What follows is an extract from a chapter on Dr. Virginia Apgar from a new book by Berend Mets, MBChB, PhD, the Professor and Chair of the Department of Anesthesiology and Perioperative Medicine at Penn State University College of Medicine, entitled “Leadership in Anaesthesia. Five Pioneers of the Deadly Quest for Surgical Insensibility.” The book is published by Cambridge Scholars Publishing, and is available at berendmets.com.
‘Birth is the most hazardous time of life.’—Virginia Apgar
The Apgar Score
Babies were dying.
At the Sloane Hospital for women, it was the first minute after birth that was most treacherous. It was then that the newborn was worst. Swaddled in a blanket and abandoned in a crib in the back of the delivery room; all attention was focused on the mother. The mother's belly massaged, the afterbirth delivered, fluids administered, and as the labor pains subsided—the inevitable question asked: "Is my baby alright?"
Usually no one confirming that it was so. Too busy with the new mother to look at the second patient in the room.
The baby, left to its own devices sometimes faltering—a few weak breaths and then nothing. No one any the wiser until the crib was moved to the post-natal room, and she was found dead in bed.
So too at this obstetric unit of the College of Physicians and Surgeons of Columbia University in 1949—The Sloane Hospital for women situated alongside the Presbyterian Hospital at Manhattan's 168th Street. Here Dr. Virginia Apgar had just been promoted to Professor of Anesthesiology, and, as the first female to hold a professorial position, had decided to dedicate herself to obstetric anesthesia and the care of the newborn.
Sitting together with a group of medical students in the hospital cafeteria early one morning after a particularly harrowing night on call; Virginia was asked a seminal question:
"Dr. Apgar, how would you evaluate a newborn?"
"That's easy you do it like this." Virginia replied reaching over to grab a 'Do Not Bus Your Trays' sign left on a trolley alongside the table they were sitting at, and jotted it down.
"Five points—heart rate, respiratory effort, muscle tone, reflex response and color—are observed and given zero, one or two points. The points are then totaled to arrive at the baby's score." A total of nine or ten was optimal. Then she rushed off to try it for herself, her white coat flapping behind as she made her way upstairs to the obstetric unit.1
A Woman's Struggle
Virginia excelled early in life. Her father, Charles Emory Apgar, teaching his only daughter to read by the age of three, using some of the theories then being developed by Dr. Maria Montessori.
Descended from the Apfelgard's of Germany, via Johannes Peter Apgard who had arrived in Philadelphia in 1732, Charles married Helen Clark, the daughter of a Methodist Minister in 1894. Together creating a happy, lively, home—'that never sat still'—filled with learning, music, creativity and science; for Charles was enthusiastic about many things. Apart from being an auto salesman by day, he was a professionally published astronomer, a radio-ham who helped crack a German submarine code, an outstanding musician, and an inventor and gadgeteer; designing the beautiful house built on a corner plot in Westfield, New Jersey, that Virginia was born to—in 1909—and grew up in; until going to university at the all-female Mount Holyoke College in South Hadley, Massachusetts. 2
Virginia was preceded by two brothers. One, Charles, dying of tuberculosis at the age of three before she was born, and the other, Lawrence, two years her elder, suffered from chronic eczema requiring many doctor's visits, but would also become a talented musician like his sister.
Before attending the elite college, however, Virginia shone at school: stamp collecting, studying music, and Greek, (she could later read passable French and German), mathematics, and science; she had boundless energy and enthusiasm. Tall and sylph slim, she loved tennis, basketball, and track, was a fierce debater, and a keen member of the school orchestra; having learnt to play the violin at 6 years of age. Her high school year book reflecting on her industry: "Frankly how does she do it."
No surprise then that Virginia sought out an unconventional route. Choosing not to get married like most of her friends after high school, but instead she was determined to become a doctor and applied to colleges as the first step. No one in the family was really quite sure why she had set her sights on this vocation (as the usual route would have been to become a nurse)—Virginia might have been influenced by the talk surrounding the premature death of her brother; the multiple visits to the family doctor that Lawrence's chronic medical condition required; the scientific bent of her father; or the caring and nurturing nature of her mother.
