769THE HEALTH OF THE COAL-MINER.

THE LANCET.

LONDON: SATURDAY, APRIL 10, 1926.

THE HEALTH OF THE COAL-MINER. I

IT is no direct part of the duty of this paper tocomment on the situation, so serious for us all, thathas been brought about by the general conditionsof coal-mining, the withdrawal of the subsidy underwhich some two-thirds of the coal is produced with-out a loss, and the issue of the Report of the CoalCommission with its far-reaching recommendationsand its detailed suggestions for adjustments. Thedecisions of the conference of miners, to be held atthe end of the week, if a forecast may be held to havebeen made by the leaders, may result in opposing themethod of a revision of wages by negotiation, leavingthe responsibility here to the employers. A resolu-tion to this effect would not be tantamount to arejection of the Report of the Commission, but itshould bring home to the community, unfortunatelyonly within three weeks of the cessation of the sub-sidy, how anxious is the impending crisis.With these large general questions we are all

acutely concerned, but, in considering the Report ofthe Royal Commission, the following comments areconfined to the recommendations more especially andimmediately concerning the safety and health of theminers. Whatever the general issue of discussionthat must now be pursued until great decisionsare arrived at, the Report of the Royal Commissionis bound to exert a far-reaching influence on the ’,sanitary conditions under which the work is done. ’iWhatever be the final results of negotiations on I,such matters as minimum and subsistence wageagreements, the broad and understanding surveyprovided by the Report of our most importantindustry, and our largest industry after agriculturewill bear good fruit. Conditions much hinted at,much surmised, and now and again demonstrated bythose who know, have become comprehensible to thepublic. Although, as was inevitable, the technicaland economic aspects of the industry have receivedthe greatest share of consideration, the human factoris kept steadily before us in valuable sections of thedocument. Thus, while State ownership of minerals,amalgamation of neighbouring mines, combinationwith allied industries, fuel research, reorganisation

Iof distribution, guarantee of quality, and pooling ofrailway wagons are all recommended, the Commis- isioners also advocate: the formation of pit com-mittees by whom other things than wages may benegotiated ; the introduction of a family allowancesystem ; obligatory profit-sharing by the workmen ;proper provision of houses as a condition of lease for Iall new collieries ; the establishment of pithead Ibaths ; and annual holidays with pay. Every one ’,of these recommendations, which but a few years ’,ago would have been deemed revolutionary, andwhich certainly involve principles which are applicableto other industries, must command the support ofmedical men. The family allowance, for long advo-cated by Miss ELEANOR RATHBONE, would improvethe wage system in exactly the way most promising ’,

to the health of the employees, but improved housingshould come concurrently.The Commissioners recognise in frank terms that

the industry presents for investigation and observationfacts and factors so far hardly realised. More than

1,000,000 men and lads are employed under workingconditions which, while broadly alike, differ in minordetails on the separate coalfields. The mortalityexperienced by coal-miners is fairly low ; yet theLancashire miner, with the South Wales miner notfar behind, has a mortality nearly double that ofhis fellow in the Nottingham area. Now the Lanca-shire and South Wales miners have always mani-fested the greatest unrest as a class ; unrest in the

industry appears therefore quite clearly as a psycho-logical expression of ill-being. The time at the

disposal of the Commissioners was too short for themto await the result of investigations into such matters-to be conclusive, a research of years rather thanof months would have been necessary-but therelation of unrest to mortality must be borne inmind as a practical as well as a humanitarian argu-ment for reforms. Apart from accidents and industrialdiseases there is no evidence to show that mining isnot a healthy occupation. But the mining industryholds an unenviable priority with regard to theincidents and accidents for which compensation ismade, as well as for occupational diseases, and thework already undertaken by the Medical ResearchCouncil should be recalled in connexion with the

