July 6, 2015 • 31 mins
Dr. Virginia Apgar broke new ground in the fields of obstetrics and anesthesiology in the middle of the 20th century. When babies are born today, one of the tools doctors use to measure whether they're thriving on their own is the Apgar score.
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Episode Transcript
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Speaker 1 (00:01):
Welcome to Stuff you missed in History Class from works
dot Com. Hello, and welcome to the podcast. I'm Tracy V.
Wilson and I'm Holly Frying. So if you've if you've
had a baby in like the last sixty years, or
been present when somebody else had a baby, or maybe
(00:22):
even just watched a TV show in which babies were born,
you've probably heard people talking about a car scores. Yeah,
but I never gave it much thought, not being particularly
a baby person, So yeah, I thought this was an acronym.
And while somebody did rework the parts of the Apgar
score so that it matched up with the letters of
her name in about nineteen sixty two, the score itself
(00:43):
is from earlier than that, and it's the work of
Dr Virginia Apgar, who really broke new ground in the
fields of obstetrics and enthusiology as well as other fields
in the middle of the twentieth century. Today, the Apgar
score is really part of the standard of care for
new for newborn babies in much of the world, and
it's totally to the credit of this one particular doctor.
(01:06):
And this one particular doctor, Virginia Apgar was born in Westfield,
New Jersey, on June seven, nineteen o nine. Her father
was an insurance executive who was fond of science and
was an amateur astronomer. And she also had a brother
who died of tuberculosis at a very young age. So
it's possible that both of these things influenced her decision
to become a doctor, But regardless, that decision was made
(01:28):
before she even got out of high school. To that end,
she went to Mount Holyoke College, where she studied zoology.
In addition to being an excellent student in that program,
she worked several part time jobs to make ends meet.
Then she also played the cello and the violin and
the orchestra, and acted and wrote for the college newspaper
and played on seven different sports teams. She sounds like
(01:53):
a medical school version of Leslie. Nope. Yeah, that's a
great description her family. She described her family at one
point as just people who never sat still, and that's
just she seems to have been constantly doing her whole life.
She graduated in ninety nine and she started medical school
(02:15):
at the Columbia University College of Physicians and Surgeons that
same year. There were ninety people in her class, and
she was one of only nine women. She scraped together
enough money to stay in school in spite of the
Great Depression, and she graduated near the top of her
class in ninety three. So she really wanted to become
a surgeon, and she was accepted into a surgical internship
(02:37):
at Presbyterian Hospital which is now New York Presbyterian Hospital
Columbia University Medical Center. She did really well in her
first year of this residency, but Dr Alan Whipple, who
was the chair of the surgical department, encouraged her to
change specialties to anesthesiology. He was concerned that she would
not be able to make a profitable career as a surgeon,
(02:59):
especially given the economic climate at the time. This was
still in the wake of the Great Depression. He also
basically had other plans for her. He wanted her to
study anesthesiology and then come back to Presbyterian Hospital to
help start a teaching program for future anathusiologists. There were
lots of reasons for Dr Apgar to change specialties. It
(03:19):
was definitely difficult for women to be respected as surgeons
at this point, and there were lots of trained surgeons,
so competition for jobs was really stiff and dr Apgar
would have had to stand out even more because of
her gender. Dr Whipple had seen his other female surgical
students really have trouble getting hired as surgeons at all,
and dr Apgar had graduated from medical school in debts,
(03:41):
so taking on a specialty in which she would probably
have trouble finding a job was a really risky proposition.
At the same time, by becoming an anathusiologist instead of
a surgeon, she was really setting out to pursue a
specialty that did not even really exist yet. As recently
as nineteen eleven, the Erican Medical Association had even rejected
(04:02):
a request to start an anesthesiast section for its members.
So while dr Apgar essentially had a job waiting for
her after she was done with her study of anesthesiology,
it was going to be a tough one because it
was in a specialty that was not regarded as a specialty.
So let's talk about why that was. For a moment um,
(04:23):
for most of Western medical history, surgery was actually seen
as inferior to the rest of medicine. So before things
like modern anesthesia and the germ theory of disease, surgeons
mostly performed things like amputations, and it was not always
likely that their patients were going to survive. Eventually, as
developments in medicine made it possible for people to live
(04:44):
through surgeries without bleeding to death or immediately dying from infection,
surgery only gradually became a more respected field, so surgeons
had to basically claw their way to respectability, and for
the most part, in the early days of surgery, as
a more prestige jist position, anesthesia was being administered by nurses.
(05:04):
I want to be super clear on this. Nurse anesthetists
are still a really important part of the field of
anesthesiology today, but at this time, instead of working under
the direction of anesthesiologists who were specialists and how to
keep a patient simultaneously unconscious and pain free and medically stable,
nurse anesthetists were usually working on the under the direction
(05:26):
of the surgeon who was performing the procedure. This meant
that even as advances in surgical techniques and infection control
practices meant patients could survive longer and more complex surgeries,
anesthesiology wasn't advancing quickly enough to keep up outside of
teaching and research hospitals, where surgeons might be dedicating some
of their focus to anesthesia. This just was not the priority.
(05:49):
And then there was the basic fact that keeping a
patient properly anesthetized while also performing a surgical procedure is
really a lot to juggle at one time. Plus, after
having been viewed as inferior to doctors for so long,
a lot of surgeons just did not want to hand
over control of part of the surgical process to another person,
even if the person they were going to be handing
(06:11):
it off to was somebody who's sole focus was on
being the best in the world of anesthesiology. So Dr
Whipple hoped that he and Dr Apgar might work together
to change all of that. And we're going to talk
about that somewhere, but first we're gonna have a word
from a sponsor. So to get back to Dr Whipple
and Dr Apgar's plans for anesthesiology, Dr Whipple basically thought
(06:35):
that Dr Apgar might really have a knack for this.
He described her as having quote the energy, intelligence and
ability needed to make significant contributions in this area. Because
anesthesiology wasn't yet recognized as a specialty for medical doctors,
there really weren't a lot of training programs for it.
At this point, there were thirteen of them in the
United States, ranging in length from two weeks to three years,
(06:57):
and only two of those were actually paid residencies. Neither
of these residency programs had a spot open when Dr
Apgar applied. Yeah, obviously, like a two week training program,
and anesthesiology is not not nearly the same thing as
the work that it would be needed to take on
a new medical specialty. Yeah, that's a wide that's a
(07:17):
wide range, a two week to three year play. Yeah. Yeah. So,
after finishing her second year of her surgical internship, Dr
Afgar went through Presbyterians Training Program for Nurse Anesthetists. She
then spent six months studying under Dr Ralph Waters at
the University of Wisconsin, Madison in a visiting position. So.