In any event it was an expensive, if unorthodox proposition—the family budget not being equal to the high fees of Mount Holyoke; Virginia made her way through gaining a scholarship and by earning extra money odd-jobbing on the side.
First reports back to her mother from Mount Holyoke were glowing: "I'm very well and happy but I haven't one minute to breathe."
Virginia well-pleased with her college choice, and they in turn well-pleased with her: she majored in zoology, minored in chemistry, took extra jobs to make ends meet: catching cats for the laboratory that would be dissected later, serving as library assistant; while playing tennis, horse riding, swimming, rowing, angling and playing basketball, and still found time to play in the orchestra—violin, cello—debate, and perform drama; winning the class prize for Zoology. Her friends calling her 'Jimmy'—the girl who did it all—from the first day on, and Dr. Chrissie Smith, her Zoology tutor, elated with Virginia's performance, waxed lyrical:
"It is seldom that one finds a student so thoroughly immersed in her subject and with such a wide knowledge of it."3
Finishing, at Mount Holyoke in the Class of '29, at the age of twenty, Virginia applied to only one medical school. Columbia University. She had been dating one of the Columbia Medical Schools Professors sons (who attended Harvard) and upon presenting herself at the College of Physicians and Surgeon's for an interview, the Professor took her straight down to the Dean's office and told him to take her. He did. And when applying for a scholarship to part pay her way, Virginia was relieved to find that: "the scholarship fellow asked me entirely about extra-curricular activities, nothing about academics at all."4
But the scholarship only provided $250 per year and was far from sufficient to pay for the tuition, board, books, equipment and other living expenses that rolled into the costs of attending medical school. So her father part supported her and two Uncles, Malcolm and Leigh, provided long-term loans. A good thing as the Great Depression had just started as Virginia embarked on her first year of medical school, October 1, 1929.
Horrified that she only received a score of 91% for her first chemistry exam, Virginia was somewhat mollified when the medical school secretary explained that this was actually the top mark in the class. Jimmy explaining this away with characteristic candor:
"I was fortunate, maybe, in going from one of the best classes that Holyoke had ever had to... P & S, it happened to be one of the less brilliant classes I got into, in fact one of the stupidest ones they ever had, so it was very easy coming from Holyoke, from the class of '29. It was very easy: I worked in hospitals during the summers and learnt a lot of things we didn't have in our Ivory Tower—no syphilis, no gonorrhea no nothing."4
One of nine women in a graduating class of ninety medical students in 1933, Virginia strove to distinguish herself; hell-bent on getting into a coveted position as a surgical intern to become a surgeon; she volunteered for extra duties: "I lived in the emergency room... when they needed a second assistant, there I was, ready to hold hooks." But there had been only four female surgeons before her at Columbia since 1916, so a surgical position was far from secure. Graduating fourth highest in the class. And on having been noticed for her efficiency by the Professor and Chair of Surgery, Dr. Allen Whipple, her future prospects brightened and a two-year surgical internship duly secured. Here she availed herself of every opportunity to advance, completing over two hundred surgeries together with her consultant colleagues in the Auchinchloss firm; she was pulled aside one day to meet with Dr. Allen Whipple in his imposing office atop of the Presbyterian Hospital.
"So Dr. Apgar, I hear you wish to pursue a career in surgery."
"Yes Dr. Whipple."
"Well. I am not sure that this is a good idea. I have trained four female surgeons in the last years and they cannot get sufficient work in New York City. Not even females want to go to female surgeon, they prefer males."
"Yes Dr. Whipple."
"However, I do need an efficiently run proper Division of Anesthesia. Why do you not find a way of being trained in anesthesia and then we can talk again about a permanent position in the Department of Surgery."
Interpretation. These were trying times for both surgery and anesthesia and more particularly for female doctors in the work-place.
For surgery—the discipline was hampered in what it could accomplish; extensive radical operations like thoracotomies were hobbled by the lack of advancement of anesthetic techniques, drug, and clinical care delivery—limited by the status quo: ad hoc anesthesia services chiefly managed through the surgeon-nurse anesthesia dyad—falling far short of the science-based progress needed to develop a physician led specialty. This was hurting surgery as bright graduating physicians were eschewing surgery for more exciting specialties. Surgery could not advance unless anesthesia improved.
