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HISTORY OF MEDICINE Profiles In Cardiology sir James Mackenzie Hamish J.C. Davidson* The first time I heard of Sir James Mackenzie was in 1944 when I was a medical student attending a lecture on the heart by D.R. Dow, Professor of anatomy at Queens College, St. Andrews University. He had alluded at length to Mackenzie’s contributions to cardiology and ended his oration in dramatic fashion by lifting a cloth on the desk in front of him, revealing a specimen jar containing Mackenzie’s heart. At that time I had no great interest in the history of medicine but learning that Sir James Mackenzie came from Scone, a village outside my home town of Perth, and that like me he had attended Perth Academy, I took more notice. My interest was reawakened fifty five years later on reading in the proceedings of the Royal College of Physicians of Edinburgh the account of the Sir James Mackenzie consensus conference: Atrial Fibrillation In Hospital And General Practice. James was born on April 1853 in Pickstonhill Farm, Scone, where his father was a tenant farmer and was the third child and second son. He attended the local school at Scone and he went to Perth Academy in 1865 but left after three years to serve an apprenticeship as a dispensing chemist for four years. After working as an assistant for a year, he decided to study medicine. After some private tuition in Latin, he passed the university entrance examination and entered the medical school at Edinburgh University, qualifying M.B. & C.M. in 1878. He worked as a locum in a colliery practice from June of that year till November when his resident post at Edinburgh Royal infirmary became available. On completing his residency in 1879, he joined Dr. Briggs and Brown in general practice in Burnley, an industrial town in England. He found himself in a very busy practice where the patients did not correspond to those in the teaching hospital or the textbooks. In Victorian England, infectious disease was rife, and in Burnley in 1879 there were 56 deaths from scarlet fever and the infant mortality was 205/1000 births. He saw 60 to 70 patients daily and attended an average of three deliveries a week but still he found time to complete his MD thesis on Hemi-paraplegia Spinalis in 1882. In his spare time, he studied Greek and German, played golf and started to write a novel, which was concerned with the social deprivation prevalent at that time. It is an interesting insight on the social and financial status of general practitioners that in 1885, he was able to afford the time and the money for a holiday in America. The highlight of his visit was to Yellowstone Park. Two years later, he married Frances Jackson and honeymooned in Italy. While engaged in this very busy practice, he made original observations and had over fifty papers published. Although many of his articles were on cardiology, he also wrote on many other topics particularly neurology and pain mechanisms. He was among the first to own a motorcar in Burnley and a photograph in one of his biographies shows him in this car with a driver. In 1890 he made the seminal observation that the chambers of the heart could beat out of their correct order, when he discovered extra systoles. But it was not till the distinguished pharmacologist, Professor Cushny, demonstrated extra systoles experimentally in the mammalian heart that Mackenzie’s findings were generally accepted. Before his discoveries were widely known, many people were made cardiac invalids by the anxiety of their doctors who, on discovering the irregularity due to extra systoles, confined the patient needlessly to bed or ordered them to curtail their activities. By carefully following up his patients with extra systoles, Mackenzie showed their benign nature. At first he used a sphygmograph for graphically recording a peripheral pulse. The tracings were made on a smoked drum which was then varnished to preserve the record, a very time consuming process. He then developed the polygraph, a portable clockwork, ink-writing instrument with two tambours with which he was able to record radial and jugular pulses simultaneously and to measure the atrioventricular interval,. He used the polygraph to diagnose the various types of heart block. This work was all done in the course of the usual busy medical practice. At this time his knowledge of cardiology was growing very fast, and it is interesting to read the section on arrhythmia in the third edition of Osler’s Textbook of Medicine 1898 and see how little was known on the subject. For example, the paradoxical pulse of Kussmaul is bracketed with sinus arrhythmia, which Mackenzie had clearly shown to be a normal finding. Mackenzie’s discoveries may not seem much to us in the 21st century but cardiac irregularities were regarded with concern by the profession and the laity, as none knew their significance. In 1897 he noted that in a patient with mitral stenosis, the presystolic murmur disappeared with the onset of irregularity of the pulse but he also noted that the ‘a’ waves in the jugular venous pulse had also disappeared and concluded that the auricle was paralyzed, which functionally it