27 July 1968 S.A. MEDICAL JOUR AL 753

provides further evidence for the allelism of the gene for,B-thalassaemia and the gene (or genes) for the ,B-chain ofHb.A.<,s,9,ll,30,3ol

SUMMARYA case of sickle-cell thalassaemia is presented. A family studyshowed that aJI the patient's children, of a normal wife, hadeither thalassaemia minor or sickle-cell trait, thus confirmingthe allelism of the gene for ,B-thalassaemia and the gene forthe ,B-chain of normal adult haemoglobin.

All the cases with thalassaemia minor had high levels offoetal haemoglobin and evidence is presented that these repre­sent the condition of 'high foetal form' of thalassaemia.

We wish to thank Dr. A. Zoutendyk for carrying out theblood-grouping studies, and the Medical Superintendent andstaff of Coronation Hospital for their assistance.

REFERENCES1. Ingram. V. M. (1963): The Haemoglobins in Genetics and Evolution.

New York: Columbia University Press.2. Pauling, L., Itano, H. A., Singer, S. J. and Wells, 1. C. (1949):

Science. 110, 543.3. Ingram, V. M. (1956): Nature (Lond.), 178, 792.4. Jonxis, J. H. P. (1966): Advanc. Pedial., 14, 91.5. Rucknagel. D. L. and Neel, J. V. in Steinberg. A. G.. ed. (1961):

Progress in Medical Genetics. ew York: Grune & Stratton.6. Teel, J. V. (1949): Science, 110, 64.7. Horton, B. 1. and Huisman, T. H. J. (1963): Amer. J. Hum. Gene!..

IS, 394.8. Pearson, H. A. (1962): Pedial. Clin. N. Amer.. 9, 635.9. Rucknagel, D. L. (1964): Ann. N.Y. Acad. Sci., 119, 436.

10. Baglioni, C. (1962): Proc. Nal. Acad. Sci. (Wash.). 48, 18 O.11. Pearson, H. A. and Moore, M. M. (1965): Amer. J. Hum. Genel..

17, 125.12. Cooley. T. B. and lee. P. (1925): Trans. Amer. Pedial. Soc .. 37. 2~.13. Sherman, M.. Weissman. K., Jeffries. I. and Karon. M. (1967): J.

Lab. Clin. Med.. 69, I 3.14. Marks. P. A. and Burka. E. R. (1964): Science. 144, 552.15. Ingram, V. M. and S'rellon. A. O. W. (1959): 'alUre (Lond.). 184.

1903.16. ltano. H. A. (1953): Amer. J. Hum. Genel.. 5, 34.17. Botha, .M. C. and Van Zyl. L. J. (1966): S. Afr. Med. J.. 40, 75318. Esrachowitz. S. R., Friedlander, '. Radloff, G. and aunders. S.

(1952): Ibid., 26, 239.19. Brain. P. (1955): Nature (Lond.). 175. 262.20. Zoutendyk, A., Kopec. A. C. and Mouranl. A. £. (1955): Amer. J.

Phys. Anthrop.. 13, 69.21. Beaven. G. H. and White. J. C. (1962): Nature (Lond.). 193.448.22. Botha. M. c., Pritchard. J. and Van Zyl, L. J. (1967): Afr. l\led.

J .. 41, 66.23. Bannerman. R. M. (1961): Thalassaemia: A Sun'ey of Some A5I't'cI5.

New York: Grune & Stranon.24. Editorial (1964): ew Engl. J. Med., 270, 1253.25. Silvestroni. E. and Bianco. I. (1944): Boil. Accad. med. Roma. 70. 347.26. Dacie. J. V. and Lewis, S. N. (1964): Pracrical Haematology. 3rd ed.