Report. An expert committee of the Council hasalready issued reportson many diseases incidental tominers, and is continuing its researches into miners’nystagmus, which accounts for more cases, and a

larger sum paid out every year, than all other com-pensation diseases taken together. The conclusionshere do not clash with those arrived at by Mr. POOLEYin an article which we publish this week, and allobservers seem agreed to consider the pathology of thedisease still not clear, and its occurrence not of thesinister importance that might seem postulated by themoney paid in compensation. Beat-knee, -hand, and- elbow, which stand respectively second, third andequal fourth with lead poisoning in the list of occupa-tional diseases, have also been considered by theMedical Research Council’s committee, and an inquiryinto the relation of lost time to sickness at differentcollieries is under weigh. Another research is dis-closing the existence, previously only dimly suspected,of silicosis among a small group of underground menwho use pneumatic drills on hard rock ; while the

physiological conditions of underground ventilationare also being closely studied. Meanwhile the Safetyin Mines Research Board, financed from the WelfareFund, is covering a wide and comprehensive field ofresearch aimed at preventing explosions and render-ing mining work less dangerous. The activities

inaugurated by the Fund are praised by the Com-missioners ; already their influence can be traced inbetter relations existing between employers andemployed.We are sure that the connexion between mortality

and unrest has always been of profound importanceto the industry. The successful dealing with themanifestations of industrial disease, and the estab-lishment of pithead baths throughout the coalfields,will go far to improve the physical and mental

well-being of the miners, of whom to-day only some8000 out of the 1,000,000, going below ground daily,have the chance of a bath at the pithead, but fromthe sanitary point of view the housing question isthe outstanding one. To set the foundations of theindustry firm economically will tax the ingenuity

770 THE RISKS OF HYPOTHESIS.-THE CARDIAC CLINIC.

of all concerned as well as their willingness to makesacrifices, but no economical reform which fails totake the health of the miner into consideration hasthe slightest chance of life, and but little chanceof being born alive. How far the various patho-logical conditions are due to or are promoted by badhousing, and what relation there may be between badenvironment and the occurrence of accidents, can

only be subjects of rough estimate. The numerous

points could not well be summarised to make a

reference for a body of expert inquirers, but apartfrom the quite possibly mischievous influence ofbad housing upon the mining industry, in particularall medical men will feel that the housing conditionsof the miners must be remedied. These conditionsare often very bad. The Report sets out what isindeed common knowledge. Many of the old miningvillages consist of poorly constructed cottages, smalland frequently overcrowded, with sanitary arrange-ments that are primitive and inadequate. This, thoughshocking, is readily to be understood when we rememberthat the mining village was often built to serve atemporary purpose ; and it is right to say here thatsome of the new colliery companies have planned forthe miners well-constructed and well-equipped gardenvillages, while in districts where the housing is usuallypoor there may be found groups of excellent new

cottages built by enterprising proprietors or localauthorities. In certain collieries the influence of thefree colliery house is baleful; the great majority ofthese houses are atrocious, and. they have set a lowstandard for the whole of the housing in Northumber-land and Durham. There is thus every gradationbetween good and bad housing, but the merits of thegood do not cancel the evils of the bad. The necessityfor a levelling-up of the housing conditions of minersis paramount, and we trust that it will be kept steadilyin the minds of those who have now to deal with theanxious and complicated situation.

THE RISKS OF HYPOTHESIS.IN his Goulstonian Lectures, which are appearing

in our columns, Dr. BERNARD HART opens upa wide subject when he lays down principles bywhich the claims of scientific hypotheses, especiallyconcerning psychopathology, can be tested andappraised. Mankind has an innate desire to know,and in satisfaction of this desire the most primitiveraces produce speculations belonging to the conceptualas opposed to the perceptual level. There is everygradation between the simple speculation of the

savage and the complex hypothesis of the man ofscience ; each is arrived at by the pressure of the samepsychological motive, each would appeal to thetribunal of experience, and in the case of each there isfelt a sense of power when a new generalisation is made.Danger lies in this sense of power, for its gratificationmay lead to a specious appearance of knowledge whenknowledge has not yet been attained ; the man whobelieved thunder to be the voice of an offended deityprobably felt immensely superior to the ignoramus wholacked that explanation.

Dr. HART, perhaps, had in mind such a danger whenhe warned us that the desired consummation of reduc-ing the concepts of psychology to the wider conceptsof physiology is brought no nearer by pretending thatit has been attained. He gives the three successivesteps, as enunciated by KARL PEARSON, which dis-tinguish the scientific method, and makes the claimthat it is the method, not the material handled, whichcharacterises science. These steps are the collection

of facts, their classification, and finally the constructionof conceptions which serve to explain them. Scientificcanons, ensuring that each step is kept in close contactwith observation, are needed to check the primitivetendency to believe that any hypothesis is better thana confession of ignorance, for at each step there maybe only a semblance of scientific method ; the facts

