Dr. Virginia Apgar and the Apgar Score

How the Apgar Score Came to Be

This article examines how the Apgar Score, one of the most important contributions of anesthesiology to medical practice, came to be. It began in 1949, with a chance remark by a medical student to anesthesiologist Dr. Virginia Apgar (1909–1974). In 1952, the Apgar Score was first presented at a joint meeting of the International Anesthesia Research Society (IARS) and the International College of Anesthetists. The next year, it was published in Anesthesia & Analgesia.¹ Soon, the Apgar Score was used around the world. It has stood the test of time^2,3 and made Virginia Apgar the most famous anesthesiologist in history.

This article reviews Virginia Apgar’s life, the incident leading to the score, the development of a scientific basis for the score, and the aftermath. Apgar originally intended the score to be a guide to resuscitation of newborns: which babies needed help making the transition to extrauterine life? Her subsequent research with L. Stanley James (1925–1994), a pediatrician, and Duncan A. Holaday (1916–2004), an anesthesiologist, documented that babies with low Apgar Scores were acidotic and hypoxic, and needed treatment. After the mechanism of low Apgar Scores was understood, it was possible to undertake evaluations of obstetric anesthesia techniques and develop improved methods for newborn resuscitation. This led to major advances in obstetric anesthesia, a topic in this issue of Anesthesia & Analgesia.

Virginia Apgar was among the most charismatic, charming, and energetic characters in American medicine. She was born in Westfield, New Jersey, to a musical family, one that “never sat down.” Her father was a busy scientist-inventor. He supported the family with various jobs, but his heart was in his basement laboratory with his homemade telescopes and radios. Virginia was often at his side, presaging her ever-curious mind and abiding interest in science. Her mother was the daughter of a Methodist minister. Music was an integral part of family life. Virginia played violin, and her brother played piano and organ. The family often gathered for musical sessions, and Virginia was in her school orchestras. Her love for music continued throughout her life. She also demonstrated early on her high-energy approach to life and her many different interests, such as stamp collecting and sports. Her energy was another trait that came to define her life story. By the time Apgar graduated from high school, she was determined to become a physician. There were few women physicians then. It is unknown what inspired her to be a pioneer for women physicians.

Apgar’s college education was at the all-female Mount Holyoke College, an institution with a long tradition of educating women of excellence in science. The family was not wealthy. Through a combination of scholarships and jobs, such a waiting tables and catching cats for zoology laboratory, Apgar paid her way through college. She graduated in 1929, still committed to becoming a physician.⁴ However, this was the low point for American women in medicine. The first woman doctor, Elizabeth Blackwell, earned the MD degree in 1849. The number and percentage of women physicians increased slowly, peaking in 1910. Changes in medical education after 1910 led to a dramatic decrease in women physicians. The decrease in the number and percentage of women physicians reached a nadir in 1930, as Apgar was ending her first year of medical school. There were just 6825 women physicians, 4.4% of the physician population, in 1930, fewer than in 1920.^5,6 Apgar began her medical career at a time of few women physicians. The difficult times that were to come would reflect this situation.

After being turned down by Harvard Medical School (Harvard did not accept women medical students until 1945),⁷ she was accepted at the Columbia University College of Physicians and Surgeons, where women had been accepted since 1917.^a She was 1 of 9 women in a class of 90.^b The Great Depression began the month after Apgar entered medical school. Her finances became more precarious. She was able to borrow money from a family friend whose assets survived the Crash, and she graduated in 1933, fourth in her class and a member of the medical honorary society Alpha Omega Alpha.^c She was $4000 in debt.^d

She loved surgery and began a 2-year surgical internship at Columbia. She performed brilliantly. But after less than 1 year of internship, she was seeking anesthesia training. What led her to change from surgery to anesthesia? No doubt the Surgery Department Chair, Dr. Allen O. Whipple (1881–1963) played a critical role. Like most American academic surgeons of the time, he realized that surgery could only advance if more physicians were involved in anesthesia.⁴ In 1934, only 159 American physicians limited their practice to anesthesia. Another 384 physicians provided anesthesia services part time. Fewer than half of United States hospitals with anesthesia services had trained physician anesthetists. This was a time when most anesthesia was given by nurse anesthetists or “other physicians.”⁸ Whipple probably saw in Apgar a smart and energetic person who could elevate the anesthesia care at Columbia to the standards he sought for his patients.

