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CRITICAL NOTICE.

First Report of the Miners' Nystagmus Committee. London: published by His

Majesty's Stationery Office. pp. 64. Price ls. 6d. net.

A survey of the facts collected by the Miners’ Nystagmus Committee leaves one in no doubt as to the wisdom of including amongst the members of the Committee some one versed in psychological investigation. The possibility of a psycho-neurotic factor in the disease had been suspected by many observers, and Dr H. W. Eddison was appointed to enquire into this aspect. The desirability of doing so becomes abundantly clear when the data collected from many sources are examined, and the compilers of the Report are to be congratulated upon placing before the public so clear a picture of a widespread and costly industrial disablement.

The facts are remarkable. What is to be considered of such an array as the following? Nearly 1,000,000 men are employed as miners in the United Kingdom. In 1908 the total number of cases of nystagmus was 460; in 1920, 7028. In 1908 the cost of all industrial diseases was £13,000; in 1920, £343,000, ninety per cent. of these sums being due to miners' nystagmus. Yet the number of men employed had risen only from 783,000 to 978,000, whilst it is noteworthy that in the same period the output in tons per man per year fell from 334 to 235. In a typical Yorkshire pit employing 2000 men, 25-38 per cent. (according to the grade of employment) of all men over the age of twentyone working underground showed oscillation of the eyes, and every one of these men could obtain a certifying surgeon's certificate and be legally disabled. In the north of France, Dransart estimated the frequency as 15 per cent., but 99 per cent. of these were unaware of the condition and were not incapacitated.

The disease varies greatly in different districts and in different pits of the same district. It is more prevalent in the dark winter months, and among the night shift workers. Slack trade causes an immediate increase of cases certified as disabled. When a lump sum is paid in settlement as compensation, the men are more likely to resume work. A man with nystagmus can always allege that he is unable to work even on the surface, and to ask an employer to prove a man's fitness is simply asking an employer to attempt the impossible.” Although every class of worker is affected, 81.5 per cent. of all cases come from the coal face. The direction of the gaze is not an essential factor in the production of the disease. The skilled workmen are the most affected.

It is possible to “infect' a pit, hitherto free from certified cases of nystagmus, by the introduction of a few bad (nystagmus) cases. Alcohol in large doses lessens and even arrests the oscillations of the eyes, but the prognosis in an alcoholic is not so good as in an ordinary individual. The average age at the time of failure is forty-two. An accident to a man's eye tends to precipitate the disease. There is a tendency for several members of one family to be affected. There is a great difference of opinion as to the influence of a purely ocular condition such as an error of refraction. Compensation has reduced the rate of return to work. A hopeful attitude on the part of the doctor increases the chances of cure. Finally, according to Dr W. H. R. Rivers, “it may now be accepted with confidence that the affection is primarily due to defective illumination."

The recital has a familiar ring to those who have come into contact with the psycho-neuroses produced by the recent war, and it is clear that Rivers' experience therein was of service in dealing with the information obtained by Dr Eddison. A critical examination of the above summary leads inevitably to

the opinion that the study of miners' nystagmus requires a broad view of the worker and his reaction to his environment, and one reads Rivers' personal report with a sense of relief that a beginning has been made, and a feeling of disappointment that the investigation of the psychological aspect has not gone very far. This implies no reproach to the Committee or Dr Eddison. The field for research is enormous; every one of the facts extracted from the Report fills one with wonder as to its significance in the life of the miner. Before speculating on this, it is worth while to see how far the psycho-neurotic miner resembles other sufferers.

After some years of work in the pit, the miner begins to feel eye-strain, followed by a difficulty of concentration of the sight on the object looked at, and a fear of harming, or being harmed by, his fellow workmen. Then follow loss of self confidence, and a fear of light. Such a history can be obtained every day from dozens of out-patients in every ophthalmic department in the country. Unfortunately the out-patients limit their spontaneous complaints to the ‘straining. For reasons unknown to themselves they omit all reference to other symptoms with the sole exception of headache, and, unless the oculist has the perspicacity of Dr Eddison, he is content to attribute the symptoms to the error of refraction which is almost invariably present, and to prescribe glasses. Specialism rarely stops to distinguish between post hoc and propter hoc.

Following the photophobia come blepharospasm, headache and giddiness. Turning again to ordinary hospital experience, 80 per cent. of ophthalmic outpatients who seek relief from other than inflammatory conditions suffer from headache and 60 per cent. from giddiness. The types still correspond closely. As the miner's disease progresses, disordered action of the heart, excessive sweating and dilated pupils may be noted; corresponding disturbances of the sympathetic nervous system are found among the out-patients. Depression and insomnia and fearful dreams are common in miners; they are also very common in the ordinary run of hospital out-patients.

