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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.
(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.
nystagmus without nystagmus ever having been noted after careful expert examination.
Only a very limited examination by the psychoanalytical method was possible in the limited time available, but it showed that the symptoms in all cases so examined formed an integral part of the mental make-up of the patient. The following case illustrates some relationship between the man's symptoms and his life in the pit. He was not, however, analysed. His eyes showed irregular nystagmoid movements. He stated that he occasionally had fainting attacks in which he usually lost consciousness, but sometimes retained some awareness of his surroundings. During the first examination he had a severe attack of generalized tremors, nystagmus and internal strabismus of both eyes, rapid shallow respiration, pulse 120 and a facial expression of marked anxiety. He stated that the fainting attacks commenced with a "rising sensation" in the abdomen closely resembling the sensation experienced while going down in the cage. A feeling of giddiness was next described similar to that felt on stooping or looking at a lamp in the dark galleries. At this stage he would fall. On coming to he would have general tremors with a subjective sensation which he said was like that previously induced by exertion and later by excitement at any time. These resemblances were all pointed out by the man himself. The fainting attack appeared to be, then, a reproduction of the various subjective sensations experienced first in the pit and later above-ground under conditions which reproduce those of the pit.
Nystagmus may have a sudden onset. Such occurrences have made themselves felt during influenza and other lowering affections1, and such necessities for psychic re-adaptation as a bereavement, also after accidents and local injuries to the head or eyes, or even accidents to remote parts, for instance, blows on the back or limbs. Events of this sort frequently serve as determining causes for the outbreak of a neurosis, so again creating a point of resemblance between nystagmus and the neuroses.
Summary of Observations.
(1) Injury sustained to the head, eyes or other part of the body, severe illness or mental anguish may be followed by severe trains of neurotic symptoms and nystagmus may be observed on examination2.
(2) Injury to, or a foreign body in one eye aggravates both the subjective symptoms and the objective signs, in cases where nystagmus already existed, for some time after the attendant conjunctivitis has cleared up.
1 Llewellyn, Miners' Nystagmus, p. 134.
2 Ibid. pp. 98-101.
(3) The effect of directing the patient's attention to his symptoms is to aggravate the symptoms.
(4) Symptoms of nystagmus may first be observed at the time of onset of a neurosis.
(5) When neurotic symptoms intervene in a case of hitherto pure nystagmus, the symptoms secondary to the nystagmus are incorporated amongst those of the neurosis.
(6) The nystagmus group of symptoms passes gradually, without line of demarcation, into the anxiety group. Tremors of the hands follow those of the head which latter are secondary to the nystagmus, and these tremors are apt to become general on excitement or exertion. Finally tachycardia, hyperidrosis and other anxiety symptoms follow.
(7) In those cases of nystagmus which are combined with an obvious neurosis the ocular oscillations are experimentally inseparable from the tremors and other neurotic signs.
(8) A few cases, in the course of analysis, became greatly agitated and suffered great exacerbation of their symptoms, including the nystagmus. In other words the nystagmus took part in an abreaction.
(9) In certain cases physical re-education of the eye movements, which really amounted to treatment by suggestion, favourably influenced the nystagmus as well as the subjective sensations.
(10) The actual nystagmus itself did not appear accessible to analysis, and, therefore, seemed to be of the nature of an actual neurotic rather than a psychoneurotic symptom.
(11) The course of the cases under treatment is a good example of the dependence of the patient upon the physician, so characteristic of hysteria.
(12) The patient exhibits resistance against the removal of his symptoms, of which resistance he is quite unaware, and over which he has no control. For instance, several of the men stated that their state came on or got worse whenever they started off for the clinic, sometimes causing them to turn back and go home. This sudden exacerbation of the symptoms occurred too often under these and similar circumstances to be a coincidence and seemed to be a definite feature of the disease.
In conclusion I wish to express my keen appreciation of the great kindness and assistance which I met with at the hands of the late Dr W. H. R. Rivers, Dr T. Lister Llewellyn and Mr G. H. Pooley of the Miners' Nystagmus Committee, and of the Managers and Staffs of the collieries which I visited in Tredegar, Newcastle-under-Lyme and Sheffield.