London: J. & A. Churchill.27. Bartlet!. R. C. (1963): Clin. Chem.. 9, 325.28. Singer. K.. Chernoll". A. I. and Singer. L (1951): Blood, 6. 413.29. Gabuzda, J. G., athan, D.' G. and Gardner. F. H. (1964): 'ew

Engl. J. Med.. 270, 1212.30. Weatherall. D. J. (1964): Ann. .Y. Acad. Sci .. 119. 450.31. Monti, A.. Feldhake, C. and Schwartz. L. (1964): Ibid., 119, 474.32. Editorial (1965): Amer. J. Clin. Path .. 43, 166.33. Thomson. R. B.. Warrington, R., Odol11. J. and Bell. W. (1965):

Acta genel. (Basel). IS, 190.34. Ingram. V. M. (1964): Ann. N.Y. Acad. Sci., 119, 485.35. Smith. C. H. (1943): Amer. J. Dis. Child., 65, 681.36. We:Hhera'l. D. J. (1965): The Tha!assaemia Syndromes. Philadelphia:

F.A. Davis Company.

GRIPE WATER*S. LEVIN, M.B. (RAND), M.R.C.P. (EDl .), D.C.H., Johannesburf?

'my bowels are troubled' Lamel1/aJions 2: 11

There it stands, the ubiquitous bottle of 'Woodward'sCelebrated Gripe Water', next to the roll of cottonwool,the mercurochrome, dummy, baby powder, Vaseline, andperhaps borax, junior aspirins, Vidaylin and other oddsand ends that a mother brings home with her new baby.

There must be few households with young babies whichlack a bottle of 'Gripe Water'. Indeed it comes as a sur­prise to observe the occasional nursery room without thiselixir for infantile ills. Repeated inquiries bring furthersurprises: I have never come across a mother who hasstated that the purchase of the 'Gripe Water' was recom­mended by a doctor or a pharmacist. Furthermore, I havenever seen an advertisement for 'Gripe Water' in the dailypress, though I recently came across one in the BritishNursing Mirror. It has been written that

The codfish lays ten thousand eggs,The homely hen lays one;The codfish never cacklesTo tell you what she's done;So we ignore the codfishWhile the homely hen we prize,Which only goes to show youThat it pays to advertise.

But W, Woodward Ltd. do not appear to need to adver­tise, So why does virtually every mother bring home abottle of 'Gripe Water'? The answer, it would seem, waswritten by a chairman of W.· Woodward Ltd. in 1923:'The greatest consumption is now and has been, andpresumably will be, for children in arms, the remedy beingpassed down from generation to generation by verbal

'Date received: 25 October 1967

recommendation, and strongly condoned by medical andnursing professions'. For many years one of Woodward's(occasional!) advertising slogans was 'Granny told MOIherand Mother told me'.

LITERATURE 0 'GRIPE WATER'

What do the medical textbooks and the medical journalssay about this preparation which far outsells any otherused for babies?

Nothing at all. The Index Medicus has been searchedfrom 1903 to date and not a single paper on Gripe Waterhas come to light. Dozens of books on paediatrics andpharmacology have been consulted in vain. It might bethought that those books published before the turn of thecentury would deal extensively with 'Gripe Water', butthey don't. They do supply pages and pages of variouscarminative mixtures, but there is no specific mention of'Gripe Water' in volumes on paediatrics or infant feedingsuch as those written by West (1874 and 1884), Smith(1884), Day (1885)', Henoch (1889), Cheadle (1889), Keatingin 4 volumes (1890) and Wells (1899).

During the first quarter of this century there is also atotal absence of detail on 'Gripe Water' in more than 20leading paediatric and pharmacological texts consulted, andit is not mentioned in popular works like those of Spockor the British Medical Association publication You AndYour Baby. It gets 'curiouser and curiouser' to observethat 'Gripe Water' is not mentioned in the leading medicaldictionaries.

The first record of 'Gripe Water' that I chanced uponin a medical work was in the 6th edition (1947) of Pater­son's Sick Children] (the reference is omitted in the 8th

754 S.A. TYDSKRIF VIR GENEESKU DE 27 Julie 1968

·1%1%4·92%

22·5%128 cc.

edition, 1963) and the information therein is faulty. It isstated that bromides were often used as gripe water. May­be so, but 'Woodward's Gripe Water' (and there is norecord that there was ever any other variety of gripe waterbefore this) has never contained bromides. The origin ofthis assertion is understandable. A century or two ago,when baby-farms flourished and numerous infants werefarmed out to the care of slovenly and disinterested nurses,fractious infants were sedated with laudanum, an alcoholicsolution of opium. The earliest labels on 'Woodward'sGripe Water' noted that the preparation contained nolaudanum, morphia or opium. A South African label fromthe early 1900s noted, in High Dutch, that 'Woodward'sBeroemd Kramp Water' was 'Een Behoedmiddel VoorKinderen' and that it was 'Zonder Laudanum'.

