Appearance, Pulse, Grimace, Activity & Respiration

Virginia Apgar
Virginia Apgar

By Karen Holt

June 7, 1909 set into motion events, which in the future would change the field of perinatology (care of infants at the time of birth).  On this day, future anesthesologist and neonatologist, Virginia Apgar debuted in Westfield, New Jersey.  The youngest of three children born into a family with a love for music and science, she began to participate in her father’s science experiments in his basement laboratory at a young age.

Her father, Charles Emory Apgar, was a businessman and automobile salesman, as well as an amateur musician.  Her mother, Helen May, shared the family’s interest in music. Virginia learned to play the violin at the age of six and took part in the family’s living room concerts.  Virginia eventually joined the local Amateur Chamber Music Players and performed with the Teaneck (NJ) Symphony.  She also learned to build her own stringed instruments.  Though she loved music, a career in medicine became her desire early in high school.  Her father’s love for science no doubt played a big part in Virginia’s desire to pursue a career in the field of medicine.  She may also have been inspired by her elder brother’s early death from tuberculosis and her other brother’s chronic childhood illness.

Following high school graduation, she enrolled in Mount Holyoke College and graduated in 1929 with a degree in zoology.  Not one to be called lazy, Virginia worked as both a librarian and waitress to put herself through school, while still finding time to earn a letter in athletics, work as a reporter for the school paper, and play the violin in the school orchestra.  Virginia was then accepted to the College of Physicians & Surgeons at Columbia University in New York City, just before the Wall Street crash in October 1929.  This was followed by an internship at Presbyterian Hospital in New York.

A time of economic distress soon enveloped the entire country as the United States entered the Great Depression from 1929-1939.  Though her financial situation was bleak at the time, Virginia was determined to finish school and managed to find the funds necessary to complete her course of study.  Though now saddled with a large financial obligation, she received her medical degree in 1933, ranking fourth in her class.   The next challenge Virginia faced was finding a job.  In addition to dealing with an economic downturn, she also faced the fact she was entering the male-dominated medical profession.

In 1937, she completed her residency in surgery at Columbia, becoming only the fifth woman to received the coveted internship.  She was discouraged, however, from continuing in the field by the chair of the department, Allen Whipple.  Dr. Whipple’s discouragement was due to the fact he had seen other women he trained in surgery fail to establish a successful career in the specialty.  Dr. Whipple also believed Virginia possessed the energy, intelligence, and ability necessary to make a significant contribution to the innovations and improvements needed in anesthesia (at that time handled mostly by nurses) if surgery was to advance.  She later stated, “Even women won’t go to a woman surgeon.  Only the Lord can answer that one.”  As a result, Virginia listened to Dr. Whipple and turned her attention in the direction of anesthesiology.

A relatively new specialty in Virginia’s day, anesthetics are drugs or gas used in medical procedures to help lessen/eliminate pain for patients during surgery.  In some cases, the medication merely numbs a particular area of the body; in others, it causes the patient to lose consciousness prior to the procedure taking place.  In the early days of anesthesiology, nurses normally administered the drugs.  As the field progressed, fully trained medical doctors replaced them in performance of the task.

Dr. Apgar now faced the challenge of where to gain the training she needed.  Due to the fact anesthesiology was normally not recognized as a ‘specialty’ until 1940, a training program in the field was difficult to find.  In 1935, Dr. Apgar began her two year study at Columbia.  She then transferred to Dr. Ralph Waters’ Department of Anesthesia at the University of Wisconsin in Madison – the first in the United States.  Here she trained for six months, after which she spent an additional six months with Dr. Ernest Rovenstine at Bellevue Hospital in New York.

After completion of her training, not only did Dr. Apgar fulfill her desire to find a position in the field of medicine; in 1937 she became the first woman to be a board certified anesthesiologist.  In 1938, she was elevated to the position of Director of Anesthesia at Columbia University.  As nice as the title was, she faced a major challenge in convincing surgeons of the fact the anesthesiologist was no longer a nurse, but instead the surgeon’s equal as a fully accredited doctor.  In her particular case, the fact she was a woman did not help, since most women in the operating room at this time were nurses rather than doctors.  Until 1940, Dr. Apgar was the only anesthesiologist on staff.

Anesthesia became an acknowledged medical specialty, requiring a residency, in 1946 and in 1949, Columbia University established an academic department for anesthesia research.  When the department head was selected, Dr. Apgar was passed over in favor of a male contender.  Though this event today would likely have caused women to scream, ‘Discrimination!’ it would later prove to be an extremely beneficial act of fate to the world of medicine.  Though Virginia was not tapped for the department head, she was given a full professorship, the first woman at Columbia to be elevated to that level.  As great as this may have been in and of itself, it paled in comparison to what was to come.

In the position of teacher and researcher, Dr. Apgar made her monumental contributions to the field of medicine over the next 10 years.  She began to focus her knowledge of anesthesia’s use in the world of the delivery room and how it served as a benefit or henderance during childbirth.

