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CHAPTER 28
After lumbar puncture (carried out in lateral position), the Queckenstedt test is
carried out to ascertain the presence or absence of a subarachnoid block, as this has some
bearing on the dosage. If there is no or only a partial block, 0-3 mg prostigmin is
injected after first withdrawing 1-2 cc C.S.F. into the syringe to mix with the prostigmin.
In high thoracic and cervical injuries, it is safer to start with 0-25 mg because of the rise
in blood pressure in these high lesions during ejaculations, as a result of powerful contrac
tions of the seminal vesicles and other ejaculatory organs, which may set up the same
autonomic hyperreflexia as described previously by the forceful contraction of bladder
and other internal organs (Guttmann & Whitteridge, 1947; Guttmann, 1954, 1969). If
there was a complete block 0-3 to 0-5 mg was injected. In some cases where the initial
test was negative and especially if the neurological examination indicated little or no
effect on muscle tone and reflexes, the test was repeated, using larger doses of prostigmin
provided there had been no untoward side effects during the original injection. Up to
1-5 mg prostigmine has been given in one exceptional case. After the injection, the needle
is withdrawn, a dressing applied and the patient turned on his back with a pillow under
his head. A suitable glass container with a screw cap is given to the patient with instructions
to observe any erections and obtain any semen ejaculated. The examination of reflexes
and muscle tone in the lower limbs is carried out repeatedly after the injection and
recorded every J-i hr as this gives a good indication of the effect of prostigmin in each
individual case. In distal lesions with areflexia, this information is, of course, not obtain
able. It is important to measure pulse and blood pressure regularly during the test,
especially in high thoracic and cervical lesions because of the possibility of exaggerated
autonomic hyperreflexia due to seminal contraction during ejaculation. Moreover, in
high thoracic and in particular cervical lesions a cystometrogram some time prior to the
prostigmine test may give a clue about the threshold of irritability of the autonomic
system.
The depressant effect on reflex function of the skeletal muscles (Table 25) started
as a rule between 15 and 20 min after intrathecal injection, but there was usually a con
siderable delay—i to 3 hr—before the onset of erections and ejaculations, which usually
occurred at the height of the reflex depression. Once an erection had started, it continued
in most cases for a considerable time, either intermittently or continuously, and some
times it persisted for hours even after emissions occurred. In 2 low thoracic lesions (Tio
and Ti2), with flaccid paralysis of the legs and one conus lesion, ejaculations occurred
without erections.
The number of ejaculations varied considerably from patient to patient and also in
different tests in the same patient. Only the minority of patients produced a single
emission and as many as 7 or more were observed in some patients within a period of 2 hr.
Table 26 shows number and percentage of positive ejaculations results in our 134
patients, divided into spastic and flaccid complete and incomplete lesions, and as can be
seen in Table 27 the majority of negative results occurred both in spastic and flaccid
lesions at levels between Tio and 14.
The volume of ejaculated seminal fluid varied considerably from patient to patient
and also in different tests on the same patient. In those cases who had several ejaculations,
the volume of each emission became progressively less. However, sometimes the second