(07:39):
Dr Waters was really one of America's earliest pioneers in
anesthesiology and he just made critical and ground breaking contributions
to this field. Once she was done studying under Dr Waters,
she spent another six months with Dr Ernest Rovestein in
New York Bellevue Hospital. He had also trained with Dr Waters,
So it's you could easily call Dr Waters like the
(08:02):
the keystone in a lot of anesthesiology work in the
United States at this point, so from there in dr
Apgar went back to Columbia University in Presbyterian Hospital and
became the director of the Division of Anesthesia and in
Attending Anesthetist. This made her the first woman to head
a division at the hospital. Dr Apgar and Dr Whipple
(08:26):
had formulated a plan for the Division of Anesthesia to
become dedicated to training doctors to be anesthesiologists, but because
of the prevailing attitudes running about anesthesiology at this point
and the low pay that came along with them, she
really had trouble recruiting peers to work with her. She
was the only staff member in the division through the
(08:47):
mid nineteen forties, but at the same time she became
a beloved teacher. As the existing staff of nurse anesthetists
left the hospital to get married or pursue other jobs,
residents filled their positions and studied anesthesiology under Dr Apgar
for between one and three years, and after the teaching
(09:07):
program was solidly established, the division also turned its focus
to research to improve the practice of anesthesiology. This is
really a long and difficult process for the first years
of the program, dr Apgar only had a couple of residents,
and she and a colleague had to write their textbook
themselves because there was no anesthesiology textbook. It was nine
(09:28):
five before anesthesia was more often administered by doctors than
by nurses at Presbyterian, which is really notable because at
this point the whole point was trying to train new doctors. Gradually, though,
perceptions about the validity of anesthesiology as a specialty started
to improve and it became recognized as a real specialty
(09:49):
in nineteen forty six. Three years later, dr Apgar became
the first woman to be named a full professor at
the Columbia University College of Physicians and Surgeons. Along with this,
in the same year, the Division of Anesthesiology became its
own department, and doctor Emmanuel Papper was selected to be
the chair of that department. So dr Afkar had sort
(10:11):
of thought she was going to be the person appointed
to this position, but the fact that she no longer
had that department had kind of role to take up
part of her time. She was able to focus a
lot more on teaching and on her work in obstetric anesthesiology.
During World War two, many doctors and surgeons joined the military,
(10:32):
which led to a labor shortage at Presbyterian Hospital and
to dr Avgar's department having more involvement in the field
of obstetric anesthesiology because the doctors and nurses who had
been doing so had gone to serve so. At this
point in the United States, uh women had generally moved
from usually delivering babies at home to usually delivering babies
(10:53):
in the hospital, but this really hadn't improved outcomes for
the women and their babies. All. Though infant mortality in
general had dropped, the rate of infant mortality within the
first twenty four hours after birth had hardly budged, even
though people were now being born in the presumably more
medically safe area of a hospital. This is where dr
(11:15):
Apgar really started to focus once she was freed up
from her previous administrative duties as a department head, and
it was known at that point that oxygen deprivation played
a part in at least half of those babies deaths.
It seemed obvious to dr Apgar that if it became
a standard practice to examine the baby and determine whether
it needed oxygen and then give it oxygen. If so,
(11:38):
then a lot of these deaths could potentially be prevented.
She was basically saying, y'all need to look at these
babies like you need to look at them so. I mean,
today this seems absurdly obvious. You should look at the baby,
make sure the baby is okay. But at the time,
in delivery rooms, medical efforts tended to be a lot
(11:58):
more focused on the mother than the baby. A lot
of times, the most junior people in the room were
the ones who were seeing to the baby after it
was born. They rarely had any training in anesthesiology or
any knowledge of how the drugs that were used during
a vaginal delivery or a cesarean section could affect a baby.
Sometimes they were really at the very beginning of their
(12:19):
medical study. They just were not trained particularly well on, uh,
what to do when the baby came out. Yeah, and
if they're that early on, they probably don't have the
confidence to like make kind of snap decisions about treatment. Uh. Plus,
it's not gonna come as a surprise to anyone who's
ever witnessed any conversation on the Internet about people's opinions
(12:42):
on childbirth. There was a whole lot of arguing going
on about how to best deliver babies and not a
whole lot of concrete data backing up people's opinions, and
even when there was data, it was often disregarded in
favor of what everybody quote already knew about it. So
dr Atgard develop uh standardized way of analyzing how the
(13:03):
baby was doing after it was born, and involved evaluating
five traits the baby's heart rate, respiratory effort, muscle tone, reflex,
and color, giving each of those a score of zero,
one or two. Then you add up those five numbers
and that's the baby's a car score. That mnemonic device
that we mentioned at the top of the episode substituted
(13:24):
appearance for color, pulse for heart rate, grimace for reflex uh,
because babies make a grimacy face as a reflex activity
for muscle tone and respiration, which was on the original list. Reportedly,
dr Agar was quite delighted when when a resident rewrote
the letters in the ACRE score to match up with
(13:44):
her names, they could remember what they all were. And
what's really important is that she assigned actual measurable criteria
to these, So a zero for heart rate meant that
the heartbeat was absent too meant that the heartbeat was
between one and one forty beats a minute zero for
muscle tone, but that there was no muscle tone, and
a tow meant the baby was actively moving. It really
(14:07):
got rid of a lot of the subjectivity in figuring
out whether her a baby was doing well or not. Yeah, so,
in addition to the extremely obvious, you need to look
at the baby. It's like, you need to look at
the baby and measure these things like that, and it
will help you understand whether the baby needs to be resuscitated,
(14:28):
whether the baby is thriving outside of the womb. She
then conducted a study using this scoring method on one thousand,
twenty one babies who were born at the Sloane Hospital
for Women at Presbyterian. She found definite correlations between the
method of delivery, the type of anesthesia used on the mother,
and the babies. After our scores, she recommended that New
(14:49):
York that newborn babies be evaluated a minute after their birth,
and also important that someone other than the attending obstetrician
do it. This was because she noticed a pattern that
obs tended to score their end quote their babies that
they delivered higher than other people in the delivery room did.
