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into the conscious sphere. Their existence is always a matter of inference. I propose to restrict the use of the term 'unconscious' to these wishes. For those wishes which can be brought up to the conscious level by analysis I would use the term 'subconscious'; the 'foreconscious' wishes are such as can be directly appreciated when the attention is directed towards them but which are not ordinarily present in the consciousness. All the three above types of wishes have got to be tackled by the psychoanalyst.

Now reverting to my case I should like to point out here that the theory of the unconscious death wish satisfied all the postulates I enumerated before and no other rival explanation could be put forward which would explain all the facts in a satisfactory manner. It is not always that we are so fortunate with a psycho-analytic interpretation. When the wish is of the unconscious type, as in many symbolisms, it can never be directly appreciated and even wishes of the subconscious type may not be made available to consciousness owing to difficulties of analysis in individual cases.

It is on such evidence as mentioned above that the whole fabric of psycho-analysis has been built up and I would urge hasty critics to pause and consider carefully the nature of the evidence before they venture to condemn psycho-analysis. To workers in the field I would press for an unbiassed mind and would urge them to weigh the evidence very carefully before asserting anything definitely. It is unfortunate that this warning should be necessary as there are evidences in current literature of personal and race bias masquerading as psycho-analytical interpretations.



UPON the kind recommendation of the late Dr W. H. R. Rivers I was appointed by the Medical Research Council to undertake a study of the psychoneurotic aspects of Miners' Nystagmus during the six months Dec. 1920-June 1921, and subsequently given permission to publish my results independently.

The investigations were carried out at Tredegar in S. Wales (75 cases), Newcastle in Staffs. (185 cases), and at Sheffield in Yorks. (50 cases).

It is my intention here to give only a brief résumé of the information obtained and the conclusions arrived at, and to omit long descriptions. of individual cases.

The majority of the symptoms are admirably described in T. Lister Llewellyn's Miners' Nystagmus, its Causes and Prevention1.

Among those symptoms, in addition to nystagmus, to which most attention has been paid, are: tremors of the head, headache, photophobia, blepharospasm, unsteadiness of the field of vision and strained attitude of the head and eyes. These I have called "symptoms secondary to the nystagmus" in contradistinction to other symptoms of a neurotic nature to which I have paid special attention.

Review of the Symptoms.

Headache. This is usually the first and frequently the most severe symptom. It is also the most persistent, often being the last to clear up when improvement occurs as the result of rest from work in the pit.

In a few cases the headache was hemicranial in distribution and appeared to be hysterical in origin. In other cases a relationship existed between waking up with a headache in the morning and being troubled with anxiety dreams the night before.

Giddiness. Almost invariably present and at first secondary to the nystagmus. But giddiness can also be elicited under the same conditions which formerly brought on the nystagmus in those cases where nystagmus can no longer be elicited. That giddiness is, in such cases, psychically determined seems probable, as in numerous patients who complained 1 Llewellyn, Miners' Nystagmus, Chap. I and p. 22.

that it was induced or aggravated by excitement, being startled, surprised or annoyed while sitting quietly at home often proving sufficient to induce an attack.

When one examines a patient as to the effects of stooping, one is often struck by the exaggerated display of the effects of giddiness. The patient usually knows where to grasp a convenient chair to save himself from falling; if there is nothing to catch hold of he sways in a most alarming manner but does not fall. Further, several of the patients, on being directed to turn their eyes upwards, complained of giddiness even before they tried to look up. After firm, gentle persuasion they were quite surprised at the range of elevation of the eyes of which they were capable without experiencing giddiness.

Orbicularis spasm, Photophobia, etc. These are frequently present in some degree. All the symptoms of this group are considerably more marked under examination or when the patient's attention is drawn to his ocular condition. The orbicularis spasm may appear as rapid intermissions in the form of winking movements, or as a fine eyelid flicker, only perceptible when the patient is directed to close his eyes. Combined with these signs there are usually a strained manner of holding the head, over-action of the frontalis with wrinkling of the forehead or elevation of one eyebrow to a higher level than the other. All these signs are exaggerated whenever the patient experiences change of illumination.

The association of these symptoms with tremors of other parts of the body is very often noted.

