Dark As a Dungeon: the Rise and Fall of Coal Miners' Nystagmus

SPECIAL ARTICLE Dark as a Dungeon The Rise and Fall of Coal Miners’ Nystagmus

Ronald S. Fishman, MD

oal miners’ nystagmus was one of the first occupational illnesses ever recognized as being due to a hazardous working environment. It aroused great concern and much controversy in Great Britain in the first half of the 20th century but was not seen in the United States. Miners’ nystagmus became a significant financial problem for the BritishC workmen’s compensation program, and the British medical literature became a forum for speculation as to the nature of the condition. Although new cases of miners’ nystagmus were rare after World War II, the condition continued to be discussed in textbooks through the 1970s, after which it abruptly disappeared without any authoritative summing-up, and thereby hangs a tale.

MINERS’ NYSTAGMUS IN tion of miners’ nystagmus appears, in NEURO-OPHTHALMIC TEXTBOOKS Cogan’s typical style—concise, clear, confident: The authoritative chapter on nystagmus, Miners’ nystagmus is...apendular nystag- written by Dell’Osso and Daroff in Glaser’s mus, an exceptionally fine and rapid one, oc- text Neuro-ophthalmology in 1999, lists curring in persons who work in poorly lighted 46 types of nystagmus in 3 columns oc- mines for long periods of time. It is much less cupying an entire page.1 Halfway down the frequent now that mines are better illumi- center column there is a listing called “min- nated. The nystagmus is accompanied by an im- pairment of vision that varies according to the er’s” with a subset called “occupational.” degree of nystagmus and occasionally by an A dagger leads the reader to a footnote illusory movement of the environment.... that consists only of the curiously at- tenuated and enigmatic phrase “may not The condition has been likened to that occur- exist,” from which the reader may justi- ring in animals reared in the dark. The progno- sis is favorable when the patient is removed to fiably infer “may never have existed.” quarters having adequate illumination. The footnote is obscure and provocative at the same time. The authors later give The amount of light at the coal face necessary miners’ nystagmus a few sentences in the to prevent nystagmus must be in the order of section on acquired pendular nystagmus, 0.1 Candle per square foot....Where power lines are not available this light is adequately but nothing else. Miller’s 1985 edition, supplied by cap lamps, and where these are Miller and Newman’s 1998 5th edition, used, as in the United States, miners’ nystag- and the 2005 6th edition of Walsh & mus is practically nonexistent.6(p192) Hoyt’s Clinical Neuro-Ophthalmology do 7 not mention miners’ nystagmus at all,2-4 Walsh and Hoyt in 1969 devoted and neither does the excellent book by 4 columns to miners’ nystagmus; the Leigh and Zee.5 So miners’ nystagmus treatment is essentially a duplication has almost disappeared from modern of Walsh’s first 2 editions in 1947 and textbooks. 1957: This contrasts with its treatment in The cause of miners’ nystagmus remains Cogan’s classic Neurology of the Ocular disputed.... 6 Muscles, a text that taught many of us our The affection is usually considered as “func- neuro-ophthalmology and may still be read tional” but it is not proven that a pathologic with profit. There the following descrip- background does not exist....