(15:14):
This will sound familiar to anyone who has heard our
episode on Dr VERA. Peters, who helped revolutionize the treatment
of Hodgkins lymphoma. When dr Apgar presented her paper at
the Annual Congress of Anesthetists into the audience was skeptical,
but she published the work in three and it has
since become a standard of care in delivery rooms in
(15:36):
much of the world, with the score measured once a
minute after birth and again five minutes after birth. So basically,
if the baby's score is not good after a minute,
you mean to resuscitate the baby. You do that and
take it again in five minutes. Uh. It's this is
one of those times where it's kind of baffling, Uh
(15:57):
that this you know, Now, it's just such a standard thing.
The baby is born and you check it out and
make sure everything's all right. Uh, this was not quite
as big of a focus when the medical team in
the room was so much more focused on the mother
than on both the mother and the baby. So, along
with Dr Duncan Holiday and Dr Stanley James, dr Apgar
(16:18):
went on to evaluate these correlations between delivery and the
baby's AFCAR scores. They slowly connected the length and difficulty
of the delivery and the types and amounts of fantasy
as you given to the mother, you know, whether it
was a vaginal birth or a cesarian section, all these
other things. With trends in the baby's scores. They figured
out that babies with a score under three needed to
(16:40):
be resuscitated. Kind of obviously, because that would be a
baby that's like blue and not moving and doesn't have
a pulse. Uh, But babies that have a score of
seven to ten had a statistically better chance of surviving
their first month of life than babies who scored six
are lower, so it would be kind of a baby
that's doing all right, but maybe not quite thriving. This
evolving body of data allowed obstetricians and obstetric anesthetists to
(17:05):
really refine their practices to improve newborn babies survival rates.
And we haven't really talked about the pretty massive differences
between anesthesia that's typically used in delivery rooms now versus
what was used in the like nineteen fifties, a totally
different world um in terms of like we it's not
(17:25):
standard practice to put women essentially unconscious to deliver babies
in American hospitals anymore. Dr Apgar and team also went
one step further and studied newborn babies blood chemistry, finding
clear physiological links between the outward appearance of the traits
examined to calculate an apgars to score and what was
actually physiologically going on in the baby's body. By the
(17:49):
late nineteen fifties, dr Apgar had attended more than seventeen
thousand births. During that time, she had seen a number
of children who were born with congenital disabilities also sometimes
known as birth defects, and in some cases it really
seemed like there was a correlation between the disability and
the baby's AFCAR score. So in Night she went on
(18:12):
a sabbatical and she pursued a master's degree in public
health from Johns Hopkins University. Originally, her intent was to
improve her knowledge of statistics and bring that knowledge back
to her work at Presbyterian Hospital, which increasingly involved statistics.
But as she studied, she became increasingly interested in whether
some of the congenital issues she was seeing when babies
(18:33):
were born could somehow be prevented. During this time, she
was approached by the National Foundation for Infantile Paralysis, which
is now known as the March of Dimes. Originally, the
National Foundation was primarily focused on polio. It had sponsored
the vaccine research of Dr Jonas Salk, and once the
polio vaccine was introduced and the rate of polio infection
(18:56):
just dropped dramatically, the Foundation wanted to find a new
place to expand its work and other conditions that they
could help with that we're affecting babies and children. The
Foundation started a new department called the Division of Congenital Malformations.
The National Foundation asked Dr Apgar to lead this new
department and she accepted, beginning her new role after she
(19:18):
completed her master's program. In this role, dr Apgar became
a huge advocate of early detection and treatment of congenital issues,
including prenail testing and treatment. She traveled extensively to talk
directly to parents and doctors and educators about congenital disabilities
and other issues that were related to prenatal and newborn health.
(19:40):
This was almost directly the opposite of her experience trying
to start an inn entusiology program while that field was
in its infancy. Congenital disabilities and disorders were huge news
in the United States at this point. The Drugslida mind
which had been given to pregnant women in much of
Europe both as a sedative and to combat morning signal.
This had been implicated in causing babies to be born
(20:03):
with missing or incorrectly formed limbs. The FDA had not
approved the drug to be used in the United States,
which the media played up as a near miss. This
was also during the post war baby boom, so parents
to be were hungry for information and dr Apgar was
really an ideal doctor to be involved in all this.
She had decades of experience and she was just extremely
(20:26):
personal and empathetic and compassionate with the people she was
talking to. In nineteen sixty four and nineteen sixty five,
a huge rubella outbreak in the United States led to
more than twelve million cases of rubella and twenty thousand
cases of congenital rubella syndrome, which occurs when a pregnant
woman contracts rubella. Congenital rubella syndrome can cause premature delivery, miscarriages,
(20:48):
and still births, and a wide variety of potential disorders
and disabilities which can affect virtually any system of the body.
These include blindness, heart problems, bone lesions, hepatite and developmental disabilities.
In the wake of this outbreak, dr Apgar led vaccination
campaigns after one became available in nineteen sixty nine. She
(21:09):
joined the faculty of the School of Pediatrics at Cornell
University School of Medicine in nineteen sixty five, and she
taught there until nineteen seventy four. She specialized in teratology.
So sometimes this is characterized as a study of congenital disabilities,
but it really incorporates any kind of disability or disorder
that arises as an organism is developing, So that can
(21:31):
include like as a child is growing or transitioning into adolescents,
or things like that. She was actually the first person
to hold a faculty position dedicated to this aspect of pediatrics.
In nineteen seventy two, dr Apgar was part of a
joint effort of the American Medical Association, the American College
(21:51):
of Obstetrics and Gynecologists, the American Academy of Family Physicians,
the American Academy of Pediatrics, and the March of Dimes.
It was the first committee on perinatal health. The committee's
goal was to put together a plan to improve maternal
health and lower infant mortality nationwide. Sadly, she died before
the committee's landmark report toward improving the Outcome of pregnancy
(22:14):
was released in nineteen seventy six. Dr Apgar published more
than sixty papers during her career, along with the book
Is My Baby All Right? Which she co wrote with
Joan Beck and published in nineteen seventy two. As this
was a book that walked through several different contentital situations
that can happen using real examples, it was a book
that there was a great need for at this point
(22:35):
because a lot of people had no knowledge of any
of these things or what to do. She also received
numerous honorary doctorates and professional accolades during her career. She
was given a commemorative postage stamp in and was inducted
into the National Women's Hall of Fame in n Throughout
her life, she continued to pursue all kinds of activities
(22:57):
and passions in addition to all this work of being
a doctor, so sort of continued what she had been
doing in college when she was on seven different sports
teams while also being a great student. She also and
what maybe is the most awesome thing in this episode.
