June 15, 2001

re: Santora v. Randolph Products Co. - C.P. 97-027781

Counsel:

This is a denied claim that was tried over an extended period of time and completed within the last month. Petitioner was employed by respondent for over 12 years. For all but a few days of this period he worked as a chemical batch-maker, a position similar to that which he had held with prior employers since October 1979. Petitioner testified that while in respondent's employ he would mix the necessary ingredients to make paint, including various solvents, in a 200 gallon open vat. The ingredients for each batch were either placed in the vat through the use of hoses similar to those found in use at a gas station, or were, in the alternative, poured by the petitioner from a container or drum into the vat. Among the chemicals or other substances that he regularly worked with while in the respondent's employ were methyl ethyl ketone, toluene, acetone, glycol ethylcellulose and various alcohols. After the necessary ingredients for a particular paint had been placed in a vat, the petitioner would mix them with a mechanical stirrer until the particular mixture was ready for unloading from the vat; the latter operation was handled by other employees. Petitioner testified that neither he nor any of his co-employees engaged in respondent's paint making operation wore gloves, masks or other protective equipment at work. I must note here that Mr. Duff, a former production manager for respondent, testified that respirators were provided for employee use but the latter were not required to wear them. He stated that the petitioner only wore such equipment when he had to mix a particularly "rough" paint, which was about twice a year.

Petitioner testified that he started experiencing loss of memory and mood swings or irritability in mid 1996. After visiting several physicians or other medical providers the petitioner started treating with Dr. Greenberg in December 1997. Dr. Greenberg, a neurologist with a specialty in behavioral neurology, continues to treat petitioner and prescribes medication for the latter. Petitioner stated that without such medication he "would just, for no reason, go berserk". Asked for an explanation, petitioner stated that he would get "very violent...I would just break things up for no reason". He further testified that he would pick up a desk and throw it - "I just couldn't stop, then I would be exhausted when I got done, I remember that." Petitioner also stated that co-incident with his mood swings he had stopped running and had gained 30-40 pounds. As for his memory loss, petitioner testified that "I was forgetting a lot...I would talk with to my friend and forget that he had a wife and kids...I would go to lunch and come back and forget what I was doing (before lunch)...If I would come to your house everyday, I'll forget where you live tomorrow...I'll be talking to someone and I'll forget who they are...I don't even know this person's name or where they're from." T-3/6/00, pp. 24-28. Petitioner stated that he only drove short distances because he gets lost/confused, and that the problem is intensified if he forgets to take his medication (Zoloft).

Petitioner presented two (2) lay witnesses in support of his testimony regarding working

conditions at respondent's plant and the recent (circa 1996) change in petitioner's behavior. His wife testified as to the latter. She stated that she and her husband had two (2) children, that she had worked in a clerical capacity for the same firm for 28 years and that until 1995-1996 they had a good relationship. At that point "John began to change" and she described both his angry outbursts and examples of his forgetfulness. She testified that he punched holes in the walls of their home and slammed a door so hard that it put a hole in an adjoining wall. Ultimately, over a period of time, she had the petitioner bring her labels or the names of the products that he worked with. Petitioner's wife also testified as to her husband's mental depression and the loss of emotion that has occurred in his relationship with both herself and his children.

Mr. Duff, a former employee of respondent who had been employed as production manager during 5 years (1989-1994) of petitioner's employment, testified that during that period the respondent mixed and made several specialty paints for the military forces and confirmed the use of those ingredients that the petitioner had previously identified. He noted that the department in which the petitioner had worked during 1989-1994 used vats of various size, from 10 to 200 gallons, depending on the order in question. In his view the ventilation provided was inadequate due to the amount of "solvents and stuff like that...especially on a hot humid day, it was bad...If there was no wind blowing, it would just hang." T-10/26/00, p. 9. From his testimony it appears that aside from opening the double doors at either end of the mixing area the only exhaust aid came from a fan "in the back"; Mr. Duff testified that "We tried to put in extra exhaust fans but they wouldn't let us" due to environmental limitations on materials/fumes being exhausted from a facility.

Mr. Duff also stated that the petitioner's mixing effort was heavily dedicated to the use of solvents (i. e. ketones, salines and toluenes), and that the solvents would constitute from 70 to 80 % of the materials used by the petitioner on a daily basis. In Mr. Duff's view the batch makers, like the petitioner, worked in the presence of chemicals throughout their 8 hour daily shifts.

