CHAPTER II HEADACHE (Part 2)

to take potassium iodid, but in November the headache became worse, and a swelling appeared on the forehead over the left eye. The pain lasted a weck and then disappeared. A week ago, after being exposed to a violent draft on a sleeping-car, he had a similar attack. This time his eyes were closed by a swelling of the lids. His forehead was tender and swollen, especially on the left. Now he complains of severe pain in the forehead, with swelling and tenderness. Two years ago he had what seemed like a similar process in the metacarpal bones of the right hand, the bone becoming enlarged and very tender. His general condition is now better than six months ago. He has taken potassium iodid, but finds that it makes the pain worse. 42 DIFFERENTIAL DIAGNOSIS He has taken as much as 225 grains a day, but not regularly. His appetite is good, his bowels regular. He has had no symptoms of iodism, and feels perfectly well but for his headache. On physical examination the points mentioned in the history were verified, and nothing else was discovered. The second left metacarpal bone was much enlarged and irregular in outline. There were also enlargements at the base of the first phalanx of the left index-finger, and a slight rounded prominence over an area the size of an egg above the left eyebrow. The temperature ranged between 98° and 99.5° F. The leukocytes were 17,200 at entrance, 78 per cent. of them being poly- nuclear. The hemoglobin was 7o per cent., and the red cells showed a slight achromia. 1. What further inquiries and examinations are likely to throw light on this case? 2. What inferences can be drawn—(a) From the effect of a draft on the pain; () from the effect of potassium iodid? 3. Why is eye-strain an unlikely cause for this headache? 4. What points against frontal sinus disease? 5. What three common chronic ulcerative processes involve the skin and deeper tissues most frequently. Further inquiry into the past history revealed the fact that he had had a chancre at twenty-eight, followed by a rash and a sore throat, with white patches in his mouth. A Wassermann test (not known in 1904) would have helped toward diagnosis. Probably the “effect” of the draft was coincidence, at most, an exciting or favoring cause. Many headaches miscalled “rheumatic” are really syphilitic. ‘There is no reason to believe that “rheumatism” ever causes headache except in acute infectious cases. The failure of potassium iodid is discussed below. Eye-strain does not often begin at thirty-six in a man who uses his eyes for such work as a longshoreman’s. The long duration of the headache is against disease of the frontal sinus. Physical examination, however, must determine the point. Three common causes for chronic ulcerative processes (excluding varicose ulcer) are: Syphilis, tuberculosis, malignant disease. {The man was scen in consultation by Drs. Bowen, Shattuck, Fitz, Gannett, A. T. Cabot, and J. P. Clark. All concurred in the diagnosis of syphilitic periostitis.] Outcome.—The day after entrance two distinct craters about the size of a half-dollar were felt on the forehead. The headache was given some immediate relief by 10 grains of phenacetin with 2 of caffein, but