Carried a penknife, an endo, tracheal tube, and a larynoscope
with her at all times, just in case someone near
(23:20):
her stopped breathing. She said, nobody, But nobody is going
to stop breathing on me. She medal Leslie, nope, is
she well, she's so I have I don't know. I
just developed this deep fondness for her in this episode
because she's like medical Leslie Nope. And we've told we've
told you all before how much I love parks and
recreation and cried when it was over. But also her
(23:43):
name is Virginia, my grandmother's names, and when you look
at pictures of her, she's got like the same kind
of uh very from the fifties I wear that you
see pictures of my grandmother's, she just reminds me of
like if my grand mother's had been like Leslie Nope
when they were young. And she actually never retired. She
(24:08):
only slowed down a little at the very end of
her life because she had progressive liver disease, which eventually
was the cause of her death. On August seven of nineteen,
she died at Columbia Presbyterian Medical Center, where she had
spent much of her career. So we've talked a few
times about the show sawt Owns, which is the snow
about medical history, which is the co production of uh
(24:31):
Sidney McElroy who's a doctor, and her husband Justin McElroy,
and they are charming and delightful. If you don't listen
to that show, I highly recommend it. It's from the
Maximum Fund podcast network. I don't think they have done
an episode that that touched on this, But the whole
time I was working on it, when I got to
this part where Dr Atgar was like, the problem is
nobody is looking at these babies, I just kept hearing
(24:52):
Sydney's voice in my head being like, you gotta look
at the babies. Look at the babies. Why aren't you
looking at the babies, Like it seems so obvious look
at the babies when they were born? It does? I
have to wonder, and I will, you know, show off
my um my ignorance in this arena. Like what the
(25:12):
thinking was like why they weren't focusing on the babies
and they were only focusing on the mothers. Were they
just so accustomed to a high mortality rate that they
were like, well, the baby may or may not make it.
The strong ones survived, let's make sure the mom gets through.
I kind of wondered that as I was, I mean,
I didn't find a lot of a lot of information
about why this was the way it is, but because
the infant mortality rate was so pronounced at that point,
(25:34):
like it seems like maybe that would be maybe not
a deliberate conclusion, but just sort of like the operating
parameters that were in people's minds that they were making
decisions in in the delivery room. Uh So, Yeah, I
was very curious in my mind about that. Also, Um,
I hope like nobody's grandfather was an obpetrician in nifty.
(25:57):
I'm not trying to be hurtful, No, I mean there
looking at the babies made a big difference. Well, it's
just one of those, you know, elements of like shifting
approaches and attitudes that happened gradually over time. It doesn't
always mean that the people involved were being negligent or
even wrong, They just hadn't shifted yet. No. Well, and
(26:17):
we got we got a listener email that I have
not read because it was just it was a little
too personal to just directly read. But it came after
that episode that we did about Dr Vera. Peters where
we talked about women who had lumps in their breasts
would basically be put under to go get a biopsy
and if they had cancer, they would wake up without
a breath anymore. And how like in today's mindset, that's horrifying.
(26:40):
Her story was about having had children during this part
of history and how basically you would go to the
hospital and you would be put under and you would
wake up with a baby. Uh and uh. She had
this whole story about the doctor that was delivering her
children had a clear preference for delivering mail children and
(27:01):
said some things that were pretty insensitive when he delivered
her daughter. So yeah, I would say that there is
still a way to go in terms of, you know,
women and babies getting the best possible medical care. Maybe
not so much babies anymore, but I know, like there're
still I know my mom personally had difficulty getting doctors
(27:24):
to take her seriously when she knew that something was
wrong with her health, and they just kept writing her
off as being a stressed out female, which was not
what was going on. She had a legitimate problem. So
medical care better, still room to improve, and I also
have listener mail, which is all is a little bit
related to the medical field. This for Maggie. Maggie says
(27:46):
Holly and Tracy. Unlike many of your listeners, I've only
been listening for the last year or so, but I
have been entirely hooked since then. As a former history
major in my undergrad days. It's super fun to find
all these new dimensions of the things I learned about
and remind myself I actually remember things too. I wanted
to specifically thank you for your episode about the Compton's
Cafeteria riots. I work with college students to spread mental
(28:09):
health awareness and enact advocacy on their campuses to make
these spaces safer for all people to live, learn and grow.
Our organization is called Active Minds, and we support over
four hundred student run chapters on campuses across the US, Canada,
and in Ecuador. I had never learned so much about
the Compton's Cafeteria riots. I had heard about it in passing,
(28:30):
but as you mentioned, we often bypassed these events in
favor of discussing Stonewall, which was obviously important but not
the loan significant event in those early days of this
civil rights movement. As a mental health educator and advocate
and a member of the lgbt community, I especially appreciated
your mention of trans mental health statistics and the violent
acts often perpetrated against that community. Lgbt Q mental health
(28:54):
has become a particular area of focus among our students
and for us at the national level. In partnership with
our friends at the Healthy Minds Network at the University
of Michigan, we were able to create the below infographics
about trans and LGBTQ mental health on campuses, and then
she gives links to them, which we will put in
our show notes. Thank you so much for spreading awareness
(29:15):
about these important events. We as a general population don't
know nearly enough about the social movements that have defined
our recent history. Between this story and your recent story
on special education, you're doing that. Thank you so much, Maggie.
I wanted to share this one specifically, UM because it
is so important to have mental health resources that are
(29:35):
specifically devoted to young people. UM Like, young people's mental
health issues and adult people's mental health issues are not
the same things, and a lot of times treatments are
really different. So I was really pleased to learn um
about this group that is doing a whole lot to
to promote that on college campuses, which I think is
critically important, and so we'll put links to those infographics
(29:57):
in our show notes. If you would like to write
to us for about this or any other subject um.
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You can also find an archive of every single episode
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(31:01):
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how stuff works dot com. M
Welcome to Stuff you missed in History Class from works
dot Com. Hello, and welcome to the podcast. I'm Tracy V.
Wilson and I'm Holly Frying. So if you've if you've
had a baby in like the last sixty years, or
been present when somebody else had a baby, or maybe
(00:22):
even just watched a TV show in which babies were born,
you've probably heard people talking about a car scores. Yeah,
but I never gave it much thought, not being particularly
a baby person, So yeah, I thought this was an acronym.