Another motivation may have been economic. At the time Apgar chose to go into anesthesia, 4 women surgeons had already trained in surgery at Columbia. None of these women surgeons were financially successful in the competitive world of New York City surgery.^e Apgar was unmarried and had to support herself and, probably in the future, her parents. At that time, unmarried women had limited options for work, typically either teaching or nursing, both low-paid professions. However, anesthesia provided opportunities for women physicians. Surgeons thought that a woman’s feminine characteristics were helpful in managing anesthesia, such as it was at the time. An additional draw was that it was difficult for women physicians to find other practice opportunities. During the period 1920 to 1940, American women physicians were found twice as often in anesthesia, based on their percentage in the physician population, compared with male physicians. Women were even chairs of some departments, and the IARS had 3 women presidents.⁵ Apgar’s move from surgery to anesthesia presented her with an opportunity for both economic and professional advancement. This was the first of the opportunities to come to Virginia Apgar.

At the time, anesthesia at Columbia University was provided by nurse anesthetists. Occasionally, a physician consultant was called in for high-profile patients. Apgar began work with the nurse anesthetists while searching for training in anesthesia. She wrote to Francis McMechan (1879–1939), founder of the IARS and prominent in the move to modern anesthesia,⁹ seeking training possibilities. McMechan recognized Apgar’s potential and wrote to Ralph Waters (1883–1979) at the University of Wisconsin, considered the father of academic anesthesiology: “She seems to be an unusually ambitious person and might prove to be an excellent find for the specialty irrespective of her sex. Do what you can for her.”^f Waters had already had 3 women residents and was not enthusiastic about more.¹⁰ Apgar applied at Wisconsin, but there were no available positions. She then interviewed with Emery A. Rovenstine (1895–1960), a Waters trainee who became chief of anesthesia at Bellevue in January 1935. He turned her down in April 1936,^g and she continued at Columbia with the nurse anesthetists.

Waters was finally able to get a “visitor” position for Apgar. He had only a few 3-year “resident” positions in his budget, but he did accept short-term visitors. For example, Robert Dripps, who became chair at the University of Pennsylvania, was not a formal trainee of Waters but another visitor in his department. Apgar arrived in Madison, Wisconsin, on January 2, 1937 (Fig. 1). There, she faced the usual woman physician problem, lack of housing for trainees, and had to sleep in Waters’ office for 2 weeks until a room was found for her, in the maids’ quarters. Her diary from this time recorded the usual disasters of learning anesthesia. She also recorded her anger at having to miss department events held in male-only dinner clubs. After 6 months in Wisconsin, Apgar went back to New York City to Rovenstine’s program for another 6 months of residency. Apparently, she was now acceptable to Rovenstine because of her training with Waters.

Figure 1: LONE WOMAN: Dr. Virginia Apgar at the University of Wisconsin, 1937. Identifications: First row, from left: J. A. Moffitt, A. J. Wineland, Ralph Waters, William A. Neff, John A. Stiles, David Treweek, Maurice H. Seevers, Emery A. Rovenstine. Second row, from left: M. Digby Leigh, Hubert Hathaway, F. A. D. Alexander, Virginia Apgar, J. H. Bennett, Perry P. Volpitto, William H. Cassells, B. B. Hershenson, Ivan B. Taylor. Source: Wood Library-Museum, with permission.

She began as Director of the Division of Anesthesia and Attending Anesthetist at Columbia January 1, 1938.⁵ Multiple issues appeared immediately. She wrote Waters 7 weeks after starting,

“By the second week I was ready to turn to law, or dress making, anything but anesthesia…

Whipple expects me to start turning out research work right now….

