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Under the heading "Conclusions" he classifies the cases into two groups. (1) Severe cases of the type recognised as incapacitating in France and Belgium. This group has not increased in these countries in recent years, and appears even to have diminished as safety lamps have improved. (2) Cases in which the psychological element largely predominates. This group is the one which has increased the reported cases.

In view of this important fact, which seems to be indisputable, one looks eagerly for an indication of the Committee's intention to turn its energies to the task of solving the psychological problem, but in vain. In the Introduction the Committee state that they are continuing their work and have some investigations in view which will deal further with the physiological problems. involved, but from all the evidence contained in their report it would appear that a psychological investigation would be more fruitful, and surely the best way of perpetuating the memory of their former colleague, Dr W. H. R. Rivers, who was deeply interested in the psychological aspect of the disease, would have been to appoint a competent psychologist to find out the significance. of the symptoms, ocular and otherwise, which make miners' nystagmus such a mystery. And this brings one to the question as to the meaning of the actual nystagmus, the oscillation of the eyeballs. The official definition of the disease allows the diagnosis to be made in the absence of oscillation. It follows either that nystagmus is an unimportant physical eccentricity, or it is a part of a psycho-neurosis. All the evidence points to its not being a cause of the nervous symptoms. The Committee appear to have neglected the opposite point of view, that nervous stress may produce the nystagmus. The latter, as has been already stated, occurs very frequently amongst miners generally. If it be granted that it is a psycho-neurotic symptom, a first stage in the development of the disease, one can easily understand the great difference in the relative incapacitating influence in Great Britain and Continental countries. In the latter the man must "get on or get out." In the former he gets compensation, and having first been persuaded officially that he is unfit, he accepts the suggestion, and actually becomes so. The same process has been observed constantly by medical officers attached to the Pensions Boards. A wrong diagnosis in the first instance, followed by a pension, ends in permanent disability, the difficulty of getting work at the present time assisting the neurotic trend. One wonders what would happen if nystagmic miners were paid handsomely to return to work instead of being paid to refrain from it. Apparently the course adopted in Germany and elsewhere has had a strikingly beneficial effect.

One cannot understand the Committee's persistence in classifying the cases according to the severity of the physical signs when throughout their Report such emphasis is laid upon the psycho-neurotic factor. After all, their function is to elucidate the nature of the disease, and thereby enable the country to avoid the waste of a million of money and to avert the secondary consequences of illness and incapacity in the men themselves. It is admitted on almost every page that no single physical sign can be taken as a guide to the severity or incapacitating effect of the disease. Nystagmus itself, in this respect, is summarily excluded on p. 19, where it is stated that "We are of the opinion that a test which encourages examination by the movements of the cornea only is unsatisfactory." Yet no effort is made to establish a formula dealing with the one great incapacitating part of the affection, the psycho-neurosis. The evidence in favour of doing so is overwhelming. The point was conceded

in 1913, when the official definition of Miners' Nystagmus was altered to include the words "whether the symptom of oscillation of the eyeballs be present or not." The Continental authorities still deal with it as a local disease. At home we have gone further practically only as far as compensation is concerned. Our scientists still cling obstinately to the idea that the nystagmus is the chief thing to be considered, and show the limited vision of the vast majority of the medical profession, who, for instance, regard asthma as a disease of the respiratory system because there is some difficulty in breathing under certain conditions. It is difficult to understand why this should be so, in the face of the facts collected. The result of the unsympathetic, but in practice very satisfactory attitude of the Belgian, French and German authorities towards the psychical symptoms has been alluded to. Abroad the latter are disregarded and not compensated, with the result that the disease is stationary or tends to diminish. In Great Britain they are compensated, and not investigated, with the result that the disease has steadily increased. On p. 18 one finds that "Indemnity Companies point out that the death-rate of those in receipt of compensation for miners' nystagmus is high, and ascribe the mortality to other intercurrent disease." Surely the natural inference to be drawn from this is, that a man who cannot face the stress of life below ground, presumably owing to low vitality, sooner or later accepts the easier conditions of life offered by compensation, gets into a backwater, and is more likely to suffer from literally any disease under the sun! This is nothing new. It is merely stating a fact familiar to everyone who has given a thought to the theory of immunity. The great questions to be solved are--Why do the British become incapacitated more than the Continental races, why do some British suffer and not others, and what has compensation to do with it?

