and thereafter remained at that weight or gained weight.

This latter type of response agrees with the generally

accepted view that anorectic agents lose their efficacy
in most patients within a relatively short time and that
their long-term administration is valueless (Adlersberg
and Mayer, 1949).
Diethylpropion did not cause any serious side-effects.
In particular there was no evidence of undue central
nervous stimulation or insomnia; a few patients noticed
dryness of the mouth.
Consideration of the results of this study together
with those of similarly conducted trials of the amphetamines and phenmetrazine (Edwards and Swyer, 1950;
Duncan et al., 1960; Hampson et al., 1960), shows that
there is little difference between the weight-reducing
influence of the three drugs. Although the amphetamines and phenmetrazine are apt to cause central
nervous system stimulation and may lead to addiction,
it is justifiable to compare the costs of the drugs. The
cost to the National Health Service of one month's
treatment with each preparation when the tablets are
prescribed in quantities of 100 on form E.C.10 and
dispensed in Scotland is as follows:
Diethylpropion (tenuate) tabs. 25 mg. q.i.d. ..
Phenmetrazine (preludin) tabs. 25 mg. t.i.d.
" Benzedrine" tabs. 5 mg. t.i.d.
..
..
" Dexedrine" tabs. 5 mg. ti.d.
..
..
Tab. amphetamine sulphate B.P. or B.N.F. 5 mg. t.i.d.
Tab. dexamphetamine sulphate B.P. or B.N.F. 5 mg.
.2 7
t.i.d.

BRnuH

OBESITY

APRIL 8, 1961

s.
28
16
5
5
3

d.

7
5
10
1
6

Finally, it is appropriate to consider the response to

strict dieting of the very obese patient in group B, who
was withdrawn from the trial because of increasing
depression and physical incapacity due to her vast size.
When admitted to hospital she weighed 355 lb. (161 kg.),
and had no physical evidence of excessive fluid retention.
For 10 weeks she was given a 600-calorie diet; during
the first four to six weeks her activities were limited,
but thereafter her daily caloric expenditure was
increased by about 600 calories by walking. Over these
10 weeks a steady weight loss of 34 lb. (15.4 kg.)
occurred, which is almost exactly that expected from
the calculated mean daily deficit of 1,300 calories.
During this time she did not experience hunger and was
satisfied with her diet. This response is frequently
seen in such patients dieted in hospital; it emphasizes
that gross and persistent overeating is often due to
psychological disturbances or habit, and therefore may
well be refractory to the influence of the most effective
of anorectic agents. It also refutes any suggestion that
the obesity was due to irreversible abnormalities of
appetite or metabolism and could not, therefore, be
corrected by suitable reduction of food intake.
Summary and Conclusions
A double-blind trial of diethylpropion tenuate was
carried out on 40 obese out-patients who had proved
refractory to dietetic advice alone.
The difference between their mean gain in weight
when given dummy tablets and their mean loss of
weight when taking diethylpropion was statistically
highly significant at all times during the 12 weeks' administration of each preparation. The absolute weight loss
was, however, disappointingly small and similar to that
previously recorded with the amphetamines and
phenmetrazine (preludin). No important side-effects
occurred.

1011

Like other anorectic agents, diethylpropion lost much

of its effect in most patients after 6 to 10 weeks of
treatment. Apart from its expense, diethylpropion
seems to be a suitable drug for use as a short-term
adjunct to the dietary treatment of obesity.
We are grateful to Professor Sir Derrick Dunlop for his

helpful advice and to Dr. D. Mansel-Jones, of MerrellNational (Laboratories) Ltd., who supplied the preparations
used. Our thanks are also due to Miss E. Wilson and Miss
M. Kellock for their invaluable help in the dietetic aspects
of the trial.
REFERENCES

Adlersberg, D., and Mayer, M. E. (1949). J. clin. Endocr., 9, 275.

Duncan, L. J. P., Rose, K, and Meiklejohn, A. P. (1960). Lancet,
1, 1262.
Edwards, D. A. W., and Swyer, G. I. M. (1950). Clin. Sci., 9, 115.
Hampson, J., Loraine, J. A., and Strong, J. A. (1960). Lancet, 1,
1265.
Keys, A., and Brolek, J. (1953). Physiol. Rev., 33, 245.
Martin, G. J. (1959). Symposium p. 5. Michigan Academy of
General Practice.
Ravetz, E. (1959). Ibid., p. 99.
Spielman, A. D. (1959). Ibid., p. 39.
Wilson, R., and Long, C. (1960). J. Irish med. Ass., 46, 86.