Finances are as theoretical as the payment of the war debt….

An office is about as theoretical as the finances…”^h

These problems, especially research and finances, continued to play out over the time she was Director. Recruitment was difficult. There seemed to be no funds for resident salaries or for their living quarters. The first resident arrived 10 months later, after she threatened to cancel cases, thus “greatly inconveniencing the surgeon,” because of lack of manpower.ⁱ She wrote Waters, asking him to refer to her resident applicants he could not use, adding “no women yet.”^j Her first 3 residents were men. The first faculty member, Ellen Foot, arrived in August 1941.¹¹ Struggles over the right of anesthesiologists to send bills to private patients were a recurring theme. Apgar even had to fight for her own salary. World War II brought a big increase in work as large numbers of physicians were drafted for war service. During this incredibly busy time, she also served as Treasurer of the newly formed American Society of Anesthetists (later the American Society of Anesthesiologists) from 1940 to 1945. She made important contributions to the financial stability of the new organization by adopting standard bookkeeping, improved budgeting, improved cash flow from dues collection, and developing funding for the new journal Anesthesiology.¹²

Many now recognized the importance of research for anesthesiology, and research was developing slowly at the national level. Apgar wrote multiple plans to develop research at Columbia and tried to recruit the few suitable candidates. She offered at least 3 men positions as head of research. Proposals to the new surgery chairman, George H. Humphreys II (1903–2001), in 1948 reveal that Apgar expected to be the chair and have the director of research report to her.^k But it was not to be; she could not recruit the few suitable candidates. And the institution may not have been ready for a woman department chair. Finally, anesthesiologist Emanuel Papper, who had research experience and who Apgar knew from her time at Bellevue, was recruited from Bellevue-New York University in 1949 as professor and chair of the Division of Anesthesiology. Full department status was reached in 1952.¹¹ There are reports of Apgar’s disappointment at not being chair of the department.^l However, Papper’s appointment freed her from the burden of administration, which she disliked. This failure to become a chair marked a pivotal point in her career. Apgar advanced to full professor (the first woman full professor in the medical school), took a 1-year sabbatical, returned to Columbia, and moved into obstetric anesthesia. And opportunity called again.

She had always been interested in this then-neglected area. Anesthesia residents began rotating on the labor and delivery floor for the first time, and she was their instructor. The anesthesiologists at Columbia gathered daily for breakfast at the hospital cafeteria. This was where the Apgar Score was born. At the time, newborns were essentially ignored in the delivery room. One day, a medical student rotating on anesthesia remarked at breakfast about the need to evaluate newborns. According to someone who was present, Apgar said, “That’s easy, you’d do it like this.” She grabbed the nearest piece of paper, a little card that said, in essence, “Please bus your own tray,” (she often used those cards for other notes) and scribbled down the 5 points of the Apgar Score. She then dashed off to the labor and delivery suite to try it out.

With a research nurse, Apgar worked to refine and test the score.^m She presented it at an IARS meeting in 1952, and it was published in 1953.¹ There was some resistance initially, focused on who was to score the baby. Obstetricians, who delivered the babies and so had a stake in their outcomes, were thought to score too high. Apgar planned that a neutral person, such as a circulating nurse, would do the score and that it be done 1 minute after birth. This would identify which babies needed help. Others started measuring it also at 5 minutes after birth, to evaluate how the baby responded to resuscitation if that was needed. Eventually, the 1- and 5-minute scores became standard. An epigram was introduced in 1962 to help staff remember the various points of the score.¹³ (Many still do not realize that “Apgar” was a person’s name but think of it only as an epigram.) A clipboard with timers for 1 minute and 5 minutes, developed by anesthesiologist MA Colon-Morales, became available in 1968 and helped to improve the accuracy of timing of the score.ⁿ

The Apgar Score spread around the world. Its method of structured thinking for evaluating clinical situations also led to numerous other clinical scores, among them the Aldrete Score, the Glasgow Coma Score, the Trauma Score and, recently, the Surgical Apgar Score.