A stimulus to tackle the problem from the point of view of the man and his reaction to his environment should have been forthcoming from one statement alone. On p. 21 one finds that out of 650 incapacitated men, 17 per cent. were over sixty years of age, though the normal proportion of men over sixty working underground is 3-4 per cent. Fifty-one of these men showed no physical signs, the symptoms being merely alleged. Again "the percentage of men not at work was found to increase with the age of the cases," and, "the duration of incapacity was found to lengthen with advancing years." In other words, it is a disease of old age, either actual or premature. A man may retire from the struggle of life at a very early age; no matter what his years, his reaction is senile.

A highly suggestive table is that given on p. 22, dealing with the relation between duration of incapacity and the presence of physical signs. It shows that the number of men disabled for two to five years was much higher than for any other period, that there was a gradual rise from a one to three months' incapacity until the two to five years' period was reached, and then a pronounced fall for the longer periods. Taking the percentage of cases showing oscillation, head tremor, and lid spasm in the same men, Mr Pooley shows a steady fall in incidence of the first condition, but a rise in the second and third from the six to twelve months' incapacity until the two to five years' incapacity is reached, and then a fall to zero. It is interesting to note that the latter two physical signs were more frequently present in those cases whose incapacity had run for two to five years, and that such cases were the most numerous in a body of 650 men investigated. In the great majority of these cases the illness had lasted from one to five years. Compare this with the Continental

evidence. Dr Stassen with his wide experience in Belgium has seen only three cases incapacitated for more than six months-"these men returned to work before the end of twelve months." The table in question shows that the longer the duration of the illness, the more definitely psycho-neurotic in character it becomes. Whatever may be the significance and origin of the oscillation of the eyeballs, one may fairly safely insist upon the neurotic nature of lid spasm, and with some show of reason, of head tremor also. In cases up to twelve months' duration oscillation of the eyeballs is the commonest sign noted, its occurrence being in the proportion of 65 per cent., as compared with head tremor 35 per cent., and lid spasm 19 per cent. But in the cases lasting one to two years, the proportions change respectively to 42, 46 and 30 per cent., and in those lasting two to five years, to 22, 32 and 15 per cent.

When the Committee state that the view taken of miners' nystagmus on the Continent is, on the whole, correct and that "The great majority of cases benefit by returning to work within from three to six months, and by continuing to work for at least six months before making a fresh claim for compensation," they are in effect admitting the psycho-neurotic basis of the disease. It would seem that they are a little inconsistent in declaring that a stricter standard based on physical signs should be adopted, in determining claims for compensation, whilst their evidence goes to show that these physical signs themselves are mere indications of a disease affecting the whole organism.

It is true that the Committee themselves have not come to any decision as to whether the psycho-neurotic symptoms themselves are an integral part of the disease. They tell us that "The standard of physical signs which is in vogue in this country for deciding whether any case should be certified as suffering from miners' nystagmus, too readily admits psycho-neurotic cases,' but if claims for compensation are to be determined by physical symptoms alone, what is one to make of the fact that "Several men with the most marked oscillation of their eyes, which they cannot keep still, even when looking down in daylight, refuse to stop work, and say they hate holidays, as they are more comfortable when working. One of these men plays cricket for his colliery." If oscillation is the crucial sign, should not such men as these be compulsorily retired? If not, what are the physical signs determining incapacity? Does not it all really amount to this, that physical signs are present in varying degree in large numbers of miners, only some of whom declare themselves to be incapacitated? In other words, the subjective symptoms are all-important to the medical man in coming to a decision.