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Since the occurrence of nystagmus with- What happened? What was go- headlamp supplied the main illumi- out symptoms is high among British ing on here? nation at the coal face11 because it miners it would be difficult to explain could be placed as close as possible the condition simply as a manifestation THE TECHNIQUE to where he had to see. Larger lamps of a neurosis. General symptomatology OF COAL MINING could be placed on the floor nearby is that of neurasthenia. There is complaint of dizziness, headache, and but were not heavily relied on. weakness...;photophobia ...; Coal had been used in ancient Rome, The favorite source of light tremors [of] . . . eyelids ...,head ..., but it was the advent of the steam through most of the 19th century and hands....7(p278) engine that greatly increased de- well into the 20th century was an oil mand for the fuel and made fea- lamp, whose wick could maintain a Now we hear a more complicated sible the deep-shaft mining of the last flameforprolongedperiods,adistinct story in a more uncertain voice: “re- part of the 19th century and the first improvementoverbarecandles.How- mains disputed,” “not proven,” “dif- part of the 20th, when most cases of ever, the bare flame could easily ig- ficult to explain.” miners’ nystagmus were noted.9 nite an explosion if it encountered Even more ambivalent was the Access to the veins of coal usu- pockets of methane. In 1816, Sir 8 work of Duke-Elder and Wybar in ally required a long approach Humphrey Davy invented a safety the multivolume System of Ophthal- through a vertical or horizontal shaft lamp by enclosing the flame in a me- mology series, in its day considered and from there through a warren of tallic meshwork that bled off the heat the encyclopedia of clinical ophthal- rooms and walls to the active coal beforeitreachedtheignitiontempera- mology. The authors were British, face. When a new area of the coal ture of methane. The dimensions of and in 1973 they devoted 6 pages to vein was to be exploited, an ap- the mesh were crucial because the miners’ nystagmus: proach tunnel was dug, shored up open pores had to be small enough The aetiology of the disease is with timbers, and the coal face un- to provide enough metallic surface to disputed.... dermined by creating a cleft as low absorbtheheatadequatelybutnottoo as possible near the floor. The small as to greatly diminish the . . . one important cause is lack of illu- “holer” or “undercutter” was a man amount of light emitted. The Davy mination at the coal face.... with some skill with a pickax and lamp had an added utility: when in- A second factor...isthecrouched and proud of it, since it often required flammable gas was encountered, the strained attitude of a miner at the coal wielding the ax while crouching or flame suddenly grew in intensity with face with his constant upward gaze at even while prone or lying on the a bluish color, and the miner thus had work which may disturb the vestibular side, striking the bottom of the coal a warning to clear the area before an apparatus and certainly brings about seam with a horizontal swing. If explosionoccurred.However,ifapar- physical and ocular fatigue. wedges pounded in high up on the ticular brand of lamp was not made A third factor may be the inhalation of coal face could not displace the coal to exact specifications, or was not noxious gases over long periods....[B]ut downwards, holes for explosives regularly cleaned, it decreased the in- possibly the most important factor of all were then drilled by hand in the up- tensity of light below a miner’s tol- is the mental make-up of the workman per layer. The blast then brought the erance. Thus, there was no unanim- himself, for many are unable to with- coal face down on the undercut. ity among miners as to the desirabil- stand the stresses of years of hard work With the undercut, larger and more ity of the Davy safety lamp. in an uncongenial environment wherein valuable pieces of coal were yielded There was a similar recalcitrance constant discomfort and occasional danger are too often evident....8(p820) when the upper area was dropped. in using battery-operated electric Some owners paid only for pieces light in the early part of the 20th Now the reader gets 4 “factors” and larger than a certain size, and this century. Batteries were relatively is further confused, usually a sign was important because miners at this large and heavy and were subject to that the writers are confused also. stage usually worked as indepen- failure at inopportune times. More That was in 1973. After that, for 26 dent contractors and were paid only popular was the acetylene light, years there is silence. British and by the bulk or weight of acceptable which gave a brilliant enough flame American ophthalmology journals coal that they produced.10 to make it also the choice for early had been silent since the 1950s. automobile headlights. The acety- Then in 1999 we get “may not ILLUMINATION lene torch is preferred at times even exist.” OF THE COAL FACE to this day by spelunkers, who are Textbooks encapsulate the wis- often drenched while exploring dom of the day and are always sub- Because the generally accepted caves and find their electric batter- ject to revision, but rarely is an en- major factor in the initiation of min- ies shorting out. Although electric- tity given such respect at one time ers’ nystagmus has been poor illu- ity provided better lighting, there only to be given such short shrift and mination at the work site, it is worth- was a certain inertia in the coal min- so ignominiously cast aside 2 or 3 while to take a moment to consider ing industry in accepting the inno- decades later, without explanation. how light was provided to the miner. vation. Electrical illumination was It’s as if an embarrassed fog had de- The albedo of the black coal face fairly standard by the 1930s (at a scended, as if there were a consen- was 7% to 8%, a very dark environ- time when there were still gaslights sus that it would be best to forget the ment that reflected little of the in- on some London streets). Because whole thing and move on. cident light. Normally the miner’s the ocular oscillations of miners’ nys-

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 tagmus usually took 2 or 3 decades of working underground to de- velop, new cases were uncommon by the 1940s.

