Edgar Leigh Collis: Industrial lung disease and ergonomics

Introduction

In 1908, after ten years as His Majesty’s sole Medical Inspector of Factories, travelling the length and breadth of the country, investigating outbreaks of industrial disease from arsenic poisoning to zinc fume fever, Thomas Legge (1863–1932) felt that he needed some assistance. And his choice for the second Medical Inspector fell on Edgar Leigh Collis, who was then a general practitioner in Stourbridge in Worcestershire, and honorary surgeon at the local Corbett Hospital. Collis was also a certifying surgeon in which capacity he had inter alia to visit the factories for which he was responsible on a regular basis, investigate outbreaks of illness, and to provide reports on any accidents that resulted in a worker being away from work for more than 48 hours. Collis took a particular interest in the workers in the local fire brick industry, which almost certainly sparked his interest in industrial lung disease and it is possible that he and Legge had met on some occasions to discuss problems at the factory. Otherwise it is hard to understand why Collis was chosen; it was certainly not because of his research output since his only published work at that point had been as co-author of an account of renal disease occurring in two members of the same family. ¹

Collis was the fourth of seven sons born to William and Helen Collis. His father was a mining engineer, wealthy enough to have two or three servants living in the house. Collis started his education at the local grammar school from where he went to Charterhouse, subsequently following his older brother, Arthur, into medicine. But whereas Arthur went to Cambridge and Guy’s Hospital, Edgar chose Oxford and St Thomas’ Hospital. He gained a first in natural sciences at Keble College and was a considerable athlete during his time there: he was president of the Oxford Swimming Club, represented the university in athletics as a hurdler, and rowed in his college eight. From Oxford he transferred to St Thomas’ Hospital to complete his medical training, qualifying in 1896 having won the Bristow medal for pathology. At St Thomas’, he was a fellow student with John Shields Fairbairn (1865–1944) who was the son of Andrew Martin Fairbairn (1838–1912) the theologian and principal of Mansfield College, Oxford. John Fairbairn ² performed the singularly useful task of introducing Collis to his sister, Barbara, whom he later married in 1898 after establishing himself in general practice in Stourbridge.

Having joined the Factory Inspectorate in 1908, Collis began to specialise in industrial lung disease, having a particular interest in the pneumoconioses, especially silicosis and its relationship to tuberculosis. But, like Legge before him, and the medical inspectors who followed him, he also investigated whatever problems were brought before him by the non-medical inspectors, including the hazards of lead smelting, bronzing, tin plating, and the occurrence of Dupuytren’s contracture in lace makers.

With the onset of the First World War, Collis left the Factory Inspectorate and was appointed as medical director of the Ministry of Munitions. In 1918, he became a member of the Industrial Fatigue Research Board which had superseded the Health and Munition Workers Committee established during the war. ³ It was this last appointment that stimulated his interest in what he always referred to as industrial hygiene, but which is nowadays known as ergonomics, or human factors. This interest was undoubtedly stimulated by contact with Horace Middleton Vernon (1870–1951) and Leonard Erskine Hill (1866–1952). Vernon was a much more significant figure in the field, while Hill became professor of physiology at University College Hospital; both contributed chapters to a small book on industrial hygiene that Collis edited and published in 1920. ⁴ This was his first substantial publication following his appointment (in 1919) to the Talbot Chair of Preventive Medicine at the Welsh National School of Medicine in Cardiff, where he stayed until his retirement in 1933 at the age of 63. Collis made relatively little impact in this post, although he did re-introduce and update the Post Graduate Diploma in Public Health. The course attracted few students but many of those who did attend went on to occupy important posts in public health in Wales. ⁵ He was also able to combine his two principal interests – pneumoconiosis and ergonomics – by studying the health of coal miners.

