James Mackenzie : Research in General Practice

Born the son of a Highland farmer in 1853, near Scone in Perthshire, James MacKenzie was destined to become a leader among medical men. He utilised the opportunities of a general practitioner to study the early symptoms of disease and the bearing of the disease on the patient’s future life. In defining how this came about, three main factors seem to emerge as especially significant in his early years. As an apprentice to a Perth chemist, he found that his “ natural bent lay in a practical rather than an academic direction”. In his preclinical years at Edinburgh University, he experienced some difficulty in passing examinations, for they were contrived for the purpose of testing memory rather than the power of reasoning — MacKenzie had difficulty in remembering isolated facts, but if facts were “ related in some consecutive manner, they could not only be remembered, but their bearing on oneanother fully appreciated” . Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, Winter 1967-68, 6(1): 27-29, 31 doi: 10.2218/resmedica.v6i1.831 “ JAMES MACKENZIE : RESEARCH IN GENERAL PRACTICE” by DAVID McLEOD, B.Sc. From a dissertation read before the Society on Friday, 20th October, 1967. Born the son of a Highland farmer in 1853, near Scone in Perthshire, James MacKenzie was destined to become a leader among medical men. He utilised the opportunities of a general practitioner to study the early symptoms of disease and the bearing of the disease on the patient’s future life. In defining how this came about, three main factors seem to emerge as especially significant in his early years. As an apprentice to a Perth chemist, he found that his “ natural bent lay in a practical rather than an academic direction” . In his preclinical years at Edinburgh University, he experienced some difficulty in passing examations, for they were contrived for the purpose of testing memory rather than the power of reasoning — MacKenzie had difficulty in remembering isolated facts, but if facts were “ related in some consecutive manner, they could not only be remembered, but their bear­ ing on one-another fully appreciated” . Thirdly, MacKenzie studied in Edinburgh at a time when the medical school was undoubtedly the foremost in Great Britain — the “ very vanguard of new ideas in medicine and surgery” . Here MacKenzie’s scientific outlook was nurtured and his inquiring instincts sharpened by his training in the midst of the controversies of the Listerian era, and further stimulated during his membership of the Royal Medical Society in 1878. BANK PARADE, BURNLEY In 1879, he entered the largest general practice in England at that time at 68, Bank Parade, Burnley. It has been commented that “ there was nothing in his environment to stimulate him to do anything more than conscientious routine work in the diagnosis and treatment of cases” — but on the contrary, MacKenzie found inspiration in both his professional colleagues and the lot of his patients. The senior partner in the firm was Dr. W illiam Briggs, and it was his confident certainty about the outcome of his patients’ illnesses that started MacKenzie off on his long study of prognosis. That such a study was vitally necessary became apparent to MacKenzie as he worked among the people of the Lancashire cotton town. Burnley lay in the wake of the Industrial Revolution during which time it had become a “ shocking mix-up of mills, foundries and pits” , each surrounded by rows and rows of back-to-back houses. The lower-class popul­ ation was outrageously exploited by the factory employers, wage disputes causing grim strikes and frequent unemployment; the widespread drunkenness and crime, plus an absence of adequate sanitation, further added to the misery of the inhabitants. Contagions abounded — epidemics of cholera, typhoid, smallpox, diphtheria and scarlet fever were commonplace, children under five years being particularly accursed. As MacKenzie worked among the poorest families in the town, he soon came to recognise the need for accurate prognosis, for he would sense the fear that lay behind such questions as “ W hat is going to happen to me?” , or “ W hen can I get back to work?” W hen the only means of employment involved strenuous labouring in mine, mill or foundry, his answers to such questions became of critical import; for advising a patient to rest might condemn him to com plete idleness and his fam ily to poverty, the workhouse or starvation. But upon what principles could he base an opinion? H e d id : not have D r. Briggs’ “ clinical instinct” , and had neither learnt in Edinburgh, nor could find in the literature any indications as to the prognostic significance of the signs and symptoms which his patients presented; he was similarly disturbed to find that he knew nothing of the m echanism of these signs and symptoms. M A C K EN ZIE 'S PO LY G RA P H M ackenzie is perhaps best known to under­ graduates as the co-inventor, with a Padiham watchmaker, of the Ink Polygraph (the poor relation of the Electrocardiograph), with which he could simultaneously record arterial and venous pulsations. Y e t I feel that a prolonged description of this and earlier instruments and discussion of interminable polygraph traces would not really be a fitting tribute to MacKenzie’s work. In his practice, M acKenzie saw a great deal of cardiac failure which was largely of rheumatic origin, and a single case history will serve to illustrate his experimental findings and his progression of thought concerning his patients and-their traces. In 1852, he attended a woman o f '42 years who had a history of four attacks of rheumatic fever; a presystolic murmur had followed and had becom e more pronounced, indicating progressive mitral stenosis. A t this time, the woman suffered from weakness and some shortness of breath: on examination, her apex beat was in the 5th space, the neck veins were not raised and the liver was two fingerbreadths below the costal margin and pulsating, Her Kymograph traces were largely normal: (Figure 1) This pattern continued for some years until i n 1898, and with dramatic suddenness, she was seized with great breathlessness and dis­ tress, and was found to be in marked failure and extremely ill. On examination, her pulse was very rapid and irregular both in tim e and force; M acKenzie knew this pulse as the .“ Dangerous Type of Irregularity” . T h e apex beat was in the 7th space, and the liver was three, inches prom inent and pulsating; there w as-a large J.V .P ., and the ventricular form o f,th e jugular venous pulse (showing absence of “ a-waves” ) was recorded: (Figure 2) 1.