WORKING CONDITIONS IN THE COAL MINE

The coal mine was arguably the worst working environment to come out of the Industrial Revolution, worse even than the dark satanic mills of the textile industry. The work was dirty, dark, damp, back- breaking, dangerous, and deadly. A long workday without being able to stand erect made it an advantage to be short. Many mines were infested with rats. Human waste disposal techniques were primitive, so the Figure 1. A “breaker” room in the Pennsylvania coal mines circa 1900, where children separated rock stench was pervasive. Explosions from the coal. Similar photographs of United Kingdom collieries show that the working environments were a constant danger where the were similar, even to the supervisor’s cane used to enforce attention to the task at hand. Reprinted from tunnels were not adequately venti- Roberts (1904).14 lated and pockets of methane could be ignited by the bare flame of of the “breaker” rooms, picking away WORKMEN’S COMPENSATION candles or oil lamps. Pockets of car- the slate and other rock mixed with IN THE UNITED KINGDOM bon monoxide or oxygen-deficient the coal that went past beneath them air could be encountered unexpect- on conveyor belts. Many of them The workmen’s compensation sys- edly and could suffocate an unsus- chewed tobacco to keep from swal- tem after the turn of the century in pecting miner in seconds. Collapse lowing the coal dust. Extant photo- the United Kingdom was a distinct of tunnel roofs, fires, and flooding graphs of breaker rooms attest to improvement over previous means could kill whole groups of miners in their similarity in the Pennsylvania of compensating workers for inju- a single stroke. Mine accidents in- coal mines and the UK collieries ries incurred on the job. This usu- volving rockfalls, machinery, explo- (Figure 1). Similar parallels ex- ally required workers to file suit sions, and being crushed by coal cars isted in mine construction and against the employer and prove his took the lives of 1000 coal miners a operation. negligence; the employer could de- year in Britain a century ago. The Manyexperiencedcoalminersfrom fend himself by asserting contribu- whole environment was even more England, Wales, and Scotland emi- tory negligence by the worker or his dangerous in the United States, grated to the Pennsylvania coal fields fellows or that the worker had where safety standards were poorly in the last half of the 19th century. known of dangers inherent in the enforced: a 1907 survey by the US Thus, at least part of the workforce in work and had therefore assumed re- Geological Survey revealed a death Britain and the United States was to sponsibility for any injury by accept- rate of 3.39 per 1000, more than 3 some extent genetically similar.14 ing employment. The process was times that of the United Kingdom, Although the working environ- subject to all the vicissitudes of the France, or Belgium.12 Even if an ac- ment and the genetic constitution of court system to establish employer cident was not fatal, it often left the the miners were similar, the preva- liability before compensation was miner maimed for life. By the time lence of miners’ nystagmus was not. paid, much like what happens cur- he had put in many years in the A survey of US miners showed that rently with medical malpractice. mines, it would have been the rare 1% to 4% had nystagmus, but al- Starting in the latter part of the 19th miner who had not observed, if not most all were asymptomatic. In the century, safety codes were enacted been an actual part of, some mine ca- United Kingdom, Llewellyn15 found specifying the responsibility of the tastrophe. (Incidentally, the rate of that 25% of underground workers employer to provide safe working fatal occupational injury in mining had oscillations, and although only conditions. Employers began to [23.5 per 100 000 employed] was 0.5% to 2% were symptomatic, the carry liability insurance and to be- still the highest of all industries in coal industry in Britain was so large come more interested in mine safety. the United States as late as 2002.13) and employed so many miners A no-fault system of liability was es- Well into the 20th century, the (more than a million) that when Brit- tablished that proved advanta- industry was a sinkhole of child la- ish claims for disability due to min- geous to both mine owner and bor. “Breaker boys” as young as 8 ers’ nystagmus became increas- miner. Government commissions years old were thought too small to ingly common after 1913, it became then set regulations and payment handle a pickax but not too young a heavy load on the entire work- scales not only for injuries but also to sit for hours in the dust and noise men’s compensation system. for disease. By listing, prescribing,

