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of chronic retention of urine resulted. The hypotensionbetween the attacks can be explained only by assumingthat the liberation of pressor substances was inter-mittent. The work of both Blacket et al. (1950) andGreen et al. (1948) suggests that the intermittent libera-tion of pressor substances might lead to hypotension.Blacket et al. (1950) showed that continued infusion of amixture of l-adrenaline and l-noradrenaline (1 part ofl-adrenaline to 5 parts of l-noradrenaline) into a rabbitled to hypotension when, after five days, saline solutionwas substituted for the mixture. Green et al. (1948)showed that in man a long infusion of adrenaline wasfollowed by a period of hypotension.The impotence in the present case cannot be explained

on a physiological basis and might be of psychologicalorigin and due to the fact that intercourse precipitatedan attack of hypertension.The changes in renal function are also difficult to

explain. Although adrenaline reduces the total renalblood-flow, the volume of glomerular filtrate is unchangedbecause there is an increase in the " filtration fraction "

(ratio of glomerular filtrate to plasma flow). This increasemay be due to a rise in glomerular capillary pressure fromvenoconstriction (Homer Smith 1951). The impairedconcentration of urine is attributable to a defect in tubular

resorption associated with impaired blood-supply. In

many of the reported cases of phæochromocytoma renalfunction was normal.The diagnosis of phseochromocytoma, though- often

easy in retrospect, may be initially difficult. In the

present case, because of many unusual symptoms, chronicnephritis, Addison’s disease, and carcinoma of the pro-state were at first considered in the differential diagnosis.

SummaryA patient with a phseochromocytoma of the right

suprarenal gland presented diagnostic difficulty becauseof two unusual features-hypotension and urinaryretention.The diagnosis was established by the production of a

classical paroxysmal attack of hypertension by theintravenous injection of histamine.The clinical features of the present case are discussed

and the pharmacological tests for phæochromocytomabriefly reviewed.We wish to thank Dr. H. P. Brody and Mr. W. J. Lytle

for permission to publish and for their helpful advice ; Dr.R. Wood for the catecholamine estimations ; and Mr. A. R.Foster for the diagrams.

REFERENCES

Barnett, A. J., Blacket, R. B., Depoorter, A. E., Sanderson, P. H.,Wilson, G. M. (1950) Clin. Sci. 9, 151.

Bierman, H. R. (1950) J. Amer. med. Ass. 144, 830.Biskind, G. R., Meyer, M. A., Beadner, S. A. (1941) J. clin. Endocrin.

1, 113.Blacket, R. B., Pickering, G. W., Wilson, G. M. (1950) Clin. Sci.

9, 247.Drill, V. A. (1949) New Engl. J. Med. 241, 777.Engel, A., von Euler, U. S. (1950) Lancet, ii, 387.Evans, J. A., Rubitsky, H. J., Bartels, C. C., Bartels, E. C. (1951)

Amer. J. Med. 11, 448.Goldenberg, M., Aranow, H., Smith, A. A., Faber, M. (1950) Arch.

intern. Med. 86, 823.Graham, J. B. (1951) Int. Abstr. Surg. 92, 105.Green, D. M., Johnson, A. D., Lobb, A., Cusick, G. (1948) J. Lab.

clin. Med. 33, 332.Crimson, K. S. (1950) Surgery, 28, 437.Guarneri, V., Evans, J. A. (1948) Amer. J. Med. 4, 806.Labbé, M., Tinel. J. (1922) Bull. Soc. Med. Paris, 46, 982.LaDue, J. S., Murison, P. J., Pack, G. T. (1948) Ann. intern. Med.

29, 914.Learmonth, J. R. (1931) Brain, 54, 147.Litman, N. N., State, D. (1949) Pediatrics, 4, 735.Mason, R. E. (1951) Amer. J. Med. 11, 524.Partridge, J. F., Burrows, M. M. (1951) Brit. med. J. i, 448.Pitcairn, D. M., Youmans, W. B. (1950) Circulation, 2, 505.Roth, G. M., Kvale, W. F. (1945) Amer. J. med. Sci. 210, 653.Shapiro, A. P., Baker, H. M., Hoffman, M. S., Ferris, E. B. (1951)

Amer. J. Med. 10, 115.Smith, H. W. (1951) The Kidney. London.Smithwick, R. H., Greer, W. E. R., Robertson, C. W., Wilkins,

R. W. (1950) New Engl. J. Med. 242, 252.Spear, H. C., Griswold, D. (1948) Ibid, 239, 736.von Euler, U. S. (1951) Brit. med. J. i, 105.