Another error is preserved on page 352 in volume 1 ofGaisford and Lightwood's work, Paediatrics for The Prac­titioner (1953).- Gaisford himself writes that 'Gripe Water'is a 'carminative ... of undoubted value, particularly inoveractive infants and those who cry at feeding times orswallow much air during their feeds. A dose of the follow­ing mixture given after a feed may quickly relieve the windand make the infant comfortable:

Bicarbonate of soda 5 gr.Aromatic spirits of ammonia 2t mSyrup of ginger 15 mCompound tincture of cardamoms 5 mDill water to 60 m'

If it be inferred that this mixture is 'Gripe Water', thenthis inference is wrong, for in England 'Gripe Water' iscopyright as a trade mark (number 100 on the BritishTrade Mark List) and it has a specific formula which canbe read on the label. The formula given by Gaisford is not'Gripe Water' but simply one of the dozens of carminativemixtures listed In the books published before 1900.

In South Africa, Catzel' mentions 'Gripe Water' but alsogives an old carminative formula rather than that of'Woodward's Gripe Water'. While Pretorius' does notallude specifically to a 'Kramp Water', he does mentiona 'karminatiewe middel' of an ancient character and notesthat it is 'van twyfelagtige waarde'.

If doctors aren't meticulous about pharmaceutical con­stituents, pharmacists are. The British PharmaceuticalCodex of 19235 briefly mentions the various materialsconstituting the 'gripe water used to correct the flatulenceof infants', while Martindale's Extra Pharmacopoeia" men­tions 'Gripe Water' and later' reproduces the formula of'Woodward's Gripe Water' correctly, with the full appre­ciation of copyright in their heading 'Gripe Water BrandCarminative (W. Woodward Ltd.)'.

The formula has varied only slightly for the past severaldecades and now consists of:

01. anethi 2 mSod. bicarb. 20 gr.Rect. spirit 106 mSyr. B.P. 490 mAqua ad 4t oz.

W. WOODWARD, 1828 - 1912Woodward's original formula is unknown. During WorldWar IT the Woodward factory was bombed and old recordswere lost or destroyed. Indeed, very little is known of

William Woodward. He was a pharmacist of ottingham,and was affectionately known as 'Doctor;. He had a soncalled William Harrison Woodward who took over thebusiness and retired in 1923 ; and, as his only son was notinterested in 'Gripe Water' and had emigrated to Canada,the second Woodward sold the business to the SanitasGroup of Companies, which still control W. WoodwardLtd., now in London.

Fig. 1. The late Williarn Woodward. (published by cour­tesy of the British Pharmaceutical Society.)

History of the Original Mr. WoodwardWoodward was born in Stamford, Lincolnshire. After

a 7-year apprenticeship he moved to London (1850 - 51)and thereafter to Nottingham where he bought an old­established business. Nottingham directories from 1853 to1877 mention him as a pharmaceutical chemist trading inLong Row and living at various nearby addresses.

In the 1840s a minor disorder of babies called Fen Feverwas troublesome in the fens, i.e. the low-lying districts ofLincolnshire and Cambridgeshire. It could not have beenof great moment, because I was unable to find any refer­ence to Fen Fever in any of the early textbooks or in TheLancet, British Medical Journal and other journals of the1840s - 1860s. However, it did come to Woodward's atten­tion and interested him to the extent that he compoundedan alternative to the laudanum or bromide preparations.