For anesthesia—the nascent physician led specialty was just beginning; there were insufficient national training programs—fifteen in the USA and four in Canada—only two actually paying residents to attend; the specialty was poorly remunerated, organized, and respected—anesthesia practice considered just "nurses work" that the less trained could do.
For female doctors in the workplace it was an unremitting struggle. Although Virginia had got a position at Columbia, seemingly quite easily, this was far from the situation elsewhere in the United States: Harvard Medical School was closed to females till 1945, and other Eastern Medical School Deans admitted that they allowed for only limited quotas of females in their classes, one stating tellingly:
"We do keep women out, when we can. We don't want them here....". A committee at Harvard only eventually recommending that the available 'mediocre men' be replaced by 'very superior women' that had proved their worth by scoring considerably higher upon the applicants conduct of the proffered aptitude tests.5
While the first female doctor, Elizabeth Blackwell, earned her degree in 1849, and started the New York Infirmary for Women and Children—launching the first American hospital staffed completely by women; the percentage of female doctors in the United States peaked around 1910 at about 6%, but then declined following the Flexner Report's vilification of American Medical Education: many of the seventeen women's medical schools created closed—unable to afford the newly scientific medical education suggested by the report.6
Consequently as Virginia Apgar was ending her first year of medical school (1930), there were only 5,825 women physicians in the US workforce (just 4.4% of the physician population), while over the period 1920-1948 women comprised a slightly larger proportion (11-13%) of the ranks of the professional anesthesia organizations in the country. 7
Surgeon Whipple's suggestion to Virginia was therefore a good one on a number of fronts.
Surgeons were well disposed to females providing anesthesia as they believed their inherent feminine characteristics—multitasking, pliability, empathy—were useful in managing the anesthesia of the time; after all it was chiefly administered by nurses who were almost without exception female.
Unmarried women had limited options for work. Typically, clerical work, nursing, or teaching; all low paid professions: the jobs inevitably terminated when they married and their future husbands could support them.
And, given the paucity of females that were (economically) successful in surgery, going into anesthesia, a relatively new specialty, might well be to Virginia's professional advantage.
Dr. Virginia Apgar certainly seemed to think so.
In 1934, while very busy as a Surgical Intern, a Senior Resident, Dr. Crunbar approached her.
Had Virginia thought of anesthesia?
No she hadn't, but:
"Maybe this wasn't such a bad idea. To be a bigger fish in a smaller puddle, because it would take three or four more years in surgery and [so] it was purely financial that I changed to anesthesia, which is not a bit dramatic, it's the truth."4
Virginia pursuing the idea immediately, wrote to Dr. Frank McMechan in his capacity as Secretary of the Association of Anesthetists in August of 1934, to enquire about possible residency positions in the United States and Canada. She was somewhat encouraged to note that there were four programs in Canada and fifteen in the United States that could be approached; four of the departments already headed by women, including Dr. Mary Botsford of San Francisco, who was the first female to devote her practice completely to anesthesia back in 1897.
Importantly, two other names appeared on the list that Dr. McMechan had sent: Dr. Arthur Guedel, of Beverley Hills, California, and Dr. Ralph Waters of Madison, Wisconsin.
And the letter added that residencies of between six months to one year; fellowships of between one to three years; and post graduate courses of any length desired, could be applied for by writing to the individuals listed.
Virginia followed suit. To all of them.
Becoming bitterly disappointed as there were no suitable positions to be had, despite her intensive networking—letter writing, going to meetings, telephone calls—for a slot in the oversubscribed residency training programs of the time.
Interpretation. It really wasn't easy to find a suitable residency training program (for anyone), because many heads of departments were struggling to convince the hospital authorities of the need to replace surgeon-nurse anesthetic practice with a physician-anesthetic model of practice.
Dr. Mary Botsford responding to Dr. Apgar's letter explained the issue cogently in August of 1934.
