2025/05/22 by R.W. Thomsen, Mellany A. Stanislaus · 1 voice
Economics, Econometrics and Finance · #Healthcare Policy and Management
paper · doi:10.1097/01.asm.0001118212.45943.44
openalex publication_date 2025/05/22 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/23
Photo courtesy of Virginia Apgar Papers, Mount Holyoke College.Is my baby all right? This question is at the forefront of every parent's mind. Virginia Apgar's formative experiences, passion for scientific discovery, and a question from a medical student would lead to the creation of one of the most impactful contributions to modern medicine. Born in 1909, Dr. Apgar attended Mount Holyoke College and worked odd jobs to support herself before starting medical school at Columbia University College of Physicians and Surgeons in 1929. One month later, the stock market crashed, ushering in the Great Depression. She graduated fourth in her class, with the modern equivalent of 98,000 worth of debt. She aspired to be a surgeon and excelled in Columbia's program. However, after 10 months, she transitioned to pursue training in anesthesia. Her decision stemmed from challenges female surgeons had achieving financial security, and advice from her mentor, Allen Whipple, about potential gender barriers limiting future opportunities. As chair of surgery, Dr. Whipple wanted to develop the medical specialty of anesthesiology and recognized his trainee's promise, saying she possessed the ”;energy, intelligence, and ability needed to make significant contributions in this area” (asamonitor.pub/3GdofbX). Dr. Apgar forged her own way in the nascent field of anesthesiology, learning the basics of anesthesia from Columbia's nurse anesthetists. A voracious student, she secured a six-month “visitor” position to train under Ralph Waters at the University of Wisconsin, then returned to New York City for additional training under Emery Rovenstine before becoming the founding director of Columbia's anesthesia division in 1938. In 1949, she became the first woman promoted to professor in the medical school's 182-year history. Although she disliked administration, she was disappointed to be overlooked in favor of Emanuel Papper for appointment as the chair of Columbia's newly formed anesthesiology department.Photo courtesy of Virginia Apgar Papers, Mount Holyoke College.Dr. Apgar redirected her energy into the underappreciated specialty of obstetric anesthesia. At the time, inhalational analgesia during labor was becoming increasingly popular, and infant mortality was rising. She believed the anesthetic was being transmitted to the fetus, causing neonatal depression. When challenged on her theory, she remarked, “Nine months' observation of the mother surely warrants one-minute observation of the baby” (Pediatr Clin North Am 1966;13:645-50). In the hospital cafeteria, a medical student asked what they should look for when evaluating a newborn. Dr. Apgar enumerated five objective signs on the back of a card that read, “Please bus your own trays.” Inspired by an assessment method used in treating drug addiction, she created an observational scoring system and, in 1953, published “A Proposal for a New Method of Evaluation of the Newborn Infant.” These signs were: Heart Rate, Respiratory Effort, Reflex Irritability, Muscle Tone, and Color. While the scoring system was promising, the acronym it formed left something to be desired. In an editorial about Dr. Apgar's score, the editor-in-chief of Current Researches in Anesthesia and Analgesia concluded, “The HRRERIMTC score may have a bright future. However, it needs a better name to help us remember it. If such a name can be found (...), then there is a bright future for Apgar's score” (Anesth Analg 2015;120:962). Dr. Apgar's team used blood gas data to show babies with low scores were typically acidotic and hypoxemic. Armed with an objective measurement tool, they were finally able to prove the administration of cyclopropane resulted in neonatal depression. They further demonstrated that regional anesthesia provided superior outcomes for both mother and child, thereby popularizing its use in obstetrics. They applied their tool to other areas of resuscitation, proving that the then-common practice of intragastric oxygen administration was ineffective at improving neonatal outcomes, advocating instead