In 1851, as soon as he opened in business, he com­pounded a remedy for Fen Fever and called it 'Gripe

27 July 1968 S.A. MEDICAL JOUR AL 755

Fig. 2. 'Gripe Water' label from England. Unlike those inSouth Africa, the chemical formula is listed, and 'Regis­tered Trade Mark' is lisIed in the side panels.

Several competitors have tried to pirate Ihe preparation,but, as one pharmacist tells me, 'substitutes, no matter howingeniously designed to resemble Ihe original, have nomarket value; this I know from personal experience'.

Future UseWhat of its future? Many factors tend to perpetuate it

use, principally the widespread idea, thousands of yearold and already known in ancient Sumeria, that infantscommonly suffer from abdominal pains, The very name forIhe chief Sumerian demon afflicting infants was Lilitu('wind'), and to this day mothers sing a lullaby, not inorder to soothe an infant, but to keep Lulla-Lili-Lilithaway. In the ancient Middle East, infusions of pomegra­nate blossoms were used for flatulence in infants, whileplants such as anise, dill, coriander and fennel were used

I-I

!!I!

I

WA

REGISTERED- nAOE M.... RK

,,-~--~. !:",='---'-,...=-...J~~ o. ,

WOODWAlWS CElE8·RA1EJJ.~ - ~ ~'-===-- "'~-:'I;~ .="-.

;~'''';L,::~~ ~'n)I~I'~ ~·W'i " .}~A..IJ.~ ;;.rft"),.,'v rn ,)~! C>! • \ :":1~.~' ~~'" '-E7'~ AN -~ "

INFANTS' PRESERVATIVE.FOR THE DISORDERS OF CHILDREN, VIZ;­

Convulsions,Gripes,Acidir)',Flatul~ncy,andthedistressingcom'plaints

incidenl2J ro Infants at the period of cutting their T<:eth, allayIng thepain, giving instant rditf, and n:ndtnng rh .. crisis p<rftetly mild andfrtt from dangtr.

DOSE :-Fora ntW born Infant balh ",a-spoonful, ontro silt months iolP t tea-spo.mful, six months to ont year old 2 ,..-spoon,ful, two 1y<ars old 2 to 3 rta-spoonsiul, Sha.k~ rht Bottle frtqutntlyand ktepir in a cool place.

..tuiu !~r~.Jimu.. Oku.Yb A.."lr.hi S.P.C. O.IO'i.,) Sodii BJca.rbooa' a.p. t.OO'~)

Sy:nJptl) a,p. 22,5(1).;. Spirit~ Recrffiatus .a.P. .:l.92~~". Net COOln1U; 118 c...c.

PFllAJ(£O OM r arW. WOODWAID, Ltd., MtI. C1aeaislS, LOlIdeo, &gIaDcl,

REGISTERED TRADE MARK .• GRIPE WATER"

emerge from his che t, huge leg from which the picture ofpseudohypertrophic mu cular dy trophy ('infant Hercule ')is justly derived, a respectable peni and prepuce but noscrotum. The labelling remains archaic, the preparationbeing recommended for' Con ul ions, Gripes, Acidity,Flatulency", Earlier labels had also recommended its valuein diarrho.ea, constipation and \ hooping-cough. On SouthAfrican labels the scrolls on either ide of Hercules arebare; in Britain they feature the words 'Registered TradeMark', and the ingredients are also noted on the label. Theflowers on the label are nonde cript-they do not looklike poppy plants.

GRIPES, CRAMPS, COLIC AND WI D

otwithstanding minimal advertisements at home andabroad, its presence was soon manifest throughout theBritish Empire, The wives of servicemen invariably tookbottles 'with them, and as a consequence its fame spreadto India and the Far and Middle East, to South Africa,Australia, New Zealand and Canada, in all of which coun­tries it still enjoys phenomenal sales, while in some, likeSouth Africa, it is locally produced under licence.