may be wrongly observed, their collection may beinadequate, and the generalisations may be premature.Perhaps the commonest error has been to leap to afinal conception before the observation and collectionof facts are sufficient, and this error plainly arisesfrom the strong desire to believe that we know. Whenwe act upon such a premature hypothesis, our resultsare probably futile and the greatest evil may lie inthe arrest of inquiry. A notable result of the hurriedleap to a conclusion is found in the case of hysteria.Attributed, on observations not entirely baseless, tothe wanderings of the unsatisfied uterus, hysteriacame to be treated with evil-tasting drugs intendedto drive that organ back to its proper place, and,although this therapeutic aim has been lost, the use ofthe drugs has survived. A fuller collection of the factsupon which the theory was thus inadequately basedmight have led our professional forbears to anticipatesome of the findings of modern psychopathology, butit is likely that even in the days of GALEN there was atendency to seek in physiological terms for a satisfyingexplanation of psychological phenomena. Suchsurvivals as lunacy, melancholia, and hypochondriaindicate the range of this tendency, and the use ofconcepts like nerve exhaustion and brain fag stillsatisfies the desire to believe we know the unknown.

Yet, as Dr. HART points out, we are not preventedfrom using a working hypothesis which is independentof phenomenal reality. Although its existence is nota fact of experience yet the scientific conception ofthe ether is most fruitful ; and the theory of theindivisible atom produced discoveries which led toits own downfall, thus demonstrating, by a curiousparadox, at the same time both its value and its

invalidity. Psychology, like other sciences, has

produced numerous hypotheses. Faculty psychologyhas proved barren; intellectualist psychology hasproved erroneous ; instinct psychology provides littlemore than a collection of algebraic expressions usefulfor resuming facts under convenient headings;suggestionist psychology, as Dr. HART shows, hasproved disastrously soothing. It seems that the

hypothesis of the unconscious has now become fruitfulafter a long period of relative futility. Framed toaccount for curious phenomena which fell outside thebounds of ordinary rational experience, it received nofurther definition for many years until FREUD foundit indispensable to explain a large number of newlyobserved facts. It is certainly free from the appealto a desire for easy explanations, and, though thisplaces it at a disadvantage when confronted by morefacile hypotheses expressed in terms of the concrete,yet this freedom should encourage us not to evade itsdifficulties in favour of more alluring, because morefacile, speculations.

THE CARDIAC CLINIC.WE referred recently to the work of the American

Association for the Prevention and Relief of HeartDisease and to their official publication, the AmericanHeart Journal. In the New York State J o1lrnal ofMedicine for Nov. 1st, 1925, Dr. JOHN WYCKOFF dis-cusses the scope and organisation of clinics for thetreatment of cardiac cases. He points out that any

771JOINT TUBERCULOSIS COUNCIL.

special clinic must necessarily overlap fields ofmedicine other than that to which it is particularlydevoted, and consequently it is essential for the

cardiac clinic to be in close touch with other depart-ments, such as the venereal clinic, the oto-laryngo-logical clinic, and the dental clinic. In addition, thereshould be available the laboratory facilities of a largegeneral hospital, both for pathological investigationsand for special studies, such as X ray and electro-cardiographic examinations. Dr. WYCKOFF emphasisesthe importance of close association of the clinic withan in-patient department, not only in the interestsof the patients, but also on account of its instructivevalue in enabling the young physician to study thedifferent aspects of heart disease. As he aptly putsit, " in the ward one sees but a small cross-section ofthe cardiac’s life, whereas in the ambulatory clinicone learns the course of chronic heart disease, its

management and treatment." Very few, if any,

physicians can hope to keep in close touch with therecent advances in all fields of medicine, and if patientsare to get the benefit of these advances, specialisationis a necessity. On the other hand, the specialist mustwork in the closest cooperation with those of his

colleagues whose interests lie in other fields.The functions of the cardiac clinic are to keep the

ambulatory patient with organic heart disease in thebest possible health for as long a time as possible ;this involves first a full and accurate diagnosis and,secondly, treatment. The diagnosis comprises notmerely the structural and functional considerations,but also a careful survey of the social conditions,environment, and habits, as well as the financialstatus and responsibilities of the patient. Unlessthese latter points receive due consideration, theactual medical treatment cannot yield the bestresults. For this purpose the staff of the clinic haveto rely principally on the social service branch, whosemembers visit the patients in their homes and arein a position to furnish the necessary information onthese points to the medical officer. In order that thesocial service workers may not waste their time in