Lossiemouth

Lossiemouth, a small town in the north east of Scotland overlooking the Murray Firth, was very important in the life of the Fairbairn family; they spent many of their summer holidays there, and Fairbairn senior built a large, detached house in the town – Blucairn – to which both he and his son John retired. At some point after Collis left the Inspectorate, he bought Tower House, a four bedroomed detached house that had spectacular views over the River Lossie, the East Beach, and part of the town below. It was here that he lived while he was working in Cardiff. How often he made the 570 mile journey back and forth to his place of work is unclear, but it most certainly could not have been very often, given the state of the roads, and the capabilities of motor cars at the time. It was a practice that was unusual enough to attract the attention of the local press, however, when the journey time was given as 40 hours. ⁶

Lossiemouth also provided a link with Ramsay MacDonald who had once lamented to Lord Elton that he had ‘[N]o close friend in the world’; ⁷ he certainly had one in Edgar Collis, however. We first meet Collis and MacDonald together, playing golf under the watchful eye of Sir Edward Troup who was then Permanent Under Secretary of State for Home Affairs, and technically Collis’s boss ⁸ – this must have been soon after Collis joined the Inspectorate. They probably also met on several other occasions in the town as it was to Lossiemouth that MacDonald repaired when he needed to recuperate from the rigours of political life. ⁹ Collis and his family spent time with MacDonald at Christmas, attended his parties, and MacDonald seems regularly to have ‘first-footed’ the Collis household. ¹⁰ Collis was active in trying to persuade the local council to erect a plaque on MacDonald’s birthplace, which he could see from Tower House, ¹¹ but this was not done until after MacDonald’s death in 1937.

Industrial lung disease

Unlike Legge, who was very much a generalist, Collis, like the majority of the medical inspectors who followed him, was encouraged to specialise in some particular aspect of industrial disease, and probably because of his early contact with the Stourbridge fire-brick workers, he chose to study industrial lung disease, especially silicosis, although he also published a significant paper on weavers’ cough, a form of asthma that occurred in cotton workers, although he incorrectly attributed the onset to moulds present on the cotton fibres; ¹² the true cause was not discovered until over fifty years later. ¹³

In the same year (1915), he was invited to give the Milroy Lectures in Public Health to the Royal College of Physicians of London, his subject being the industrial pneumoconioses, ¹⁴ concentrating especially on silicosis and its relationship to pulmonary tuberculosis, something not well understood at the time. When Collis became interested in silicosis it was not a notifiable disease but it attracted much attention because of the high death rates from what was then referred to as dust phthisis. Among some workers exposure to quartz dust accounted for over half the deaths at all ages. When Collis gave his Milroy Lectures, there was considerable confusion about the aetiology of the disease but the prevalent view was that it was an atypical form of pulmonary tuberculosis, having many of the characteristics of that disease, breathlessness, non-productive cough and weight loss, for example.

Collis was able to demonstrate high rates of tuberculosis in those occupations that involved exposure to free silica and he reported the results of a small-scale study that he had conducted among the flint knappers of Brandon in Suffolk. This trade had been practiced in Brandon since the invention of the flint-lock musket and Brandon was the main supplier of flints to the British Army. ¹⁵ Flint knapping in that part of the country had a very much longer history, however, since it was known to have been practiced in the Neolithic period, the flints coming from the local mines now known as Grimes’ Graves. Collis, almost certainly correctly, suggested that silicosis due to flint knapping was probably the oldest occupational disease.

Collis compared the rates of tuberculosis among the flint knappers with those of males from the Brandon rural district, with the rate in all males in England and Wales, and with that of the wives of the flint workers. Interestingly, he found that none of the wives had contracted tuberculosis thus ruling out the effects of any domestic or other shared environmental factors, but found a greatly enhanced risk among the flint knappers when compared with males from the Brandon area. Using the data in table 2 of his first Milroy lecture, the flint knappers had a thirty times greater risk of contracting pulmonary tuberculosis than the Brandon males. The death rate of the flint knappers was only slightly elevated compared with all males in England and Wales, however, which was not surprising given that this group contained many workers who were exposed to silica-containing dusts in other occupations, and that tuberculosis was the most common cause of death at the time. Collis subsequently investigated the prevalence of tuberculosis and other respiratory diseases among a group of silica brick makers, finding that they were about six times more likely to die from any respiratory disease than males in other occupations and almost eighteen times more likely to develop tuberculosis. ¹⁶ Collis supposed that silicosis somehow made individuals more prone to tuberculosis, an observation that has been amply confirmed since. ¹⁷

