Case 577. (Binswanger, July, 1915.)
A Russian from the Ukraine was received at the nerve hospital, Jena, December 12, 1914. Through an interpreter it was established that he was a peasant, had been under shell fire in a skirmish at the beginning of November, and had been hurled (so he said) 1¼ meters into the air without loss of consciousness. There was a wound of the right shoulder and also, he thought, of the legs, from the air pressure. Becoming a German prisoner, he had been treated in various hospitals.
He was a strong man of medium height, with a healthy complexion. There were two healed wounds of the right shoulder, and near the twelfth spinous process a third similar scar. There were a number of ulcers and furuncles over the os sacrum.
Neurologically, the knee-jerks and Achilles jerks could not be obtained, and the plantar reflex, extinct on the left, was weak on the right. Sensitiveness to pain on both sides was lost from the knee downwards but there was hyperalgesia in the thigh. Inaccurate statements in response to tactile tests were made, apparently on account of lack of understanding. In lying down, there was a slight restriction in the movements of the legs, and active movements of the joints of the foot on the right side were impossible. Gait was ataxic-paretic, more markedly so right than left. He could walk only with two canes, and during walking the musculature of the thigh fell into a spastic tension. The tongue deviated to the left. There were severe rheumatic pains in the thighs.
It appears that some weeks before, this Russian soldier had suffered from severe rheumatic pains in both sides and was at that time absolutely unable to walk or stand. At that time, however, there was no question of a crural paraplegia of organic origin, since the man could move his legs well enough when in dorsal decubitus. There were no signs of paralysis of the rectum or bladder at that time.
Treatment at Jena consisted in regular walking exercises with support at the shoulders. The lower legs and feet remained weak and paretic. The decubital ulcers disappeared.
About the middle of December rectal incontinence began, the stool being discharged without the patient’s noticing it while being led to the bath. Later there was incontinence of feces in bed. Pains in the legs were constantly complained of. Nevertheless improvement in walking was maintained. The toes were dragged at every step and the knee-joints were thrown outward in walking. The musculature of the lower legs was weak. Knee-jerks could not be elicited more than before. He constantly complained of pains in the knees and right hip. The rectal disorder did not again occur during January.
Toward the close of January, the patient’s right lower leg and left foot would occasionally feel asleep; both legs felt cold and itched. In a general way, however, the pains had become less marked than they were at first. It seemed that he had no sensations at stool, and consequently had to resort to the closet at a definite time. Moreover, urine was discharged irregularly and involuntarily when he coughed. It appears that a few days after receiving his wounds in battle, there had been pains on micturition as well as blood in the urine, and it appears that he had been catheterized. It is probable that he had suffered from distention, as he described his abdomen, thighs and sex organs as swollen.
In February he began to be able to move alone with two canes through the ward, but he moved his legs from the knee downward very little, and dragged them after the rest of the body. Upon galvanic examination, the peroneal and tibial nerve trunks were found normally excitable. At this time the sensibility situation had changed somewhat, since complete analgesia was present only in the foot, and hypalgesia had developed upon the anterior surfaces of the lower legs. Pin-pricks were described as touches. The posterior surface of the left lower leg was normally sensitive. There was an oblong stripe about 3 cm. long, beginning in the popliteal space and stretching downward on the left side. The right lower leg was entirely insensitive. The posterior surfaces of both thighs as far as the gluteal folds were completely insensible to pain. The Wassermann reaction of the blood was negative. In this condition the patient was transferred to a prison camp hospital.
Re bloody urine, see [Section B], [Case 202]. Re rectal incontinence, it might be inquired whether this was possibly functional. Roussy and Lhermitte devote a chapter to visceral disorders. They do not list rectal incontinence amongst the disorders noted in this war, nor have any cases of hysterical anorexia or disorders of sensation in the intestinal tract been seen during the war despite the occurrence of these latter disorders in the civilian group. The main digestive disorder that the war cases show is vomiting (see Cases [495] and [500]).