Authors: Xina M Uhl and Melanie Ann Appel
This book, written with a relatively young audience in mind, is one of the rare works that celebrate the life of a female doctor who made one of the most pivotal contributions to medical practice. Referring to Virginia Apgar as ‘a woman ahead of her time’, and as a legend and trailblazer who created ‘a path for other women to follow’, the book explores not just how she developed a simple but ‘profound‘ and ‘groundbreaking‘ newborn assessment tool, but also how this breakthrough ‘paved the way for women in a world that had been dominated by men’. Although the book understandably focused on the neonatal scoring scale which now bears her name, and which had a ‘lasting, life-saving impact on people’s lives’, it also explores how the obstetric anaesthesiologist’s early life and education fashioned her character and enabled her to introduce what is now a critical assessment of every baby born in every delivery room in the world. Beyond the Apgar score, the book also chronicles her other remarkable, even if less appreciated, contributions to medicine (pages 4 and 87).
Whilst the newborn scoring system has become routine in healthcare, the story of how Apgar conceived and developed it is less familiar. The intriguing story the book narrates highlights the influence of serendipity on creativity, and illustrates how experience and long-preparation focus the mind at the critical time of innovation. The account had Apgar eating breakfast when a passing student asked her ‘if there was a correct way to evaluate newborn babies‘. With no apparent hesitation, the authors said Apgar used the back of a notice to write out ‘the five important points to look for in a newborn’. Energised by this insight, the authors said ‘Apgar hurried up to the obstetrics department to try out her new idea‘, which worked quite well. In emphasising the impact of this moment, which the authors stressed cannot be overstated, they described how the score became an indispensable assessment tool of every newborn baby, its value being its ability to predict ‘whether a baby needed resuscitation or other care right away, instead of when it was already too late’ (pages 38-41).
Whilst the anecdote the book narrated appeared to be a seminal trigger experience for Apgar to devise and implement her assessment system, the book made it clear that it was her observant attitude that laid the groundwork for it. Indeed, the authors argued, Apgar was already concerned about how ‘newborn babies were too often being neglected in the delivery room‘, and about the ‘inconsistent and somewhat dangerous‘ methods by which doctors assessed babies after birth. Particularly disturbing for Apgar, the authors added, was her observation of how frequently babies ‘who had seemed so perfect at birth‘ would ‘develop a problem suddenly‘ and ‘all too often…died‘. The authors argued that this unfortunate situation, ‘to Apgar’s brilliant and compassionate mind’, was ‘a completely unacceptable way for babies to begin life’ (pages 29, 37 and 41).
As is typical of most medical innovations, the authors regretted that the score, initially called the Newborn Scoring System, ‘did not catch on right away’ when Apgar announced it in 1952. Indeed, consistent with the time medical breakthroughs gain widespread acceptance, the authors stated that it was about a decade later, after Dr Joseph Butterfield created the catchy acronym, that it became widely adopted. In its detailed description and interpretation of the system, the authors explained that Apgar stood for appearance, pulse, grimace, activity, and respiration, and that each item has a score of 0-2, and the score is measured twice: at one minute, and then at five minutes after birth. The book also provided an insight into the implications of the total score, 7-10 being normal, 4-6 meaning ‘a baby might need some help with its breathing and heartbeat, and 0-3 indicating that a baby ‘will need major help right away in order to survive’. It is heartwarming that Apgar’s work was recognised in her lifetime with awards and honorary degrees, and after her death with a commemorative postage stamp, and with induction into the National Women’s Hall of Fame (pages 42-48 and 81-84).
The book chronicled Apgar’s medical journey in detail, and this revealed some interesting details. For example, the authors noted that her initial intention was to specialise in surgery, but she was dissuaded from this course by Alan Whipple, the Chair of Surgery at Columbia Presbyterian Hospital where she commenced her surgical internship in 1933. Rather, he encouraged her to enter the new field of anaesthesiology where he thought her aptitude was best suited, and where, as a female doctor, he thought her career prospects were brightest. It is pertinent, the authors noted, that Whipple recognised that ‘Apgar was smart enough and had enough energy and ability to be one of the people who could help change the field of anaesthesiology’. The book chronicled her anaesthesiology training postings and final residency at Bellevue Hospital in New York, becoming only ‘the second woman ever to receive board certification’ in that specialty. The authors also recounted her return to Columbia to assume the role of anaesthesia division chief – the first woman to hold such a position in the United States. The book also explored Apgar’s impact on obstetric anaesthesiology beyond developing the neonatal score, and this included how she improved the non-standardised technique of infant resuscitation which was hitherto ‘not well understood’, and how she demonstrated that local anaesthesia was feasible in labour, and that it enabled women to be ‘awake and able to enjoy the beauty of giving birth’ (pages 19-21, 24-28, and 35-36).
In its biographical account of Apgar’s early life, the book attempted to identify the first influences that determined her scientific bent and innovative outlook. One of the most prominent the book cited was her father, ‘an extremely intelligent and creative man’, who ‘was fascinated by science in general and by astronomy in particular’, and who shared his passion for science with his daughter. The authors also attributed her very early determination to become a doctor to the sad experience of living with two brothers who suffered with childhood chronic diseases. The biographical narrative also depicted Apgar’s life outside anaesthesiology, and this included earning a Masters degree in public health, contributing to the study of birth defects, and participating in the crusade to eliminate poliomyelitis as a member, and later as vice president, of the National Foundation for Infantile Paralysis – later known as March of Dimes. The book similarly highlighted her very diverse interests outside of science and medicine, the most salient being lifelong interests in playing the violin, stamp collecting, and deep fishing, and later pastimes such as ‘extensive travelling‘ and learning to fly (pages 4, 8-11, 15, 51-53 and 60-67).
This book’s strength lies in is its simple prose and focused story-telling which served to simplify the complex medical themes covered, and to bring out the key aspects of Apgar’s life and achievements. In very illuminative terms, the book documents her concise but illustrative biography in which her childhood influences, her diverse interests, and her character shine through. The book also succeeded in effectively conveying the sense of the magnitude of her immense contributions to medicine which go far beyond the familiar score whose acronym coincidentally bears her name. In this way, the authors have ensured that the book serves as an inspiration not just for women, but for all advocates of good medicine.
The Apgar score is a universally applied method of safeguarding the health of every newborn, and Apgar’s intuition and practical-mindedness were crucial to its development. The authors charted Apgar’s insights that resulted in what is a simple, low-cost but powerful healthcare tool. The book also highlighted the lessons of how passion and concern for the welfare of all people serve as driving forces for innovating critical healthcare advances and for promoting well-being, and I recommend it to all doctors.
Publisher, Place, Year: Rosen, New York, 2020
Number of chapters: 8
Number of pages: 104
Star rating: 4