Taking a broad view of all these facts, the necessity for further psychological investigation becomes apparent. What is the peculiarity associated with the miner's occupation which distinguishes it from practically all others? He is an average kind of man working far down in the bowels of the earth, in very poor light (the illumination of the coal face is sometimes reduced to do foot candle), in considerable danger (in 1913 there were 195,000 accidents recorded), and it is found that he tends to become affected with a disease almost as easily as a child becomes afraid of the dark. Increase the illumination and the disease lessens much in the same way as a child's terrors diminish in the comfort and assurance of a night light. Even the fact that he is on a night shift affects him adversely, and like so many nervous children he becomes photophobic. Introduce to the small apparently healthy herd a few bad examples, and a small stampede occurs with startling ease. Encourage the man to give way to his difficulties by granting compensation, and the incidence increases still more. With cheerful confidence encourage the sufferer to get well, and he improves. Diminish the healthy man's sight still further, if only temporarily, by an accident to his eye, and he gets a definite percentage of increase in the risk of becoming nystagmic. Make him forget his troubles by large doses of alcohol, and the nystagmus may disappear, whilst the man who has made it a habit to drown his troubles in drink and failed, cannot be cured. Let him go on working until he begins to get on the down grade in vitality at the age of about fortytwo, and he throws in his hand. Bring him back to safety and sunlight, and the sufferer has a reasonable chance of pulling himself together, especially with J. of Psych. (Med. Sect.) III

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the aid of a lump sum settlement, and eventually of trying his luck once more down below. It is the disease of a creature with a mind : pit ponies do not suffer from nystagmus. The higher his mental grade—the more skilled he becomes — the more likely the worker is to be incapacitated. Surely these are not unfair inferences to draw from all the statements in the Report! The psychologist may claim that his department has not been unduly represented in the investigations, and that the disease is worthy of further examination along his own lines, especially when such prominence is given to the dictum by Llewellyn that “the eye has a greater influence on the mind than has any other part of the body.” The opposite view, that is, the expression of mental states by eye symptoms, might be inquired into with advantage to ophthalmic science. To emphasise, for example, the need of a careful refraction of the miner's eyes, and not to press for further exploration of the miner's mind, would betray a sad lack of a sense of proportion. The disease should pass from the hands of the oculist. Take away the oscillation of the eyes, and nothing is left but a complex psycho-neurosis which is costing £300,000 in actual disbursement, £1,000,000 directly and indirectly, and an incalculable amount of misery to the miners and their families. What is the remedy? The Report fails lamentably at this point. Beyond recommending better illumination it is practically silent. The environment is to be altered; the man is merely to be cured when damaged. The Manager feels that more insecurity of compensation may have a salutary effect. The Owner is inclined to cut his loss.

The collected data of the actual eye lesions show nothing new, nor are the explanations attached to them impressive. Faithful to the prevailing notion that severe nervous symptoms can follow directly upon the presence of an error of refraction, many observers have sought the solution of the problem of causation in this direction. Thompson, Romiée and Nieden lay stress on defects of vision: Snell and Dransart think the factor of no importance. Dransart says 90 per cent. are emmetropic, Norman found error in upwards of 90 per cent. This amazing discrepancy alone is sufficient to make specialism suspect in official quarters. Ohm, who appears to have brought to the study of the subject great breadth of view and a really scientific mind, attached no importance to the factor of refractive error, since the proportion of occurrence is not greater than among the general population. On the other hand, Anderson, the most recent writer on this subject, makes error of refraction the chief factor in the disease. The Report does not show how this is to be harmonised with the fact that it is rare to find a perfectly emmetropic person in the general population, and that in any case every man after his early forties is out of focus by reason of presbyopia. That reliance must not be placed upon any ophthalmic surgeon's deductions until his personal equation is known is illustrated by the recent statement of a well-known oculist that he had cured a case of ‘shell shock' by prescribing so weak a lens as.125D cylinder for astigmatism. Equally efficacious has been the hypodermic injection of plain water instead of morphia to bring sleep to the restless. Is it in a similar way that “correction of refractive error gives relief to symptoms although it may not bring about cessation of oscillations”?

Ohm alone of all the observers seems to have thought that heterophoria may be one of the important predisposing factors. He offers no opinion as to the cause of the heterophoria, and so perhaps misses an important clue to the origin of the nystagmus. In this direction the oculist should be able to give invaluable help, and Mr Pooley's report may throw some light upon it. There is abundant evidence to be got in the ophthalmic departments that heterophoria is associated with a “neurotic'state. Unlike errors of refraction, which are usually regarded as congenital, heterophoria is acquired and may be found to be directly due to emotional stress in a large proportion of cases. Indeed the influence of emotion on ordinary concomitant squint is so common and pro found that it may be suspected as a factor in most cases of disordered muscle balance. Here then, if Ohm is right, may chance to be one of the items of a formula regulating the employment of men in the various occupations in mines.

