Chicago, Illinois, United States
|A coal miner without a headlamp digging an undercut at the coal face, using only the dim light supplied by a small flame lamp. From Snell 12|
It’s dark as a dungeon and damp as the dew,
Where the danger is double and pleasures are few
Where the rain never falls and the sun never shines
It’s dark as a dungeon way down in the mine.
From the song “Dark as a Dungeon” – Merle Travis
Nystagmus is a repetitive oscillation of the eyes. It may cause blurred vision with an illusory motion of the environment that may be temporarily disabling (for instance as a feature of true vertigo). Its main significance is as a readily apparent diagnostic sign of a potentially serious abnormal condition of the eye, the inner ear, or the central nervous system. A recent authoritative textbook lists the intimidating number of forty-six different types of nystagmus.1 It then selects one particular type—“miners” or “occupational”—for a footnote with the curiously enigmatic phrase “may not exist.” The reader immediately wonders what this means, especially since the condition was given considerable space in the textbooks of the twentieth century until the 1970s, when it was almost completely dropped without explanation. Rarely is an entity given such respect at one time, only to be given short shrift and ignominiously cast aside later. And thereby hangs a tale.
Coal miners’ nystagmus was one of the first occupational illnesses recognized as being caused by a hazardous working environment. Ostensibly the cause was the perpetually dim light with which the miner was forced to operate. This was likened to the nystagmus of experimental animals raised in the dark, or to children born with dense cataracts that prevented the formation of a clear image on the retina, and who thus never developed the reflexes needed to stabilize the eyes. Extended study of affected miners could not reveal any underlying disease process in the central nervous system or inner ear. As electric lighting became widely available and lighting conditions improved in the mine, this type of nystagmus became rare after World War II. 2
But the coal miner’s work site had worse hazards than dim light. It 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, backbreaking, dangerous, and deadly. A long workday without being able to stand erect made it an advantage to be short. Explosions were a constant danger where the tunnels were not adequately ventilated and pockets of methane could be ignited by the bare flame of candles or oil lamps. Pockets of carbon monoxide or oxygen-deficient air could be encountered unexpectedly and suffocate an unsuspecting miner in seconds. Collapse of tunnel roofs, fires, and flooding could kill whole groups of miners in a single stroke. Mine accidents took the lives of 1,000 coal miners a year in Britain a century ago. The whole environment was even more dangerous in the United States, where safety standards were poorly enforced and the death rate was more than three times that of the United Kingdom, France, or Belgium. Even if an accident was not fatal, it often left the miner maimed for life. By the time he had put in many years in the mines, it was the rare miner who had not observed or been an actual part of some mine catastrophe.3,4
Symptomatic coal miners’ nystagmus was relatively common in Great Britain but rarely diagnosed in the US. Yet working conditions in the coal mine were much the same, if not even more hazardous in the US. What accounted for this disparity? This question evidently was never seriously dealt with in print, although it was surely a case of the Holmesian hound that did not bark in the night.
The answer was the different attitudes of government in providing for the injured workman. In Great Britain, a form of government-mandated workmen’s compensation was introduced in 1906. Coal mining was also a major industry in the US but its labor history was very different, with violent confrontations and much less sympathy from the government for the injured miner.
Before the enactment of workmen’s compensation in Britain, the injured miner had to file suit against the mine owner, a process subject to all the vicissitudes of the court system, to establish employer liability before compensation was paid, much like what is currently the case with medical malpractice. A no-fault system of liability was established in Britain that proved advantageous to both mine owner and miner. Government commissions then set regulations and payment scales not only for injuries but also for disease. By listing or scheduling a disease as being caused by unavoidable exposure to the work environment, coverage was extended to diseases incurred in the line of work.5,6
The basic problem with miners’ nystagmus in Britain was the conflation of an objectively seen eye defect—nystagmus—and a group of secondary manifestations into one “disease” called “miners’ nystagmus.” Originally in cases involving a coal miner, nystagmus had to be manifest. The requirement that actual nystagmus need not be present was passed by a parliamentary commission in 1913, in what was probably a contentious and acrimonious session with:
“much divergence of opinion and experience . . . [T]he term ‘nystagmus in the process of mining’ should be replaced by ‘the disease known as miner’s nystagmus’, whether occurring in miners or others, and whether the symptom of oscillation of the eyeballs be present or not.”7
This change extended the scheduled disease to include other manifestations. At that point, the incidence of new cases each year began to climb rapidly, and by 1938 it is said that 1.4% of all underground miners in the United Kingdom were affected, a heavy burden to the system. Physicians in Britain were right in the middle of the problem because they had to certify the presence of miners’ nystagmus for the worker to claim disability. In this they were acting as mediators between the state, the courts, and the individual; an uncongenial role for physicians, but they thus brought to light a problem that could well have been ignored, as it likely was in the US at the time.
