Virginia Apgar

Physician

• Born: June 7, 1909
• Birthplace: Westfield, New Jersey
• Died: August 7, 1974
• Place of death: New York, New York

American physician

Noted for contributions in anesthesiology, public health, genetics, and basic research, Apgar is best remembered for the Apgar Newborn Scoring System, a system of health evaluation that has saved the lives of countless infants worldwide.

Areas of achievement Medicine, physiology, public health, genetics

Early Life

Virginia Apgar (AP-gahr) was born in Westfield, New Jersey. She may have become interested in science through the influence of her father, who built a telescope and experimented with radio waves and electricity in his basement laboratory. She never knew what caused her to go into medicine, but by the time she went to college, Apgar knew she wanted to be a doctor. At Mount Holyoke College, she relied on scholarships and several jobs, including one in the zoology laboratory, to support herself. After she completed her bachelor’s degree in 1929, Apgar entered the College of Physicians and Surgeons at Columbia University in September. The stock market crashed that October, and Apgar had to borrow money during the Great Depression to continue her education. She owed nearly $4,000 (a considerable sum in those days) when she graduated in 1933, but finished fourth in her class.

Columbia awarded her a coveted surgical internship, but she was advised not to continue in surgery, since she had to support herself at a time when even male surgeons were having difficulty establishing themselves in New York City. Apgar decided to enter anesthesia, which was considered a more suitable field for a woman at the time. Although anesthesia was considered a nurse’s job, surgeons were beginning to acknowledge that surgical advances were dependent on advances in anesthesia. Many of these same medical professionals believed that women physicians were ideally suited to develop the field of medical anesthesiology. Apgar completed her surgical internship in 1935 and spent the next two years in an anesthesiology residency program at Columbia, at the University of Wisconsin in Madison, and at Bellevue Hospital in New York.

Life’s Work

In 1938, Apgar was named as director of the division of anesthesia at Columbia. She worked hard to overcome formidable problems in staff recruitment, an overwhelming workload, resistance from surgeons who refused to accept anesthesiologists as their equals, and an inadequate salary. (Physician anesthetists were not permitted to charge professional fees.) She was the only staff member in the division until 1940. By 1945, however, more anesthetics were administered by physicians than by nurses, and by 1948, there were eighteen residents in the program. (The number of nurse anesthetists on staff decreased from fourteen in 1937 to four in 1948.) Apgar’s workload improved when many physicians returned from World War II to enter anesthesiology. Apgar often came into conflict with older surgeons who were accustomed to giving nurse anesthetists orders, but eventually she was able to win over the younger surgeons. The problem with getting satisfactory financial compensation was resolved only after Apgar threatened to resign in 1940 and a separate budget for the anesthesia division was funded in 1941.

By 1946, anesthesia was becoming recognized as a specialty on a national level. There was a move at Columbia to establish a physician-only department, separate from surgery, with a strong research program. Apgar expected to be made chair of this new department. In 1949, however, a Bellevue anesthesiologist with a research background replaced her as head of the division. Six months later, when the division was made a department, Apgar was appointed professor, making her the first female full professor at Columbia University.

Freed from administration of the department, Apgar moved on to obstetric anesthesia, where she made her greatest contribution. Before her development of the Apgar score, there was no standard evaluation of the transition of the newborn to life outside the uterus. The initial examination of the infant at birth was often haphazard and disorganized, since obstetricians often devoted most of their attention to mothers. In response to a medical student’s question about evaluating the newborn at the time of delivery, Apgar developed her scoring system in 1949. She listed five categories heart rate, respiratory effort, muscle tone, reflex irritability, and color that should be assessed at one minute after birth to indicate the need for resuscitation. (Eventually, the score would be repeated at five and ten minutes after birth to evaluate the baby’s response to resuscitation.) Each category was to be scored as 0, 1, or 2 points and then added for a total score for the baby. A score between 7 and 10 indicated that the newborn was in satisfactory condition; a score between 4 and 7 indicated the need for further observation and possible intervention; and a score of less than 4 alerted the staff to the need for immediate intervention, with concerns about the survival of the infant. The score was first published in 1953 and was eventually adopted throughout the world.

Apgar had always appreciated the need for research, but her heavy clinical workload and administrative duties had left her little time to pursue her interest in this area. With the development of new technology to measure blood gases, pH levels, and blood levels, she was able to collaborate with Duncan Holaday, an anesthesiologist-researcher, and L. Stanley James, a pediatrician, to study the effects of labor and delivery and maternal anesthetics on the baby’s condition, using the Apgar score as a standard evaluation. Low Apgar scores noted in babies with poorly oxygenized blood (hypoxia) or pH imbalanced blood (acidosis) could alert attending physicians that these conditions should be promptly treated. During her studies, Apgar was the first person to catheterize the umbilical artery of the newborn, a procedure that became an essential component of neonatal care. In their studies of the effects on the newborn of anesthetics given to the mother during labor, Apgar and her coworkers discovered that cyclopropane gas, which had been considered a harmless anesthetic, markedly depressed the newborn. After reviewing the data, Apgar is said to have remarked, “There goes my favorite gas.” The obstetrical use of cyclopropane declined dramatically after the research was published. Another Apgar study with significant implications for neonatal care was a collaborative research project, involving twelve institutions and 17,221 infants. It determined, unequivocally, that the Apgar score, especially as assessed at five minutes after birth, was a good predictor of neonatal survival and neurologic development.

Apgar assisted in the education of more than 250 physicians in anesthesiology, and her ideas inspired both practice and research. Her motto was “Do what is right and do it now.” She always admitted her mistakes at a time when errors were usually denied and her constant encouragement, her honesty, and her humility enabled students to accept criticism without being offended.