With regard to the nystagmus, it may well be, as Rivers says, that it plays a part in the production of the psycho-neurotic symptoms. From the evidence adduced, however, such can be only a secondary part. Hundreds of men suffer from nystagmus, without obvious mental symptoms or incapacity. It may be present one day, and obtained only with difficulty the next. In some cases “after prolonged absence from work, well marked neurotic and even hysterical symptoms may appear; in these cases although almost all objective signs have disappeared, the subjective symptoms remain well marked.” It is highly probable, therefore, that the nystagmus and the mental symptoms have a common origin, and that the type of patient determines whether the psychical or the physical symptoms shall predominate.

It is surprising that Rivers did not suggest combined psychological investigation and treatment along the lines adopted for the 'shell-shocked' victims of the war. The good results obtained are indisputable, notwithstanding the varying calibre of the medical men engaged therein. As a preliminary measure why not engage half-a-dozen capable psycho-analysts to make an exhaustive examination of the psycho-neurotic symptoms from which the men suffer? The cost of the disease would justify this. The cost per case per year varied in 1920 from £32 in one district to £112 in another. The results of analysis could be collated, and the prospects of cure on a large scale discovered or at least conjectured. The disease might even be prevented by the discovery of a formula showing the likelihood of infection’ in any particular case, thus allowing suitable men to be apportioned to the various classes of surface and underground work. Judging by the photographs in the Report of several men affected with the disease, the type likely to suffer should not be difficult to recognise even without applying a formula.

A secondary result of a psycho-analytical enquiry into a disease which by common consent is intimately associated with working in light sometimes so bad as to amount practically to darkness would be a gain of information regarding the mentality of the blind or nearly blind. The application of this knowledge to such problems as the education of blind children might prove so beneficial as to make the expense worth while, whatever the effect upon the disease under review.

Since the publication of the Report an important case, described in the Press as being the first of its kind under the Compensation Act, has been tried in the County Court, wherein the widow of a man sued his employers for £300 compensation. The man had been certified as suffering from miners' nystagmus. Previously he had been strong and healthy, but afterwards his interest in life failed, and he drowned himself. The Judge, who was advised by a Medical Assessor, found sufficient relationship between the disease and the manner of death to decide in favour of the applicant.

Both the tragedy and the possibilities following upon this judgment make it still more desirable that the nature of miners' nystagmus should be fully probed, in the interests of the community generally.

W. INMAN.

REVIEWS.

Fundamental Conceptions of Psychoanalysis. By A. A. Brill, M.D. George

Allen and Unwin. pp. vii + 344. Price: 12s. 6d. net.

English readers who are not conversant with the German language owe Dr Brill a debt of gratitude which should, of itself, ensure a friendly reception of any book written by him; for it was through his translation of Freud's earlier writings that such readers acquired their first knowledge of the doctrines of Psycho-Analysis. But good wine needs no bush, and this book can well afford to be judged on its merits, irrespective of any feeling of indebtedness towards its author which on other grounds we may entertain.

It may perhaps be thought that Dr Brill has chosen too big a title for a work which is elementary in its contents and popular rather than technical both in exposition and in appeal. We might have supposed that the fundamental conceptions of psycho-analysis provided a theme which lent itself to a highly technical and formal treatment of the essentials of psycho-analytic theory, and that some critical or expository reference to Freud's more recent speculative hypotheses would have here been forthcoming. But the introduction to the book allavs such expectations and disarms such criticism as might legitimately have been made if this work had been addressed primarily to professional students rather than to "those who are occupying themselves with problems of education and psychology."

The material of the book is taken from lectures given by Dr Brill at an elementary course in the department of pedagogics of the New York University. The author has therefore tried to avoid technical expressions as much as possible and has "not taken the trouble to clutter this volume with a lot of references, which a book intended for professional people would necessarily demand.” But anyone who knows of Dr Brill's activities realizes that all his work is built on Prof. Freud's foundations and is referred to the work of the master for more detailed and more technical information.

Perhaps no more attractive introduction to the whole subject of psychoanalysis has been written than that contained in Dr Brill's first two chapters. He treats historically the development of psycho-analysis from the “cathartic method” and deals in an illuminating manner with “The Symptom: its Nature and Function.” Then follow chapters on "The Psychology of Forgetting”; “Psychopathology of Every-day Life"; “Wit: its Technique and Ten dencies”; “The Dream: its Function and Motive”; “Types of Dreams”; “Common Forms of Insanity"; "The Only Child”; “Fairy Tales and Artistic Productions”; “Selections of Vocations.”

On all these topics Dr Brill writes with a sure touch and not the least part of the charm of his exposition is due to the wealth of original observations and the appositeness of the illustrations which he brings forward in support of his contentions. A third of the whole volume is devoted to the subject of Dreams, and in this connection the author makes some interesting observations on the production and analysis of artificial dreams, and on the cognate "problem of lying."

The chapters on “The Symptom: its Nature and Function," and on “Common Forms of Insanity” will be specially useful to non-professional

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