And while somebody did rework the parts of the Apgar
score so that it matched up with the letters of
her name in about nineteen sixty two, the score itself
(00:43):
is from earlier than that, and it's the work of
Dr Virginia Apgar, who really broke new ground in the
fields of obstetrics and enthusiology as well as other fields
in the middle of the twentieth century. Today, the Apgar
score is really part of the standard of care for
new for newborn babies in much of the world, and
it's totally to the credit of this one particular doctor.
(01:06):
And this one particular doctor, Virginia Apgar was born in Westfield,
New Jersey, on June seven, nineteen o nine. Her father
was an insurance executive who was fond of science and
was an amateur astronomer. And she also had a brother
who died of tuberculosis at a very young age. So
it's possible that both of these things influenced her decision
to become a doctor, But regardless, that decision was made
(01:28):
before she even got out of high school. To that end,
she went to Mount Holyoke College, where she studied zoology.
In addition to being an excellent student in that program,
she worked several part time jobs to make ends meet.
Then she also played the cello and the violin and
the orchestra, and acted and wrote for the college newspaper
and played on seven different sports teams. She sounds like
(01:53):
a medical school version of Leslie. Nope. Yeah, that's a
great description her family. She described her family at one
point as just people who never sat still, and that's
just she seems to have been constantly doing her whole life.
She graduated in ninety nine and she started medical school
(02:15):
at the Columbia University College of Physicians and Surgeons that
same year. There were ninety people in her class, and
she was one of only nine women. She scraped together
enough money to stay in school in spite of the
Great Depression, and she graduated near the top of her
class in ninety three. So she really wanted to become
a surgeon, and she was accepted into a surgical internship
(02:37):
at Presbyterian Hospital which is now New York Presbyterian Hospital
Columbia University Medical Center. She did really well in her
first year of this residency, but Dr Alan Whipple, who
was the chair of the surgical department, encouraged her to
change specialties to anesthesiology. He was concerned that she would
not be able to make a profitable career as a surgeon,
(02:59):
especially given the economic climate at the time. This was
still in the wake of the Great Depression. He also
basically had other plans for her. He wanted her to
study anesthesiology and then come back to Presbyterian Hospital to
help start a teaching program for future anathusiologists. There were
lots of reasons for Dr Apgar to change specialties. It
(03:19):
was definitely difficult for women to be respected as surgeons
at this point, and there were lots of trained surgeons,
so competition for jobs was really stiff and dr Apgar
would have had to stand out even more because of
her gender. Dr Whipple had seen his other female surgical
students really have trouble getting hired as surgeons at all,
and dr Apgar had graduated from medical school in debts,
(03:41):
so taking on a specialty in which she would probably
have trouble finding a job was a really risky proposition.
At the same time, by becoming an anathusiologist instead of
a surgeon, she was really setting out to pursue a
specialty that did not even really exist yet. As recently
as nineteen eleven, the Erican Medical Association had even rejected
(04:02):
a request to start an anesthesiast section for its members.
So while dr Apgar essentially had a job waiting for
her after she was done with her study of anesthesiology,
it was going to be a tough one because it
was in a specialty that was not regarded as a specialty.
So let's talk about why that was. For a moment um,
(04:23):
for most of Western medical history, surgery was actually seen
as inferior to the rest of medicine. So before things
like modern anesthesia and the germ theory of disease, surgeons
mostly performed things like amputations, and it was not always
likely that their patients were going to survive. Eventually, as
developments in medicine made it possible for people to live
(04:44):
through surgeries without bleeding to death or immediately dying from infection,
surgery only gradually became a more respected field, so surgeons
had to basically claw their way to respectability, and for
the most part, in the early days of surgery, as
a more prestige jist position, anesthesia was being administered by nurses.
(05:04):
I want to be super clear on this. Nurse anesthetists
are still a really important part of the field of
anesthesiology today, but at this time, instead of working under
the direction of anesthesiologists who were specialists and how to
keep a patient simultaneously unconscious and pain free and medically stable,
nurse anesthetists were usually working on the under the direction
(05:26):
of the surgeon who was performing the procedure. This meant
that even as advances in surgical techniques and infection control
practices meant patients could survive longer and more complex surgeries,
anesthesiology wasn't advancing quickly enough to keep up outside of
teaching and research hospitals, where surgeons might be dedicating some
of their focus to anesthesia. This just was not the priority.
(05:49):
And then there was the basic fact that keeping a
patient properly anesthetized while also performing a surgical procedure is
really a lot to juggle at one time. Plus, after
having been viewed as inferior to doctors for so long,
a lot of surgeons just did not want to hand
over control of part of the surgical process to another person,
even if the person they were going to be handing
(06:11):
it off to was somebody who's sole focus was on
being the best in the world of anesthesiology. So Dr
Whipple hoped that he and Dr Apgar might work together
to change all of that. And we're going to talk
about that somewhere, but first we're gonna have a word
from a sponsor. So to get back to Dr Whipple
and Dr Apgar's plans for anesthesiology, Dr Whipple basically thought
(06:35):
that Dr Apgar might really have a knack for this.
He described her as having quote the energy, intelligence and
ability needed to make significant contributions in this area. Because
anesthesiology wasn't yet recognized as a specialty for medical doctors,
there really weren't a lot of training programs for it.
At this point, there were thirteen of them in the
United States, ranging in length from two weeks to three years,
(06:57):
and only two of those were actually paid residencies. Neither
of these residency programs had a spot open when Dr
Apgar applied. Yeah, obviously, like a two week training program,
and anesthesiology is not not nearly the same thing as
the work that it would be needed to take on
a new medical specialty. Yeah, that's a wide that's a
(07:17):
wide range, a two week to three year play. Yeah. Yeah. So,
after finishing her second year of her surgical internship, Dr
Afgar went through Presbyterians Training Program for Nurse Anesthetists. She
then spent six months studying under Dr Ralph Waters at
the University of Wisconsin, Madison in a visiting position. So.
