564

THE COLLIERY GUARDIAN.

March 13, 1914.

a most important part in the causation of the disease,
and there was no doubt but that injuries to the eye, or
general injuries to other parts of the body, might be the
determining factor in the onset of symptoms. He had
noticed that nystagmus often came on during con-
valescence from an accident, and he thought this was
sometimes due not to the accident itself, but to the fact
that the man when at work had been able to overcome
the tendency to the disease. This opinion had been
confirmed by the number of cases who broke down
following resumption of work after the big strike of
1912 ; the six weeks’ enforced holiday had thrown them
out of gear. In his own series there was a distinct
connection between the onset of the disease and an
accident in 94 cases.

Treatment.

. The treatment of miners’ nystagmus must be con-
sidered under two headings. In the first place they
must consider the treatment to be applied to the
sufferer, and in the second place consider what preven-
tive measures might be employed for the purpose of
either diminishing the number of cases or eliminating
the disease altogether.

With regard to the personal treatment: this would
depend entirely upon the severity of the case. In severe
cases it was necessary for the man to give up work
entirely and to have complete rest. If the examination
of the eye showed any refractive error, this should be
corrected by means of glasses, and in many cases after
the patient had become accustomed to the altered
conditions under which the muscles of the eye worked,
he obtained some relief, at all events from such subjec-
tive symptoms as headaches, giddiness, and nausea,
while in some, cases these symptoms disappeared
altogether. Ernest Clarke had pointed out that in
neurasthenic cases the correction of small ocular defects
was of the greatest importance, and he believed that in
many cases the greatest amount of eye strain resulted
from the smallest error of refraction.

Neurasthenic symptoms must be treated in the ordi-
nary way, and if the patient was suffering from neuras-
thenia of a marked degree, Weir Mitchell treatment
might be advised for a period of from four to six weeks.
He did not think sufficient attention had been paid to
the application of Weir Mitchell treatment in cases of
nystagmus, and he believed that the association of
miners’ nystagmus with neurasthenia had not been
sufficiently recognised. He had pointed out in a
previous lecture that in this country there were not
sufficient facilities in the hospitals for the treatment of
neurasthenia, especially by the Weir Mitchell treatment
for working men who require such a course of treatment,
and it was obvious that in their homes this treatment
could not be carried out. As far as he knew, Weir
Mitchell treatment was only properly carried out in
England in nursing institutions, or in, perhaps, one or
two hospitals in London devoted exclusively to the
treatment of nervous diseases ; but in view of the fact
that there were thousands of coalminers in the different
colliery districts of this country incapacitated for work
on account of miners’ nystagmus associated with
neurasthenia, from an economic point of view it was
most desirable that arrangements should be made in the
hospital centres of colliery districts to provide the best
possible treatment, in order to bring about speedy
recovery. The best that could be done at the present
time was generally to advise massages in the patients’
homes, although this could not be carried out unless the
employer or insurance company was prepared to bear
the burden of the expense, as the charges, speaking
generally, were beyond the means of the average
working man. In some cases, the patient might be sent
to such a hospital as the Devonshire Hospital at
Buxton, where a course of massage and baths would do
a great deal of good for the sufferer. Convalescent
cases derived great benefit from change of air, especially
at bracing seaside resorts such as Blackpool or Rhyl.

While the patient was “ suffering ” from any symptoms
of this disease, work in the pit should be forbidden; but
in mild cases, and in cases which were convalescent, a
change of employment on the surface might result in
great benefit, because his mind was occupied^ and he was
not worrying about himself, as was very common in
these cases: and, further, the exercise which ordinary
manual work necessitated would do a great deal towards
improving his nervous system.

Some writers had stated that on recovery the miner
might be allowed to work in the pit again, and this was
a practice which was prevalent to a large extent in all
mining districts ; but he thought to reduce the risk of
recurrence it was advisable to place the man at such work
that he was less liable to contract the disease than at
his previous employment; for instance, a man who had
worked as a holer might be employed as a roadman or
a dataller, but if there were any recurrence after this
return to different work, then the man should never be
allowed to work in the pit again.

During illness it was important that the man should
lead a well-regulated life. He should keep good hours,
and should be abstemious with regard to alcohol and
tobacco. If there had been any previous tendency to
excess in either of these habits, they should be entirely
forbidden; and a patient suffering from nystagmus,
whether he was incapacitated from work or not, should
realise that the flickering of cinematograph performances
had a detrimental effect upon his condition.

With regard to medicinal treatment in cases where
the nervous symptoms were pronounced, where the
appetite was poor and there was sleeplessness, glycero
phosphates and bromides might be given with good
results, and among the other drugs which had been
found to be successful are strychnine, quinine, and nux
vomica. Romiee had advised the local application to
the eye of eserine drops in a 3 per cent, solution three
times a day. Atrophine had been tried without success.

