June 30, 2018 • 29 mins
This episode revisits the life of Dr. Virginia Apgar, who 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 (00:02):
Happy Saturday. Today we are going back to with our
episode on Virginia Apgar, who developed the app car score
for newborn babies, and I have a soft spot for
her because she reminds me of my grandmother. Although my
grandmother didn't walk around with everything she would need to
do an emergency tracheotomy just in her handbag. That was
not how my grandmother operated. No, I think my grandmother
(00:25):
maybe could have cobbled together the required items, but it
wasn't necessarily her goal. One of the things that we
talked about in this episode is how when Appgar started
practicing medicine, there was a lot more focus on what
was going on with laboring mothers than on what was
going on with their newborns, and that focus has really
swung in the opposite direction in the decades since then,
(00:46):
to the point that there have been a lot of
headlines and studies about an ongoing maternal health crisis in
the three years since this episode came out. So that's
part of this whole arc of history that is definitely
still developing. Welcome to Stuff You missed in History Class
from how Stuff Works dot Com. Hello, and welcome to
(01:14):
the podcast. I'm Tracy B. Wilson and I'm Holly Frying.
So if you if you've had a baby in like
the last sixty years, or been present when somebody else
had a baby, or maybe 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,
(01:35):
I thought this was an acronym. And while somebody did
rework the parts of the Acar score so that it
matched up with the letters of her name in about
nineteen sixty two, the score itself 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 anesthesiology,
as well as other fields in the middle of the
twentieth century. Today, the Apcar score is really part of
(01:58):
the standard of care for new for newborn babies and
much of the world, and it's totally to the credit
of this one particular doctor, and this one particular doctor.
Virginia Apgar was born in Westfield, New Jersey, on June
seven of nineteen o nine. Her father was an insurance
executive who was fond of science, and was an amateur astronomer.
(02:19):
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 before she even got
out of high school. To that end, she went some
Mount Holyoke College where she studied zoology. In addition to
being an excellent student in that program, she worked several
(02:42):
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 a medical school
version of Leslie. Nope. Yeah, that's a great description her family.
(03:04):
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
nine nine, and she started medical school 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
(03:26):
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 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,
(03:48):
but Dr Alan Whipple, who was the chair of the
surgical department, encouraged her to change specialties to anthesiology. He
was concerned that she would not be able to make
a profitable career as a siren, especially given the economic
climate at the time. This was still in the wake
of the Great Depression. He also basically had other plans
(04:08):
for her. He wanted her to study anesthesiology and then
come back to Presbyterian Hospital to help start a teaching
program for future an enthusiologists. There were lots of reasons
for Dr Apgar to change specialties. It 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
(04:30):
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, so taking on
a specialty in which she would probably have trouble finding
a job was a really risky proposition. At the same time,
(04:51):
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 Reese as nineteen eleven, the
American Medical Association had even rejected a request to start
an anesthesiast section for its members. So while dr Apgar
essentially had a job waiting for her after she was
(05:12):
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. For most
of Western medical history, surgery was actually seen as inferior
to the rest of medicine. So before things like modern
(05:33):
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 through surgeries
without bleeding to death or immediately dying from infection. Surgery
only gradually became a more respected field, so surgeons had
(05:55):
to basically claw their way to respectability, and for the
most part, in the early days of surgery as a
more prestigious position, anesthesia was being administered by nurses. 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
(06:15):
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 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
(06:40):
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.
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
(07:01):
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
it off to was somebody who's sole focus was on
being the best in the world of anesthesiology. So Dr
(07:21):
Whipple hoped that he and Dr Apgar might work together
to change all of that. And we're going to talk
about that some more, 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
(07:43):
thought 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
this point. There were thirteen of them in the United States,
ranging in length from two weeks to three years, and
(08:06):
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 that's a wide range, a two week to
(08:27):
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 Dr Waters was really
(08:49):
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 Rovstein in New York Bellevue Hospital.
