Cancer of the Breast
It is submitted that the word " primary " in connexion with pain is inapplicable; and an experienced rhinologist might be allowed to examine pre-operatively the next case which Mr. Rowbotham has marked down for a procedure which makes an interesting neuroanatomical experiment.
Abstract
SIR,-I was profoundly impressed by Mr. G. F. Rowbotham's paper on the treatment of pain in the face by intramedullary tractotomy in your issue of November 26 (p. 1073). What impressed me was not that the pain had been relieved (it should be, if our anatomy and physiology books are reliable) but that he was able by his analysis of the patient's description of certain subjective sensations to make a diagnosis of "primary" pain, apparently without having searched for those pathological conditions in the area subserved by the sensory branches of the trigcminal nerve which are commonly found to be productive of any and every type of pain in the face. I hope that Mr. Rowbotham will assure us that he carried out an exhaustive examination of the nasal sinuses and the teeth -before he made his very skilled inroad into the central nervous system. If he is in the habit of taking the quality of the pain (as described by the patient) for a guide as to its "primary " nature, I would refer him to the very interesting observations upon somatic pain recently recorded by Sir Thomas Lewis (British Medical Journal, 1938, 1, 321), which indicate how misleading a patient's description of pain may be. Sluder (Trans. Amer. laryng. Ass., 1912, 35, 42) painted the interior of the sphenoidal sinus with 20 per cent. cocaine and found that the whole of the face on the same side became anaesthetized, an observation which emphasizes the intimate anatomical relation between this sinus and the Gasserian ganglion. It helps to explain how absorption of toxins under pressure from a blocked sphenoidal sinus can inflame the ganglion of the trigeminal and lead to pain anywhere in its distribution. Siice sphenoidal sinus work has become a commonplace of rhinological practice, it is so usual to find that facial pain can be relieved by adequate sinus ventilation that one had forgotten that there were still medical men who believed in essential neuralgia. I submit that the word " primary " in connexion with pain is inapplicable; and I would suggest that an experienced rhinologist might be allowed to examine pre-operatively the next case which Mr. Rowbotham has marked down for a procedure which, as he so rightly remarks, " makes an interesting neuroanatomical experiment."-I am, etc.,