Collis continued his interest in the relationship between occupation and tuberculosis after he moved to Cardiff, reporting that, in his opinion, more than half the adult deaths from the disease were occupationally related, and specifically those in which exposure to free silica dust was involved. ¹⁸

By the mid-1920s, Collis was able to state that pulmonary silicosis was a well-recognised clinical and pathological entity and he compiled a list of occupations where the risk of contracting the disease was particularly high, including miners, stone masons, potters and grinders in the cutlery trade. Somewhat later, he conducted another survey comparing the mortality of workers exposed to silica with those exposed to non-silicaceous dust. This time he had the help of George Udny Yule (1871–1951) the statistician whom he had met during his time at the Ministry of Munitions. In this paper, they introduced the concept of the Comparative Mortality Figure (CMF) which nowadays is known as the Standardised Mortality Ratio (SMR). On this showing, tin miners headed the list with a CMF that was over four times greater than that of the randomly selected control group. Masons, pottery workers, and metal grinders also had elevated risks, but none as great as the tin miners. ¹⁹

By the skilful use of epidemiological data, Collis was able to differentiate silicosis from tuberculosis and since silicosis was more common in older workers he suggested that there was what he called a latent period between exposure to dust and the onset of symptoms. The concept of a latent period is now common to many types of occupational exposure, but Collis seems to have been the first to use the term. He also clearly differentiated between silicosis, and asthma, pneumonia, and bronchitis. He also showed that by no means all workers who were exposed to dust developed silicosis, no matter what the concentration. The determining factor was the presence of free silica in the dust and the prevalence of the disease varied directly with the concentration of free silica in the dust in the workplace. ²⁰

Collis became increasingly interested in tuberculosis itself and the disease was the major subject of the Harben Lectures that he delivered to Royal Institute of Public Health in 1924. He compared mortality rates in many countries including the United Kingdom, Ireland, Europe, and Japan, before finally returning to the ill effects of exposure to silica dust. ²¹ His last word on tuberculosis appeared after his retirement from the Cardiff chair. This was an account of its occurrence during the First World War, and written at a time when England was again at war with Germany. He showed that deaths from tuberculosis increased substantially from 1914 to 1918, due to changes in social conditions, and particularly to the impoverishment of the diet. After 1918, deaths from tuberculosis fell sharply but only because they were replaced by a much more fearsome disease, the great influenza epidemic. Collis used these data to warn about the possible consequences of the war that was currently underway, but the increase in the number of deaths from tuberculosis that he feared did not occur. ²²

Industrial hygiene

It was through the Industrial Fatigue Research Board that Collis encountered what was then referred to as industrial hygiene but nowadays would more usually be known as ergonomics or human factors. The theory was that if the conditions of work were well controlled – the temperature, lighting, noise and ventilation, for example – then the health of the workers would be maintained, they would be less fatigued, and their work would be of a high standard. The unions were of the opinion that the Ministry of Munitions was more concerned with output than with the health of the workers, and they were probably right, since it was crucially important that as many munitions were produced as possible given the rate at which they were being used on the Western front. ²³ Collis was never in the forefront of the development of the subject, Vernon and Hill were much more significant figures but he nevertheless contributed something. His first publication on the subject was the multi-authored book that he edited in 1920 – The Industrial Clinic. This was followed the next year by a much larger volume written with Major Greenwood (1880–1949), the medical statistician whom Collis knew from his work at the Industrial Fatigue Board. ²⁴ It covered many aspects of health and work including industrial legislation, industrial activity and fatigue, the prevention of accidents, the employment of women, nutrition, many aspects of the physical environment, the evils of alcohol – a pet subject of Collis’s – and various aspects of the application of statistics to industry. There was also, inevitably, a chapter on tuberculosis, and others on occupational cancer, and the prevention of accidents. Collis’s brother Arthur contributed a chapter on the rehabilitation of the disabled, something that had become necessary due to the great number of casualties resulting from the war. Collis wrote a few other papers on industrial hygiene, in one stressing the importance of fitting the worker to his job, and the job to the worker, perhaps the most important concept underlying the whole subject. ²⁵ He wrote about the future of factory medical services, suggesting that the examination of young people for work should be carried out by the local Medical Officers of Health, thus integrating local and factory medical services, something that never came to pass. ²⁶ And, inevitably, he wrote on industrial fatigue and tuberculosis, suggesting that chronic fatigue, especially in middle life, was an important factor in promoting the onset of that disease. ²⁷