Of the cases who suffered from these spasms and tremors the majority no longer exhibited nystagmus even where the latter had been previously present.

General Muscular Rigidity is a prominent feature in the majority of cases both during exertion and at rest.

Anxiety Symptoms are present in the vast majority of patients, and in no way differ from the various symptom groups of the anxiety neurosis and anxiety hysteria. Phobias are chiefly those of darkness, closed spaces or of escape being cut off.

Pupillary signs. These occur as in the anxiety state. In some cases the pupils were dilated but reacted to light and convergence, while in a few one pupil was found to be larger than the other. In two such cases a unilateral blepharospasm was observed, being, in both cases, on the side of the larger pupil. Anxiety symptoms were present in both.

There seems to be no relationship between the state of the pupils and the duration of the disease.

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Two further ocular symptoms are:

(1) When the man fixes his gaze upon an object for a minute or two his vision becomes blurred. If the eyes be examined during such fixation no nystagmus or other ocular movements can be made out in men in whom nystagmus can otherwise be elicited by other methods.

(2) Giddiness on trying quickly to accommodate vision to change of illumination.

Tremors vary in their distribution but are of very frequent occurrence. They are, as Llewellyn says, frequently met with as a rotatory tremor of the head. Those about the eyes have also been mentioned. Tremors of the hands are very common, and usually bilateral, but in unilateral cases examined the right hand was the one most commonly affected.

The association of nystagmus with tremors of other parts of the body suggests an etiological connection. For instance, in one case in which nystagmus and spasms of the orbicularis, frontalis and eyelids occurred together, experimental aggravation of the nystagmus induced a fine rapid tremor of the right hand.

Mode of Onset.

The order in which the symptoms come on varies much in different localities, and appears to be considerably influenced by the mental type of the patient.

The usual story is that the man goes to work cheerfully, thinking of little else than his work. As years pass, however, he begins to feel that he is straining his eyes, and that the coal-face or other object of his attention appears to be nearer or further away than it really is, and he experiences difficulty in focussing his eyes upon it. He can no longer see, for instance, the exact spot which he is trying to hit with his pick, nor

can he fix his eyes definitely upon any particular mark on the coal-face, with the result that his eyes tend to move irregularly over a wider and wider area, with nothing very definite to fix. Further, he may be obliged to guard against approaching within harmful range of other men's picks, or injury to himself or others with his own pick-another reason for taking his eyes off the already widened point of fixation. This stage may last for several months or years before the disease becomes what Llewellyn calls "manifest1." The usual subjective symptoms, described by Llewellyn, now make their appearance, and the man becomes apprehensive of his condition. His inability to fix objects in the pit renders him apprehensive of danger, which in turn causes him to be easily startled and lacking in self-confidence. He frequently has to stop work to rest his eyes, he screws up his eyes when he looks around him, and then finds that the lamps dazzle him and appear to dance irregularly or to revolve rapidly in small circles. When he first observes this he screws up his eyes still more and so comes to the surface of the pit. Here he finds himself dazzled by the daylight. This latter factor, aggravated by fear as to the fate of his eyes, and incidentally of his income, all serves to keep the ocular condition at the focus of attention.

In other cases the onset is more insidious, and the condition may only be discovered accidentally while the eyes are being examined for some other condition. In many such cases no subjective symptoms are complained of whilst in others mild anxiety symptoms and signs are found.

The manner in which the varieties of mental types of miners influence the clinical picture is as follows: in Yorkshire the men tend to be somewhat stolid and unimaginative, and to scorn to think about or admit the existence of "nervous" symptoms such as anxiety, irritability, phobias, etc., while the Welshmen, on the other hand, are more excitable and pay more attention to the psychic aspects of the disease. The Staffordshire miners appear to be intermediate in this respect. The corresponding variations in the symptomatology are shown thus: in the case of the Yorkshiremen the symptoms usually appear as the anxiety neurosis with the addition of nystagmus. With the Welshmen the onset is more of the nature of anxiety hysteria plus nystagmus. The Staffordshire men occupy an intermediate position, though approximating to the actual neurosis rather than to the psychoneurosis.

There are, however, many cases of undoubted hysteria and anxiety hysteria in which the symptoms closely simulate those of miners' 1 Llewellyn, Miners' Nystagmus, p. 3.

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