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Will Pickles, who lived from 1885 to 1969, served his patients in Wensleydale, Yorkshire, for more than 50 years. But he also served a wider world. For more than a quarter of a century he carefully recorded observations on infectious disease in the Dale, and is now seen as one of the greatest general practitioners of all time. Pickles showed that the rural general practitioner had opportunities for making observations on disease that were denied to other medical men.
A source of inspiration was the physician-epidemiologist William Budd, who relished the fact that almost everyone who fell ill in his village and its surroundings came immediately under his care: ‘For tracing the part of personal intercourse in the propagation of disease, better outlook could not possibly had’1. In his biography2, Pemberton quotes a passage from one of Pickles' lectures, describing his thoughts on looking down on Wensleydale from a hilltop:
‘... one by one I made out most of our grey villages with their thin pall of smoke. And as I watched the evening train creeping up the valley with its pauses at our three stations, a quaint thought came into my head and it was that there was hardly a man, woman or child in all those villages of whom I did not know the Christian name and with whom I was not on terms of intimate friendship. My wife and I say that we know most of the dogs and, indeed some of the cats’.
Pickles was influenced by another great nineteenth century general practitioner, James Mackenzie, who wrote emphatically on the advantages of general practice as a medium for research and contended that it was the family doctor alone who saw disease in its true perspective. Pickles advised all young doctors and medical students to read McNair Wilson's biography of Mackenzie The Beloved Physician.
Pickles was born in 1885 in Leeds, his father a general practitioner (John Jagger Pickles) and his grandfather a local pharmacist; his mother had a strict and upright manner and a Quaker ancestry. At 9 years of age he felt he would like to be a parson but this ambition faded and he eventually became agnostic. Deep admiration for his father combined with the example of a brother doing medicine led to him enrolling in medical school at the age of 17. At one time four Pickles sons were studying medicine simultaneously and this caused some financial hardship in the family. In his final year Will dispensed for a general practitioner in the evenings, like Mackenzie before him. For this he was given tea and 15 shillings a week. When his employer was called out on urgent cases, Will had to finish the surgeries and in doing so he built on the knowledge of general practice obtained from his father.
After several locum stints he became an assistant to Dr Horsfall and Dr Eddison of Bedale in the North Riding of Yorkshire. Will did his rounds by bicycle and there was no telephone. He helped in operations and did most of the midwifery. It was during the Bedale assistantship that his interest in epidemiology was first aroused. An incident is recorded on p. 1 of his most famous work, Epidemiology in Country Practice3:
‘A gypsy woman driving a caravan into a village in the summer twilight, a sick husband in the caravan, a faulty pump at which she proceeded to wash her linen, and my first and only epidemic of typhoid, left me with a lasting impression of the unique opportunities of the country doctor of infectious disease.’
Just as John Snow in 1866 had recommended the authorities to chain up the handle of the Broad Street pump if they wished to end the epidemic of cholera, so Will arranged for the village pump to be put out of commission and the epidemic of typhoid ended.
Will joined the partnership in Aysgarth, Wensleydale, in 1913. The practice included eight villages and at the time the district had a population of 4267. The First World War broke out the next year and he joined the Royal Navy, serving in the Atlantic for the duration. The experience led him to write his first published article, which was about Vincent's disease4. Poor oral hygiene among sailors, combined with physical or emotional stress and smoking, must have provided him with plenty of subjects; and shipboard life accustomed him to the notion of a defined denominator. The cause of Vincent's disease, with its malodorous ulceration of the gums, has since proved to be a fusospirochaetal organism.
In October 1928 an epidemic of jaundice in the Dale marked the start of Pickles' researches into the transmission of infectious illness. In Epidemiology in Country Practice he describes the illness as often having
‘a pre-icteric period, commencing with headache and vomiting and abdominal discomfort which amounted to pain in some patients, and lasted about four days. In some instances the initial day was the worst, and, in children, the subsequent period before the appearance of jaundice was free from symptoms, so that the child returned to school, a significant factor in the spread of infection...’.
This epidemic turned out to be unusually severe. Out of a total estimated population of 5700 in the Dale there were 250 known cases of jaundice, of whom Pickles and his partner Dunbar attended 118. 78 of these were in children of school age. Today we would call this disease hepatitis A. Most infections in children produce few symptoms and immunity is longlasting, so severe disease tends to occur in non-immune adults5. At that time, estimates of the incubation period ranged from as low as 3-4 days to up to 40 days. Pickles wrote to the Ministry of Health and as a result an epidemiologist, Dr WA Lethem, came to visit. The epidemic ran on for 2 years and Pickles later stated: ‘Lethem and I believed we had conclusive evidence of an incubation period of 26-35 days, and this was confirmed in a later small epidemic in 1935-1936’. In Epidemiology in Country Practice he describes a second study of patients with epidemic catarrhal jaundice, in the village of Bainbridge, the intervals between 10 patients being 29, 29, 27, 28, 26, 25, 27, 26 and 27 days.