attempting to cover too wide an area, any one clinicshould confine its attentions to such patients as livewithin easy range of the hospital, and when a patientmoves his residence he should be transferred to anotherclinic. The staff of the clinic includes a clerical section

composed of lay workers, whose duty it is to relievethe medical staff of all non-technical matters, and tofacilitate the following up of cases and statistical Iresearch by an efficient system of record-keeping andcross-indexing. As cases come up for re-examinationit should be possible to obtain the latest data concern-ing their progress and the results of previous treatment,in order that these may be carefully reviewed beforethe future line of treatment is decided upon. A regularroutine in the examination of patients is essentialwhere large numbers of patients are being dealt with,and the method which has been adopted at the BelleVue Hospital is as follows. At the first visit thepatient’s history is taken, he is examined, andtemporary treatment is instituted. The social serviceworker then visits his home. The following weekspecial examinations of the nose and throat, electro-cardiogram and X ray are made, while on his thirdvisit he is seen by the dentist, and the physician incharge has at his disposal the full informationnecessary to enable him to institute a permanent lineof treatment.

Dr. WYCKOFF raises an important point with regardto the transference of patients from the children’s

to the adult clinic. It is at this stage that patientsare most liable to be lost sight of, and he suggeststhat the best remedy is to form an intermediateadolescent clinic which will take them over at theage of 16 and subsequently transfer them to the adultclinic at the age of 18, when they are more likely torealise the importance of continuing their attendance.The writer points out the importance of differentiatingbetween cases which are likely to benefit from a periodin a convalescent home from those which cannot haveany reasonable hope of building up their cardiacreserve by convalescent treatment. For althoughthese latter may be able to live within their cardiacreserve for several months while at the convalescenthome, sooner or later they are bound to become bedcases. They occupy accommodation at the con-

valescent home without the prospect of deriving anycorresponding benefit therefrom, and provision shouldbe made for them in the form of a hospital forpermanently disabled.The work which is being done by the cardiac clinics

in America is of economic value. It enables those whoare the subjects of heart disease, but still able to work,to obtain expert advice and treatment, and so

diminishes the wastage from this cause during themost productive period of life. v

THE JOINT TUBERCULOSIS COUNCIL.IN the general development of tuberculosis work

which followed the provision of sanatorium benefitand the appointment of tuberculosis officers a needwas apparent for close cooperation between themany and varied bodies and individuals concerned.But such cooperation, with resulting coordinationof effort, was not by any means easily attainable.Although consultants, tuberculosis officers, researchworkers, medical superintendents of sanatoriums, andothers all had their own circles of interest and infor-mation, those circles and their societies had fewopportunities for effective joint discussion of commonproblems or for common action. In order to meetthis state of affairs the Joint Tuberculosis Councilwas set up, and has gone far to remedy the defectsof organisation. The Council comprises representa-tives of practically all societies, associations, andGovernment departments aetively concerned intuberculosis work. It meets quarterly, or more oftenas may be required, and the considerable amount ofwork it has done since its inception in March, 1924,shows that the meetings are not merely formal. A

special committee has taken in hand projects forcollective research, keeping in touch with the MedicalResearch Council. Post-graduate courses have beenheld (some of which are announced on page 790),and are being further developed. Evidence hasbeen given before the Royal Commission on NationalHealth Insurance ; and such subjects as the employ-ment of tuberculous persons have been considered inpractical detail. The whole object of, and justifica-tion for, the Council is the attainment of cooperationand coordination amongst all tuberculosis workers.With such an object and such practical evidence ofuseful work already performed the Council is to bewelcomed as a valuable addition to the antituber-culosis forces of the country. Sir HENRY GAUVAI-Nis the chairman, and Dr. E. WARD the hon. secretary.

AN election to the Council of the Royal College ofSurgeons of England will be held on Thursday,July 1st, 1926. There are four vacancies, and thefollowing 12 have signified their intention to becandidates : Mr. E. W. Hey Groves, Sir HerbertWaterhouse, Mr. Warren Low, Mr. W. E. Miles,Mr. H. J. Paterson, Mr. Victor Bonney, Mr. J. P.Lockhart-Mummery, Mr. Philip Turner, Mr. C. A. R.Nitch, Mr. Hugh Lett, Mr. G. Grey Turner, and Mr.C. C. Choyce. Prof. Hey Groves, retiring from theCouncil in rotation, is standing for re-election.