Journal of the American Medical Women's Association

1984, Vol. 39, No. 6, p184-188

 

Virginia Apgar:

a woman physician's career in a developing specialty

 

Written by Selma Harrison Calmes, MD

Virginia Apgar was born in 1909 in Westfield, New Jersey. Her father, an interesting character, did experiments with electricity and radio waves in his basement laboratory and built a telescope for his astronomy work. He even wrote several scientific papers on the moons of Jupiter. It was probably through him that Apgar got her interest in science. By the time she graduated from high school she was determined to be a doctor. No specific event seems to have led to this decision; Apgar never met a woman doctor until after college graduation and had no serious illness. But an older brother had died of tuberculosis at age three, and her other brother was chronically ill with childhood eczema (interview with Larry Apgar, 29 August 1981). Perhaps talk of the older child's death or her brother's frequent visits to the family doctor influenced her.

Apgar attended Mt. Holyoke College, graduating in 1929. There, she received scholarships and supported herself with a variety of jobs, including catching cats for the zoology laboratory. She also entered energetically into an incredible number of extracurricular activities.[1] In September 1929, she entered the College of Physicians and Surgeons at Columbia University. In October the stock market crashed, America's Great Depression began, and Apgar's financial problems worsened. Despite small scholarships, she had to borrow money from family friends. She graduated in 1933, fourth in her class, a member of Alpha Omega Alpha, and nearly $4,000 in debt.[2]

She was determined to become a surgeon and won a prized surgical internship at Columbia,[3] where she performed brilliantly. But Dr. Alan Whipple, chairman of surgery, discouraged her from continuing. Whipple had at least two reasons for deterring her: First, he had trained four other women surgeons and they had not been financially successful. Surgery was a crowded specialty in New York City, and it was the Depression &emdash; it was hard even for men to get established (interview with George Humphreys, MD, 4 September 1981). And Apgar had to support herself; her family was not wealthy and she was not married. Her predecessors' difficulties were surely a major factor in her move into anesthesia.

Another reason Whipple urged her not to continue in surgery was his recognition of the need for better anesthesia. At that time, few physicians specialized in the field, and most anesthesia was given by nurse anesthetists. Academic surgeons of the time were trying to develop better anesthesia; they realized that surgery could not advance unless anesthesia did. Whipple saw in Apgar the energy, intelligence, and ability needed to make significant contributions in this area.[4]

Although this is not documented, Whipple may also have urged Apgar to enter anesthesia because it was then thought to be a suitable field for a woman. The nurse anesthetists, who began their work in America in the 1880s, were reliable, patient, and technically skilled. Some thought that women physicians, who would have the same "feminine" traits in addition to medical training, would be the ideal physician anesthetists.[5] Women doctors did enter anesthesia relatively commonly after 1900 and were even leaders, serving as presidents of the national anesthesia organizations.[6]

 

Entry into Anesthesia

Whipple's arguments must have convinced Apgar. In August 1934, less than a year after starting her surgical internship, she began her search for anesthesia training. She wrote to Dr. Frank McMechan, secretary-general of the Associated Anesthetists of the United States and Canada (the major American anesthesia organization at that time), requesting a list of possible training positions. There were 13 training institutions then. Length of training ranged from two weeks to three years and only two programs paid salaries.[7]

Apgar stayed at Columbia after finishing her surgical internship in November 1935, probably for financial reasons, and started work with the head nurse anesthetist there.[8] On January 1, 1937, she arrived in Madison, Wisconsin, as a "visitor" in Dr. Ralph Waters's department of anesthesia, the first and most important anesthesia department in the country. During her six months in Madison, she suffered from a common problem for women physicians working in hospitals at the time: lack of housing facilities. She moved three times in six months.[9] In July, she went back to New York City to spend six months with Dr. Ernest Rovenstine, another Madison graduate, who was at Bellevue. There she again faced housing problems, finally ending up in the clinic building's maids' quarters. She also, for the first time, recorded in her diary her feelings about being excluded from male medical activities: "Fairly good meeting but stag dinner-MAD!"[10]

Apgar returned to Columbia as "Director of the Division of Anesthesia and Attending Anesthetist" in 1938.[11] She was very enthusiastic initially, but enormous problems occurred. These were in four areas: recruitment, an overwhelming clinical load, reluctance by the surgeons to accept anesthesiologists as their equals in the operating room, and difficulty getting adequate compensation. Recruitment was difficult because administering anesthesia was still thought of as a nurse's job. Apgar was the only staff member until August 1940, when Dr. Ellen Foot, one of the residents, joined her. The clinical work load increased tremendously after 1940 as many male physicians entered the armed services. But many of these physicians returned from World War II interested in anesthesia, and in 1945 more anesthetics were given by doctors than by nurses for the first time.[12] The number of nurse anesthetists decreased sharply during this period-from l4 in 1937 to l2 in 1945 and then to 4 in 1948,[13] by which time there were 18 residents in the Columbia program.