There was also a third small series, about which he wrote:
`The five names... are those of the only sufferers from jaundice in the whole district who commenced in the week 24 September to 1 October. Three of these were from the village in which the fete was held on August 28, and I found, as I expected, that they had all been present. I felt sure also that I was on the track of an interesting discovery when it transpired that the other two from distant villages had this, and only this, experience in common with these three. Someone suffering from jaundice therefore, had also probably been a visitor at the fete. I tried various sources, and at last after a long search, I discovered the culprit where I least expected, almost on my own doorstep.
‘This was a young girl (B) whom I had actually seen in bed on the very morning of the fete and who I never dreamt would be able to get up that day. I have no doubts she exercised considerable skill and elusiveness at the entertainment, for I was also among the throng and did not know of her presence. This girl had as a friend another girl of 16 (E) who lived in a distant village, and these two girls spent the afternoon together, with the result that E herself commenced with the disease on October 1, and infected four others in this village. She was employed as a maid, and she infected her employer's small son, the boy's friend, and her own great aunt, who lived in the village. The infection in all these was easy to explain, but in the fourth (M), a rather pathetic little fellow of middle age, it was not so clear. At last I tackled his sister, who gave him away quite shamelessly. Studies in epidemiology sometimes reveal romances. “Oh yes” she said, “he's very fond of ER. He often goes in the back door in the evenings, and helps her wash up”. The brother of M in the same house commenced on December 5, and the faithless sister, above mentioned, with poetic justice succumbed on November 4. J who was a friend of H and E commenced on November 4, his small brother on December 8, and this small brother's friend on January 8. Thus to my knowledge, thirteen instances of this disease resulted from the determination of one girl, jaundice or no jaundice, not to be deprived of what she considered to be her legitimate amusement’3.
He wrote up this study under the title Epidemic catarrhal jaundice: an outbreak in Yorkshire6.
Pickles also looked into the period of infectivity of this disease:
‘It is difficult to decide a figure for this..., but I have found proved infectivity on the fifth and seventh days of the disease and have been successful in acting on the assumption that a fortnight is sufficient... Having this evidence I have allowed children to return to school after this period’7.
Today we know that faecal shedding of the virus occurs during the incubation period and usually ceases at least a week after symptoms begin. Vaccination against hepatitis A is now being considered for children of both developing and developed countries. Travellers to hepatitis A endemic areas already have access to the vaccine.
In 1993 Pickles was called to see a small boy age 2½ who had suddenly developed pain in the upper abdomen. On revisiting him later, Pickles found the boy's face flushed, his temperature 101°F and his respirations 60 per minute. ‘The boy was lying in a dazed condition, taking no notice of what we were doing as we examined him, his alae nasi were working, he had an expiratory grunt and a short cough’. 2 days later the boy had recovered. Two brothers were attacked 2 days later.
In an article on all of these patients: he summarized the symptoms as follows:
`Onset with very acute upper abdominal pain, which occurred in spasms, and was accompanied by profuse sweating. All the children placed their hands with the centre of the palm over the xiphisternum when asked to indicate the site.
`Rapid, shallow respiration, obviously extremely painful. Pain on yawning and deep breathing between the spasms. No abnormal signs in the chest.
`Fever up to 103 degrees, rapidly subsiding, but tending to rise again with a return of the pain on the third day.
`Absence of vomiting or diarrhoea. Tongue coated... of the white strawberry variety.
`No faucial injection, but nasal catarrh in one child and unilateral conjunctivitis in the other.
‘Complete recovery in from four to six days and in absence of sequelae’8.
Sylvest9, a general practitioner from Denmark, was the first to describe this disease. He named the condition epidemic myalgia, or Bornholm disease after the island in the Baltic which was the scene of an outbreak. Pickles was the first person to describe the disease in detail in Britain and noted the absence of an effective treatment, though ‘hot applications are much appreciated’. At a meeting where the subject was discussed, one speaker humorously remarked that, since there was no treatment, it was a disease which could be safely left to the care of the physician. In Pickles' view, however, the only possible danger in the disease was that on some occasions it would come under the care of the surgeon. The condition is now known to be caused by a group B Coxsackie virus, but the treatment has not changed much.