While Apgar was working on her eponymous score, 2 physicians arrived at Columbia to help establish a scientific basis for the Apgar Score: researcher-anesthesiologist Duncan A. Holaday and pediatrician L. Stanley James. Apgar had tried to recruit Holaday in 1947 as the research person for the department. However, at the time, Holaday was a fellow in experimental pharmacology under E.K. Marshall at Johns Hopkins. Holaday joined the department in 1950 after Papper became chair. Papper honored Apgar’s commitment to Holaday, who set up the first laboratory for anesthesiology research at Columbia. Holaday’s first project was trying to learn how to measure blood gases in the presence of anesthetic drugs using a Natelson microgasometer. This was a microtechnique, amenable to use on neonates. Holaday also worked on pH measurement, a difficult task at the time, especially with the small samples of blood available from newborns. The Astrup pH electrode became commercially available in 1955. Apgar’s group purchased one of the first ones available, greatly simplifying the studies on neonates.^o

L. Stanley James was a pediatric resident at Bellevue. His interest in newborn respiration,and resuscitation led him to Virginia Apgar. He did 6 months of post-residency research with her, working on expansion of neonatal lungs. In 1955, he moved to Columbia to work with her on acid-base status and oxygenation of infants at birth as well as the effects of various anesthetics on neonates.^p Together, they published a second paper on the Apgar Score, establishing the relationship between blood gas data and the Apgar Scores, thus confirming that babies with low scores were acidotic and hypoxic. They demonstrated that acidosis and hypoxia were not the normal situation at birth, as previously thought.¹⁴ The team also compared maternal and fetal outcomes for different obstetric anesthesia techniques. They documented that cyclopropane, then commonly used for vaginal and cesarean delivery, caused depression of babies. They showed that regional anesthesia gave the best outcomes for both mother and infant,¹⁵ launching the move to regional anesthesia in obstetrics.

Apgar’s team also addressed infant resuscitation. At that time, intragastric oxygen was a common way to “resuscitate” depressed newborns. With the ability to measure physiologic data, the group demonstrated that intragastric oxygen was useless.¹⁶ They advocated the need to expand the lungs at birth and evaluated several methods of doing so. They taught airway management and newborn resuscitation at pediatric meetings, even smuggling in newborn cadavers for practicing tracheal intubation.^q Their extensive teaching efforts included films that circulated nationally.

Apgar’s team published other useful papers. Two anesthesiologists also interested in obstetric anesthesia, Frank Moya and Sol Shnider (1929–1994), arrived at Columbia and expanded the work of the group on evaluating the effects of anesthesia on fetuses and neonates. Moya and Schnider became leaders in obstetric anesthesia.

To help with the statistical analyses of their studies, Apgar went to Johns Hopkins School of Public Health in 1959 to earn a Master of Public Health degree. While there, opportunity presented itself again. She was offered the position of Head of the Division of Congenital Malformations at the National Foundation-March of Dimes in 1959. Polio was now ending because of the success of vaccine research, and the March of Dimes organization needed a new direction. It chose to fight birth defects. Apgar was enormously successful in this new position. In 1967, she became the Director of Basic Research and Vice President for Medical Affairs of the National Foundation, managing the research direction and funding in birth defects. She was still in this position when she died in 1974.

Numerous awards came her way during her life, most important, the Distinguished Service Award from the American Society of Anesthesiologists in 1961. She was the first woman to receive this.^r The Neonatal Section of the American Academy of Pediatrics established an Apgar Award in 1974. It is awarded annually to those who have made significant contributions to neonatal medicine.^s A 20-cent United States postal stamp was released in her honor in 1994, an effort led by the Neonatal Section of the American Academy of Pediatrics.^t Apgar was a lifelong stamp collector, so this was an appropriate honor.