Another problem was the surgeons' difficulty accepting anesthesiologists as their equals in the operating room. Surgeons had previously had to give anesthesia, and thus they often thought they knew what was best for the patient, even though anesthesia practice had changed markedly. They were also accustomed to giving the nurse anesthetists orders. Conflict was inevitable, but Apgar gradually won over the younger surgeons (interview with George Humphreys, MD, 4 September 1981).

Finally, there was the problem of adequate financial compensation. Physicians giving anesthesia were not allowed to charge professional fees. In October 1940, Apgar threatened to resign because of inadequate compensation and inability to charge fees, and followed through in December.[14] Although not documented, this conflict was apparently resolved, because she did return. The anesthesia division was funded by charges for operating room use until 1941 when a budget was allowed. Bills for the operating room service were "to be submitted to private and semiprivate patients at the discretion of the surgeon." So the surgeon decided if the anesthesiologist could bill! And even then the anesthesiologist could not bill for services provided outside the operating room.[15]

Being able to charge a fee is the ultimate symbol of a professional. Why could the anesthesiologists at Columbia not charge fees, as the other hospital physicians did? The answer is not clear, but probably relates to attitudes toward anesthesia as a merely technical exercise that "even nurses can do." Whatever the reason, the prohibition against fees for Columbia anesthesiologists reveals the status of physician anesthetists then.

These were the problems Apgar faced in this first period at Columbia. A critical time came in 1946. The end of World War II had brought relief in staffing and recruitment problems and anesthesia was being recognized nationally as a specialty. It seemed time to form a physician-only department, to separate from surgery, and to develop a strong research program.[16]

Apgar had recognized the need for a research element in her division from the beginning, although she initially thought, as her mentor Ralph Waters had, that research would follow naturally as the more important areas of patient care and teaching were improved.[17] Apgar did do clinical research, but had little time for it because of the overwhelming clinical load. She also lacked sophisticated research training, as did most anesthesiologists of that time. There was quite a struggle over the department's structure and the role of research from 1946 to 1949. Evidence indicates that Apgar expected to be made chair. But in 1949, Emmanuel Papper, a Bellevue anesthesiologist with a research background, was made head of the division. It became a department six months later. Apgar and Papper were both appointed professor, making her the first woman full professor at Columbia (interviews with Belmont and William Musicant, MD, 6 June 1981; George Humphreys, MD, 4 September 1981; and Duncan Holaday, MD, 18 October 1981).

 

Obstetric Anesthesia

Apgar then moved into a new phase of her Columbia years: obstetric anesthesia. Freed from the frustration of administration, she was able to make her greatest contributions here, contributions that were sorely needed. Her most important contribution was, of course, the Apgar Score.*

*Five points&emdash;heart rate, respiratory effort, muscle tone, reflex response, and color&emdash;are observed and given 0, 1, or 2 points. The points are then totaled to arrive at the baby's "score."

Until its development, no standard evaluation of the newborn's transition to extrauterine life could be made. The idea for the score came in 1949. One day, over breakfast in the hospital cafeteria, a medical student said something about the need to evaluate the newborn. Apgar said, "That's easy! You'd do it this way." She picked up the nearest piece of paper (the "Please bus your own trays" sign) and wrote down the five points of the Apgar Score. She then dashed off to obstetrics to try it out (information provided in an interview with Richard Patterson, MD, 19 June 1980).

The score was first published in l953.[18] There was some resistance initially, but the score was eventually accepted and is now used throughout the world. The importance of the score is that someone now looks at the baby in a standard way and looks at more than one sign. Apgar first planned the score to be taken one minute after birth, as a guide to the need for resuscitation. Others began to take measurements at longer intervals, to evaluate how the baby had responded to any necessary resuscitation. Eventually, the one- and five-minute Apgar Scores became standard.