Mr. Duff also testified that the respondent, during the period 1989-1994, was permitted to utilize certain substances, i.e. xylene and toluene, for government contracts notwithstanding the fact that such substances had been re-called due to a link with carcinogens. Mr. John Randolph, who has served as president of the respondent for roughly 35 years also testified. He stated that his firm had operated in their current premises for over 60 years and had successfully met the OSHA requirements at the time (during Mr. Duff's tenure) that such agency had visited his plant. He described the "mixing room" as being roughly 50' x 40' in size with a 15' ceiling. It has four (4) doors, three (3) of which lead to other sections of the building, i. e. warehouse, offices, etc., and one (1) of which leads to the outside. All were usually kept open during working hours with the exception of the last mentioned door which was shut in cold or bad weather. The number of exhaust fans was never determined, though it is clear that there was at least one. Mr. Randolph also noted that there was a row of windows running "about 30 feet down the side of one wall" of the mixing room. In this witness' view the ingredients used in making paint for military purposes are no more toxic than the ingredients used in making commercial paints.

Respondent presented the testimony of three (3) lay witnesses by way of rebuttal to petitioner's allegation(s) that exposure to chemicals while in respondent's employ had affected him both in an emotional sense and as regards his memory. The first of these witnesses was Ms. Beverly Harrison, an employee of respondent's carrier. Ms. Harrison performed surveillance on petitioner on ten (10) separate days during the period August through early December 2001. On all but two (2) of these occasions she observed the petitioner's vehicle parked at his residence and her only sighting of the petitioner was when he walked his two (2) children to school and then returned to his home (on foot).

The first of the exceptions occurred in November when, after walking his children to school, the petitioner returned to his home, got into his car and drove his vehicle 3.6 miles when he pulled over for no apparent reason. Ms. Harrison, who had been following him, was required to pass the petitioner and thereafter lost sight of his vehicle after the petitioner entered the Garden State Parkway. When Ms. Harrison returned to the petitioner's home, his vehicle was parked in his driveway. On another day Ms. Harrison observed the petitioner drive his vehicle to a local drug store and return home.

Respondent's other lay witnesses were two (2) of the petitioner's three (3) sisters. The

testimony of these witnesses, introduced to show the alleged violent nature of the petitioner prior to his being employed by respondent, is diametrically opposed, one to the other. The testimony of both was offered through a submission of their respective deposition transcripts. These depositions were taken in November and December 2000 as part of discovery in a third party action that petitioner and his wife have brought against several of his former employers, including the respondent.

Pauline Ruger, who is seven (7) years younger than the petitioner, recalls a childhood wherein she and her sister Anna were on more than one occasion beaten severely by the petitioner during a period when he would have been between 15 and 25 years of age. Based on information received from her since deceased mother, she believes that the petitioner was badly beaten on more than one occasion by their father (who left the household while the children were still young), and that her brother spent various periods in a detention center, the last such visit for a period of nine (9) months. Pauline confesses to being rather outspoken in her views and acknowledges that her brother has not threatened or confronted her in any meaningful way in roughly 30 years and that she has not (with one brief exception) seen or spoken with him in 12 years. Over the last 20 years there have been various periods that Pauline has not spoken to her sisters as well; she has apparently not talked to her oldest sister (Alice) in roughly 25 years and did not talk to her sister Anna for a period of 7 years. Her relationship with Anna remains on the fragile side apparently due to Pauline's willingness to give advice or direction when it has not been solicited.

Anna Greene, in her deposition, denies the occurrence of many of the events that Pauline Ruger recites. Anna is three (3) years older than Pauline and four (4) years younger than the petitioner. It is to be noted that when the event or situation being described involves primarily another member of the family besides petitioner, the family history presented by these depositions is fairly clear. However, where the petitioner is the central character Anna and Pauline offer opposite views. Regardless of past history however, there is nothing in the 200 pages of deposition transcript which supports a finding that the petitioner was physically violent or abusive in the presence of either sister in the last twenty (20) years, or that he has exhibited an alleged loss of memory to either one during the same period.

Carole McCue/Santora, the petitioner's wife testified by way of rebuttal to certain allegations of physical abuse or violent behavior included in Pauline Ruger's deposition. Mrs. Santora directly denied Ms. Ruger's statements insofar as they relate to herself and offers the picture of the petitioner as a caring father of two (2) young children. She also presented illustrations of her husband's current memory lapses and his inability to follow driving directions.

