Document nkr1y7EDN3BrLGZjap6Oxzzg6

December 22, 1930 Mr. Josiah Stryker, Lindenury, Pepue and Faulks, Prudential Building, 763 Broad Street, Newark, I:. J. Dear Mr* Stryker: In accordance with my telephone conversa tion of last Wednesday, I am sending you herewith, a brief re port of the examination of Mr. made with Dr. Deling at his home on Tuesday, December 16. The examination was not a3 complete as I should have liked to make it. However, it was entirely satis factory in that it was possible to obtain information suffici ent to guide your activities in his case. By the time we had spent some two or three hours obtaining such information as might have been obtained in the case of a normal individual in a third of that time, Mr. Evans was in such a state that one was justified in fearing.that he might be greatly upset by a continuation of the examination. Under these conditions I felt it advisable to take the information which we had without going further. By this time I dare say you have had some conversation with Dr. Beling, and I am certain that you may well be guided by what Dr. Beling has said to you. It was a pleasure to me to be associated with him in the examination of this man, and I learned very quickly to have a very great res pect for his human understanding and hi3 clinical judgment. Report Mr. Vn^ls a young man apparently of strong physique, without any obvious evidences of general physical disability. However, one immediately notices a very great nervous irrita bility seen in the almost continuous movement of the hands, the fingers, and the feet. He seems to have a very great diffi culty in restraining himself, and seems on the point of a very strong emotional outburst. His general appearance is that of a man tremendously excited on the slightest provocation, his pupils dilate widely, his muscular movements increase in speed and amplitude,., and his speech becomes that of an individual very much excited. One gains the impression that he is putting forth a continuous effort to keep do-vm this emotional excit ability, but that he does not succeed In doing so. It Is necessary to continually reassure him and soothe him In or der to get any response to questioning and In order to make any physical observations. Eventually however, he becomes quiet to such an extent that it is possible to make certain observations for a limited period of time. The eyes are equal, have a tendency to dilltatlon, and respond to light. The movements of the eyes are some what jerky, but there is no paralysis of the extrinsic or intrinsic muscles. The orbital fissure is widened, and there is a definite lid lag with movements of the eye. The nose shows'a septum deflected to the left, with a small nasal spur. The mucous membrane of the nose is somewhat dry and bright red, with a considerable amount of mucopurulent secre tion. The throat is bright red: the tonsils are large, ir regular and congested, the left one is somewhat scarred, and both are involved with either a chronic or subacute inflamma tion. The teeth show several Inflamed edges, and there is a considerable amount of what appears to be bridge.work in the front upper jaw. The examination of his teeth is somewhat unsatisfactory on account of the condition of the patient, but one is certain that the teeth in general are in poor con dition. One suspects that there are a number of devitalized teeth. The face is definitely a-symmetrieal due to weakness of the musculature of the right side. The skin is smooth over the right forehead, strongly creased over the left. There is a strong tendency for the face to be thrown into grimaces, and oh the slightest provocation these become intense. The musculature of the neck and of the back Is jTLaeeld to palpation, &3tT there Is a considerable amount of ^ .X^fptrease In tone more striking on the left than on the right. The left arm shows a definite decrease of tone of the muscula ture, ^his being seen in the deltoid, triceps and biceps, but more particularly in the extensor of the forearm. In the case of the left arm there is a continual going and coming of tonus In theright there is very little tonus at any time. Despite the subject's right-handedness the right arm is smaller than the left, especially the fore-arm, and the grip is very much reduced* The reflexes are decreased on the right, and in creased on the left, especially with the periodic heighten ing of tone. The strength of the right is very greatly di minished. This same situation prevails but to a much lesser degree in the case of the legs. Reflexeipr are present and active In both, but comparatively less in the case of the right. The strength of the right Is also diminished, this resulting In the patient's moving to the right when he at tempts to walk and Suddenly accomodating himself and chahging *6 0On 458 his course in order to arrive at a given point. The abdominal reflexes are absent* The cremasteric are present on both sides but more strikingly on the left. A very casual examination of the chest shows no gross abnormalities. No attempt was made to examine the abdomen and its contents. No urinalysis was made, no blood examination was made. On the basis of the above observations It is entirely clear that the patient has destructive lesions involving the corpus striatum and lenticular nuclei. Further and more care ful examinations may possibly show central nervous system lesions at other points. In any case the lesions are fairly diffuse in this area. It is probably true also that tho corpus callosum is-in some degree involved. A prolonged study v/ould be required to determine the exact extent of the lesions, and also to determine whether or not they are progressive in char acter. From-the patient's history tip to the present, I would be led to believe that they are progressive. In assigning a cause for this condition one i3 present ed with several possibilities. The entire picture may be the result of Infection. The existence at present of foci of in fection in the nose and throat suggests this possibility, but by no means proves it. One does not know how long the present condition of the nose and throat has been in existence. It may have antidated his Illness, or it may have been a conse quence. The possibility of certain poisons being effective in producing the condition is present. It is possible, but not likely in my opinion, that the condition might have been produced as result of lead poisoning. This is not however, the type of thing which is usually seen following lead encepha lopathy, There is a fairly frequent association of the condi tion seen in this man with carbon monoxide poisoning. One the sequelae of carbon monoxide poisoning which is seen clind^- cally and at autopsy, is a diglhftlve lesion affopting he basi lar nuclei of the brain, which are most concerned in this case. Whether or not Mr. had carbon monoxide poisoning of a severe type at any time, or whether he.was exposed to suffici ent concentrations of carbon monoxide over a long period of time* I do not know. It is one thing however, which I would consider in this case, and one which I would investigate. In any case there is no explanation of the existence of definite lesions of the brain. The origin of these lesions it is Impossible to state on the basis of the present available information. HE- 0017459 ' . r-.,,Discussion , ; It Is my opinion that presentation of the case in court would be followed by a verdict In Mr. WRRKK0 favor even If only the most casual evidence could be presented on- the relation of his condition to his occupation. In fact his condition will speak for itself in court, and without any attempt on his part he will demonstrate to the court end'to,the Jury a most pitiable condition of illness, which. In my opinion. Is more likely to progress than to Improve. , I should regard his present situation as a perma nent and practically complete disability, and I should be inclined to settle the question of compensation on this basis with due regard for what may be regarded in his state as a proper compensation for such permanent disability. Very truly yours, 7 ;Vj P -yv ; ; RAK:EJ Hn /;. - ') ' ,' - ... .' - -.V-';; :;<y. . " ' v-; 4 -is7;-': He 0017460