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CHAPTER 24
lesions as to their awareness of abdominal hunger, dread and nausea before and after
their spinal lesion. They came to the conclusion that these sensations arising from the
abdomen are mediated by the vagus and not the sympathetic supply.
In analysing my own observations on pain and other nociceptive, subjective pheno
mena arising from visceral activity, particularly pain, below the level of a spinal cord
lesion due to distension or reflex activity of bladder, urethra, uterus and colon, various
types of responses can be distinguished:
Following distension of the bladder the first is discomfort or a throbbing sensation,
which is localized by most patients with complete lesions in the lower abdominal region
(more or less distinctly in the suprapubic area), occasionally spreading to the lateral
aspect of the thighs. This local effect of bladder distension may be found in patients with
complete lesions at any level, including complete lesions of the cervical cord. It was
observed during routine bladder washouts and cystometric studies or as a result of
blockage of a urethral or suprapubic catheter. Blockage of a ureter by a stone, resulting in
violent ureteric contractions and acute hydro- or pyonephrosis, may also be accompanied
by local pain and discomfort in these patients. The local sensation may not necessarily be
painful. This was found before or during ejaculations, as a result of intrathecal injection of
prostigmine in patients with complete traumatic lesions of the mid-thoracic and lower
cervical cord, who experienced some pleasurable sensation in the penis.
The other subjective response observed following bladder distension is not closely
related to the area of the distended organ but occurs after a certain latent period as a
result of cardio-vascular effects following reflex vaso-constriction in the paralysed area
elicited by the distension of the bladder. The patient experiences a throbbing or some
times 'quivering' or shivering sensation, which extends upwards in the midline of the
body to the throat, sometimes associated with tightness in the chest, and progresses to
the back of the neck, causing a feeling of fullness or heat (or both) in the head, which
is followed by frontal headaches, the latter being especially marked behind the eyes.
These sensations are very conspicuous in lesions above T5 and cervical lesions.
The mechanism of these remote nociceptive sensory responses, some of which have
been described by previous authors (Bowley, 1890; Riddoch, 1917) has been studied in
detail by me, in co-operation with Whitteridge (1947), and is described in the chapter
on Bladder Disturbances.
Another mediator of afferent impulses arising from abnormal visceral activity in the
anaesthetic area, in complete spinal cord lesions of higher level, is the phrenic nerve. In
one of our patients—a girl of 24, with a complete lesion below T2/3—the initial sign of
an acute perforation of a duodenal ulcer was a violent pain first in the right then in the
left shoulder. When seen immediately after by the M.O. in charge of the ward, she
showed signs of a vasomotor collapse. The spasticity in both legs was greatly increased
and, in particular, the abdominal muscles were quite rigid. Having regard to the pre-
paraplegic history of a duodenal ulcer in this case, a perforation was diagnosed and
confirmed at operation carried out immediately. She made an excellent recovery and
satisfactory rehabilitation.
This case raises another important point—namely, whether, in a paraplegic of high
level who, in his pre-paraplegic life, had been suffering from pain and discomfort, as a