Three (3) medical experts testified in this matter: Dr. John Greenberg, M.D., who has treated the petitioner on what appears to be a quarterly basis since mid 1997, and Dr. Susan Daum, M.D., testified on behalf of the petitioner. Dr. Nancy Fiedler, Ph.D., testified for the respondent. In addition, among the numerous written exhibits introduced into evidence was an evaluational report authored by Dr. David Mahalick, Ph.D. (March 1997), as well as petitioner's personnel file (for his employment with respondent), and a copy of petitioner's toxic exposure and base line health questionnaire (circa 1995).

Dr. Greenberg presents rather impressive credentials in the field of neurology and has specialized in behavioral neurology for roughly 30 years. In addition to his private practice he is a faculty member at the New Jersey College of Medicine and is the medical director of the Neurobehavioral Institute of New Jersey which evaluates and treats brain damaged patients. Dr. Greenberg accepts petitioner's claim(s) that (i) the latter currently suffers from mood swings and occasional lapses into violent conduct as well as memory loss, and (ii) that such traits are causally related to his extended exposure to various chemical substances and/or fumes while employed by respondent. Dr. Greenberg also accepts the results of the testing administered by Dr. Mahalick to the petitioner approximately four (4) months before Dr. Greenberg initially saw/treated the petitioner. Dr. Mahalick, a neuropsychologist who heads the Dept. of Neuropsychology at UMDNJ, Newark, N.J., concluded as a result of such testing (administered during early 1997) that the petitioner had experienced both significant memory and intellectual impairment and that such cognitive impairments and related emotional difficulties could be associated with toxic brain injury from his workplace exposure to various toxic solvents and other substances. Dr. Mahalick also found the petitioner medically disabled and urged that he not be employed in the operation of machinery which could result in harm to himself or others.

Following the petitioner's initial testing, a program of treatment was commenced at/through the Neurobehavioral Institute which included individual psychotherapy, which dealt with the petitioner's relationship with others and his depression, and cognitive therapy which offers alternative measures to compensate for memory loss and other areas of intellectual impairment.

Dr. Greenberg also examined the petitioner (July 1997)and diagnosed three (3) different types of depression, relating principally to mood, personality disorder and cognitive impairments, respectively. His diagnosis was toxic encephalopathy, which he defined as meaning a disorder of the brain with cognitive impairment, personality changes and depression. Dr. Greenberg also offered a second diagnosis of peripheral nerve injury related to toxic solvent exposure which he found to be confirmed by the results of an EMG.

The latter procedure, which involved reviewing/testing nerves in the petitioner's arms and legs, disclosed mild sensory neuropathy in the petitioner's legs. Dr. Greenberg identified the medication currently prescribed to petitioner as (i) Zoloft 50 mg. twice a day, (ii) Stelazine 2 mg. at bedtime. He is of the opinion that the petitioner's disabilities, now more than three (3) years in existence, are permanent in nature and that they are such that the petitioner is totally disabled.

Dr. Greenberg was questioned on the issue as to whether he believed the petitioner was malingering or otherwise acting in a less than forthright manner when he responded to or otherwise participated the testing that Dr. Greenberg and/or Dr. Mahalik had administered. Dr. Greenberg answered in the negative and based such response on the fact that:

from a behavioral neurological point of view we look for inconsistencies in presentation of the clinical exam, clinical features during a specific evaluation and from evaluation to evaluation three months apart he never displayed to me anything that I would consider to be consistent with malingering.

T-12/4/00, p. 23.

 

Dr. Greenberg also notes that petitioner had been successively examined, evaluated and tested by Pavonia, the Neurobehavorial Institute and himself over a course of more than three (3) years and that each of the prior medical providers, as well as himself, found the petitioner's complaints to be legitimate and sincere. In discussing the fact that the petitioner did not perform as well on certain diagnostic tests given in 2000 as he had on similar testing administered in 1997, Dr. Greenberg stated that he expected the petitioner to continue to decline in cognitive ability as the years went by.

