James Joyce: steps towards a diagnosis

Uveitic secondary glaucoma: influence in James Joyce's (1882-1941) last works

James Joyce, considered one of the pre-eminent novelists of the 20th century, attained international renown with his work Ulysses. Its lack of standard punctuation makes it difficult to read. An example would be the famous non-punctuated 'Molly Bloom soliloquy' in the last chapter of Ulysses. Why is Joyce considered so difficult to read? He wrote and proofread Ulysses and Finnegans wake, his last works, during his battle against glaucoma, when his vision was seriously blurred. The distracting and confusing diacritical marks might be explained by Joyce's reduced visual acuity. Could Ulysses and Finnegans wake have been different if Joyce's visual problems had begun in the second rather than the first half of 20th century?

Syphilis, psychiatry and offending behaviour: clinical cases from nineteenth-century Ireland

BACKGROUND

Syphilis presented substantial challenges to nineteenth-century medical and psychiatric services.

AIMS

To illustrate the clinical course and diagnostic challenges associated with neurosyphilis in nineteenth-century Ireland.

METHOD

This paper uses original archival material from the Central Criminal Lunatic Asylum, Dublin to present clinical cases and inform a discussion of related issues.

RESULTS

Mr A, a 34-year-old banker convicted of "felonious entry", demonstrated many psychiatric and neurological features of neurosyphilis ("general paralysis of the insane"); he soon became "feeble", "paralytic" and "demented", and died within 2 years. The case of Mr B, a 38-year-old game-keeper convicted of "attempting to upset trains", illustrates diagnostic dilemmas associated with neurosyphilis, especially when complicated by evidence of tuberculosis ("scrofulous diathesis").

CONCLUSIONS

The clinical and diagnostic challenges presented by syphilis have changed over the past century, but these cases, combined with recent evidence of syphilis outbreaks, highlight ongoing needs for clinical and epidemiological vigilance.

Biological basis for syphilis

Syphilis is a chronic sexually transmitted disease caused by Treponema pallidum subsp. pallidum. Clinical manifestations separate the disease into stages; late stages of disease are now uncommon compared to the preantibiotic era. T. pallidum has an unusually small genome and lacks genes that encode many metabolic functions and classical virulence factors. The organism is extremely sensitive to environmental conditions and has not been continuously cultivated in vitro. Nonetheless, T. pallidum is highly infectious and survives for decades in the untreated host. Early syphilis lesions result from the host's immune response to the treponemes. Bacterial clearance and resolution of early lesions results from a delayed hypersensitivity response, although some organisms escape to cause persistent infection. One factor contributing to T. pallidum's chronicity is the paucity of integral outer membrane proteins, rendering intact organisms virtually invisible to the immune system. Antigenic variation of TprK, a putative surface-exposed protein, is likely to contribute to immune evasion. T. pallidum remains exquisitely sensitive to penicillin, but macrolide resistance has recently been identified in a number of geographic regions. The development of a syphilis vaccine, thus far elusive, would have a significant positive impact on global health.