He had also trained with Dr Waters, So it's you
could easily call Dr Waters like the the keystone in
(09:12):
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 had formulated a
(09:36):
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 mid nineteen forties,
(09:58):
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 program was solidly established,
the division also turned its focus to research to improve
(10:20):
the practice of anesthesiology. This was 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 ninety five before anesthesia
was more often administered by doctors than by nurses at Presbyterian,
(10:43):
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 in
nineteen forty six. Three years later, dr Apgar became the
first woman to be named a full professor at the
(11:04):
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 Apgar had sort
of thought she was going to be the person appointed
to this position, but the fact that she no longer
(11:26):
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,
which led to a labor shortage at Presbyterian Hospital and
to dr Apgar's department having more involvement in the field
(11:47):
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
in the hospital, but this really hadn't improved outcomes for
the women and their babies. Although infant mortality in general
(12:10):
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 Apgar
really started to focus once she was freed up from
her previous administrative duties as a department head, and it
(12:32):
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, then
a lot of these deaths could potentially be prevented. She
was basically saying, y'all need to look at these babies
(12:53):
like I need to look at them. So, I mean,
today this seems early 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
more focused on the mother than on the baby. A
lot of times, the most junior people in the room
were the ones who were seeing to the baby after
(13:14):
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 medical study. They just were not trained particularly
well on, uh, what to do when the baby came out. Yeah,
(13:38):
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
on childbirth. There's 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
(14:00):
when there was data, it was often disregarded in favor
of what everybody quote already knew about it. So dr
Apgar developed a standardized way of analyzing how the 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,
(14:23):
one or two. Then you add up those five numbers
and that's the baby's app CAR score. That mnemonic device
that we mentioned at the top of the episode substituted
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
(14:44):
original list. Reportedly, dr Apgar was quite delighted when when
a resident rewrote the letters in the Apgar score to
match up with her name so 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 to meant
(15:06):
that the heartbeat was between one and one forty beats
a minute. Zero for muscle tone meant that there was
no muscle tone and a two meant the baby was
actively moving. It really 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,
(15:29):
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, 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.
(15:49):
She found definite correlations between the method of delivery, the
type of anesthesia used on the mother, and the baby's
After our scores, she recommended that New York that newborn
babies be of evaluated a minute after their birth, and
also important that someone other than the attending obstetrician do it.
This is because she noticed a pattern that obs tended
(16:13):
to score their end quote their babies that they delivered
higher than other people in the delivery room did. 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 Annual
(16:34):
Congress of Anesthetists in the audience was skeptical, but she
published the work in three and it has since become
a standard of care in delivery rooms in 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
need to resuscitate the baby. You do that, take it
(16:58):
again in five minutes. Uh, it's this is one of
those times where it's kind of baffling, Uh 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
(17:19):
on both the mother and the baby. So, along with
Dr Duncan Holiday and Dr Stanley James, dr Apgar 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 annesthesia given
(17:39):
to the mother. You know, whether it was a vaginal
birth or a cesarean section, all these other things. With
trends in the baby's scores, they figured out that babies
with a score under three needed to 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
(18:01):
of life than babies who scored six or lower, So
that 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 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
(18:22):
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 standard practice to put
women essentially unconscious to deliver babies in American hospitals anymore.
Dr Apgar and team also went one step further and
(18:44):
studied newborn babies blood chemistry, finding clear physiological links between
the outward appearance of the traits examined to calculate an
Apgar score and what was actually physiologically going on in
the baby's body. By the 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
(19:06):
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 a sabbatical and she pursued
a master's degree in public health from Johns Hopkins University. Originally,
(19:27):
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 were born could somehow be prevented.