Dear Dr. Apgar:
In a couple of months the status of physician anaesthetists will be settled, following a verdict from the Supreme Court as to whether nurses may legally administer anaesthetics and if decided in our favor, there will be opportunities in either the University of California or Stanford Medical School for training and ultimately positions.
Dr. Arthur Guedel, who was serving as an expert witness for the prosecution in testifying against Nurse Anesthetist Dagmar Nelson at the time (referred to in the above letter), wrote less hopefully:
Dear Doctor,
Beverly Hills, and Los Angeles at the present time offers little or no opportunity for instruction in anaesthesia.
We hope in the future to establish post graduate training in the subject at our General Hospital here, but although there is such instruction now by name, it is not sufficiently well developed to be attractive.
And Dr. Ralph Waters,
Dear Doctor Apgar,
I liked your letter of August 10th....The appointments, however, are full at the present time, and so far as I can see are likely to be full for a long time to come in that I have four men....and we hope that they will stay at least three years.
In truth though, at a time when masculinity was unabashed, there was still strong sentiment by men against employing women in the workforce.
In correspondence between Guedel and Waters: Guedel declared: "I don't believe in women doctors" and "Women are bunk." Waters corroborating this. Not because they both believed that women were less competent than men, but because women tended to get married; removing them from the workplace.8
And then there was the prevalent thinking that if a woman took a man's position she would be robbing a family of a breadwinner. Depriving the father of the opportunity to support his wife and kids.
Not one to dwell on the situation too long without a plan, Virginia tried another tack to gain anesthetic training experience. In November of 1935, having completed two years of surgical internship, she was offered an Assistant in Surgery position2 and while doing research in the animal laboratories, trained in anesthesia with the Presbyterian Hospital's nurse anesthetists. More specifically with Miss Anne Penland who was the head of the nurse anesthesia service and would become a life-long friend, living to be 95 years of age.
Upon being appointed as a Resident in Anesthesia at the Presbyterian Hospital in July of 1936, Virginia was now officially in training, but knowing full well that she needed more experience than that could be had through the nurse anesthesia program there, she again pursued a position with Dr. Ralph Waters in the preeminent, and first, physician led residency training program in the country.
Dr. Waters responding to her telegram and letter that he strongly supported Dr. Whipple's efforts to improve anesthesia at Columbia, and given that she could not spend a full three years residency training—there were no positions—he recommended that she consider being a visitor and observer at the Madison program for at least seven months starting January 1937 and extending to August 1—in order to avail herself of the clinical practical experience that resident vacations and sickness leave would inevitably provide.
However, according to Virginia, Dr. Ralph Waters had been twice burnt in the past with women anesthetists in Wisconsin: "one got married and one went crazy, and I had to tell him I wasn't going to do either."
And there was another problem that Ralph brought up: uncertain accommodation prospects for women residents. The chief of the hospital, Dr. B. Buerki, willing and able to provide board but no lodging. There were only rooms reserved for male residents in the hospital, but Dr. Waters wrote, relatively cheap quarters were nearby or she might find a 'hole in the wall', and if all else failed, he had it on good authority that she could be roomed at one of the two undergraduate women's dormitories: either Ann Emery or Langdon Hall.2
References
- Mets B. Waking Up Safer? An Anesthesiologist’s Record Bristol: Silverwood Books, 2018.
- Mets B. Archival Material Mt Holyoke Archives and Special Collections. 50 College Street, South Hadley, M.A., 2020.
- Smith CR. In Memoriam. Dr Virginia Apgar ‘29. Mount Holyoke Alumnae Quarterly 1974;58:178-9.
- Houston J. Apgar Interview Transcript. Mt Holyoke Archives and Special Collections, 1974.
- Hudson PL. Women in the Work Place. 1996:14-43.
- Calmes SH. Dr. Virginia Apgar and the Apgar Score: How the Apgar Score Came to Be. Anesth Analg 2015;120:1060-4.
- Calmes SH. Virginia Apgar, M.D. At the Forefront of Obstetric Anesthesia. ASA Newsletter 1992;56:9-12.
- Waters RM, Guedel AE. Correspondence between Dr Guedel & Dr Waters. Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco 2019.