Using the score as a method of standard evaluation, Apgar went on to relate it to the effects of labor and delivery and of maternal anesthetics on the condition of the baby. She was aided in this by the arrival of important personnel at Columbia and the development of new technology. Duncan Holaday, an anesthesiologist-researcher, provided new methods of measuring blood gases, blood levels of anesthetics, and pH. Stan James, a pediatrician, had a background in cardiology and technical knowledge (interviews with Duncan Holaday, MD, 18 October 1981 and L. Stanley James, MD, 14 January 1981). With this personnel and the new technology, Apgar was able to demonstrate important basic concepts. Hypoxic, acidotic babies were found to have low Apgar Scores. She realized that acidosis and hypoxia are not normal conditions at birth, as was previously thought, and that they should be treated promptly.[19] Apgar was the first person to catheterize the umbilical artery of the newborn, when, as part of these studies, she and James were investigating changes in venous pressure after birth and were passing catheters into the right atrium through the umbilical vein. They recognized the significance of what she accidentally did, repeated it, and taught visiting neonatologists how to do it (interview with L. Stanley James, MD, 14 January 1981). It has become an essential part of newborn care.

Next, they investigated the effects of maternal anesthetics on the baby. They found cyclopropane to be more depressant than other agents, and its use in obstetrics declined markedly after publication of their study.[20] Finally, the Collaborative Project, a 12-institution study involving 17,221 babies, established that the Apgar Score, especially the five-minute score, is a predictor of neonatal survival and of neurologic development.[21]

In 1959, Apgar took a sabbatical and went to Johns Hopkins University to get a masters of public health degree. Her goal was to learn more about statistics, to help with the evaluation of her studies with James and Holaday (interviews with Duncan Holaday, MD, 18 October 1981 and L. Stanley James, MD, 14 January 1981). In April 1959 she was urged to become director of the National Foundation's (previously the March of Dimes) new division of congenital defects. She took the job, feeling there was no place else to go at Columbia, and left anesthesia.[22] The second phase of her life, the years at the National Foundation, began in June 1959.

She was enormously successful and was still there when she died in 1974.

 

Conclusion

As a woman, Apgar could not be a surgeon so she entered anesthesiology, which needed physicians. When she could not be a department chair, she entered obstetric anesthesia where, once again, there were great needs. This move freed her from administration, and allowed her to make her greatest contributions. A chance remark led to her formulation of the Apgar Score in 1949. The arrival of important personnel and the development of new technology for measuring blood gases, pH, and anesthetic blood levels made further development of the Apgar Score possible. There was a reciprocal relationship between Apgar and the developing field of anesthesiology during the Columbia years. She needed the opportunities available in this specialty and anesthesia needed her contributions.

Did she recognize the lack of opportunity for her as a woman physician? Yes, but not publicly. She often declared that "women were liberated from the time they were born." She appears to have had little regard for women residents, and she never participated in female medical organizations. She felt she did not need them. But in her diary and in conversations, she expressed outrage at such things as salary differentials between her and her male colleagues and the "stag" dinners that followed professional meetings. While in private she clearly acknowledged the restrictions facing her, like most women doctors of the time, she did not speak out about them. She overcame the restrictions limiting her and took advantage of the available opportunities to create the most outstanding career of any woman anesthesiologist to date.

 

References

1. Apgar interview. Mount Holyoke College card from scholarship file on students: Box 1, Folder 1, Apgar Papers (AP), Mt. Holyoke College Library Archives (MHCLA).

2. "Expenses," 1929-1937, Box 10, AP-MHCLA. Willard C Rappleye to Apgar, 7 June 1933: Box 5, Folder 21, AP-MHCLA.

3. Matthew Fleming to Apgar, 1 March 1933: Box 5, Folder 21, AP-MHCLA.

4. The history of anaesthesia is documented in: Duncum B:

The Development of Inhalational Anesthesia. New York, Oxford University Press, 1947; Keys T: The History of Surgical Anesthesia. Huntington, NY, Kneger, 1978; Eckenhoff JE: Anesthesia from Colonial Times: A History of Anesthesia at the University of Pennsylvania. Philadelphia, Lippincott, 1966; and Thatcher S: History of Anesthesia with Emphasis on the Nurse Specialist. Philadel phia, Lippincott, 1953.

