The Patient Was…

The patient was a 19-year-old male who was being mustered out of the U. S. Air Force on charges related to refusal to perform his assigned duties and malingering.

He had entered active duty in the Air Force not long before, and after basic military training was assigned to a military police unit at an Air Force base overseas. His specific assignment was to patrol the fenced perimeter of the base at night, accompanied by a canine partner.

He neither expressed nor displayed disappointment or resentment at the nature of the assignment, but shortly after he began the duty he complained that after walking a bit his left leg became weak and he was unable to maintain his pace. Initially, he was told to, in effect, “suck it up.” But he continued to complain and soon said that he was unable to walk the entire perimeter to which he was assigned.

He was sent for a medical examination on the base and was declared fit for duty. No cause for his symptoms was discovered. But he maintained his inability to do his job. He was then sent to a larger regional military center for another medical examination, with similar results: No medical cause was found to explain his symptoms.

The patient was sent back to the U. S. to be examined at one of the largest Air Force bases in the country, where sick and wounded military personnel were routinely evaluated and treated on evacuation from overseas locations. Once again, medical examination failed to reveal a cause for his persistent complaint of left leg weakness on walking his post.

Since he had entered active duty in the geographical area where I was assigned as a U. S. Air Force physician, procedure at the time apparently was that his formal separation be at the same location. Since I had asked, and received from my commanding officer, permission to do medical consultations (although I had had only three months of Medical Residency training before being called to active duty), I was assigned to do the final medical evaluation of the young airman before he was dishonorably discharged.

My initial impressions, as I talked with the patient, were that he was sincere, rather naïve, and guileless. He told a simple and straightforward story, didn’t elaborate and try to make things sound bad, and seemed genuinely to want to stay in the service.

My physical examination was methodical and thorough. If this young man were to be labelled a malingerer, I wanted to be sure to eliminate any possibility that he might be telling the truth about the weakness in his leg. I started at his head and worked my way down, ensuring that I didn’t overlook any abnormality that might be relevant to his complaint. I reserved neurological examination for last, because if there were a medical cause for his symptoms it would likely be in that sphere and I wanted to rule out everything else.

As expected, examination from head to foot was normal. I then turned to a detailed examination of his neuromuscular system, the nerves and muscles that controlled body movement and motion. Strength in his arms and legs seemed normal and, most importantly, symmetrical. Since he insisted his leg weakness was unilateral, confined to one side, symmetry of findings on the right and left sides was significant. Sensory testing, the ability to perceive things like light touch and pin pricks and vibrations, was normal and similar on both sides of his body.

The first and only discordant note was when I tested his so-called deep tendon reflexes. Most people are probably familiar with a physician tapping the area just below their knee a with a rubber hammer and watching the knee jerk. One can test similar tendon reflexes in other parts of the body, but these are done less frequently unless specific symptoms call attention to those areas. An ankle reflex is produced by tapping the Achilles tendon, the one above the back of the ankle that connects the calf muscles to the heel bone.

The reflex response to tapping a tendon seems simple, but it actually represents a complex neurological phenomenon, involving different nerves carrying signals up and down the spinal cord, nerve connections within the spinal cord itself, and nerves leaving the spinal cord and triggering movements of body parts.

All of the patient’s deep tendon reflexes seemed to be normal except for his left ankle reflex. This was striking because it correlated with his symptoms. The ankle jerk reflex depends on a nerve that emerges from the spinal cord at a specific spot called the S1 spinal segment, near the bottom of the spinal column. If this nerve were somehow damaged, it could have something to do with his symptoms.

The abnormality I found was not very dramatic; the left ankle jerk seemed only slightly less vigorous than the right one, and determining reflex activity is pretty subjective anyeway. I wondered if this seemingly naïve young man could somehow know that a diminished ankle reflex might justify his complaint, and could he consciously make that reflex less active. It was doubtful but it had to be tested.

There is a technique used to distract a patient from trying to control their reflex responses; this maneuver can also enhance underactive reflexes. It involves having a patient activate other muscle groups distant from the area being tested. When I did this with the patient, the discrepancy in right and left ankle reflexes was still evident.

My examination of this young airman was supposed to be a prelude to his discharge from the military. But now I had found something, perhaps subtle but to me undeniable, that would make that decision inappropriate and premature. I felt that further investigation and e valuation were in order.

My hospital commander was surprised and somewhat skeptical. He knew the history of the case, that several medical examinations had found nothing wrong, and that my conclusions would upset a process well in place. But, unless I changed my medical opinion, the discharge proceedings would have to wait.

The patient was transferred to one of the major air bases in the country, the headquarters of our command. They were equipped to do sophisticated medical testing and procedures. There wasn’t an easy and established means to get follow-up information on military patients at the time, but I managed to find out what had happened to the patient.

He had undergone specialized testing and was found to have a tumor of his spinal cord, fortunately benign. I never found out further information, but the experience remains one of the most satisfying of my professional life.