was. This disordered irregularity described by Mackenzie was later called auricular fibrillation. Another of his discoveries was the action of digitalis on conduction in the atrio-ventricular bundle, so slowing the ventricular response in atrial fibrillation. He also devised a safer and simpler regimen for prescribing digitalis. How did he manage time for research with the heavy workload of family practice? First, he had an enormous capacity for work and second, he was driven by an intense desire to advance his understanding of disease. He was expert with the polygraph and painstaking in storing and interpreting those records. He filed his notes and tracings for further reference and as illustrations in his textbooks. At the age of 49, the first of his books, The Study of the Pulse was published after twenty-three years in general practice. What did the patients in his practice think of this big man, six feet two in height with a large frame and head? In an era when doctors generally were respected, I had imagined that he would have been regarded with awe rather than affection but the working class patients of the practice called him the “beloved physician.” What a remarkable GP he was! How did he manage to see a sufficient number of cardiac patients in an ordinary general practice to acquire his expertise and authority in cardiology? It seems likely that he didn’t see many more than the average GP but he studied them thoroughly, kept careful notes, and used his polygraph records to help solve some of the problems. In addition as his reputation grew he was increasingly asked by his colleagues for a second opinion on cardiac patients. By 1902 when he published his book on the pulse he had, according to Professor J. MacMichael, become the world clinical authority on heart disease. His publications attracted the attention of many famous medical personages and he was visited in Burnley in 1905 by Osler who was then professor of medicine in Oxford; quite something a Professor of medicine going to visit a humble GP. Perhaps not so humble! By 1902 he was in correspondence with Wenckebach whom he visited in Holland and his association with the anatomist Arthur Keith began. Mackenzie sent the hearts of patients obtained at autopsy to Keith who studied the pathology particularly the conducting system. In 1906 he attended the BMA meeting in Toronto and the GP from Burnley became engaged in a lively debate with Dr. Morrow, professor of physiology at McGill University and it appears Mackenzie got the best of the argument. The following year saw the formation of The Association of Physicians of Great Britain and Ireland, the membership of which was limited to 200 hospital physicians and lectures in clinical medicine. Mackenzie, although a general practitioner, was elected and opened the discussion on the heart at the first meeting. He left Burnley for London and set up as a consultant in November 1907. He was invited to join the staff of the West End Hospital for nervous disease and was appointed to the staff of Mount Vernon Hospital Hampstead. His second book, Diseases of the Heart, was published the same year. The following year, he rented consulting rooms in Harley Street and in a very short time, was very busy with private patients. It was remarkable for a newcomer, an outsider, and a general practitioner to have such early success with consultant work; and he himself attributed his good fortune to the timely publication of his book. Two years later, he was elected FRCP but his main objective, a place on the consultant staff of the London Hospital eluded him although he was appointed lecturer in cardiac research to that hospital and was allowed the use of six beds. Thomas Lewis and Mackenzie met in 1908 when they started their collaboration on cardiac research and the Welshman was encouraged by the Scot to found the journal Heart. Mackenzie’s third textbook, Symptoms And Their Interpretation, was published in 1909 and the following year he was made an LLD of Aberdeen University. More honors followed in 1911 when he delivered the Oliver Sharpey lecture on heart failure to the Royal College Of Physicians and the Schorstein lectures on auricular fibrillation to the London hospital. In 1913 he was appointed physician in charge of the cardiac department at the London hospital and was involved in setting up the military cardiac department at Mount Vernon hospital where Osler, Clifford Albutt and Mackenzie were consultants. In his eleven years in private consultant medicine, he did not charge excessive fees but still earned a considerable amount of money. In 1915, he received the highest British scientific award when he was elected a fellow of the Royal Society; a knighthood followed later that year. To all intents he had made it in London, become a consultant to the prestigious London Hospital, and had done well financially. So, it seems strange that two years later, at the age of sixty-four, he decided to leave London and move to St. Andrews to set up an institute for research in general practice. By October 1919 he had established his research institute in St. Andrews and managed to involve all the general practitioners in the town in his project. The