After a distinguished career of thirty years at Columbia-Presbyterian Medical Center, Apgar decided to improve her knowledge of statistics related to research, and she left anesthesiology to earn a master of public health degree from Johns Hopkins University School of Hygiene and Public Health. She considered her pursuit of this degree at the age of fifty to be her most significant decision. It changed her whole life, and she never regretted it.

In 1959, Apgar was persuaded to join the National Foundation-March of Dimes, where she headed the division on congenital malformations from 1959 to 1967 and directed the foundation’s basic research program from 1969 to 1972. This period was a critical time in the foundation’s history, when the focus of its mission was being diverted from preventing poliomyelitis to the prevention of all birth disorders. From 1973 until the time of her death, Apgar served as the foundation’s vice president for medical affairs. As principal fund-raiser, she increased the foundation’s annual income from $19 million in 1959 to $46 million in 1974, helping to fund research into the many causes of birth disorders as well as their prevention and treatment. As comfortable with the public as she was with her medical colleagues, Apgar made frequent public talks and coauthored a book for parents about birth disorders, Is My Baby All Right? (1972). During this time, she also served as a research fellow in medicine at Johns Hopkins University and a clinical professor of pediatrics at Cornell University Medical College, where she was the first physician in North America to have an appointment that included teratology (birth disorders) as a subspecialty.

In recognition of her important scientific contributions, Apgar received many honors. The American Academy of Pediatrics named a prestigious award for her and the American Society of Anesthesiologists presented her with the Ralph Waters Medal. In 1973, she was awarded the Gold Medal of Columbia University for special service to medicine. Her undergraduate alma mater, Mount Holyoke College, named an academic chair in her honor. In addition, Apgar received four honorary degrees and was honored by Ladies’ Home Journal as Woman of the Year in 1973.

Apgar’s private life was full and rewarding she was a gifted musician, an avid gardener, an aviator, a photographer, and a philatelist. She was also an untiring student: When she died in 1974 at age sixty-five, she was commuting from her March of Dimes work in New York to Johns Hopkins University in Baltimore to study genetics.

Significance

During her career, Apgar received international recognition for her pioneering work in anesthesiology, neonatology, and teratology. She probably did more to improve the health of mothers and infants than anyone during the twentieth century. Modern obstetricians, pediatricians, and nurses include the Apgar score a scientifically validated standard for evaluating the newborn in their vocabulary as a result of her concern for babies during the critical first few moments after birth. As a professor of anesthesiology at the Columbia-Presbyterian Medical Center for more than twenty years, Apgar assisted in the delivery of more than seventeen thousand babies. Apgar’s research laid the foundation for the development of perinatology, and countless infant deaths have been prevented because of her work. She was a wonderful teacher, and her ideas inspired much productive research.

When she could not become a surgeon because she was a woman, Apgar became an anesthesiologist. When she could not become department chair, Apgar entered obstetrical anesthesia. When she believed there was no room for her to advance at Columbia-Presbyterian Medical Center, Apgar became enormously successful in preventing birth disorders and developing the field of teratology. While not publicly supportive of feminism, Apgar was outraged at the restrictions facing women. Nevertheless, she believed there were ample opportunities, particularly within various medical fields, for both men and women who were willing to overcome their limitations. She considered women more competitive, more rational, more sincere, and stronger than men. She took advantage of every available opportunity, made an incalculable contribution to society, created a marvelous career, and served as a role model for women, and men, everywhere.

Further Reading

Apgar, Virginia, and Joan Beck. Is My Baby All Right? A Guide to Birth Defects. New York: Trident Press, 1972. A book written to answer the questions of parents and general readers, in nontechnical terms, about birth disorders. There are interesting details of Apgar’s life in the preface and “About the Authors” section.

“Baby Monitor.” Science, August 4, 2006. Explains the Apgar score as well as the course of its development by Apgar.

Calmes, Selma. “Virginia Apgar: A Woman Physician’s Career in a Developing Specialty.” Journal of the American Medical Women’s Association 39 (November-December, 1984): 184-188. The best source of information about Apgar’s early life and career at Columbia University. The article’s wealth of detail comes from its author’s skillful use of such primary sources as Apgar’s diary, letters, and reports.

Diamonstein, Barbaralee. Open Secrets: Ninety-four Women in Touch with Our Time. New York: Viking Press, 1972. An entertaining interview with Apgar that reveals her delightful sense of humor and opinions on many topics.

Kass-Simon, G., and Patricia Farnes, eds. Women of Science: Righting the Record. Bloomington: Indiana University Press, 1990. Contains only a brief paragraph about Apgar, but the preface and introduction give valuable feminist insights into the context in which women scientists have worked and the obstacles they have had to overcome.

Mitford, Jessica. The American Way of Birth. New York: E. P. Dutton, 1992. Mitford’s work provides little direct coverage of Apgar’s life, yet it does give a historical overview of the changing attitudes toward childbirth that have prevailed from medieval times through the twentieth century and their impact on American obstetrical medicine. Although her acerbic comments fall short of a purely objective history, Mitford does provide a context for understanding modern obstetrical practices as well as childbirth alternatives, such as delivery by licensed nurse midwives and lay midwives.

Vare, Ethlie Ann, and Greg Ptacek. Mothers of Invention: From the Bra to the Bomb Forgotten Women and Their Unforgettable Ideas. New York: William Morrow, 1988. Although this work is primarily devoted to women inventors in fields outside medicine, it does include a sketch on Apgar that provides details of her research as well as her fund-raising efforts on behalf of the National Foundation-March of Dimes.