for endotracheal intubation. Dr. Apgar's score caused an evolutionary shift in the care of marginally viable infants. Up to that time, these infants were frequently considered lost causes and left for dead. Now that resuscitative efforts could be evaluated and refined, all babies would be given a chance at life. The score's magic was its simplicity. It required no equipment and was easy to administer – if you could remember it. In 1962, Joseph Butterfield recognized the tool's value and that many providers couldn't memorize its components. He created an epigram to help recall the components without altering its essence: Appearance (Color), Pulse (Heart Rate), Grimace (Reflex Irritability), Activity (Muscle Tone), Respiration (Respiratory Effort) – APGAR. Today, every physician learns this mnemonic in medical school, and it's been said that every baby born is viewed through the eyes of Dr. Apgar. Her successes weren't limited to her eponymous score. Dr. Apgar understood that professional stewardship was essential in advancing her specialty. She was the second woman to achieve board certification in anesthesiology, served on numerous committees, and chaired the Board of Governors of the American Society of Anesthetists, which would become the American Society of Anesthesiologists. In 1940, she became treasurer, the first woman to hold any ASA office. By 1945, her meticulous bookkeeping and organizational abilities had reversed the mismanagement of her predecessor. In 1961, she was the first woman to receive the society's highest honor – the Distinguished Service Award. Later in her career, Dr. Apgar pursued a Master of Public Health from Johns Hopkins to expand her knowledge of congenital malformations and their statistical relationship with maternal disease. She directed the Congenital Malformations Division of the National Foundation for Infantile Paralysis, today known as the March of Dimes. She was an early advocate for the prevention of hemolytic anemia using RhoGAM and worked tirelessly with the March of Dimes through her fundraising efforts and educational campaigns. Endearingly regarded as “The Mother of Neonatal Resuscitation,” Dr. Apgar was recognized by Surgeon General Julius Richmond as doing “more to improve the health of mothers, babies, and unborn infants than anyone else in the 20th century” (asamonitor.pub/3RSQxed). The Apgar score has dramatically reduced neonatal mortality around the world and highlights the benefit of evidence-based practice. The effectiveness of her clinical scoring system popularized this approach in other areas of medicine where structured evaluation improves patient care. We celebrate Virginia Apgar with this first edition of “Anesthesiology Giants of the 20th Century,” and we commemorate her commitment to research, education, and patient care. Suggested Reading “Scoring for Life: The Legacy of Virginia Apgar in Neonatal Medicine” Ahmed Elashmawy, Anas Haq, Angelo Frederico, Mohammadali Chokr, Ali J. Bazzi (Cureus 2024;16:e69281). “Virginia Apgar (1909-1974): The Mother of Neonatal Resuscitation” Andrew R. Ray, Daniel Haines, Ryan Grell (Cureus 2024;16:e61115). “A Proposal for a New Method of Evaluation of the Newborn Infant” Virginia Apgar (Anesth Analg 2015;120:1056-9). “Evaluation of the Newborn Infant-Second Report” Virginia Apgar, Duncan A. Holaday, L. Stanley James, Irvin M. Weisbrot, Cornelia Berrien (J Am Med Assoc 1958;168:1985-8). “Dr. Virginia Apgar and the Apgar Score: How the Apgar Score Came to Be” Selma Calmes (Anesth Analg 2015;120:1060-4). “Practical Epigram of the Apgar Score” Joseph Butterfield, Mervyn J. Covey (JAMA 1962;181:353). “Changing the Face of Medicine: Celebrating America's Women Physicians: Dr. Virginia Apgar” Tony Delamothe (asamonitor.pub/3GdofbX). This new quarterly column series will feature individuals who have shaped our specialty from the U.S. and abroad and was created in partnership with the Wood Library-Museum of Anesthesiology.Robert W. Thomsen, MD, FASA, ASA Assistant Treasurer, and Vice Chair, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.Mellany A. Stanislaus, MD, Clinical Associate, and Postdoctoral Research Fellow, Department of Anesthesiology and Critical Care Medicine, Division of Obstetric, Gynecologic and Fetal Anesthesia, Johns Hopkins University School of Medicine, Baltimore, Maryland.