged to carry on Waters's work of raising the standards and improving the quality of anesthesiology education and practice. The group held annual reunions in Madison from 1937 to 1947 (when Waters retired) and occasionally after that. Forty of the sixty "Aqualumni" went on to teaching positions in academic centers; half of those--including Apgar--became chairs or directors of new academic programs in the U.S. and beyond. During the second half of 1937, Apgar returned to New York for further training with Emery Rovenstine, an Aqualumnus who had recently established an anesthesiology program at Bellevue Hospital.