FATAL ACUTE FRONTAL-LOBE ABSCESPRESENTING AS PYREXIA OF UNKNOWN

ORIGIN

G. W. C. JOHNSONM.B. Camb.

GENERAL PRACTITIONER

ABSCESSES of the frontal lobe may be difficult to

diagnose. The one reported here shows how obscurethey may be, and how urgent it is to discover them.

Case-reportA boy, aged 14, complained of headache, which lasted only

a few hours. Two days later he felt feverish but denied anyother symptoms. Examination revealed no abnormal physicalsigns except an oral temperature of 103°F and a trace ofalbuminuria. For six days his temperature stayed above100°F, usually being highest in the mornings. He had drench-ing sweats. Repeated examination revealed no cause. Onthe fifth day of his illness his left upper eyelid was slightlypuffy and red. Sulphadimidine had been prescribed for asuspected urinary infection, and perhaps because of this theeyelid was normal next day ; the significance of the findingwas not appreciated. Meanwhile investigation of the urineproved negative. On the sixth day of his illness he vomited,and after this his neck was slightly stiff towards the limit offlexion. His optic fundi were normal.

Blood examination showed red cells 4,050,000, Hb 125 g.per 100 ml., erythrocyte-sedimentation rate (E.s.R.) 33 mm.in 1 hr. (Westergren), and white cells 8200 (neutrophils 71%,lymphocytes 27%). A blood-culture proved negative.

T1’eatrnent and Course.—On the ninth day of his illness histemperature fell below 100°F. Recovery seemed in progress,and it was decided to attempt to expedite this by givingpenicillin instead of sulphadimidine, although the diagnosiswas still obscure. After receiving 0-8 mega unit in forty.eight hours the boy was apyrexial, and his only complaintswere anorexia and slight cough. Penicillin was then with,held. Apart from some understandable depression (he wasmissing a holiday) the boy’s mental state caused no remark.He soon claimed to feel well ; he remained apyrexial and onthe fourteenth day was allowed up. Examination showednothing except pallor. There was now no neck rigidity.

Adrrzission to Hospital.-Next morning he was again pyrexialand was admitted to hospital, where slight puffiness of theupper eyelids was again noted, also mouth breathing. Minimalneck stiffness prompted lumbar puncture, which yieldedclear colourless c.s.F. under a pressure of more than 300 mm.of water and containing chlorides 660 mg. per 100 ml., sugar114 mg. per 100 ml., protein 93 mg. per 100 ml. (normalvalues 720-750, 40-80, and 20-40 mg. per 100 ml. respectively),and 80 white cells per c.mm. (polymorphs 55%, lymphocytes45%), but no micro-organisms. The blood showed slightlyincreased anaemia, much raised E.s.R. (80 mm. in 1 hr.) andwhite cells 24,000 per e.mm. (neutrophils 93%).

Course.—The boy’s condition now rapidly deteriorated.He became confused and lethargic, lying on his right sidewith his legs drawn up, photophobic, and resenting inter-ference. He could not complete simple sentences. As drowsiness increased, he vomited twice and lapsed into coma with,dilated pupils and neck rigidity. A second lumbar punctureshowed only 42 mg. of protein per 100 ml., but 225 whitecells per c.mm. (polymorphs 90%). Several hours later theboy made convulsive movements with-his right arm, becamecyanosed, and died on the seventeenth day of illness. Strepto-mycin had been given after admission, but his temperatureremained raised though fluctuating. His pulse-rate had beenabout 100 but fell sharply to below 60 a few hours beforedeath. The respiratory rate rose latterly from 22 to 28.