Laudatory testimonials came thick and fast: from physi­cians ('it is a safe and reliable remedy, , . for irritation ofthe brain, painful teething, and colic'), pharmacists ('greatvalue in the various simple and familiar ailments of infantsand young children, especially during the period of teethingand diarrhoea'), nurses ('I have never found it to fail')and mothers ('the children love it'). Current advertisements(which have to be solicited) still advise that if an infant iswindy and fretful a teaspoonful of 'Woodward's GripeWater' will solve the problem, 'Gripe Water' has also beenrecommended for pregnant and nursing mothers, in oldpeople and for postoperative flatulence,

An important factor in its rapid spread was the asso­ciation of the name with the trade-marked (number 99)device of the infant Hercules holding two serpents, Theoriginal of this painting, by Sir Joshua Reynolds, is be­lieved to be in Paris, and a copy is present in the Wood­ward London offices, The mythical Hercules was notedfor his immense strength and even while in his cradle hestrangled two serpents which Juno had sent to destroyhim.

Close inspection of a modem label (Figs, 2 and 3)reveals a surly infant with lots of curly hair parted on theleft, a broadly mis-shapen abdomen and chest lackingnipples, an absent right arm, the forearm seeming to

Water'. In the 19th century infantile gastro-enteritis wasknown as the watery gripes and it was surely a stroke ofvery considerable astuteness to reverse these words and callthe remedy for watery gripes gripe water. It presupposedthat infants with diarrhoea did have gripes, a word of oldEnglish and Teutonic origin though hardly used today,colic, cramps and wind being the current equivalents.

Woodward was fortunate enough to get some half-dozenlocal doctors to do a clinical trial for him. They reportedfavourably on its use in Fen Fever and also noted its valuein soothing fretful babies and dissipating the varioustummy troubles associated with infant feeding.'

The Original 'Gripe Wafer'The use of 'Woodward's Gripe Water' rapidly encom­

passed England and was sold to doctors, hospitals andwholesalers. Woodward registered the words 'Gripe Water'and the Hercules symbol as trade marks in 1876. In 1903a limited company was formed to run the business and itsubsequently came under the direction of William HarrisonWoodward, M.A. (Oxon), whose primary interests wereliterary but who ably managed the business until 1923.

The characteristic shape of the 'Gripe Water' bottle hasremained unchanged since the early 1900s. By the 1920s,when a bottle of 'Gripe Water' sold for Is. 3d., the head­quarters of the business had shifted from Nottingham toLondon.

756 S.A. TYDSKRIF VIR GE 'EESKU DE 27 J u1ie 1968

as carminatives in biblical times and are still to be foundon the shelves of modern pharmacies.

1 do not believe that crying infants commonly haveabdominal colic. 1 think their disturbance originates moreoften in the thalamus than in the stomach. evertheless,such is the force of ancient tradition, that remedies forcolic, , ind, cramps and gripes will continue to be de­manded and will be supplied in the form of 'Gripe Water'or, where this is not generally available, as in the USA,in other preparations.

Fig. 3. 'Gripe Water' label from the early 1900s, in HighDutch.

'Gripe Water' was a good name and Woodward musthave had a shrewd understanding of advertising. It helpsto sell a product if one can have or invent a disorder whichthe product can cure. 'Gripe Water' was no treatment insearch of a disease; the disease was already there: thewatery gripes.

But this word 'gripes' is now archaic; nobody uses it andthe time may well come when the product may have tochange its name to Cramp Water or Colic Water, and,indeed, other preparations on the market do trade on thisword colic.

Competition from newer and more sophisticated (thoughnot necessarily more efficacious) products will inevitablyaffect the use of 'Gripe Water'. This is already evident inSouth Africa, where few mothers give it as a medicine. Thehuge majority use it as an application to a dummy. Itseems to me that this indicates a gradual attrition of itsfunction. It comes as something of a surprise, therefore,

to learn that the sales of 'Gripe Water· in South Africa arenot steadily decreasing, but are increasing from year toyear, and this despite the fact that grandmothers tend todie off, that the British influence is waning in the Com­monwealth, and that doctors, nurses and pharmacists con­tinue to ignore the presence of 'Gripe Water'. Increasedsales are at least partly due to the increase of the Whitepopulation, augmented by British immigration, as well asthe greater awareness and purchasing power of the Bantu.