Medical Memoranda
A Case of Genital Prolapse in a
Newborn Baby
Genital prolapse in the newborn is a rare condition
usually associated with spina bifida. The following
record is of a baby who showed no evidence of an
associated lesion and who has made an apparently
complete recovery after replacement of the prolapsed
uterus. Some features of the mother's pregnancy and
labour suggested that her abnormal uterine action was
the important aetiological factor.
CASE REPORT
A married woman aged 23 was referred to the antenatal
clinic at 35 weeks with a breech presentation. One year
previously she had an abortion at 11 weeks, but her medical
history contained no significant feature.
During her present pregnancy there had been very slight
vaginal bleeding at 5 and 13 weeks. A breech presentation,
corrected at 34 weeks by external cephalic version, had
recurred.
On her first visit to the clinic a midline fundal " dimpling"
was noted and a provisional diagnosis of a degree of uterine
duplication was made. Attempted version was again
unsuccessful. At 37 weeks the impression of a fundal
depression was confirmed, but exact palpation was difficult
and the breadth of the uterus aroused a suspicion of twins.
A flat abdominal film showed a single foetus presenting by
the breech with both legs extended. Erect lateral pelvimetry
demonstrated a true conjugate of 4.35 in. (11 cm.) and a
pubo-sacral diameter of 4.25 in. (10.8 cm.). The pelvic
shape appeared normal.
On later examinations the uterus felt normal and the
foetal parts were much more readily palpable. The baby
seemed small, and it was decided to await the spontaneous
onset of labour in anticipation of a normal vaginal delivery,
with the proviso that caesarean section be performed should
progress not be satisfactory.
The patient was admitted to hospital three days before
term. The membranes had ruptured spontaneously and
clear liquor was draining. No contractions had been felt,
the breech was free, and the foetal heart was satisfactory.
Vaginal examination excluded cord prolapse.

1012 APRIL 8, 1961

MEDICAL MEMORANDA

After some hours mild contractions began, and continued

throughout the day, but did not cause discomfort severe
enough to require analgesics. Twenty hours after membrane
rupture, morphine sulphate, i gr. (16 mg.) was given in an
attempt to ensure a good night's rest in anticipation of
improved uterine action the next day, but the palpable
contractions remained weak and irregular. The breech had
not entered the pelvic brim.
Thirty hours after rupture of the membranes the foetal
heart rate rose to 160 a minute. Initially the rhythm was
regular, tbit within 10 minutes there was irregularity
followed by rapid variations in rate between 120 and 160
a minute. The contour of the uterus was normal and there
was no impression of hypertonic uterine action. The cervix
was dilated two finger-breadths and no cord prolapse was
palpable. In view of the foetal distress and uterine inertia
probably on the basis of minor pelvic contraction,
caesarean section was performed.
Operation
A lower-segment caesarean section was carried out under
thiopentone, nitrous oxide, cyclopropane, and ether anaesthesia with relaxants. The uterus appeared to be normal and
there was no drawing up or oedema of the bladder, which
was reflected easily from the lower uterine segment. There
was a notable lack of bleeding on incision of the uterus. The
legs were flexed and delivered easily, followed by the trunk
and arms. Difficulty was suddenly experienced in attempting
to deliver the head, and on palpation of the interior of the
uterus a tight constriction-ring was felt about the child's
neck. The anaesthetic was deepened and an attempt made
to stretch the ring digitally and apply Wrigley's forceps.
This was unsuccessful, but jaw and shoulder traction,
combined with fundal pressure by an assistant, effected the
delivery of an asphyxiated girl of 5 lb. 15 oz. (2,705 g.)
who responded to resuscitation.