During this time, she was approached by the National Foundation
(19:48):
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 just dropped dramatically, the Foundation wanted to
find a new place to expand its work and other
(20:11):
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 completed her master's program. In this role,
dr Apgar became a huge advocate of early detection and
(20:33):
treatment of congenital issues, including prenatal 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. This was almost directly the
opposite of her experience trying to start an in enthusiology
(20:54):
program while that field was in its infancy. Congenital disabilities
and disorders were huge new us in the United States
at this point. The drug Thelida mind, which had been
given to pregnant women in much of Europe both as
a sedative and to combat morning sickness had been implicated
in causing babies to be born with missing or incorrectly
formed limbs. The FDA had not approved the drug to
(21:16):
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 personable and empathetic and compassionate
(21:37):
with the people she was talking to you. 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, and still births, and
(21:58):
a wide variety of potential disorders and disabilities which can
affect virtually any system of the body. These include blindness,
heart problems, bone lesions, hepatitis, and developmental disabilities. In the
wake of this outbreak, dr Apgar led vaccination campaigns after
one became available in nineteen sixty nine. She joined the
(22:18):
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 include
(22:39):
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
(23:00):
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,
(23:22):
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. 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 because
(23:44):
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. Throughout her life, she
continued to pursue all kinds of activities and passions in
(24:07):
addition to all this work of being a doctor. So
it 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, in what maybe
is the most awesome thing in this episode, carried a
pen knife, an endo, tracheal tube, and a laryngoscope with
her at all times, just in case someone near her
(24:28):
stopped breathing. She said, nobody, But nobody is going to
stop breathing on me. She medic 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
(24:49):
cried when it was over. But also, her 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 grandmother's had
(25:09):
been like Leslie Nope when they were young. And she
actually never retired. She 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, nine. She died at Columbia Presbyterian Medical Center,
where she had spent much of her career. So we've
(25:37):
talked a few times about the show sabb Owns, which
is a snow about medical history, which is the co
production of uh 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 of the Maximum Fund podcast network. I don't think
they have done an episode that that touched on. But
(26:00):
the whole time I was working on it, when I
got to this part where dr Apgar was like, the
problem is nobody is looking at these babies, I just
kept hearing 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
(26:23):
off my um my ignorance in this arena. Like what
the 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,
(26:45):
but because the infant mortality rate was so pronounced at
that point, 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 as they
were making decisions in in the delivery room. Uh So, yeah,
I was very curious in my mind about that. Also. Um,
(27:07):
I hope like nobody's grandfather was an oppetrician in nineteen fifty.
I have not tried to be hurtful, No, I mean, seriously,
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
(27:28):
even wrong. They just hadn't shifted yet. No. Well, and
we got we got a listener email that I have
not read because it was just it was a little
too personal 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
(27:49):
breast anymore. And how like in today's mindset, that's horrifying.
Her story was about having had children during this part
of history and how basic 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
(28:11):
children had a clear preference for delivering male children and
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
(28:31):
not so much babies anymore, but I know, like there
are still I know my mom personally had difficulty getting
doctors 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. Thank you
(29:00):
so much for joining us for this Saturday Classic. Since
this is out of the archive, if you heard an
email address or a Facebook U r L or something
similar during the course of the show that may be
obsolete now, so here is our current contact information. We
are at History podcast at how stuff works dot com,
and then we're at Missed in the History. All over
(29:20):
social media that is our name on Facebook, Twitter, Tumblr, Pinterest,
and Instagram. Thanks again for listening. For more on this
and thousands of other topics. Is it how stuff works
dot com.
Happy Saturday. Today we are going back to with our
episode on Virginia Apgar, who developed the app car score
for newborn babies, and I have a soft spot for
her because she reminds me of my grandmother. Although my
grandmother didn't walk around with everything she would need to
do an emergency tracheotomy just in her handbag. That was
not how my grandmother operated. No, I think my grandmother
(00:25):
maybe could have cobbled together the required items, but it
wasn't necessarily her goal. One of the things that we
talked about in this episode is how when Appgar started
practicing medicine, there was a lot more focus on what
was going on with laboring mothers than on what was
going on with their newborns, and that focus has really
swung in the opposite direction in the decades since then,
(00:46):
to the point that there have been a lot of
headlines and studies about an ongoing maternal health crisis in
the three years since this episode came out. So that's
part of this whole arc of history that is definitely
still developing. Welcome to Stuff You missed in History Class
from how Stuff Works dot Com. Hello, and welcome to
(01:14):
the podcast. I'm Tracy B. Wilson and I'm Holly Frying.
So if you if you've had a baby in like
the last sixty years, or been present when somebody else
had a baby, or maybe 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,
(01:35):
I thought this was an acronym. And while somebody did
rework the parts of the Acar score so that it
matched up with the letters of her name in about
nineteen sixty two, the score itself 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 anesthesiology,
as well as other fields in the middle of the
twentieth century. Today, the Apcar score is really part of
(01:58):
the standard of care for new for newborn babies and
much of the world, and it's totally to the credit
of this one particular doctor, and this one particular doctor.
Virginia Apgar was born in Westfield, New Jersey, on June
seven of nineteen o nine. Her father was an insurance
executive who was fond of science, and was an amateur astronomer.
(02:19):
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 before she even got
out of high school. To that end, she went some
Mount Holyoke College where she studied zoology. In addition to
being an excellent student in that program, she worked several
(02:42):
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 a medical school
version of Leslie. Nope. Yeah, that's a great description her family.