Although Collis’s output on industrial hygiene was relatively small, it did attract some international attention and in March 1927 he and Barbara set sail for America bound for a lecture tour beginning at Harvard. None of the Harvard lectures is extant and it is not known how many were delivered. The end of the tour was marked by the DeLamar Lecture given at Johns Hopkins University on 21 March. The subject was ‘The Personal Factors in Coal Mining.’ This lecture has not survived either but it is unlikely to have been anything remarkable if the content was remotely like that of the Harvey Lecture given in New York two days earlier. This lecture – on Health and Activity ²⁸ – was of almost stupefying dullness being elementary in content and dull in delivery. The audience might well have felt cheated having been treated to the excellent Joseph Erlanger (1874–1965) on the action potential in nerves the month before. There were no further invitations to lecture thereafter.

Coal miners

It was inevitable that having moved to Cardiff, Collis would become interested in the health of coal miners, tens of thousands of whom worked in the Welsh coalfields. He co-authored a report on the ‘beat’ diseases of miners ²⁹ – various forms of bursitis caused by crawling through mine shafts to reach the coal face – but perhaps his major contribution was to show that non-silicaceous coal dust caused bronchitis and pneumonia, but not tuberculosis. ³⁰ The condition, now known as black lung, or miners’ pneumoconiosis, was not universally recognised until the 1950s, ³¹ and in this respect, Collis was well ahead of his time and he has never been sufficiently credited for this observation. In this paper, he also suggested that miners suffered from an excess of skin cancer, a finding that has not subsequently been confirmed.

Collis brought together his interest in occupational disease and industrial hygiene in a paper in which he discussed all aspects of the miner’s working life, ³² his nutritional needs, the diseases to which he was prone – nystagmus, the beat diseases, pneumoconiosis, and hookworm and Weil’s disease – the need for pithead baths, the baleful effects of alcoholism, his mortality, and even his fertility which Collis found to be unusually high, certainly in terms of number of children conceived. Also, unusually high were the number of accidents in the pits; indeed, the accident rate was exceeded only by those at sea, and he noted that the personal factor in the causation of accidents had been too little researched a matter that was not put right until much later.

Finale

Collis retired from his chair in 1933 at the relatively young age of 63, perhaps the long drive from Cardiff to Lossiemouth had become too much for him. He was not idle, however. He joined the Territorial Army with the rank of Lt Colonel and he was also appointed as a JP. He was also able to socialise with his brother-in-law and his wife, John Fairbairn having retired to Lossiemouth in 1936. Their houses were about a 15-minute walk apart and they would have enjoyed golf and gardening, perhaps swimming on the few occasions when the sea was not too unbearably cold, activities that would have continued until John Fairbairn’s death in 1944; his wife died just four years later. Ramsay MacDonald’s house, Hillocks, was a 5-minute walk from Tower House and no doubt the families met when MacDonald was in Scotland. Any social contact was, however, short lived, for although MacDonald had spent most of the summer of 1937 pottering about in Lossiemouth, he died suddenly of heart failure later in the year whilst on board a ship bound for South America. He was cremated at Golders Green crematorium and his ashes were taken back to Scotland to be buried in a grave overlooking the Moray Firth. ³³

Collis survived his brother-in-law by thirteen years, dying from heart failure in 1957. Barbara survived a further five years, before she too died from heart failure at the advanced age of 89; there were no children.

Conclusion

Collis’s important contributions to occupational health included the recognition of the relationship between silicosis and tuberculosis, he differentiated between silicosis and several other types of lung disease, he noted the harmful effects of non-silicaceous coal dust, he introduced the concept of the latent period into occupational health, and he understood the need to fit the worker to the job, and the job to the worker, the basis of modern ergonomics. He held a number of important positions during his life-time, was the friend of a prime minister, and as Keats said of Coleridge, was not content with half-knowledge.