Does 'Gripe Water' work? Does it matter? The ideaexists that babies have gripes and a remedy for gripes willbe demanded. The probability that the gripes are cerebralrather than intestinal in origin does not affect the issue. Ithappens now and then that a distended abdomen willreceive a further teaspoon of 'Gripe Water', the sodiumbicarbonate of which will react with the stomach's hydro­chloric acid to produce just a little more carbon dioxide,and this extra volume of liquid and gas may be just suffi­cient to expel some air via the oesophagus. The 'wind' isthus broken (note how this verb suggests a tempestuousnature to wind) and 10 and behold, the 'Gripe Water' quiteevidently, and audibly, works.

If its efficacy is in dOUbt, its safety is not. On 30 July1967 a 5-month-old boy was given 4 oz. of 'Gripe Water'by a flustered baby-sitter. A half-hour later he looked paleand unhappy but recovered rapidly thereafter.

An instance of addiction to 'Gripe Water' (possibly theonly such case in the world) has also come to my attention.A woman of 24 years, born in South Africa, as was hermother, has been addicted to 'Gripe Water' ever since shecan remember. As a small child she would steal heryounger brother's 'Gripe Water' and the mother had tolock it away. As a young girl she would use her pocketmoney to buy it. For several years she has been drinkingsome 10 bottles a month. She sips small amounts many·times a day. It afforded her no particular relief during herown pregnancy but she appreciated it especially after arecent abdominal operation. She has no love of alcohol,tobacco, condiments or drugs, and drinks 'Gripe Water'because '1 simply like the taste of it'. Her siblings are notaddicted and her own baby gets it on the dummy. Herhusband and friends regard her addiction with amusedtolerance. At 35 cents a bottle she finds her habit ratherexpensive but cannot change, because she did once trycheaper brands of gripe water but they were simply not assatisfying as the Woodward's variety.

SUMMARY

William Woodward, M.P.S., of ottingham, England, com­pounded 'Gripe Water' in 1851 as a remedy for the waterygripes, as gastro-enteritis was then known. Its principal ingre­dients were, and are, sodium bicarbonate and some 5°~

alcohol. It caught on as an elixir for minor abdominal ills ininfants and, like religion, was disseminated in the wake ofarmies. The wives of British servicemen popularized its use inhalf the world, where it still enjoys phenomenal sales. Thewidespread view that infants commonly suffer from gripes,cramps, colic and wind ensures continued sales though itsreal efficacy is doubtful. In South Africa it is not often usedas a medicine but rather as an application for dummies.

Most of the information in this paper has been suppliedthrough the courtesy of Mr. L. G. Williams, currently Manag­ing Director of The Sanitas Company Ltd. I wish to thank thelibrarian of the British Pharmaceutical Society, who kindlysent me a photocopy of an article on William Woodward

27 July 1968 S.A. MEDICAL JOUR AL 757

which appeared in the Chemist alld Druggi;;r of 31 January1914, and the Deputy Librarian of the ottingham PublicLibrary who was also helpful.

REFERE 'CESI. Pater.;on, D. (1947): Sick Chi/dren .. 6th ed. London: Ca ell.2. Gai ford. W. and Lightwood. R. (1953): Paediatrics for the Practi­

tione,.. London: Buuerworth.

3. Catzel. P. (1963): Paediatric {',-.,criber. 2nd ed. Oxford: lllack\\ell.4. Pretorius. P. J. (1966): 8aoo,'oedi/lK. Kaapstad: 'asou Bpk.

Council of the Pharmaceutical Society of Great Britain (1923):British Pharmaceutical Codex. London: Pharmaceuti al Pres.

6. Idem (1921): Nlarti"dale"s Extra Pharmacopoeia. 17th eo.. \'01 2­London: Pharmaceutical Pre s.

7. Idem (1943): Ibid .. 39th ed .. vol. 2. London: Pharmaceutical PresWilliams. L. G. (Managing Director. W. Woodward. I td.) (1907):Personal communication.

