F • CLINICAL ASPECTS OF SPINAL CORD INJURIES
451
at the height of its depressant effect to determine the degree of flexion contracture
developed as a result of intractable spasticity. In the course of this study, I found that a
dosage of 0-25-0-3 mg was sufficient to elicit erections and ejaculations in traumatic
paraplegics and tetraplegics, who hitherto were thought to be completely impotent and
infertile. This test has been employed systematically ever since to assess the potentialities
of erections and fertility in the spinal man, and the results on 34 and 90 patients respec
tively have been previously published (Guttmann, 1953, 1960). Recently, results on 134
patients at levels ranging from €5 to 84 were published, in whom over 180 tests were
carried out (Guttmann & Walsh, 1970). One hundred and two patients had complete
and 32 incomplete lesions. One hundred and four showed spasticity of various degrees
and 30 were flaccid. The average age of the patient was about 28, the youngest being 18,
the oldest 47. All patients were in satisfactory general condition at the time of the test
and free from infected sores, but the great majority had some infection of the urinary
tract.
Indications
The initial test was carried out to determine spermatic abnormalities, as it is well known
that reduction of sperm concentration and reduced motility play an important role in
male infertility. Both married and unmarried paraplegics in the great majority are natur
ally greatly interested in their chances of reproductive activity. Repeated tests were
carried out:
1
to check the motility and concentration of sperms and their cytology,
2
to repeat the test with a higher dosage, when the first test revealed a negative result.
In a few of the patients, the dosage had to be increased to 0-5, 0-7 and even i mg.
3
to check motility concentration and differential cytology following hormone treatment,
4
for the purpose of artificial insemination.
Methods and dosage
Because of certain undesirable side effects, especially vomiting, the patient has to refrain
from solid food for some hours before the test and for 3 hr before injection the
patient should not take anything by mouth. Before the test, a full neurological examina
tion of the lower limbs is carried out and full assessment of reflexes and muscle tone has
to be made. This is of special importance in more distal cord lesions, as there are often
mixed forms of spasticity and hypo- or areflexia in certain parts of the lower limbs. This is
particularly apparent in transverse lesions below TIO/II, where the injury may also affect
the conus and epiconus, or in higher transverse lesions which are combined with longi
tudinal damage.
Procedure.
The patient is prepared in the usual way for a lumbar puncture and the test
is carried out in a separate room. The drug used was neostigmin methyl sulphate
(Prostigmin—Roche), made up in i cc ampules each containing 0-5 mg, and a clearly
marked 2 cc syringe is essential for the accurate amount of prostigmin injected.