Dr. Susan Daum, M.D., testified as petitioner's medical expert in the area of Occupational Medicine. Dr. Daum has been associated with the Mt. Sinai Medical Center (N.Y.C.) for many years and in addition to her private practice she serves as a faculty member at both Mt. Sinai and the Albert Einstein College of Medicine. Her professional background includes the fact that she has specialized in Occupational Medicine for nearly 30 years and she has had rather extensive experience and given lectures on the subject of brain function damage resulting from exposure to toxic agents. She has worked for over 25 years with the well-known Selakoff Clinic at Mr. Sinai.

By way of explaining the toxic effect of exposure to solvents on the human brain, Dr. Daum noted that solvents are used for their ability to dissolve grease. Because the human brain is composed of fats, solvents have the ability to dissolve important parts of the brain through the debilitation of peripheral nerves.

Her report, diagnosis and findings closely follow the testimony offered by Dr. Greenberg. Additional findings offered by this witness included (i) the fact that the MRI of petitioner's brain (3/97) showed more atrophy than would have been expected in a person of his age, (ii) the petitioner experienced feelings of depression, including crying, on days that he was mixing toluene while in respondent's employ, (iii) both he and other employees experienced/demonstrated feelings of hostility on days that they were working with MEK and other chemicals, and (iv) it was presented as a well known fact that toxic encephalopathy with abnormalities of cognition and subclinical abnormalities in nerve conduction will occur to people who are employed in the preparation of paints. Further, Dr. Daum stated that all solvents are deemed capable of causing these syndromes and that solvents can act additively or synergistically to produce brain damage. Dr. Daum also drew attention to a short article from The Lancet (April 1997, p. 1239 et. seq.) which focused on the connection between solvents and neurotoxicity. Exhibit P-13. In Dr. Daum's view, the lengthy exposure of petitioner to a variety of solvents and chemicals, including MEK and acetone, is totally consistent with his getting toxic encephalopathy, and his complaints throughout such exposure, such as headaches, psychiatric symptoms, abnormal behavior, memory failure, as well as lack of motivation and the inability to initiate or continue a task are consistent with that diagnosis.

When presented with the argument that the petitioner had not cooperated to the best of his ability in the calendar year 2000 testing, Dr. Daum noted that (i) no one had questioned the lack of petitioner's full cooperation in the earlier (1997) testing, and that petitioner's failure to cooperate fully during the recent (2000) testing doesn't mean that he got below normal in the areas tested. Dr. Daum noted that the petitioner had been followed on a quarterly basis by Dr. Greenberg and the latter was convinced that petitioner did indeed have toxic encephalopathy. In the course of endorsing Dr. Greenberg's diagnosis, Dr. Daum noted specific reactions that the petitioner presented with respect to certain solvents to which he had been exposed, e.g. fits of crying and depression after exposure to toulene, which she indicated were to be anticipated following exposure to the named solvent(s). I view Dr. Daum's comments in this area as further proof of the effects of the solvent exposure suffered by the petitioner as well as confirmation of the causal relationship between petitioner's exposure to noxious fumes and substances and his current day complaints regarding loss of cognitive abilities.

Dr. Daum, as noted above, found petitioner's behavior to be consistent in an abnormal fashion. She further opined that she did not expect him to improve to any extent in the future and noted that the L a n c e t article (Exh. P-13) indicates that in the more severe cases of chronic toxic encephalopathy it has been found to be irreversible.

Of further interest was Dr. Daum's testimony on cross examination that toxic encephalopathy is rarely if ever reflected by the results of purely neurological testing or by the results of an electroencephalogram. Rather, she stated that toxic encephalopathy "has always been associated with subclinical findings which are not seen on gross neurologic or gross anatomical testing...The syndrome has always been based on neuropsychological testing and symptoms." T-11/17/00, pp.26, 27. In discussing the failure of an electroencephalogram to diagnose toxic encephalopathy the witness explained that the abnormalities of the latter syndrome are cellular and may not be evidenced on an MRI. "They may have cellular transmissions on the surface. Due to the amount of fat on the cells the cells may not die but you still don't have function." Thus, an MRI or other "gross tests" are not accurate in determining the presence of toxic encephalopathy.

The last witness to testify was Dr. Nancy Fiedler, Ph.D., who was presented by the respondent as its expert in the field of Environmental and Occupational Health Sciences.