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 ary manifestations into one “disease” called “miners’ nystagmus.” The British physician tended to di- agnose “miners’ nystagmus” when confronted by a symptom complex that included giddiness, insomnia, de- pression, tremors of hands or head, lid tics (specified as “clonic spasms” in the regulations), headache, night blindness, photophobia, anxiety, and palpitations in a coal miner—even in the absence of nystagmus. When it came down to it, the nystagmus was not crucial. The whole symptom complex in a coal miner was due to the malign nature of the work in a susceptible individual. Figure 2. A miner digging the undercut at the coal face. The head had to be extended backward and the Voices unsympathetic to miners eyes kept in upward gaze for prolonged periods. This led to speculation that fatigue or disordered objected that money spent on dis- oculovestibular reflexes produced the nystagmus. Reprinted from Snell.22 abled miners raised the price of coal and made British coal less competi- or scheduling a disease as being Thus, coverage was extended to tive against foreign sources. But all caused by unavoidable exposure to “miners’ nystagmus” in 1906, origi- were caught in a logical bind due to the work environment, coverage was nally referring only to symptom- the contemporary definition of oc- extended to diseases incurred in the atic ocular oscillations. However, in cupational disease: if the disability 16-19 line of work. The court system 1913 the definition was changed to was due to a scheduled disease or to could still be used if an employer de- “the disease known as miners’ nys- illness even indirectly subsequent to nied that a certain case was cov- tagmus,” and this change in effect it, the worker was eligible for com- ered by the regulations. extended the scheduled disease to in- pensation just as much as if the dis- In the words of the parliamentary clude other manifestations. At that ability were due to an accident. commission on workmen’s compen- point, the incidence of new cases Physicians searched for purely or- sation, the criteria were as follows: each year began to climb rapidly, and ganic pathophysiologic rationales for by 1938 it is said that 1.4% of all un- [T]hose symptoms which were due to the clinical findings, and the dark- derground miners in the United ness model became the most popu- a cause which operated at a definite mo- 21 ment of time were regarded as the re- Kingdom were affected. One indi- lar for explaining the ocular oscil- sult of “accidents”; others were the re- vidual who experienced miners’ nys- lations. Some were taken with the sult of “diseases” or injuries not being tagmus was said to have been An- prolonged contortions, with the head injuries caused by “accident.” Two other eurin Bevan, who, as minister of held back at an angle,22 required of tests applied to any disease or injury con- health in the Labor Party govern- the miner at the coal face digging the sidered were (i) did it incapacitate for ment voted into power in 1945, was undercut, especially when the vein more than one week? and (ii) was it so instrumental in establishing the specific to an employment that the cause of coal pitched upward (Figure 2 cradle-to-grave national health ser- and Figure 3). It was hard then to could be established in individual vice of the postwar years. instances?20 resist the temptation to feel that dis- turbed vestibular reflexes or oculo- The requirement that actual nys- THE PHYSICIAN’S DILEMMA motor fatigue were involved. tagmus need not be present was Others recognized that there were passed by a parliamentary commis- Physicians in Britain were right in psychogenic elements but gener- sion in 1913 in what sounds