(03:04):
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
nine nine, and she started medical school 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
(03:26):
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 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,
(03:48):
but Dr Alan Whipple, who was the chair of the
surgical department, encouraged her to change specialties to anthesiology. He
was concerned that she would not be able to make
a profitable career as a siren, especially given the economic
climate at the time. This was still in the wake
of the Great Depression. He also basically had other plans
(04:08):
for her. He wanted her to study anesthesiology and then
come back to Presbyterian Hospital to help start a teaching
program for future an enthusiologists. There were lots of reasons
for Dr Apgar to change specialties. It 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
(04:30):
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, so taking on
a specialty in which she would probably have trouble finding
a job was a really risky proposition. At the same time,
(04:51):
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 Reese as nineteen eleven, the
American Medical Association had even rejected a request to start
an anesthesiast section for its members. So while dr Apgar
essentially had a job waiting for her after she was
(05:12):
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. For most
of Western medical history, surgery was actually seen as inferior
to the rest of medicine. So before things like modern
(05:33):
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 through surgeries
without bleeding to death or immediately dying from infection. Surgery
only gradually became a more respected field, so surgeons had
(05:55):
to basically claw their way to respectability, and for the
most part, in the early days of surgery as a
more prestigious position, anesthesia was being administered by nurses. 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
(06:15):
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 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
(06:40):
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.
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
(07:01):
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
it off to was somebody who's sole focus was on
being the best in the world of anesthesiology. So Dr
(07:21):
Whipple hoped that he and Dr Apgar might work together
to change all of that. And we're going to talk
about that some more, 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
(07:43):
thought 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
this point. There were thirteen of them in the United States,
ranging in length from two weeks to three years, and
(08:06):
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 that's a wide range, a two week to
(08:27):
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 Dr Waters was really
(08:49):
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 Rovstein in New York Bellevue Hospital.
He had also trained with Dr Waters, So it's you
could easily call Dr Waters like the the keystone in
(09:12):
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 had formulated a
(09:36):
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 mid nineteen forties,
(09:58):
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 program was solidly established,
the division also turned its focus to research to improve
(10:20):
the practice of anesthesiology. This was 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 ninety five before anesthesia
was more often administered by doctors than by nurses at Presbyterian,
(10:43):
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 in
nineteen forty six. Three years later, dr Apgar became the
first woman to be named a full professor at the
(11:04):
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 Apgar had sort
of thought she was going to be the person appointed
to this position, but the fact that she no longer
(11:26):
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,
which led to a labor shortage at Presbyterian Hospital and
to dr Apgar's department having more involvement in the field
(11:47):
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
in the hospital, but this really hadn't improved outcomes for
the women and their babies. Although infant mortality in general
(12:10):
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 Apgar
really started to focus once she was freed up from
her previous administrative duties as a department head, and it
(12:32):
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, then
a lot of these deaths could potentially be prevented. She
was basically saying, y'all need to look at these babies
(12:53):
like I need to look at them. So, I mean,
today this seems early 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
more focused on the mother than on the baby. A
lot of times, the most junior people in the room
were the ones who were seeing to the baby after
(13:14):
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 medical study. They just were not trained particularly
well on, uh, what to do when the baby came out. Yeah,
(13:38):
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
on childbirth. There's 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
(14:00):
when there was data, it was often disregarded in favor
of what everybody quote already knew about it. So dr
Apgar developed a standardized way of analyzing how the 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,
(14:23):
one or two. Then you add up those five numbers
and that's the baby's app CAR score. That mnemonic device
that we mentioned at the top of the episode substituted
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
(14:44):
original list. Reportedly, dr Apgar was quite delighted when when
a resident rewrote the letters in the Apgar score to
match up with her name so 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 to meant
(15:06):
that the heartbeat was between one and one forty beats
a minute. Zero for muscle tone meant that there was
no muscle tone and a two meant the baby was
actively moving. It really 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,
(15:29):
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, 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.
(15:49):
She found definite correlations between the method of delivery, the
type of anesthesia used on the mother, and the baby's
After our scores, she recommended that New York that newborn
babies be of evaluated a minute after their birth, and
also important that someone other than the attending obstetrician do it.