Necropsy (20 hours after death).-A large diffuse abscessin the anterior two-thirds of the left cerebral hemispherewas found. There was creamy pus directly under the duramater, and a small area of eroded bone on the inner table of theskull. Both frontal sinuses were full of pus, but their mucouslining was not hypertrophic. There was no overt infectionof the other sinuses or of either middle ear. There was noevidence of compression of the ventricular system, and onlya very slight medullary pressure cone. The spleen was"

septic " and the adrenal glands large. No other abnormalitywas revealed. The pus showed numerous organisms on direct

273

smear. These were with difficulty cultured, and proved to bemicro-aerophilic streptococci sensitive t,o the usual antibiotics.

Comment

Turner and Reynolds (1931) have shown that it is noteasy to determine the incidence of intracranial complica-tions of frontal sinusitis. Certainly they are not undulyrare, and are much more commonly found in acute

infections than in chronic ones. Evans (1931) collected194 cases of cerebral abscess from 14,534 necropsies at,

the London Hospital in 1908-25, of which frontal-sinusinfection caused 8.

Sulphonamides and antibiotics have no doubt reducedthe danger, but two points call for mention. This caseillustrates that a sinusitis may be completely overlookedby several examiners ; the infection may have alreadyextended before effective treatment is begun. Further,there is the paradoxical hazard, exemplified in the present

case, of masking symptoms by chemotherapy until thesituation is irretrievable. Howells (1954) gives anotherinstance of this, and states that lethargy may be theonly demonstrable sign of a fronta-1-lobe abscess. Eventhis was not apparent in the present case. Tests of

memory were not applied. Papillœdema was absentthroughout, and bradycardia was terminal only, as wasthe speech defect.

I owe thanks to Dr. L. A. Little and Dr. P. C. McCrea forthe pathological reports, and to Dr. J. V. Wilson and Dr. C. W.Curtis Bain for helpful criticism and permission to publish.

REFERENCES

Evans, W, (1931) Lancet, i, 1231, 1289.Howells, G. II. (1954) Orbital Complications of Sinus Infections.

In Ellis, M. Modern Trends in Diseases of the Ear, Nose, andThroat. London ; pp. 263, 275.

Turner, A. L., Reynolds, F. E. (1931) Intracranial PyogenicDiseases. Edinburgh.

New Inventions

A PLASTIC PEDOGRAPH

THIS apparatus has been devised to provide recordsof the vertical forces beneath each part of the foot duringwalking. It consists of 640 vertical rods of transparent’Perspex,’ each 6 in. long and 3 8 in. square in cross-section. These are packed within a perspex jacket toform a block 15 in. long, 6 in. high, and 6 in. wide.Beneath the rods is a thick slab of firnx Sorbo ’ spongerubber. Each rod is scored with a horizontal line asshown in fig. 1 ; ; the essential feature is that the lineon every member of one row is 3 8 in. higher than thaton the next row. The block is inset within a woodenplatform 9 ft. long and illuminated from one side. Onlooking into the opposite face one obtains the impressionthat it is a page of graph paper made up of 3 8 in. squares.When a person walks upon the platform, planting onefoot upon the apparatus in the process, some of the rodsare momentarily depressed, and the correspondinghorizontal lines on the "

graph paper ’’

are seen todescend. Since the space between the horizontal lines isexactly the same as the thickness of’ each rod. a full-sizeimpression is produced of the overlying foot, and thepressure in any region is proportional to the extent thatthe horizontal lines are depressed. To record the rapidlychanging distribution of pressures and the profile of thefoot and ankle at any instant, 16 xmn. films are made at30 frames per second, the camera being set 12 ft. from thepedograph. Selected frames are then projected on tocardboard sheets, and those lines that have been displacedare traced in ink. The records are improved by colouringthe rectangular area between each depressed line and itsoriginal level, and by superimposing an inked outlineof the corresponding foot. Typical normal records fromtwo people, one wearing shoes, are sliown in fig. 2.The apparatus may be calibrated by measuring the

displacement of the rods under known pressures. It can

Fig. 1.

be used for a quantitative study of normal and abnormalgaits and for analysing the effects of different types offootwear.

I am indebted to Mr. A. L. Wooding for the photographicwork.

Fig. 2.

C. H. BARNETTM.A., M.B. Camb., F.R.C.S.

Anatomy Department,St. Thomas’s Hospital Medical School,

London