like a the middle of the problem because ally were adamant in denying that contentious and acrimonious they had to certify the presence of these men were malingering (al- session: miners’ nystagmus for the worker though there undoubtedly were such It was suggested that miners suffering to claim disability. In this they cases). Certainly if one looks at the from clonic spasm of the eyelids had were acting as mediators between paltry sums the miners were paid for been refused certificates because they the state, the law courts, and the disability, the money does not seem did not exhibit nystagmus, ie. oscilla- individual, an uncongenial role for to be much of a motive. Also, a claim tion of the eyeballs. There was a con- many physicians and a factor that for disability held a good deal of risk siderable divergence of opinion and may help explain some of the acri- for the miner. Usually these men had experience....Theterm “nystagmus in mony that developed around the been many years in the pits before the process of mining” should be re- placed by “the disease known as min- diagnosis. symptoms disabled them, and they er’s nystagmus, whether occurring in The basic problem with miners’ usually improved in 3 to 6 months miners or others, and whether the symp- nystagmus in Britain was the confla- if they could spend days and nights tom of oscillation of the eyeballs be tion of an objectively seen eye defect— above ground. However, benefits present or not.”20 nystagmus—and a group of second- were paid for only a limited time. If

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 a recovered miner wished to re- sume work, and the only work his employer was willing to assign him was a return to the coal face, mine owners often resorted to various le- galisms to avoid continuing to em- ploy such a miner at all.23 Still, what the diagnosis of miners’ nystagmus gave these miners, consciously or unconsciously, was a socially acceptable excuse to get out of the mine, at least for awhile. There was a certain logic to all this, but it led to controversy and confusion. British journals were full of the discussion.24-64 A spirited ex- change of letters occurred in The Lancet in March and April 1940, just before blitzkrieg hit the British and French armies.65-67 After Dunkirk, miners’ nystagmus disappeared from the pages of The Lancet until 195162 and then disappeared for good. Figure 3. Closeup of eye position while undercutting. Reprinted from Snell.22 But miners’ nystagmus persisted in the textbooks. What could have This crucial question evidently was shock, or post traumatic stress disor- been done would have been to split never raised in print, although it was der....During the 1880’s, English phy- the condition in two: (1) a nystag- surely equivalent to the Holmesian sicians began to describe numerous cases mus in coal miners with subse- hound that did not bark in the night. of “traumatic hysteria”: men suffering quent blurred vision of a sort, illu- First, the US compensation system from physical symptoms and emo- sory motion of the environment, and tional distress after railway accidents for disability was just starting to rec- perhaps also head tremor (which is [which had exposed them to] fear, ognize industrial disease.69 But there common in acquired pendular nys- shock, and terror.... was also something else. The epide- tagmus due to brainstem or cerebel- miology of miners’ nystagmus in the And hysteria was a significant lar disease), and which in and of it- United Kingdom resembled that of burden on both sides of the Atlantic: self was infrequently symptomatic, a contagious disease. There were “in- and (2) another syndrome of vari- By the end of [World War I] 80,000 fected mines” just as there were “in- ous psychogenic dysfunctions with [British] men with shell shock or war fected regiments” with shell shock or without nystagmus and with a neurosis had sought medical help....In in World War I. Suggestibility is problematic relation to it. 1932, 36% of British veterans receiving common in those susceptible to hys- disability payments...werepsychiat- In effect, this is what Cogan did in teria, and there was surely a pool of ric casualties. In the USA, 58% of the pa- his textbook; he discussed the first such miners