Anaesthesia - Essays on Its History
Edited by Joseph Rupreht, Marius Jan van Lieburg, John Alfred Lee, Wilhelm Erdmann
© Springer-Verlag Berlin Hiedelberg 1985
Development of the Apgar Score
Written by Selma Harrison Calmes, MD
One contribution of American anesthesia is important for other specialties also. The Apgar Score, for evaluation of the transition of the newborn baby to extrauterine life, is used by both obstetrics and pediatrics as well as anesthesiology. I investigated the development of the Apgar score as part of a larger project on Virginia Apgar's life. For this study, I recorded oral history interviews with nine of her colleagues and reviewed archival material at Mount Holyoke College, South Hadley, Massachusetts.
The Apgar Score was the result of the interaction of several factors: Apgar's situation as a woman in the male medical world, the development of new technology, and the arrival of important personnel at Columbia. Probably the most important factor was that Virginia Apgar was a woman. She had wanted to be a surgeon after graduation from Columbia University's College of Physicians and Surgeons in 1933. She won a surgical internship at Columbia, and she performed brilliantly. However Dr. Alan Whipple, Chairman of the Surgery Department, discouraged her from becoming a surgeon and argued that she should enter anesthesia instead. The four other women surgeons that Whipple had trained had not been able to become financially successful, because of patients' attitudes towards woman surgeons and because of inability to get further training. Whipple also felt strongly that anesthesia needed more physician involvement. Most anesthesia in America at that time was given by nurse anesthetists who were excellent technicians. Whipple felt, however, that technical skill was not enough and that surgery could not progress unless anes thesia was improved . Apgar was nearly US $4000 in debt from her medical school expenses  and it was the middle of America's Great Depression. She accepted Whipple's advice and entered anesthesia.
Her anesthesia training was first with the nurse anesthetists at Columbia. This was for 1 year . Then she spent 6 months with Ralph Waters at Madison, Wisconsin and another 6 months at Bellevue Hospital, New York with Ernest Rovenstine . She returned to Columbia in 1938 as Director of the Division of Anesthesia under the Department of Surgery . She proceeded to develop a strong Division, although it was an uphill battle. She began medical student teaching, began residency training, phased out the nurse anesthetists, introduced all the new agents and techniques as they became available, and expanded the Division's activities outside the operating rooms (see Table 1).
These achievements were in spite of enormous problems. There was great difficulty in recruitment. Anesthesia was thought to be a nurse's job, and it was difficult to attract bright physicians, especially males. There was an overwhelming work load, especially during World War II. Some of the surgeons, who were used to ordering the nurse anesthetists around, would not accept physician-anesthesiologists. She had difficulty getting inadequate compensation and even being able to charge fees!
In 1948, the move for a separate Department of Anesthesia, not just a Division under the Department of Surgery, was begun. Some said that because she was a woman she would not be considered for the departmental chairmanship  (R. Patterson 1980, personal communication). Others said she disliked administration and was glad to be freed from it [1,6]. Many of the administrative difficulties which led her to dislike administration were due to the fact that she was female. No matter what the exact cause, Emmanuel Papper, one of the few research trained anesthesiologists, was brought in to be Chairman of a separate Department of Anesthesia in 1949.
Apgar moved then into obstetric anesthesia. Freed from the time-consuming hassle of administration, this was where she made her greatest contributions. At that time, this was quite a neglected area, and she developed a teaching program. Residents were now required to rotate on obstetric anesthesia for 2 months. Two of these residents, Sol Shnider and Frank Moya, went on to become the leaders in obstetric anesthesia research and training. She expanded the agents and techniques available. However, general anesthesia was still given by mask. The risk of aspiration in pregnant patients was still not fully recognized [7,8].
Probably her greatest achievement was the development of the Apgar Score. The idea for this came in 1949. Each day, the Columbia anesthesiologists ate breakfast together in the hospital cafeteria. One day, 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. which was the sign that said, "Please bus your own trays", and wrote down the five points of the Apgar Score. She then dashed off to obstetrics to try it out (R. Patterson 1980, personal communication). It was first presented at a meeting in 1952 and was published in 1953 . There was some resistance initially, but the Score was accepted and is now used throughout the world.