In 1935 Pickles addressed the Epidemiology Section of the Royal Society of Medicine on measles. At that time the textbooks indicated that the incubation period varied from 7 to 18 days. Pickles had recorded case after case where the incubation period was exactly 12 days. One of the cases that Pickles described to the Section was as follows:
‘A farm boy came one day to the surgery and announced that he had “gitten mazzles”. This was certainly the case, and he was told to go home, shout to his mother outside the door, and have the living room cleared of his small brothers and sisters. He then proceeded to his bedroom where he remained a fortnight. On the twelfth day following, his aunt, and only his aunt, became a victim of the disease, although she had never seen the boy and left the morning after his sickness began. It was found that the boy's bedroom and the living room directly below were lit by one long window, giving direct aerial access from one room to the other. The meal table was directly below the gap, and the aunt had sat directly underneath’10.
A chest condition well known to farmers, previously described by Campbell11, was also one of Pickles' interests. Both doctors described severe dyspnoea, cyanosis and rales in the chest. Writing in the journal Public Health in 1944, Pickles named the condition farmer's lung12. This disabling condition, a hypersensitivity pneumonitis caused by Microspora faeni or Thermoactinomyces vulgaris, is brought about by repeated inhalation of the dust from mouldy hay.
Pickles disciplined himself to be objective in his research. In a handwritten dedication to a copy of Epidemiology in Country Practice he quoted from one of the letters of TH Huxley: ‘Sit down before fact as a little child: be prepared to give up every preconceived notion’ (Fox R, personal communication). He developed contacts at the London School of Hygiene and Tropical Medicine where in 1934 Major Greenwood, head of the Department of Epidemiology and Medical Statistics, encouraged him to embark on the book. Thereafter, according to Pemberton, evening surgeries in 1937 in the Aysgarth practice were kept to a minimum and often there were no patients at all; in the preface to Epidemiology in Country Practice Greenwood wrote, ‘The old race of epidemiologists is not extinct. We have indeed had to wait a long time for a second Budd, but I think we have found one’. Greenwood later remarked:
‘It is futile to assign an order of precedence in scientific merit—like debating who was the greatest poet in history. But if I had to choose the best contribution to statistical epidemiology made in England in the last ten years I should pass over the officials and professors and cite Epidemiology in Country Practice... Dr Pickles knew and cared for the people the records of whom were his statistics. He made discoveries which eluded officials and professors whose material was just cards. It is a very long time since research on that level has been done by town doctors. This is a model of research in social medicine’13.
In the introduction to a reprinted edition14 John Hunt paid tribute to Pickles' wife Gerty (Figure 1) and their daughter Patience, who both helped with the charting of his epidemiological observations—especially Gerty, on whose scrupulous recording and industry the work depended.
In 1947 Pickles was invited to give the Cutter lecture at Harvard, in the course of which he remarked:
‘I do hope that I have been able to pass on to you a little of the atmosphere of a busy country practice in England, and as I speak from 37 years' personal experience, it is a full and happy life. It may, of course, be a mere repetition of irksome tasks, but this is probably the fault of the practitioner who like Bunyan's man with the muck rake, rakes to himself the straws and sticks and dust of the floor and can look no way but downward regardless of the crown which is being held over his head’15.
In 1949 he received an honorary DSc from the University of Leeds. He was elected the first President of the Royal College of General Practitioners in 1953 and in 1954 gave the first Sir James Mackenzie lecture. Pickles became CBE in 1956 and was elected FRCP in 1963. The Pickles legacy is still alive today. As examples I would cite rural general practitioners establishing the prevalence of Chlamydia trachomatis infection in pregnant women in Tennessee16 and the inquiries into ‘fifth disease’ in Western Australia17. The requirements of a legatee are to be a country doctor in a population that is well known and defined, to have excellent observational skills and to have a deep interest in the paradigm that Murrell describes as human ecology18.
Will Pickles died from pneumonia in 1963 and Gerty from cancer five months later. In a BMJ obituary Pickles was described as probably the most distinguished country doctor of our time. ‘Of epidemic catarrhal jaundice’, the obituary continued, ‘he established its incubation period by the study of cases where there was only one short and possible contact... As well as being a great field epidemiologist Will was a great family doctor. Scrupulously careful in his recording and visiting, never underrating a patient or his symptoms, he was courteous and kind to all, even the most awkward patients’19.
These personal characteristics no doubt led to Joan Pomfret's poem in his honour which is recorded in Pemberton's biography. I quote two verses here:
Wind shakes the trees, year in year out,
Full blown, December bare:
He knows each face and cottage door,
Each hearth and narrow stair;
The rain's song and the river's song
The living and the dead
And all the troubles and the pains,
He cured and comforted.
Early and late, the seasons through,
This was the path he chose,
A country doctor on his rounds...
And everybody knows
His voice, his smile, the way he walks,
His presence in the Vale;
They will remember evermore
His name in Wensleydale.
For this account I have leaned greatly upon the excellent biography by John Pemberton, who had at times been Pickles' locum at Aysgarth.