in both countries. Luck- tients in VA hospitals were neuropsy- and ignored the second. But the Brit- 70 ily the United States was far enough chiatric casualties of the Great War. ish physician could not do that. Only away from the United Kingdom— “miners’ nystagmus” was scheduled and without television—so as to es- WAS THERE A UNIQUE as a compensable disease—not anxi- cape spread of the contagion to sug- FORM OF NYSTAGMUS ety reaction or hysteria or neurasthe- gestible US miners. DOWN IN THE MINE? nia or any other psychiatric term. Showalter’s70 views on hysteria, “Miners’ nystagmus” it had to be. sometimes controversial, are par- Was there actually a core condition ticularly germane here: of nystagmus induced by pro- WHY DID THE UNITED STATES longed years of working at the ESCAPE THE EPIDEMIC OF Hysteria is a mimetic disorder: it mim- coal face in dim light? Leigh et al71 MINERS’ NYSTAGMUS SEEN ics culturally the permissible expres- write of miners’ nystagmus in their IN THE UNITED KINGDOM? sions of distress....[H]ysterical epi- discussion of acquired pendular demics require at least three ingredients: nystagmus: “Is there any point to which you would physician enthusiasts and theorists; un- wish to draw my attention?” happy, vulnerable patients; and appro- Miners’ nystagmus is a rarity, limited pre- priate cultural environments....Al- sumably to mine workers in the UK. It “To the curious incident of the dog in though male hysteria has been clinically is described as a small-amplitude, hori- the night-time.” identified at least since the 17th cen- zontal and vertical nystagmus that is of- “The dog did nothing in the night-time.” tury, physicians have hidden it under ten more pronounced in upward gaze. such euphemistic diagnoses as neuras- The pathogenesis of this putative dys- “That was the curious incident,” re- thenia, hypochondria, phthiarism, neu- function is uncertain but functional con- marked Sherlock Holmes.68 rospasm, Briquet’s syndrome, shell tamination with voluntary “nystag-

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 mus” is suspected; a secondary gain would trust the astuteness of these fibromyalgia, irritable bowel syn- setting is usually present.71 early observers. drome, Gulf War illness, and pre- menstrual dysphoria, for example, This supposes that voluntary nys- THE MORAL OF THE STORY are still puzzling conditions with no tagmus, usually considered a kind of clear pathogenesis.83 Even defining parlor trick by a few unusual indi- Of what earthly use is there in dis- these entities is problematic.84 The viduals, was much more common cussing the passing of an obscure distinction between a hysterical con- down in the pits than usually and (yes!) minor eye condition that version syndrome and malingering thought true of the general popula- was rarely seen in the United States? continues to be vexing85 especially tion72-77 (although one opinion, For one thing, miners’ nystagmus in military medicine. Chronic post- based on an informal study of a lives on in the many books and Web traumatic stress disorder, a term single sample, feels that some 5% of sites devoted to the history of the criticized by some as medicalizing the general population may have the coal mining industry and the sub- normal human emotions, seems to knack78). It also implies that most of ject of occupational disease gener- be so widely accepted today that the miners’ nystagmus cases were ally. A search of the Web via the psychological counseling is ad- malingering. Google browser in August 2006 re- vised for its prevention in victims not Yet what was Llewellyn15 seeing vealed 948 Web sites discussing min- only of war but also of crime and when he recognized nystagmus in up ers’ nystagmus, including the es- natural disasters.86-88 to a quarter of all veteran miners? teemed Dorland’s Illustrated Medical A recent appearance of miners’ Whatever it was, I doubt it could Dictionary, which repeats material nystagmus in the literature—in an really have been all a voluntary nys- from the textbooks of 30 to 40 years editorial actually labeled “Miners’ tagmus, no matter how mischie- ago. The International Classifica- Nystagmus”—appeared in of all vous his subjects were. tion of Diseases, Ninth Revision, lists places the