The importance of the Score was that the newborn baby could now be observed in a standard way which looked at more than one sign. She at first planned the Score to be done 1 mm after birth so that it would he a guide to the need for resuscitation. She had to emphasize that physicians should not wait the entire I mm to complete the Score before resuscitating an obviously depressed baby . Others started measuring the Score at longer intervals after birth to evaluate how the baby responded to resuscita tion, if that was necessary. Eventually, the 1-mm and 5-mm Apgar Scores became standard. Acceptance of the 5-mm Score came when it was found to be a predictor of mortality in the neonatal period and also of future neurologic development .
Using the Score as a method of standard evaluation, she then went on to relate it to the baby's acid-base status and to maternal anesthetics. She was aided in this by the arrival of important personnel and the development of new technology. L. Stanley James, a pediatrician from New Zealand, had met Apgar soon after his arrival in the United States, because of his interest in infant resuscitation. After finishing a pediatric residency at Bellevue Hospital, New York. he went to work for her as a research assistant in 1955. He had a background in cardiology and had technical knowledge. These became his contributions to the projects . The other important person was Duncan Holaday, who had trained in anesthesia and who then did research at Johns Hopkins. Apgar recruited him, and he arrived at Columbia in 1950. For their projects, he developed a nitrogen washout technique for measuring cyclopropane, used the Nadelson microgasometer to measure arterial blood gases in the presence of anesthetics, and, finally, developed better pH measurements . The availability of the Astrup pH electrode in 1960 made pH measurement much easier, and the group bought one of the first available .
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. Also, acidosis and hypoxia were not normal conditions at birth, as was previously thought. These conditions should be treated . They investigated the effects of maternal anesthetics on the baby. They found cyclopropane to be more depressant than other agents, and consequently its use in obstetrics decreased mar kedly [12,15]. Finally, the Collaborative Project, a 12-institution study involving 17221 babies, established that the Apgar Score, especially the 5-min Score, was a predictor of neonatal survival and of future neurologic development. This was published in 1964 [12,17].
Apgar, a woman, couldn't be a surgeon so she entered anesthesiology, which needed physicians. She couldn't be a departmental chairman, so she entered obstetric anesthesia, where once again there were great needs. This move freed her from administration, and she made her greatest contributions in this area. A chance remark to her led to the birth of the Apgar Score in 1949 and its publication in 1953. The arrival of Duncan Holaday and L. Stanley James at Columbia, and the development of new technology for measuring blood gases, pH, and anesthetic blood levels, were other contributing factors to the development of the Apgar Score. These all interacted to give us today a most useful tool. a tool that serves as a common language between the three specialties that care for newborns obstetrics, pediatrics, and anesthesiology
I Interview with George Humphreys, 4 September 1951; transcript in possession of author
2. Expenses: 1929-1937, Box II). Apgar Papers:, Mt. Holyoke College Library/Archives (AP MIICLA)
3. Personal diary: Box 10, AP-MCLHA
4. Matthew C. Fleming to Apgar, 15 June 1938: Box 4, Folder 21. AP-MHCLA
5. Interview with Belmont and William Musicant, 6 June 1981: transcript in possession of author
6. Interview with Emmanuel Papper. 12 January 1981; transcript in possession of author
7. Interview with Sol Shnider. 13 January 1951; transcript in possession of author.
8. Interview with Frank Moya. 17 October 1981; transcript in possession of author
9. Apgar V (1953) A proposal for a new method of evaluation of the newborn infant. Cure Res Anesth Analg 32: 260-267
10. Apgar V (1966) The newborn (Apgar) scoring system. Pediatr Clin North Am 13: 645-650
11. Drage JS, Berendes 11(1966) Apgar scores and outcome of the newborn. Pediatr Clin North Am 13: 635-643
12. Interview with L Stanley James. 14 January 1981: transcript in possession of author
13. Interview with Duncan Holaday, 18 October 1981; transcript in possession of author
14. Siggaard Anderson 0, Engel K. Astrup P (1960) A micro-method for determination of pH, carbon dioxide tension, base excess and standard bicarbonate in capillary blood. Seand J Clin Lab Invest 12:172-176
15. Apgar V, Holladay DA, James LS, Weisbrot IM (1958) Evaluation of the newborn infant-second report. JAMA 165:1985-1988
16. Apgar V. Hollady DA. James LS Ct at (1957) Comparison of regional and general anesthesia in obstetrics. JAMA 165: 2155-2161
17. Drage JS, Kennedy C. Schwarz BK (1964) The Apgar score as an index of neonatal mortality. Obstet Gynecol 24: 222-230