(07:39):
Dr Waters was really one of America's earliest pioneers in
anesthesiology and he just made critical and ground breaking contributions
to this field. Once she was done studying under Dr Waters,
she spent another six months with Dr Ernest Rovestein in
New York Bellevue Hospital. He had also trained with Dr Waters,
So it's you could easily call Dr Waters like the
(08:02):
the keystone in a lot of anesthesiology work in the
United States at this point, so from there in dr
Apgar went back to Columbia University in Presbyterian Hospital and
became the director of the Division of Anesthesia and in
Attending Anesthetist. This made her the first woman to head
a division at the hospital. Dr Apgar and Dr Whipple
(08:26):
had formulated a plan for the Division of Anesthesia to
become dedicated to training doctors to be anesthesiologists, but because
of the prevailing attitudes running about anesthesiology at this point
and the low pay that came along with them, she
really had trouble recruiting peers to work with her. She
was the only staff member in the division through the
(08:47):
mid nineteen forties, but at the same time she became
a beloved teacher. As the existing staff of nurse anesthetists
left the hospital to get married or pursue other jobs,
residents filled their positions and studied anesthesiology under Dr Apgar
for between one and three years, and after the teaching
(09:07):
program was solidly established, the division also turned its focus
to research to improve the practice of anesthesiology. This is
really a long and difficult process for the first years
of the program, dr Apgar only had a couple of residents,
and she and a colleague had to write their textbook
themselves because there was no anesthesiology textbook. It was nine
(09:28):
five before anesthesia was more often administered by doctors than
by nurses at Presbyterian, which is really notable because at
this point the whole point was trying to train new doctors. Gradually, though,
perceptions about the validity of anesthesiology as a specialty started
to improve and it became recognized as a real specialty
(09:49):
in nineteen forty six. Three years later, dr Apgar became
the first woman to be named a full professor at
the Columbia University College of Physicians and Surgeons. Along with this,
in the same year, the Division of Anesthesiology became its
own department, and doctor Emmanuel Papper was selected to be
the chair of that department. So dr Afkar had sort
(10:11):
of thought she was going to be the person appointed
to this position, but the fact that she no longer
had that department had kind of role to take up
part of her time. She was able to focus a
lot more on teaching and on her work in obstetric anesthesiology.
During World War two, many doctors and surgeons joined the military,
(10:32):
which led to a labor shortage at Presbyterian Hospital and
to dr Avgar's department having more involvement in the field
of obstetric anesthesiology because the doctors and nurses who had
been doing so had gone to serve so. At this
point in the United States, uh women had generally moved
from usually delivering babies at home to usually delivering babies
(10:53):
in the hospital, but this really hadn't improved outcomes for
the women and their babies. All. Though infant mortality in
general had dropped, the rate of infant mortality within the
first twenty four hours after birth had hardly budged, even
though people were now being born in the presumably more
medically safe area of a hospital. This is where dr
(11:15):
Apgar really started to focus once she was freed up
from her previous administrative duties as a department head, and
it was known at that point that oxygen deprivation played
a part in at least half of those babies deaths.
It seemed obvious to dr Apgar that if it became
a standard practice to examine the baby and determine whether
it needed oxygen and then give it oxygen. If so,
(11:38):
then a lot of these deaths could potentially be prevented.
She was basically saying, y'all need to look at these
babies like you need to look at them so. I mean,
today this seems absurdly obvious. You should look at the baby,
make sure the baby is okay. But at the time,
in delivery rooms, medical efforts tended to be a lot
(11:58):
more focused on the mother than the baby. A lot
of times, the most junior people in the room were
the ones who were seeing to the baby after it
was born. They rarely had any training in anesthesiology or
any knowledge of how the drugs that were used during
a vaginal delivery or a cesarean section could affect a baby.
Sometimes they were really at the very beginning of their
(12:19):
medical study. They just were not trained particularly well on, uh,
what to do when the baby came out. Yeah, and
if they're that early on, they probably don't have the
confidence to like make kind of snap decisions about treatment. Uh. Plus,
it's not gonna come as a surprise to anyone who's
ever witnessed any conversation on the Internet about people's opinions
(12:42):
on childbirth. There was a whole lot of arguing going
on about how to best deliver babies and not a
whole lot of concrete data backing up people's opinions, and
even when there was data, it was often disregarded in
favor of what everybody quote already knew about it. So
dr Atgard develop uh standardized way of analyzing how the
(13:03):
baby was doing after it was born, and involved evaluating
five traits the baby's heart rate, respiratory effort, muscle tone, reflex,
and color, giving each of those a score of zero,
one or two. Then you add up those five numbers
and that's the baby's a car score. That mnemonic device
that we mentioned at the top of the episode substituted
(13:24):
appearance for color, pulse for heart rate, grimace for reflex uh,
because babies make a grimacy face as a reflex activity
for muscle tone and respiration, which was on the original list. Reportedly,
dr Agar was quite delighted when when a resident rewrote
the letters in the ACRE score to match up with
(13:44):
her names, they could remember what they all were. And
what's really important is that she assigned actual measurable criteria
to these, So a zero for heart rate meant that
the heartbeat was absent too meant that the heartbeat was
between one and one forty beats a minute zero for
muscle tone, but that there was no muscle tone, and
a tow meant the baby was actively moving. It really
(14:07):
got rid of a lot of the subjectivity in figuring
out whether her a baby was doing well or not. Yeah, so,
in addition to the extremely obvious, you need to look
at the baby. It's like, you need to look at
the baby and measure these things like that, and it
will help you understand whether the baby needs to be resuscitated,
(14:28):
whether the baby is thriving outside of the womb. She
then conducted a study using this scoring method on one thousand,
twenty one babies who were born at the Sloane Hospital
for Women at Presbyterian. She found definite correlations between the
method of delivery, the type of anesthesia used on the mother,
and the babies. After our scores, she recommended that New
(14:49):
York that newborn babies be evaluated a minute after their birth,
and also important that someone other than the attending obstetrician
do it. This was because she noticed a pattern that
obs tended to score their end quote their babies that
they delivered higher than other people in the delivery room did.
(15:14):
This will sound familiar to anyone who has heard our
episode on Dr VERA. Peters, who helped revolutionize the treatment
of Hodgkins lymphoma. When dr Apgar presented her paper at
the Annual Congress of Anesthetists into the audience was skeptical,
but she published the work in three and it has
since become a standard of care in delivery rooms in
(15:36):
much of the world, with the score measured once a
minute after birth and again five minutes after birth. So basically,
if the baby's score is not good after a minute,
you mean to resuscitate the baby. You do that and
take it again in five minutes. Uh. It's this is
one of those times where it's kind of baffling, Uh
(15:57):
that this you know, Now, it's just such a standard thing.