Journal of Hand Surgery, Duke-Elder and Wybar8 cite ob- miners’ nystagmus (300.89) under where the author uses miners’ nys- servations of unilateral nystagmus, nystagmus (379.50) (and just after tagmus as an object lesson for mod- in which the movements were fre- nymphomania [302.89]).80 British ern physicians trying to deal with quently vertical, and dissociated nys- books from the interwar period re- hand pain in computer operators and tagmus, in which 1 eye had vertical fer to miners’ nystagmus when they other “repetitive stress [or strain] in- oscillations and the other eye had ro- attend to the hardships experi- juries” that rely on patient symp- tary movements, a bit too bizarre for enced by coal miners and their fami- toms alone and do not have demon- volitionalaction.Theyreprintanelec- lies. Orwell’s classic book of the strable abnormalities.21 tronystagmogram of 1 patient with 1930s on the British underprivi- Last, there is the behavior of the conjugate pendular movements but leged, The Road to Wigan Pier,81 medical literature, both then and do not indicate whether nystagmus evokes sympathy for the scourge of now. Miners’ nystagmus was ac- was sustained. That would have been miners’ nystagmus. A contrary view knowledged on both sides of the At- a crucial way of distinguishing it by Cronin in his famous novel The lantic Ocean to be a serious prob- from voluntary nystagmus, which is Citadel 82 berates miners for faking lem. The US Department of the rarely sustainable for more than a symptoms. Miners were certainly ex- Interior in 1916 commissioned a minute. ploited, but to present them as either monograph that dealt with miners’ It is useful here to read the ear- fakers or as subject to some devas- nystagmus at some length (with 8 liest reports of miners’ nystagmus, tating disease of the central ner- references from Germany, 11 from before the entity became common vous system does not make the best France and Belgium, 56 from the knowledge and controversial, case for them. United Kingdom, and none from the and when the miners themselves The story is also an example of United States), as if the Bureau of could be assumed to be more unso- how the social milieu influences the Mines was preparing itself for the phisticated about its implications. appearance and management of dis- other shoe to fall.69 Meanwhile, like The clinical findings as described ease. Without workmen’s compen- a camel with its nose under the tent in the early reports of the condi- sation and the ensuing litigation it flap and soon to occupy center stage, tion in the 1870s and 1880s do not occasioned, there may have been just pneumoconiosis was making a ten- impress the reader as a conspiracy as many distressed miners, but they tative and long-delayed appearance to confuse the examiners.26,27 would have come rarely to the at- in the literature.89-93 Also, a recent article79 from tention of anyone but a few physi- The British ophthalmic litera- Pakistan, in a context where work- cians, and those physicians would ture on miners’ nystagmus ex- men’s compensation was not a have had a harder time getting bet- tended more than 70 years. There likely factor, found nystagmus in ter lighting and other reforms ap- were panel discussions, letters to the almost 3% of miners, even suppos- plied to the mines. editor crossing back and forth, ar- edly with modern forms of illumi- More generally, there is the con- ticles on dark adaptation, color vi- nation underground. tinuing problem in medicine of how sion, binocular vision in miners, I think there probably was a to deal with patient symptoms for even the deliberate induction of nys- unique phenomenon down there which no anatomical or biochemi- tagmus in immature kittens62 and in in the darkness, and although now cal abnormality can be demon- a 7-month-old chimpanzee94 kept in we will never know for certain, I strated. Chronic fatigue syndrome, the dark for prolonged periods, and