The British physician tended to diagnose “miners’ nystagmus” when confronted by a symptom complex that included giddiness, insomnia, depression, 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. To be compensable, it could not be anxiety reaction or neurasthenia or some other psychiatric term. “Miners’ nystagmus” it had to be.
Much effort went into proposing purely organic pathologic mechanisms for the clinical picture. British physicians of the time were not obtuse. They recognized psychogenic elements but were generally unwilling to accept purely psychological explanations, partly for the social stigma involved, although Britain after 1914 became very much aware of the shell shock or war neuroses induced by the unprecedented viciousness of trench warfare.8 They generally were adamant in denying that these men were malingering. Certainly if one looks at the paltry sums the miners were paid for disability, the money does not seem to be much of a motive. Also, a claim for disability held a good deal of risk for the miner. Usually these men had been many years in the pits before symptoms disabled them, and they usually improved in three to six months if they could spend days and nights above ground. However, benefits were paid for only a limited time. Still, the diagnosis of miners’ nystagmus gave these men, consciously or unconsciously, a socially acceptable excuse to get out of the mine, at least for a while.
One might well ask: of what earthly use is there in discussing an obscure and (yes!) minor eye condition that was rarely diagnosed in the United States? Does it give any insight into the continuing problem in medicine of how to deal with patient symptoms for which no organic abnormality can be demonstrated? Chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, Gulf War illness, and premenstrual dysphoria, for example, are still puzzling conditions with no clear pathogenesis. Even defining these entities is problematic. The distinction between a hysterical conversion syndrome and malingering continues to be vexing, especially in military medicine. Chronic posttraumatic stress disorder, a term criticized by some as medicalizing normal human emotions, is however real enough today to account for the shockingly high suicide rate in returning combat veterans.9-11
So coal miners’ nystagmus was eventually dropped from the medical literature. But “may not exist”? Perhaps, in a narrow sense. But “coal miners’ nystagmus” did exist at one time. Was it real? Yes, it was real, as real as all the other hardships that assailed these men when they went underground.
- Dell’Osso LF, Daroff RB. Nystagmus and saccadic intrusions and oscillations. In: Glaser JS, ed. Neuro-ophthalmology.3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:371
- Fishman, RS. Dark as a Dungeon: The Rise and Fall of Coal Miners’ Nystagmus. Arch Ophthalmol. 2006. 124: 1637-1644
- Freese B. Coal: A Human History.London, England: Penguin; 2003
- Long P. Where the Sun Never Shines: A History of America’s Bloody Coal Industry.New York, NY: Paragon House; 1989:29.
- Bartrip PWJ. Workmen’s Compensation in Twentieth Century Britain: Law, History, and Social Policy.Aldershot, England: Avebury; 1987.
- Bellamy PB. A History of Workmen’s Compensation 1898-1915: From Courtroom to Boardroom.New York, NY: Garland; 1997.
- Allbutt T, Ruegg AH, Legge A, Griffith EJ. Report of the Departmental Committee Appointed to Inquire and Report Whether the Following Diseases Can Properly Be Added to Those Enumerated in the Third Schedule of the Workmen’s Compensation Act, 1906; Namely: (1) Cowpox; (2) Dupuytren’s Contraction; (3) Clonic Spasm of the Eyelids, Apart From Nystagmus; (4) Writers’ Cramp.London, England: HMSO; 1913;18:649.
- Shephard B. A War of Nerves: Soldiers and Psychiatrists 1914-1994. London, England: Pimlico; 2002.
- Komaroff AL.The Psychopathology of Functional Somatic Syndromes by Peter Manu[book review]. N Engl J Med.2004; 351:2777-2778.
- Hyams KC. Developing case definitions for symptom-based conditions: the problem of specificity.Epidemiol Rev.1998; 20:148-156.
- Rogers R. Malingering of posttraumatic disorders. In: Rogers R, ed.Clinical Assessment of Malingering and Deception. 2nd ed. New York, NY: Guilford Press; 1997:130-145.
- Snell S. Fatigue of ocular muscles owing to constrained attitude at work as the main cause of nystagmus. Br Med J. 1892; 2:838-839.
RONALD S. FISHMAN, MD, is a retired ophthalmologist and currently a visiting professor in history of medicine at the University of Illinois in Chicago. He has written over fifty articles, book chapters, and other publications on the history of ophthalmology.