Dr. Fiedler is an Associate Professor at UMDNJ and her specialty is the cognitive and psychological effect of exposure to neurotoxicants. She both interviewed and tested the petitioner during April 2000. His test results were for the most part below both what she had expected to see and significantly below the scores he had achieved on similar testing administered by Dr. Mahalick (1997). Given the fact that the petitioner's scoring on some areas of Dr. Fiedler's test(s) placed him in the lowest percentile of the population for his age, I must conclude that the petitioner did not make his best effort in responding to Dr. Fiedler's test(s). This view appears to be shared by Drs. Daum and Fiedler. My conclusion is based upon (i) his appearance and performance as a witness in this matter, (ii) the common testimony of his sisters Pauline and Anna that they did not notice any memory problem when they attended the christening of his daughters (2), and (iii) the clearly superior reasoning and memory that he exhibited when tested by Dr. Greenberg in 1997. As noted by Dr. Daum, such failure to do his best on Dr. Fiedler's test(s) does not mean that he is not disabled, but rather that such test scores may not accurately reflect the petitioner's current cognitive and/or memory ability. Notwithstanding such testing results, I found the following admissions and/or findings offered by this witness to be of interest in evaluating the petitioner's current ability to function to be of interest:

(i) based on her overall experience with the petitioner, including a review of his school records, Dr. Fiedler would place him in the average to low average range of cognitive ability;

(ii) Dr. Fiedler agrees with Dr. Daum that an MRI of the brain is not an appropriate test to determine toxic brain injury; and

(iii) Dr. Fiedler agrees that the results of his 1997 test (administered by Dr. Greenberg) were accurate in presenting the petitioner's cognitive and memory abilities at that time and were reflective of an individual who had been exposed to solvents over a long and continuous period of employment.

Dr. Fiedler did not agree with Dr. Daum on the issue as to whether the petitioner had incurred a severe progressive dementia as a result of his solvent exposure while in the respondent's employ, and further, challenged Dr. Daum on the question as to whether long term exposure to solvents would lead to progressive dementia. These are questions I do not have to answer, however, since (i) as expressed earlier I seriously doubt that petitioner is in the lowest percentile of all individuals of his age as regards cognitive ability and/or memory, and (ii) I find the petitioner to be permanently disabled based on the results of Dr. Mahalick testing and subsequent evaluation, Dr. Greenberg's overview for roughly a 3 year period, as well as the supporting opinion of Dr. Daum, a well-known physician and authority in the field of occupational medicine. I note in this area that the opinions of both Dr. Mahalick and Dr. Greenberg were offered in their position as treating physicians rather than experts who might not see the petitioner on more than one occasion. I must add that I found the combination of testimony offered by Dr. Greenberg, as a well qualified treating physician with a multi-year acquaintance with petitioner, and the expert testimony of Dr. Daum, whose knowledge of the residual effects of toxic solvent exposure to the brain appeared to be superior to all other witnesses who appeared, to be rather conclusive in this case. While I respect Dr. Fiedler's credentials and experience, but they do not match Dr. Daum's. Further, and of perhaps equal importance, Dr. Fiedler, although acknowledging that petitioner's intellectual abilities placed him in the "borderline range", offered no alternative in the area of causal relationship regarding the petitioner's condition as of 1997 other than to opine that she expected the petitioner to improve once he left the area of exposure. If, as Dr. Daum testified, solvents have the ability to dissolve parts of the brain through the debilitation of peripheral nerves, why should one expect an individual who has suffered exposure to solvents to improve? Rather the best that can happen is that their mental abilities are not further diminished.

Ciuba v. Irvington Varnish & Insul. Co., 27 N.J. 127 (1958), teaches that the successful petitioner must introduce evidence sufficient in quality to generate belief in the facts critical to his case. It need not meet the element of "certainty", but it must support or produce a presumption well-founded in reason and logic. " The evidence must be such in quality as to lead a reasonably cautious mind to the given conclusion." Id. p.140. Similarly, coincidence is not favored as an explanation in the face of evidence which demonstrates a causal relationship. Aromondo v. Rubin Bros. Drug Sales Co., 47 N.J. Super. 286 (App. Div. 1957), cert. den. 26 N.J. 244 (1958). It is clear from the testimony and evidence presented in this case that the petitioner was exposed to toxic fumes from solvents and other substances on a nearly continuous basis during his employment with respondent. It is similarly clear that such exposure can result in cognitive impairment of the type and nature presented by and/or as found by Dr. Mahalick, Dr. Greenberg and Dr. Daum, the first two of whom were associated with the petitioner in a "treating" capacity.