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©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 cited to defend the miner with “nys- hardships that assailed these men 10. Long P. Where the Sun Never Shines: A History tagmus” from being automatically when they went underground. of America’s Bloody Coal Industry. New York, NY: Paragon House; 1989:29. deemed neurotic. The writing was It’s dark as a dungeon and damp as the 11. Pohs HA. Let There Be Light: The Miner’s Flame sober, earnest, and considered. Much dew, Light Book: The Story of Man’s Development of of it consisted of unvarnished clini- Underground Light. Denver, Colo: Flame Publish- cal impressions, with writers pro- Where the danger is double and plea- ing Co; 1995. moting their favorite theories and, sures are few, 12. Workmen’s Compensation Acts in the United States. The Medical Aspect. Washington, DC: Na- until relatively late, often failing to Where the rain never falls and the sun tional Industrial Conference Board; 1907. Re- distinguish ocular oscillations from never shines, search Report No. 61. the other manifestations. Only oc- 13. Bureau of Labor Statistics Safety and Health Sta- It’s dark as a dungeon way down in the casionally did the literature get to the tistics Program. Census of fatal occupational in- 60 mine. juries: fatal injuries. http://www.bls.gov/iif/oshcfoi1 core of the problem. (See particu- .htm. Accessed July 15, 2005. larly the eminently sensible discus- [From the song “Dark as a Dungeon” by 14. Roberts P. Anthracite Coal Communities. New York, sion by an anonymous psycholo- Merle Travis] NY: MacMillan; 1904. gist in 1940.95) Physicians of the time 15. Llewellyn L. Discussion on miners’ nystagmus. were not obtuse but were unwill- Submitted for Publication: Janu- Brit J Ophthal. 1925;9:545-556. ary 9, 2006; final revision received 16. Wilson A, Levy H. Workmen’s Compensation. Vol ing to accept purely psychological 1. London, England: Oxford University Press; 1939. explanations, partly for the social February 2, 2006; accepted Febru- 17. Somers HM, Somers AR. Workmen’s Compen- stigma involved, although Britain af- ary 7, 2006. sation: Prevention, Insurance and Rehabilitation ter 1914 became very much aware Correspondence: Ronald S. of Occupational Disability. New York, NY: John of the shell shock or war neuroses Fishman, MD, 47880 Cross Manor Wiley & Sons; 1954. 18. Bartrip PWJ. Workmen’s Compensation in Twen- induced by the unprecedented vi- Rd, Saint Inigoes, MD 20684 tieth Century Britain: Law, History, and Social 96 ciousness of trench warfare. One ([email protected]). Policy. Aldershot, England: Avebury; 1987. cannot avoid the impression that the Financial Disclosure: None 19. Bellamy PB. A History of Workmen’s Compensa- social implications of the problem— reported. tion 1898-1915: From Courtroom to Boardroom. trade unions vs mine managers, class Previous Presentation: This study New York, NY: Garland; 1997. 20. Allbutt T, Ruegg AH, Legge A, Griffith EJ. Report vs class, lawyers and press chiming was presented in part at the 18th an- of the Departmental Committee Appointed to In- in—induced much of the acrimony nual meeting of the Cogan Ophthal- quire and Report Whether the Following Dis- and made the calm and dispassion- mic History Society; April 10, 2005; eases Can Properly Be Added to Those Enumer- ate scientific voice harder to hear. Durham, NC. ated in the Third Schedule of the Workmen’s Acknowledgment: We thank Steven Compensation Act, 1906; Namely: (1) Cowpox; This then presented a grand op- (2) Dupuytren’s Contraction; (3) Clonic Spasm portunity for the authors of text- M. Fishman, MHS, of the Johns Hop- of the Eyelids, Apart From Nystagmus; books, and that opportunity was lost. kins University School of Public (4) Writers’ Cramp. London, England: HMSO; In the writing of a textbook, each au- Health for providing useful refer- 1913;18:649. thor strikes a balance between the ences on epidemiology. 21. Davis TR. Miners’ nystagmus [editorial]. J Hand Surg [Br]. 2001;26:399-400. urge to be all-inclusive when abstract- 22. Snell S. Fatigue of ocular muscles owing to con- ing the literature and the obligation REFERENCES strained attitude at work as the main cause of to qualify it with the author’s per- nystagmus. Br Med J. 1892;2:838-839. sonal opinion, so as to give the reader 1. Dell’Osso LF, Daroff RB. Nystagmus and sac- 23. Figlio K. How does illness mediate social rela- some guidance. Walsh and Duke- cadic intrusions and oscillations. In: Glaser JS, ed. tions? 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