As the Committee favour strongly the Continental practice of restricting compensation, on the ground that the incidence of nystagmus is thereby greatly reduced, it would be interesting to know whether Continental miners thus saved from nystagmus remain healthy men. It is a common observation in psycho-neurotic cases that the cure of one symptom frequently leads to the emergence of others, and it is conceivable therefore that on the Continent, whilst the incidence of nystagmus is reduced, there may be a rise in that of diseases classified under other names. On this point we have no information. One cannot cure a neurosis simply by driving the sufferer back to the environment which produced it. Would not it be possible to discriminate between cases mainly due to temporary stress, whether above or below ground, and those in which the man's vitality has been so far sapped that he will never be fit for underground work again?

Were further argument necessary to convince the Committee that it has

a long way to go, if it persists in attaching so much importance to physical signs, it is to be found on p. 22, where it is stated that "A pronounced divergence was found between the work which was being done and that which the men appeared to the examiner capable of doing when they were assessed on the basis of the amount of physical signs of miners' nystagmus present." The actual figures are too striking not to be quoted.

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Med. Psych m

Assessed
Condition

270

154

226

The precise meaning of these figures is not clear, but it is evident that the miner and the examiner were far from being of the same mind.

"Means should be established for re-assessing periodically the amount of incapacity present; this is purely a medical question, which should be in the hands of those who possess special experience of the disease" (pp. 23, 24). Did one of them make the above assessment? No wonder the legal profession and legislature are bewildered when they turn to the medical profession for guidance in compensation cases!

In a paper on Miners' Nystagmus read before the Medico-Legal Society recently, a barrister spoke of the great confusion of mind produced by the first report, and pleaded for greater clarity of thought in medical pronouncements. The reproach must be accepted.

W. INMAN.

22

REVIEWS.

An Outline of Psychology. By WILLIAM MCDOUGALL, F.R.S., Professor of Psychology in Harvard College. Methuen & Co., Ltd. Pp. xvi + 456. Price 12s. net.

It would be difficult to overestimate the value and importance of this volume. Designed to introduce the student to his science, to furnish him with a profitable line of approach and a fruitful way of thinking of psychological problems, with a terminology as little misleading as possible, it admirably achieves this aim. But it does more than this, in spite of its author's disclaimer, and presents a compact yet lucid summary of the generally accepted facts and laws of normal psychology, which makes it a reliable text-book of the science. Its most characteristic feature, that which distinguishes it from most if not all other text-books, is the thorough-going consistency with which it adheres to one guiding principle, the principle that "purposive action is the most fundamental category of psychology." In an interesting introduction Prof. McDougall summarises in a masterly way the chief historical systems in psychology, such as the psychology of ideas, the atomistic or mosaic psychology, the fusion of the two with more recently acquired facts of brain physiology which constitutes so-called physiological psychology, and the thorough-going mechanical reflex theory which is modern "behaviourism." He indicates their respective short-comings, and persuasively argues the claims of purposive psychology to be a more accurate statement of the facts.

Conformably with this view, his opening chapters do not present the timehonoured sequence of Sensation, Perception, Mental Images and Ideas, etc., but are devoted to a detailed analysis of the behaviour of the lower animals, the insects, the vertebrates, including fishes and birds as well as the mammals and man. These make extremely interesting reading and give overwhelming proof of the pragmatic value of his central principle. Prof. McDougall enumerates the following seven marks of "behaviour," viz.: (1) a certain spontaneity of movement, (2) the persistence of activity independently of the continuance of the impression which may have initiated it, (3) variation of direction of persistent movements, (4) the coming to an end of the animal's movements as soon as they have brought about a particular kind of change in its situation, (5) preparation for the new situation toward the production of which the action contributes, (6) some degree of improvement in the effectiveness of behaviour, when it is repeated by the animal under similar circumstances, (7) a total reaction of the organism, as distinct from the partial reaction of reflex action. As regards mark (6), he writes: "No doubt, when such improvement may be observed, it provides the surest criterion; but, without this sixth mark, we may infer mental activity from the other five." (He is not considering mark (7) in this passage.)

On this basis, he proceeds to demonstrate the mutual implication of instinct and intelligence in all purposive activity. He also shows the necessity of distinguishing instinctive activity from the various motor mechanisms through which it may be manifested, and brings forward further arguments for his

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