5. Anesthesia service in hospitals. J Am Med Assoc 1940; 114:1260-1261. Bevan A: The choice of the anesthetic. J Am Med Assoc 1911; 57:1821. Bevan A: The nurse anesthetist question. Kentucky Med J 1917; 15:149.

6. Calmes SH: American anesthesia from 1920-1950: was it women's work? Read before the annual meeting of the American Association for the History of Medicine, San Francisco, CA, May 5, 1984. McMechan F: Editorial. Am J Surg (Anes Suppl) 1922; 36:123. McMechan F: More honors richly deserved. Am J Surg (Anes Suppl) 1924; 38:89.1930 Directory of Anesthetists. Cleveland, International Anesthesia Research Society, 1930.

7. Frank McMechan to Apgar, 8 August 1934: Box 5, Folder 21, AP-MRCLA. Apgar's letter to McMechan is not available. Untitled, list of available training: Box 1, Folder 4, AP-MRCLA.

8. Signature undecipherable (no typed name) to Apgar, 17 June 1935: Box 4, Folder 21, AP-MRCLA. Matthew Fleming to Apgar, 15 June 1936: Box 4, Folder 21, AP-MRCLA.

9. Ralph M Waters to Apgar, 27 April 1936 and 29 October 1936: Box 5, Folder 21, AP-MRCLA. Personal diary starting 1 January 1937; entries for 3 and 16 January and 1 April 1937: Box 10, AP-MHCLA.

10. Personal diary starting 1 January 1937; entries for 1 January and 22 and 24 September 1937: Box 10, AP MHCLA.

11. Matthew Fleming to Apgar, 15 June 1932: Box 4, Folder 21, AP-MHCLA.

12. Data summarized from the department's annual reports: Box 1, Folders 3 and 4, AP-MHCLA.

13. First Annual Anesthesia Report: Box 1, Folder 3, AP MHCLA. Apgar to Alan Whipple, 29 September 1938: Box 5, Folder, 3, AP-MRCLA. Anesthesia Report for the Surgical Executive Committee, 10 January 1940, pp 3-4: Box 1, Folder 3, AP-MHCLA. William D Cutter to John F MacCormack, 19 December 1939: Box 5, Folder 22, AP-MHCLA. Third Annual Report of the Division of Anesthesia: Box 1, Folder 3, AP-MRCLA. Sixth Annual Report~Division of Anesthesia, 194i Box 1, Folder 4, AP-MRCLA. Present Plan of Anesthesia Department, 1 July 1948: Box 1, Folder 4, AP-MRCLA. Apgar to Alan Whipple, 29 November 1937: Box 5, Folder 21, AP MHCLA. Ninth Annual Report: Division of Anesthesia, 1946: Box 1, Folder 4, AP-MHCLA.

14. Anesthesia Report for the Surgical Executive Committee. 10 January 1940: Box 1, Folder 3, AP-MRCLA. Apgar to Alan Whipple, 29 October 1940 and 17 December 1940: Box 5, Folder 22, AP-MHCLA.

15. Fourth Annual Report of Division of Anesthesia: Box 1, Folder 4, AP-MHCLA.

16. Second Annual Report, 1939, p 3: Box 1, Folder 3, AP-MHCLA.

17. Waters RM: The requirements of an anesthetic service. Curr Res Anes Anal 1932; 11:219-223. Waters RM: Anesthesiology in the hospital and in the medical school. J Am Med Assoc 1946;130 :909-912. Apgar to Alan WhippIe, 29 November 1937: Box 5, Folder 21, AP-MHCLA.

18. Apgar V: Proposal for a new method of evaluation of the newborn infant. Curr Res Anes Anal 1953; 32: 260.

19. Apgar V, Roladay DA, James LS, et al: Evaluation of the newborn infant-second report. J Am Med Assoc 1958; 168:1985.

20. Apgar V, Holaday DA, James LS: Comparison of regional and general anesthesia in obstetrics. J Am Med Assoc

1957;165: 2155.

21. Drage JS, Kennedy C, Schwartz BK: The Apgar Score as an index of neonatal mortality. Obstet Gynecol 1 964;24:222.

22. Apgar to "Aunt Edith," 22 April 1959: Box 5, Folder 23, AP-MHCLA.

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