The baby is born and you check it out and
make sure everything's all right. Uh, this was not quite
as big of a focus when the medical team in
the room was so much more focused on the mother
than on both the mother and the baby. So, along
with Dr Duncan Holiday and Dr Stanley James, dr Apgar
(16:18):
went on to evaluate these correlations between delivery and the
baby's AFCAR scores. They slowly connected the length and difficulty
of the delivery and the types and amounts of fantasy
as you given to the mother, you know, whether it
was a vaginal birth or a cesarian section, all these
other things. With trends in the baby's scores. They figured
out that babies with a score under three needed to
(16:40):
be resuscitated. Kind of obviously, because that would be a
baby that's like blue and not moving and doesn't have
a pulse. Uh, But babies that have a score of
seven to ten had a statistically better chance of surviving
their first month of life than babies who scored six
are lower, so it would be kind of a baby
that's doing all right, but maybe not quite thriving. This
evolving body of data allowed obstetricians and obstetric anesthetists to
(17:05):
really refine their practices to improve newborn babies survival rates.
And we haven't really talked about the pretty massive differences
between anesthesia that's typically used in delivery rooms now versus
what was used in the like nineteen fifties, a totally
different world um in terms of like we it's not
(17:25):
standard practice to put women essentially unconscious to deliver babies
in American hospitals anymore. Dr Apgar and team also went
one step further and studied newborn babies blood chemistry, finding
clear physiological links between the outward appearance of the traits
examined to calculate an apgars to score and what was
actually physiologically going on in the baby's body. By the
(17:49):
late nineteen fifties, dr Apgar had attended more than seventeen
thousand births. During that time, she had seen a number
of children who were born with congenital disabilities also sometimes
known as birth defects, and in some cases it really
seemed like there was a correlation between the disability and
the baby's AFCAR score. So in Night she went on
(18:12):
a sabbatical and she pursued a master's degree in public
health from Johns Hopkins University. Originally, her intent was to
improve her knowledge of statistics and bring that knowledge back
to her work at Presbyterian Hospital, which increasingly involved statistics.
But as she studied, she became increasingly interested in whether
some of the congenital issues she was seeing when babies
(18:33):
were born could somehow be prevented. During this time, she
was approached by the National Foundation for Infantile Paralysis, which
is now known as the March of Dimes. Originally, the
National Foundation was primarily focused on polio. It had sponsored
the vaccine research of Dr Jonas Salk, and once the
polio vaccine was introduced and the rate of polio infection
(18:56):
just dropped dramatically, the Foundation wanted to find a new
place to expand its work and other conditions that they
could help with that we're affecting babies and children. The
Foundation started a new department called the Division of Congenital Malformations.
The National Foundation asked Dr Apgar to lead this new
department and she accepted, beginning her new role after she
(19:18):
completed her master's program. In this role, dr Apgar became
a huge advocate of early detection and treatment of congenital issues,
including prenail testing and treatment. She traveled extensively to talk
directly to parents and doctors and educators about congenital disabilities
and other issues that were related to prenatal and newborn health.
(19:40):
This was almost directly the opposite of her experience trying
to start an inn entusiology program while that field was
in its infancy. Congenital disabilities and disorders were huge news
in the United States at this point. The Drugslida mind
which had been given to pregnant women in much of
Europe both as a sedative and to combat morning signal.
This had been implicated in causing babies to be born
(20:03):
with missing or incorrectly formed limbs. The FDA had not
approved the drug to be used in the United States,
which the media played up as a near miss. This
was also during the post war baby boom, so parents
to be were hungry for information and dr Apgar was
really an ideal doctor to be involved in all this.
She had decades of experience and she was just extremely
(20:26):
personal and empathetic and compassionate with the people she was
talking to. In nineteen sixty four and nineteen sixty five,
a huge rubella outbreak in the United States led to
more than twelve million cases of rubella and twenty thousand
cases of congenital rubella syndrome, which occurs when a pregnant
woman contracts rubella. Congenital rubella syndrome can cause premature delivery, miscarriages,
(20:48):
and still births, and a wide variety of potential disorders
and disabilities which can affect virtually any system of the body.
These include blindness, heart problems, bone lesions, hepatite and developmental disabilities.
In the wake of this outbreak, dr Apgar led vaccination
campaigns after one became available in nineteen sixty nine. She
(21:09):
joined the faculty of the School of Pediatrics at Cornell
University School of Medicine in nineteen sixty five, and she
taught there until nineteen seventy four. She specialized in teratology.
So sometimes this is characterized as a study of congenital disabilities,
but it really incorporates any kind of disability or disorder
that arises as an organism is developing, So that can
(21:31):
include like as a child is growing or transitioning into adolescents,
or things like that. She was actually the first person
to hold a faculty position dedicated to this aspect of pediatrics.
In nineteen seventy two, dr Apgar was part of a
joint effort of the American Medical Association, the American College
(21:51):
of Obstetrics and Gynecologists, the American Academy of Family Physicians,
the American Academy of Pediatrics, and the March of Dimes.
It was the first committee on perinatal health. The committee's
goal was to put together a plan to improve maternal
health and lower infant mortality nationwide. Sadly, she died before
the committee's landmark report toward improving the Outcome of pregnancy
(22:14):
was released in nineteen seventy six. Dr Apgar published more
than sixty papers during her career, along with the book
Is My Baby All Right? Which she co wrote with
Joan Beck and published in nineteen seventy two. As this
was a book that walked through several different contentital situations
that can happen using real examples, it was a book
that there was a great need for at this point
(22:35):
because a lot of people had no knowledge of any
of these things or what to do. She also received
numerous honorary doctorates and professional accolades during her career. She
was given a commemorative postage stamp in and was inducted
into the National Women's Hall of Fame in n Throughout
her life, she continued to pursue all kinds of activities
(22:57):
and passions in addition to all this work of being
a doctor, so sort of continued what she had been
doing in college when she was on seven different sports
teams while also being a great student. She also and
what maybe is the most awesome thing in this episode.