Apgar’s life story shows how history can shape lives. Her life was shaped by the history of women in medicine, the economic history of the early 1900s, the history of anesthesiology, and the history of polio. Anesthesiology, of little interest to men in the 1930s, needed “manpower” and provided opportunities for women physicians. After Apgar was freed from administrative duties, she found opportunity in a poorly developed specialty: obstetric anesthesia. The end of polio provided her final opportunity. Virginia Apgar, smart, energetic, and creative, was able to take advantage of each opportunity.

As she moved through life from opportunity to opportunity, she also left an amazing personal legacy. She connected with everyone she met. Those she met most often remember her speedy lifestyle. She spoke fast, walked fast, and drove fast.¹⁷ The Columbia Medical School class of 1943 included a ditty (sung to the tune of “Yankee Doodle Dandy”) on her in their class show:

The only advice that I can give

If you can get the knack

Is talk as fast as I do

So nobody can talk back.

But I maintain they’re wrong.

‘Cause I can tell them twice as much

And take only half as long!

Others remember seeing her carry on 2 conversations at the same time on 2 separate phones, 1 in each ear. Her driving was legendary. Local traffic policemen all came to her funeral; she had been their best customer for tickets. And she was said to drive her car like an airplane, the wheels never touched the ground. There are many stories like these. Then there was her music: she played violin or cello whenever possible, always traveled with an instrument, and as a member of the Catgut Society, called around in various towns as she traveled to set up impromptu musical sessions. In 1956, she met instrument maker Carleen Hutchings (a patient) and went on to learn how to construct string instruments. This led to the famous “phone booth caper,” in which the 2 women sawed off a shelf from a phone booth in the hospital to use for the back of a new viola. Apgar eventually made 2 violins, a viola, and a cello (all now are at Columbia and are played at events related to her).^u She accumulated large numbers of friends who often joined with her various other interests such as baseball, stamp-collecting, deep-sea fishing, and travel. Personally, she never married, stating she never met a man who could keep up with her. She was close to her mother, brother and sister-in-law, and their children, and friends filled her social needs.

Virginia Apgar was an unforgettable character unique in American medicine (Fig. 2). Her zest for life, for people, for the specialty of anesthesia, for newborns, for scientific research, and for her dearly loved music left an indelible memory on anyone she met. She also left us a lasting tool, the Apgar Score, providing a structured approach to evaluate newborns. Her score serves as a common language among the various specialties, including anesthesiology, that care for newborns. Her score led to better treatment of newborns and to great advances in anesthesia for their mothers. Her score was a unique contribution to anesthesiology, to maternal and child health, and to a generation of researchers dedicated to improved neonatal outcomes.

Figure 2: Apgar with one of her newborn patients. Source: http://profiles.nlm.nih.gov/ps/access/CPBBBK.jpg (open access).

DISCLOSURES

Name: Selma H. Calmes, MD.

Contribution: This author collected the data, analyzed it, and wrote the manuscript.

Attestation: Selma H. Calmes, MD, approved the final manuscript and maintains the archival records, unless otherwise noted.

This manuscript was handled by: Steven L. Shafer, MD.

ACKNOWLEDGMENTS

Many people have, for many years, helped me understand Virginia Apgar’s life; for this, I am very grateful. They include the following: My UCLA colleague Dr. Richard Patterson (now deceased), who first told me Apgar stories and urged me to write my first paper; Librarians: The Apgar Papers at Mount Holyoke College Library and Special Collections, South Hadley, MA; the Ralph M. Waters collection at the University of Wisconsin, Madison, WI; the Wood Library-Museum of Anesthesiology, Schaumburg, IL; and the Guedel Memorial Anesthesia Center, San Francisco, CA; Oral history interviewees (all subjects are deceased except Dr. Moya): Drs. George H. Humphreys II, L. Stanley James, Duncan A. Holaday, Emanuel M. Papper, Frank Moya, and Sol Shnider; The Apgar family: Larry and Margaret Apgar (both deceased), Rick Apgar (deceased), and Eric Apgar.