Operative treatment in the form of tenotomy had
been recommended in cases of miners’ nystagmus ; but

in every case, as far as he knew, in which an operation
has been performed, disappointing results had ensued.

Preventive Measures.

Preventive measures might be considered under three
headings : (1) Improvement in illumination of the mine ;
(2) the extension of the use of coal-cutting machines;
and (3) efficient ventilation of the workings.

Going into some detail on this part of his subject, Dr.
Shufflebotham said every man on his way to and from
the face should be compelled to use a shade at the back
of his lamp. He had often been told by men that they
had had to sit down “ to let the lamps go by.” These
shades should be provided by the management, but
could be readily improvised by means of a piece of card-
board or folded newspaper.

It was the general opinion of working miners them-
selves that bad air in the mine was the exciting cause
of this disease ; whether this was so or not there was no
doubt that bad air had a deleterious effect upon the
general condition of the miner, and as they had seen
that impaired general health was a predisposing cause
of the onset of the disease, efficient ventilation in the
mine was an important factor in its prevention.

Mr. McMurray had suggested that all miners should
be subjected to a systematic examination of the eyes, so
that cases with any refractive error or with any other
ocular defect could be prevented from commencing or
continuing this kind of work. Undoubtedly, such a
procedure would greatly diminish the incidence of
nystagmic cases, but he (Dr. Shufflebotham) questioned
whether the Miners’ Federation would consent to the
institution of such an examination, as it would mean at
the present time dismissal of thousands of miners who
had worked in the pit all their lives, and who were
continuing to do regular and efficient work, and further,
it would mean the constant elimination at each periodic
examination of numbers of workers who would be
deprived of their means of livelihood, and with little
chance of gaining employment elsewhere unless it were
in the ranks of the casual labourer. If, however, a
periodic examination were made, and the power of
dismissal were prohibited in case of any ocular defects
other than miners’ nystagmus being discovered, then
it had been suggested that the workers be induced
to wear spectacles when on the surface. In this way it
is hoped that the correction of the refractive error will
lessen the severity of the symptoms of this complaint.

Incapacity for Work.

Miners’ nystagmus was essentially an industrial
disease. In spite of the various theories for the explana-
tion of the symptoms, it could not be denied that the
complaint was one which was a direct result of the
conditions under which the miner works, and in view
of the fact that it was a disease to which the Workmen’s
Compensation Act applied, it was important to consider
to what extent incapacity for work might result from
this complaint.

In the first place, he would point out that there was
no necessary relation between the objective and sub-
jective symptoms. Cases where the movements were
very slight might be accompanied by distressing head-
aches, attacks of giddiness, and other subjective
symptoms, while well-marked oscillations sometimes
might cause no trouble. It was difficult to tell whether
a miner suffering from nystagmus was incapacitated
from work or not.

The objective symptoms by themselves might not
cause any discomfort or incapacity for work ; but when
associated with subjective symptoms they might have
a case of total incapacity for work. A great deal,
however, depended upon the subjective symptoms, for
the existence and severity of which they were compelled
to trust to the patient’s honesty.

Meighan had classified the degrees of incapacity for
work under three headings :—

1.	Those slightly affected—men who suffer to a
slight extent from the characteristic oscillations of
the eyeballs—especially when they assume positions
that strain the muscles of the eye. These men
continue work and never become incapacited. He
believes that 5 per cent, of all miners are affected
slightly.

2.	Those who suffer from the oscillations and feel
giddy at times. These should be obliged to leave off
the work in which they are engaged. They may
require a rest for six months, but should not return
to their old employment.

3.	Those who suffer badly from oscillations, head-
aches, giddiness, and other symptoms mentioned
previously. These should give up underground work

v entirely, and never return to it.

Dr. Shufflebotham said complete incapacity for work
might occur in those cases where the symptoms of
nystagmus were absent or had disappeared, but where
clonic spasm, plus other objective symptoms, were
complained of. From the point of view of capacity for
work, giddiness was the most troublesome subjective
symptom and, if the attacks were at all frequent and
came on without warning, the patient must be regarded
as being totally incapable of work, and it was not safe
to give him light work even on the surface. One-eyed
men who suffered to any pronounced extent from the
disease must be regarded as totally and permanently
incapacitated. Again, cases in which neurasthenia was
a prominent symptom must be regarded as of a severe
type.

Malingering.