THE EFFECT OF INTRA-UTERINE ENVIRO MENT AND ANAESTHETIC FACTORS 0THE CONDITION OF THE BABY AFfER CAESAREAN SECTIO *

J. M. E. DU PLESSfS, M.B., CH.B., M.MED. ( AES.) (CAPE Tow), H. J. D TorT, M,B., CH.B., M.MED. (ANAES.)(CAPE TOWN), G. G. HARRIso , M.D. (CAPE ToWN), F.F.A.R.C.S. AND C. CRAIG, M.D. (CAPE Tow), M.R.C.O.G ..

Departments of Anaesthetics and Obstetrics and Gynaecology. University of Cape Town

use of a non-return system. Muscular relaxation was ob­tained with d-tubocurarine.

Group 2 - moderate risk:Foetal maturity >36 weeksDuration of labour >18<)0 hoursNo foetal distress

Group 3 - high risk:Foetal maturity <36 weeksDuration of labour >30 hoursFoetal distressPlacental insufficiency

For the purpose of thi study, the presence of meconiumin any amount in the liquor and a foetal heart-rate below120 beats/min. were regarded as signs of foetal distress.

A special anaesthetic card was devised to facilitate thecollection of all the data required. The relevant details

The induction agent used constituted the only variablein the anaesthetic technique. Induction agents used were:

I. Thiopentone in doses not exceeding 250 mg.2. Nitrous oxide with 25% oxygen.3. Methohexital in doses not in excess of 100 mg.

The use of methohexital was a later introduction to thisinvestigation.

Assessmelll of Foetal RiskThe foetal risk was based on an assessment of foetal

maturity, the duration of labour, and the presence ofsigns of foetal distress. The pre-delivery intra-uterine en­vironment was judged as resulting in high, moderate orlow foetal risk as follows:

Group 1 - low risk:Foetal maturity >36 weeksDuration of labour <18 hoursNo foetal distress

Much has been written about the effect of general anaes­thesia on the depression of the baby after caesarean sec­tion. Although general anaesthesia and its conduct mustinfluence the condition of the baby at birth, the import­ance of the pre-operative intra-uterine environment hasoften been disregarded. In an attempt to evaluate therelative importance of certain aspects of general anaes­thesia, as opposed to that of the intra-uterine environmenton the condition of the baby at birth following caesareansection, we undertook a survey of 1,011 caesarean sectionsperformed in the Maternity Unit of the University ofCape Town Teaching Hospitals. These included emer­gency and elective caesarean sections. All patients whohad received opiate sedation within 6 hours of delivery,or avertin, were excluded from this survey. We also ex­cluded 11 cases which resulted in stillbirth. The surgeonsand anaesthetists involved were of both registrar andconsultant status. The selection of the surgeon and anaes­thetist was completely random, depending upon depart­mental assignments at the time.

The status of the baby was assessed by means of theApgar score' determined at I min. and 5 min. after de­livery. The Apgar score was reckoned out of a total of 8points, the points awarded for colour in Apgar's originaldescription of this method being omitted.' This scoringwas done by the paediatric registrar in attendance, or,when he was not present, by the anaesthetist.

The incidence of the use of intubation and IPPR re­quired during resuscitation of the baby was used as aseparate additional factor in -the evaluation of the con­dition of the baby after delivery. The need for intubationand IPPR was assessed by the person directing the re­suscitation of the baby and was instituted when the respi­ratory function of the baby appeared grossly inadequate,or when the heart rate dropped below 100 beats/min.

Anaeslhetic TechniqueCertain aspects of the anaesthetic technique were stan­

dardized (Table I). All patients received 0·65 mg. ofatropine intramuscularly or intravenously. Endotrachealintubation was performed following the injection of suc­cinylcholine. Anaesthesia was maintained with nitrousoxide and oxygen (25% or greater) delivered by an IPPRtechnique with either carbon dioxide absorption or the

'Based on a paper presented at the 46th South African Medical Congress(M.A.S.A.), Durban, July 1967.

Induction:

Maintenance:

TABLE I. ANAESTHETIC TECH 'IQUE

Thiopentone sodium <250 mg.or

Methohexital < 100 mg.or

,0/0, (minimum 0, 25 %)

N,O/O,dTcIPPR