The Infant
After delivery the ring was still palpable to a lesser degree
about the middle of the uterus. The placenta was removed
manually after the injection of ergometrine, 0.5 mg., into
the uterine muscle, and careful exploration of the cavity did
not show any evidence of a septum. The uterine exterior
and adnexa were normal. Despite the deepening of the
anaesthesia the avascularity of the uterine incision was
maintained and the operation was completed without any
further complication. The puerperium was normal.
A congested oedematous mass protruded from the baby's
vulva. The apex of the mass was the cervix, and the
whole uterus appeared to lie outside the introitus. A
transverse ridge corresponding to the bladder was visible.
The mass appeared to become more congested and
oedematous before the examiner's eyes, and, as the baby
was still pale and shocked, digital reposition was performed.
This was done easily, with an immediate improvement in
the baby's condition.
The baby was observed closely on crying and there was
no recurrence of the uterine prolapse nor occurrence of
rectal prolapse. Digital examination at the end of a week
showed the cervix to be well supported at a high level. The
introitus admitted an average-sized index finger more readily
than expected.
Follow-up examinations of the infant were performed 3
and 17 months after delivery and no abnormality was found.
There had been n sign of recurrence and bowel and bladder
function was normal. She had walked at 11 months, and
the lumbar spine, sacrum, and external genitalia were
normal to inspection and palpation. Radiological
examination showed no evidence of spina bifida.

DISCUSSION
Findley (1917) stated that genital prolapse in the
newborn was usually not detected at birth but after the
first week; and in his series it was associated with
spina bifida in 86% of cases.
Noyes (1927) reviewed 24 bona-fide cases from the
literature (not all of these were in the newborn) and
concluded that spina bifida was the primary aetiological
factor. The lower sacral nerve roots, particularly the
fourth sacral, are drawn through the lumbar vertebral
defect to produce a partial or complete paralysis of the
pelvic floor musculature.
Radwansky (1898) recorded a case in which the
prolapse was detected on the day after delivery and
replaced successfully, with a satisfactory result on
examination six months later. Spina bifida occulta was
not excluded in this instance.
Malpas (1955) has classified the causes of prolapse
into: (a) primary-for cxample, congenital tissueweakness, obstetric trauma; and (b) secondary-for
example, raised intra-abdominal pressure. Had
congenital tissue-weakness been an important factor in
the above case one would have expected a recurrence,
It is
with the stresses of crying and defaecation.
possible that raised intra-abdominal pressure due to
abnormal uterine action was the primary cause.
Palmer (1951) described a series of apparent
abnormalities of the uterus which were observed at
caesarean section and were due to abnormal uterine
action. A similar mechanism may have produced the
impression of a bicornuate uterus noted at the antenatal
clinic. During labour there was no clinical evidence of
hypertonic uterine action-rather the reverse. The
avascularity of the lower segment was remarkable, and,
with the contraction ring, did seem to indicate
hypertonus. The alterations in the foetal heart rate and
rhythm could be explained by embarrassment of the
utero-placental circulation, by pressure on the cord, or
by alteration of the circulation within the foetus.
My thanks are due to Mr. P. R. Mitchell, under whose
care the patient was admitted, for permission to publish
this report.
R. D. FRASER, M.B., M.R.C.O.G.,
Dominions Assistant,

Nuffield Department of Obstetrics and Gynaecology, Oxford.

REFERENCES

Findley, P. (1917). Amer. J. Obstet. Dis. Wom., 75, 12.

Malpas, P. (1955). Genital Prolapse and Allied Conditions.
Harvey and Blythe, London.
Noyes, I. H. (1927). Amner. J. Obstet. Gynec., 13, 209.
Palmer, A. C. (1951). Proc. roy. Soc. Med., 44, 867.
Radwansky (1898). Munch. med. Wschr., 45, 52. Quoted by
Noyes (1927).

Peripheral Neuropathy in Association with

Carcinoma of Thyroid
Neurological syndromes associated with cancer, not due
to metastatic deposits, were first noted by Oppenheim
(1888), and occasional cases were recorded by Nonne
(1900), Siefert (1902), Parkes Weber and Hill (1933),
and Greenfield (1934). However, it was not until the
report by Denny-Brown (1948) of sensory neuropathy
in two patients with carcinoma of the lung, in which he
demonstrated degeneration of the posterior root ganglia
at necropsy, that the association became widely accepted.
A variety of syndromes are now recognized (Brain and