The argument between the parties in this case is not whether he was exposed to toxic fumes and substances while employed by respondent, for clearly he was, but rather whether he is now disabled by reason of such past exposure and the extent of such disability. Respondent presses the further argument that the 2000 test results do not accurately reflect petitioner's current cognitive abilities and should be both disregarded and recognized as evidence of the petitioner's bad faith in failing to perform in the course of such tests to the best of his ability.

While I am prepared to accept the fact that the petitioner, whether by choice, chance, or the result of existing toxic encephalopathy, did not perform to the best of his abilities while participating in the 2000 test, I accept Dr. Daum's conclusion that he has not improved since he was tested in 1997 and therefore remains totally disabled to date due to his exposure to toxic fumes and substances while employed by respondent.

In addition I reject respondent's contention that the petitioner "malingered" or otherwise deliberately acted in a manner to present inaccurate results to his 2000 testing procedure.

I believe he testified credibly in court and I have received no complaint from respondent that he had acted in other than a cooperative manner with respect to medical examinations, etc. Indeed, he was found to be "highly motivated" to perform to the best of his ability on each of the tasks presented to him during the 1997 test procedure. I also note that he had a full time working career of nearly 30 years with four (4) employers before leaving his employ with respondent. Certainly, to the time that he commenced complaining about exposure to toxic fumes/substances at respondent's plant he exhibited no indication of malingering. I also note the finding of Dr. Mahalick at the time of the 1997 tests to the effect that the petitioner was found generally to be "impaired" with respect to functions or actions which required attention and concentration, and "severely impaired" as to tasks requiring abstract nonverbal reasoning, flexibility of thought or problem solving.

Since respondent denied coverage for this claim petitioner is entitled to recover for the cost of related treatment that he sought so long as the amount of same is reasonable and necessary. The petitioner has advanced two medical bills for payment - that of the Behavioral Institute of New Jersey (treatment and testing) in the amount of $ 25,538, and that of Dr. Greenberg for $ 2,025. I find both bills to meet the criteria for payment by the respondent. I note that there is no testimony on the record challenging the amount of these bills or that the services of the providers were other than necessary to treat the petitioner. Further, after a review of the Lancet article, which was offered by Dr. Daum in the course of her testimony, I have accepted the same into evidence as Exhibit P-13. I find it speaks to the issue before me in this case and note that no claim or challenge of unfair treatment of the subject matter by or in such article was raised or presented by respondent's expert.

It is my understanding that one or more liens or credits may apply to the total disability award that is being granted to the petitioner in this matter. In addition, I have not been advised to date as to the trial expenses, if any, for which petitioner's counsel may seek reimbursement. Under the circumstances I suggest that counsel meet with me at their earliest convenience for the purposes of determining the figures that will be placed in the Judgment to be filed in this case. I would also suggest that at least 5 days prior to such meeting petitioner's counsel prepare and forward to the court and his adversary a draft copy of such Order.

Neale F. Hooley
Judge of Compensation

EXHIBIT A

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Listed below are scores or comments from/regarding the cognitive tests that

Dr. Mahalick administered to the petitioner during 1997.*

__________________________________________________________________

Test Name or Area Petitioner's score or percentile rating

Overall intellectual functioning average

Digital Symbol- coding subtest 50th percentile

Trail Making test Trail A - 34"; Trail B - 97"

Digit Span subtest 50th percentile

Recalling # forward 50th percentile

Recalling # backward 70th percentile

Motor Function 63rd percentile of dominant hand;

37th percentile of non-dominant hand

Stroop Test 46th percentile

I.Q. Testing average (96-99 on various tests)**

Memory impaired for both verbal and visuospatial memory ** Logical Memory 57th percentile

CVLT testing impaired

Block Design and Picture Completion 37th percentile

Higher Integrative Function 25th percentile on similarities

63rd percentile on comprehension

(Current (i.e. 2000)Language and Sensory test results did not significantly differ from 1997)

1997 Summary - Petitioner reveals consistent and reliable evidence of higher cortical dysfunction which is consistent with initial effects of long term toxic exposure.**

_____________________

* 1997 scores noted in Dr. Fiedler's neuropsychological evaluation report of petitioner

dated 4/12/00 and marked Exhibit R-1.

**Comments taken from Dr. Mahalick's 1997 report (Exhibit P-15)