various programs considered at the institute included the investigation of pain, of glandular enlargement, disease of children and consumption, a somewhat daunting task for five GPs. He was very keen to get the general practitioner involved in keeping good records and in the epidemiology of the maladies occurring in practice. He was probably one of the first to think of epidemiology in terms of non-infectious diseases. In 1920 he was appointed Honorary Physician to the King and he put forward proposals for a postgraduate school for training panel doctors. In 1923 his large output of textbooks was expanded with the two publications, Heart Disease in Pregnancy and Angina Pectoris. The achievements of the institute were modest and it did not last long after his death but he did draw attention to the importance of family doctors and their need for special training. It is worth noting that three university chairs of general practice in Britain are named in his honor. Mackenzie had suffered from angina pectoris for many years and died on a visit to London in January 1925. A postmortem examination was carried out by his former assistant, Sir John Parkinson who on Mackenzie’s prior instructions, had his heart taken to the anatomy department of St. Andrews University. The famous American cardiologist, Paul D. White, considered Mackenzie a great pioneer and the "father" of modern cardiology. In Mexico City Cardiology Centre, the history of cardiology is depicted in two murals and in the second panel Mackenzie takes his place alongside Wenckebach, Einthoven, Lewis, Waller, and Wilson. Recently Sir John McMichael affirmed the very large contributions to cardiology of both Mackenzie and Lewis, but he also related that when Dr. Sam Levine wrote to Mackenzie telling him about Elliot Cutler’s pioneering operation on a stenosed mitral valve in 1923, Mackenzie’s comment was that it was a foolish thing to do as the myocardium was all important. Although he published over fifty papers after he left Burnley, probably his best work was carried out while he was in general practice. He was strongly of the opinion that the doctor must never become too reliant on machines and he mocked the London consultant who had to arrange an electrocardiogram to diagnosis auricular fibrillation before prescribing digitalis. Like other innovators he became rather closed in his thinking and did not seem keen on new ideas. Some critics said he did not like the electrocardiograph but Sir J. Parkinson defended him saying if he had not liked it he would not have bought one. One can sympathize with him in his reluctance to get too involved with the then new electrocardiograph because although very expert with clockwork gadgets he could not have been familiar with electricity. It should be remembered that most houses were still lit by gas at that time not electricity. In the fourth edition of Diseases of the Heart, he neither showed how useful electrocardiograms were or might become and he claimed that too much was read into the tracings. He stated many times that the doctor should only use mechanical aids till he had learned enough and could then dispense with them. He would have been astounded by the recent suggestion that cardiac failure cannot be diagnosed in primary health care and that a measurement of natriuretic peptide and an echocardiogram may be necessary to do so (Hobbs, R. Can heart failure be diagnosed in primary care? Editorial. Brit Med. J. 2000; 321:188 – 189). His fear that “the heart specialist would cease to be a physician looking at the whole body, but one with increasingly complicated instruments used in a narrow and restricted area of the body” may not be so far away. But had Sir James been alive now, I am sure he would have readily agreed that the advances which benefit the patients today would not have been possible without all those sophisticated machines cardiologist use every day. References: 1. Atrial Fibrillation in Hospital and General Practice: the Sir James Mackenzie Consensus Conference. Proc. R. Coll Physicians Ed. 1999.29.Suppl. no. 6. 2. Hobbs R. Can heart failure be diagnosed in primary care? Editorial. Brit Med. J.2000; 321:188 – 189. 3. Mair A. Sir James Mackenzie MD., 1853-1925, general practitioner. Edinburgh, Churchill Livingstone 1973. 4. Mackenzie J. The Study of the Pulse. Young J. Pentland Edinburgh and London 1902. 5. Mackenzie J. Diseases of the Heart. Henry Frowde, Hodder & Stoughton 1908 First edition. Fourth edition 1926. 6. Monteith W.B.R. Bibliography with synopsis of the original papers of the writings of Sir James Mackenzie. Oxford: Oxford University Press, 1930. 7. McMichael J. A transition in cardiology: the Mackenzie Lewis era: the Harveian Oration of 1975. London. Royal College of Physicians of London, 1976. 8. Osler W. The Principles and Practice of Medicine, Young J. Pentland, Edinburgh and London, 1898. 9. Wilson, R McNair. The beloved physician: Sir James Mackenzie: A biography. London J. Murray, Albemarle Street. London. Acknowledgment:
The author wishes to thank the librarian of the Royal College of Physicians of Edinburgh for help with the bibliography.
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