This is because she noticed a pattern that obs tended
(16:13):
to score their end quote their babies that they delivered
higher than other people in the delivery room did. 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 Annual
(16:34):
Congress of Anesthetists in the audience was skeptical, but she
published the work in three and it has since become
a standard of care in delivery rooms in 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
need to resuscitate the baby. You do that, take it
(16:58):
again in five minutes. Uh, it's this is one of
those times where it's kind of baffling, Uh 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
(17:19):
on both the mother and the baby. So, along with
Dr Duncan Holiday and Dr Stanley James, dr Apgar 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 annesthesia given
(17:39):
to the mother. You know, whether it was a vaginal
birth or a cesarean section, all these other things. With
trends in the baby's scores, they figured out that babies
with a score under three needed to 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
(18:01):
of life than babies who scored six or lower, So
that 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 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
(18:22):
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 standard practice to put
women essentially unconscious to deliver babies in American hospitals anymore.
Dr Apgar and team also went one step further and
(18:44):
studied newborn babies blood chemistry, finding clear physiological links between
the outward appearance of the traits examined to calculate an
Apgar score and what was actually physiologically going on in
the baby's body. By the 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
(19:06):
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 a sabbatical and she pursued
a master's degree in public health from Johns Hopkins University. Originally,
(19:27):
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 were born could somehow be prevented.
During this time, she was approached by the National Foundation
(19:48):
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 just dropped dramatically, the Foundation wanted to
find a new place to expand its work and other
(20:11):
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 completed her master's program. In this role,
dr Apgar became a huge advocate of early detection and
(20:33):
treatment of congenital issues, including prenatal 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. This was almost directly the
opposite of her experience trying to start an in enthusiology
(20:54):
program while that field was in its infancy. Congenital disabilities
and disorders were huge new us in the United States
at this point. The drug Thelida mind, which had been
given to pregnant women in much of Europe both as
a sedative and to combat morning sickness had been implicated
in causing babies to be born with missing or incorrectly
formed limbs. The FDA had not approved the drug to
(21:16):
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 personable and empathetic and compassionate
(21:37):
with the people she was talking to you. 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, and still births, and
(21:58):
a wide variety of potential disorders and disabilities which can
affect virtually any system of the body. These include blindness,
heart problems, bone lesions, hepatitis, and developmental disabilities. In the
wake of this outbreak, dr Apgar led vaccination campaigns after
one became available in nineteen sixty nine. She joined the
(22:18):
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 include
(22:39):
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
(23:00):
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,
(23:22):
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. 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 because
(23:44):
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. Throughout her life, she
continued to pursue all kinds of activities and passions in
(24:07):
addition to all this work of being a doctor. So
it 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, in what maybe
is the most awesome thing in this episode, carried a
pen knife, an endo, tracheal tube, and a laryngoscope with
her at all times, just in case someone near her
(24:28):
stopped breathing. She said, nobody, But nobody is going to
stop breathing on me. She medic 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
(24:49):
cried when it was over. But also, her 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 grandmother's had
(25:09):
been like Leslie Nope when they were young. And she
actually never retired. She 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, nine. She died at Columbia Presbyterian Medical Center,
where she had spent much of her career. So we've
(25:37):
talked a few times about the show sabb Owns, which
is a snow about medical history, which is the co
production of uh 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 of the Maximum Fund podcast network. I don't think
they have done an episode that that touched on. But
(26:00):
the whole time I was working on it, when I
got to this part where dr Apgar was like, the
problem is nobody is looking at these babies, I just
kept hearing 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
(26:23):
off my um my ignorance in this arena. Like what
the 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,
(26:45):
but because the infant mortality rate was so pronounced at
that point, 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 as they
were making decisions in in the delivery room. Uh So, yeah,
I was very curious in my mind about that. Also. Um,
(27:07):
I hope like nobody's grandfather was an oppetrician in nineteen fifty.
I have not tried to be hurtful, No, I mean, seriously,
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
(27:28):
even wrong. They just hadn't shifted yet. No. Well, and
we got we got a listener email that I have
not read because it was just it was a little
too personal 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
(27:49):
breast anymore. And how like in today's mindset, that's horrifying.
Her story was about having had children during this part
of history and how basic 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
(28:11):
children had a clear preference for delivering male children and
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
(28:31):
not so much babies anymore, but I know, like there
are still I know my mom personally had difficulty getting
doctors 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. Thank you
(29:00):
so much for joining us for this Saturday Classic. Since
this is out of the archive, if you heard an
email address or a Facebook U r L or something
similar during the course of the show that may be
obsolete now, so here is our current contact information. We
are at History podcast at how stuff works dot com,
and then we're at Missed in the History. All over
(29:20):
social media that is our name on Facebook, Twitter, Tumblr, Pinterest,
and Instagram. Thanks again for listening. For more on this
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