Amongst other observations under this heading, Dr.
Shufflebotham said all observers were agreed that it was
impossible to imitate the nystagmic movements of the
eye, so that there could be no malingering with regard
to this, the most prominent objective symptom. There
was a difference of opinion as to whether clonic spasm
of the eyelids could be simulated or not, but careful
observation in any given case would easily detect

malingering, as it was impossible for the patient to
sustain, but for a minute or so, the twitching of the
eyelids, and further, the voluntary movements which
were induced by a malingerer were altogether different
to a skilled observer from those which were seen in true
cases of clonic spasm of the eyelids. Dr. Moody had
pointed out that the movements in the latter case were
quicker and finer, and if a miner attempted voluntarily
to blink his eyelids quickly, he must bring other
muscles into play apart from those which actually blink
the eyes, and in Dr. Moody’s opinion the man would be
easily found out. It should be clearly and widely
known among all miners who might imagine that the
simulation of this symptom was an easy matter, that
they were entirely mistaken, and that if they tried it on
before a skilled observer, they would be almost imme-
diately found out. They might therefore, say that the
two principal objective symptoms could not be simu-
lated, and if a man was known to have attacks of
giddiness and to fall about, to be suffering from night
blindness, and, when tested by Cridland’s method, from
a diminished field of vision, there could be no question
as to the genineness of the case.

The only difficulty might arise in mild cases where
patients were capable of following some kind of employ-
ment, such as light work on the surface, or in an
occupation independent of coalmining. In many cases,
as he had stated previously, miners with a definite
oscillation of the eyeballs were able to do their work
without any complaint for years in the absence of head-
ache, dizziness and other subjective symptoms; but if a
miner suffering from such a mild degree of the disease
suddenly became aware of the presence of nystagmus,
should he, for the purpose of claiming compensation
under the Workmen’s Compensation Act, desire to
make complaints of headache, giddiness, feelings of
sickness and other symptoms for the existence of which
they had to trust to his honesty, it would be most
difficult to disprove the statements. The examining
doctor would have to take into consideration the man’s
record for work and his demeanour while under observa-
tion, and assistance might be given by friends and
neighbours who could testify one way or another as to
the man’s general state of health.

In dealing with such cases it was absolutely necessary
to make a complete examination of the man, and a
special examination of his eyes, such as he had described
under the heading of “ Symptoms,” and he believed that
a great deal of help would be obtained by paying special
attention to the extent to which the field of vision is
limited.

There were undoubtedly many cases of miners who
knew that they were suffering from miners’ nystagmus,
but who went on working in spite of the complaint, and
it was only when they gave up work, either on account
of bad trade, or a strike, or because of some quarrel
with an official or their employer, that they made a
claim for compensation. During the coal strike of 1912,
many such cases were recorded in different coal districts
of this country.

In all disputed cases, he would suggest that the medical
referee under the Workmen’s Compensation Act not
only relied upon his own examination and the reports
submitted to him by the medical advisers of the work-
men and the employers, but that he also took into
consideration either verbal or written statements of
workpeople or other persons who could speak as to the
man’s previous history and his general condition of
health.

(To be continued.}

Royal Commission on Railways.—Mr. Marshall Stevens,
first manager of the Manchester Ship Canal and now
chairman and managing director of the Trafford Park
Estates, made some noteworthy suggestions before the
Royal Commission on Railways in London on Friday. His
three main proposals were as follow :—(1) That the railway
companies must be compelled to charge separately for
conveyance. (2 ) That the conveyance charge must be a
reasonable one, having regard when compared with the
present rates of carriage to the cost to the railway company
of the other services and accommodation provided. (3.)
That the Railway Commission should be reorganised, with
full authority to take the initiative and to carry out each
and every one of the recommendations of the Committee of
1872, as well as to revise the rates of conveyance and
create through traffic arrangements upon broad lines*
These reforms, ho said, were obtainable with very
little alteration in the existing laws. Should it be
thought that the railway companies would in any way
be harshly treated by the recommendations being put
into operation without some consideration, he would further
recommend that — (a) the State should acquire the
permanent way of the railways and convey traffic without
providing any other services in regard to it; or (b) having
taken a valuation of the permanent way of a railway, the
State should guarantee the company interest upon that
valuation in exchange for absolute freedom in the fixing of
conveyance rates both for merchandise and passengers.
Mr. Stevens declared that he was prejudiced against State
ownership in the ordinary way, but it seemed absolutely
impossible that, as regarded the working of general
merchandise traffic, greater administrative waste could take
place if the railways were owned by the State than was now
taking place with the railway companies. The total amount
of rates payable by the companies was .£5,000,000. Assuming
that half of that was applicable to the railway lines, the
.£2,500,000, capitalised upon a’25 years’ basis, would mean a
contribution of 621 millions by the local authorities towards
the purchase price. The Commission adjourned.