At this time when a baby was born, the doctor’s attention was more often focused on the mother rather than the newborn.  Thus, many life-threatening conditions in the newborn at the time of birth ran the risk of being overlooked, possibly resulting in the death of the baby.

As an anesthesiologist who attended over 17,000 births,Dr. Apgar developed a quick and efficient method to decide if an infant was raring to go at the time of arrival, or needed a bit of a helping hand.  This method – her greatest contribution to the field of medicine – is now known as the Apgar Newborn Scoring System.  The test she devised is performed one minute after the infant’s birth by a nurse or midwife.  Five points are measured – heart rate, respiration (breathing), reflexes, muscle tone and color.  Each part of the test is given 0, 1 or 2 points.  The points are then totaled to determine the baby’s score.  The test is done after one minute to determine whether the baby needs resuscitation.  Second and third applications of the test serve to evaluate the infant’s response to the applied resuscitation.  In most cases, however, the standard Apgar Scores are the result of tests performed at one and five minutes after birth.  This test has now become a standard the world over for evaluating the infant’s chances for survival and rate of development; serving to drastically reduce infant mortality.

Dr. Apgar’s contribution to healthy childbirth did not stop with this test.  She also studied the use of anesthesia during childbirth and its affect on both the woman and her baby.  Working with colleagues Dr. Stanley James and Dr. Duncan Holaday, Dr. Apgar began to create new methods of measuring blood gases and blood levels of anesthesia, in addition to contributing specialized knowledge in cardiology.  Her research showed cyclopropane, a popular anesthesia used during childbirth at the time, had a noticeably negative effect on the overall condition of the newborn; resulting in low Apgar Scores due to highly acidic blood and low levels of blood oxygen.  She immediately ceased the use of cyclopropane during the deliveries she participated in, and also published a report to broadcast her findings.  Doctors around the country soon followed her lead after reading her reports.  The collaborative project, involving 17,221 babies in a twelve-institution study, established the fact the Apgar Score, especially the five-minute test, can predict neurological development and neonatal survival.

Dr. Apgar ended her career with Columbia after twenty years.  She then enrolled in Johns Hopkins University where she earned a masters degree in public health, then began a new career with the March of Dimes (formerly known as the National Foundation for Infantile Paralysis).  In 1959, she was named head of the division on congenital birth defects (physical or developmental abnormalities resulting prior to birth) and headed the research program in 1969.

During 1964-1965, a rubella pandemic occurred, with 12.5 million reported cases.  If a woman contracts rubella during pregnancy, her baby runs a high risk of severe congenital disorders.  The pandemic resulted in upwards of 11,000 miscarriages and 20,000 cases of congenital rubella syndrom (CRS).  2,100 infants died and of those who survived, 1,800 were mentally retarded, 12,000 deaf, and 3,580 blind due to microphthalmia and/or cataracts.  Dr. Apgar became an outspoken advocate for a vaccine to prevent  transmission of rubellafrom mother to child.

During this time Dr. Apgar was responsible for changing the focus of the foundation in an effort to prevent birth defects in the first place.  She now went on a lecture circuit and published a book entitled, Is My Baby All Right? in 1972.  When she received her professorship at Cornell University, she became the first medical professor in the US to specialize in birth defects.

The contributions to the world of medicine made by Dr. Virginia Apgar during her career were highly significant – both in the laboratory and the classroom.  The training she gave to the hundreds of doctors in her classes went on to create a lasting effect in the field of neonatalolgy (care of the newborn).  Her accomplishments were recognized with numerous rewards and accolades; among them:

  • Honorary doctorate, Women’s Medical College of Pennsylvania (1964)
  • Honorary doctorate, Mount Holyoke College (1965)
  • Distinguished Service Award from the American Society of Anesthesiologists (1966)
  • Elizabeth Blackwell Award, from the American Women’s Medical Association (1966)
  • Honorary doctorate, New Jersey College of Medicine and Dentistry (1967)
  • Alumni Gold Medal for Distinguished Achievement, Columbia University College of Physicians and Surgeons (1973)
  • Ralph M. Waters Award, American Society of Anesthesiologists (1973)
  • Woman of the Year in Science, Ladies Home Journal (1973)
  • Inducted into the National Women’s Hall of Fame in Seneca Falls, New York, (1995)

Though Dr. Apgar was many times the first or only woman to win an accolade or serve in a particular position during her career, she never participated in the ‘women’s movement’.  By her way of thinking, women were liberated from the moment they left their mothers’ wombs.

In an effort to enhance public awareness of various medical conditions, Dr. Apgar spoke not only to the movers-and-shakers of her time, but also to tennagers.  Making appearances at youth conferences sponsered by the March of Dimes, Dr. Apgar spoke on teen pregnancy and congenital disorders at a time when such topics were considered taboo.

Dr. Virginia Apgar died in New York City on August 7, 1974 at Columbia-Presbyterian Medical Center.  She is best remembered for the way she encouraged her students as they entered the field of medicine and research.  Today’s field of neonatology and anesthesiology owe much to the pioneering determination of this great doctor.