Carried a penknife, an endo, tracheal tube, and a larynoscope
with her at all times, just in case someone near
(23:20):
her stopped breathing. She said, nobody, But nobody is going
to stop breathing on me. She medal Leslie, nope, is
she well, she's so I have I don't know. I
just developed this deep fondness for her in this episode
because she's like medical Leslie Nope. And we've told we've
told you all before how much I love parks and
recreation and cried when it was over. But also her
(23:43):
name is Virginia, my grandmother's names, and when you look
at pictures of her, she's got like the same kind
of uh very from the fifties I wear that you
see pictures of my grandmother's, she just reminds me of
like if my grand mother's had been like Leslie Nope
when they were young. And she actually never retired. She
(24:08):
only slowed down a little at the very end of
her life because she had progressive liver disease, which eventually
was the cause of her death. On August seven of nineteen,
she died at Columbia Presbyterian Medical Center, where she had
spent much of her career. So we've talked a few
times about the show sawt Owns, which is the snow
about medical history, which is the co production of uh
(24:31):
Sidney McElroy who's a doctor, and her husband Justin McElroy,
and they are charming and delightful. If you don't listen
to that show, I highly recommend it. It's from the
Maximum Fund podcast network. I don't think they have done
an episode that that touched on this, But the whole
time I was working on it, when I got to
this part where Dr Atgar was like, the problem is
nobody is looking at these babies, I just kept hearing
(24:52):
Sydney's voice in my head being like, you gotta look
at the babies. Look at the babies. Why aren't you
looking at the babies, Like it seems so obvious look
at the babies when they were born? It does? I
have to wonder, and I will, you know, show off
my um my ignorance in this arena. Like what the
(25:12):
thinking was like why they weren't focusing on the babies
and they were only focusing on the mothers. Were they
just so accustomed to a high mortality rate that they
were like, well, the baby may or may not make it.
The strong ones survived, let's make sure the mom gets through.
I kind of wondered that as I was, I mean,
I didn't find a lot of a lot of information
about why this was the way it is, but because
the infant mortality rate was so pronounced at that point,
(25:34):
like it seems like maybe that would be maybe not
a deliberate conclusion, but just sort of like the operating
parameters that were in people's minds that they were making
decisions in in the delivery room. Uh So, Yeah, I
was very curious in my mind about that. Also, Um,
I hope like nobody's grandfather was an obpetrician in nifty.
(25:57):
I'm not trying to be hurtful, No, I mean there
looking at the babies made a big difference. Well, it's
just one of those, you know, elements of like shifting
approaches and attitudes that happened gradually over time. It doesn't
always mean that the people involved were being negligent or
even wrong, They just hadn't shifted yet. No. Well, and
(26:17):
we got we got a listener email that I have
not read because it was just it was a little
too personal to just directly read. But it came after
that episode that we did about Dr Vera. Peters where
we talked about women who had lumps in their breasts
would basically be put under to go get a biopsy
and if they had cancer, they would wake up without
a breath anymore. And how like in today's mindset, that's horrifying.
(26:40):
Her story was about having had children during this part
of history and how basically you would go to the
hospital and you would be put under and you would
wake up with a baby. Uh and uh. She had
this whole story about the doctor that was delivering her
children had a clear preference for delivering mail children and
(27:01):
said some things that were pretty insensitive when he delivered
her daughter. So yeah, I would say that there is
still a way to go in terms of, you know,
women and babies getting the best possible medical care. Maybe
not so much babies anymore, but I know, like there're
still I know my mom personally had difficulty getting doctors
(27:24):
to take her seriously when she knew that something was
wrong with her health, and they just kept writing her
off as being a stressed out female, which was not
what was going on. She had a legitimate problem. So
medical care better, still room to improve, and I also
have listener mail, which is all is a little bit
related to the medical field. This for Maggie. Maggie says
(27:46):
Holly and Tracy. Unlike many of your listeners, I've only
been listening for the last year or so, but I
have been entirely hooked since then. As a former history
major in my undergrad days. It's super fun to find
all these new dimensions of the things I learned about
and remind myself I actually remember things too. I wanted
to specifically thank you for your episode about the Compton's
Cafeteria riots. I work with college students to spread mental
(28:09):
health awareness and enact advocacy on their campuses to make
these spaces safer for all people to live, learn and grow.
Our organization is called Active Minds, and we support over
four hundred student run chapters on campuses across the US, Canada,
and in Ecuador. I had never learned so much about
the Compton's Cafeteria riots. I had heard about it in passing,
(28:30):
but as you mentioned, we often bypassed these events in
favor of discussing Stonewall, which was obviously important but not
the loan significant event in those early days of this
civil rights movement. As a mental health educator and advocate
and a member of the lgbt community, I especially appreciated
your mention of trans mental health statistics and the violent
acts often perpetrated against that community. Lgbt Q mental health
(28:54):
has become a particular area of focus among our students
and for us at the national level. In partnership with
our friends at the Healthy Minds Network at the University
of Michigan, we were able to create the below infographics
about trans and LGBTQ mental health on campuses, and then
she gives links to them, which we will put in
our show notes. Thank you so much for spreading awareness
(29:15):
about these important events. We as a general population don't
know nearly enough about the social movements that have defined
our recent history. Between this story and your recent story
on special education, you're doing that. Thank you so much, Maggie.
I wanted to share this one specifically, UM because it
is so important to have mental health resources that are
(29:35):
specifically devoted to young people. UM Like, young people's mental
health issues and adult people's mental health issues are not
the same things, and a lot of times treatments are
really different. So I was really pleased to learn um
about this group that is doing a whole lot to
to promote that on college campuses, which I think is
critically important, and so we'll put links to those infographics
(29:57):
in our show notes. If you would like to write
to us for about this or any other subject um.
We are a history podcast at how stuffworks dot com.
We're also on Facebook at Facebook dot com slash missed
in History and on Twitter at miss in History. Our
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we're also on Pinterest at pinterest dot com slash miss
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(30:18):
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So you can get that at our at our store
which is missed in History dot spreadshirt dot com. We're
also cooking up some ideas for some more shirts in
that store. Uh. If you would like to learn more
about what we talked about today, you can come to
our parent company's website, which is how stuff works dot com.
(30:41):
Put the word childbirth into the third bar and you
will find how childbirth works. You can also come to
our website, which is missed in history dot com. That
is where our show notes are, which is where we're
gonna put links to these infographics that I just mentioned.
You can also find an archive of every single episode
we have ever done, and show notes for the episodes
that Holly I have worked on. So you can do
(31:01):
all that and a whole lot more at how stuff
works dot com or miss the history dot com for
more on this and thousands of other topics because at
how stuff works dot com. M
Stuff You Missed in History Class News
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Holly Frey
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