-Born the son of a Highland farmer in 1853, near Scone in Perthshire, James M acKenzie was destined to become a leader among medical men.H e utilised the opportunities of a general practitioner to study the early symptoms of disease and the bearing of the disease on the patient's future life.
In defining how this came about, three main factors seem to emerge as especially significant in his early years.As an apprentice to a Perth chemist, he found that his " natural bent lay in a practical rather than an academic direction" .In his preclinical years at Edinburgh University, he experienced some difficulty in passing examations, for they were contrived for the purpose of testing memory rather than the power of reasoning -M acKenzie had difficulty in remembering isolated facts, but if facts were " related in some consecutive manner, they could not only be remembered, but their bear ing on one-another fully appreciated" .Thirdly, M acKenzie studied in Edinburgh at a time when the medical school was undoubtedly the foremost in Great Britain -the " very vanguard of new ideas in medicine and surgery" .Here M acKenzie's scientific outlook was nurtured and his inquiring instincts sharpened by his training in the midst of the controversies of the Listerian era, and further stimulated during his membership of the Royal Medical Society in 1878.

BANK PARADE, BURNLEY
In 1879, he entered the largest general practice in England at that time at 68, Bank Parade, Burnley.It has been commented that " there was nothing in his environment to stimulate him to do anything more than conscientious routine work in the diagnosis and treatment of cases" -but on the contrary, M acKenzie found inspiration in both his professional colleagues and the lot of his patients.
T he senior partner in the firm was Dr. W illiam Briggs, and it was his confident certainty about the outcome of his patients' illnesses that started M acKenzie off on his long study of prognosis.T h at such a study was vitally necessary became apparent to M ac-Kenzie as he worked among the people of the Lancashire cotton town.
Burnley lay in the wake of the Industrial Revolution during which time it had become a " shocking mix-up of mills, foundries and pits" , each surrounded by rows and rows of back-to-back houses.T h e lower-class popul ation was outrageously exploited by the factory employers, wage disputes causing grim strikes and frequent unemployment; the widespread drunkenness and crime, plus an absence of adequate sanitation, further added to the misery of the inhabitants.Contagions abounded -epidemics of cholera, typhoid, smallpox, diphtheria and scarlet fever were commonplace, children under five years being particularly accursed.
As M acKenzie worked among the poorest families in the town, he soon came to recognise the need for accurate prognosis, for he would sense the fear that lay behind such questions as " W hat is going to happen to me?" , or " W hen can I get back to work?" W hen the only means of employment involved strenuous labouring in mine, mill or foundry, his answers to such questions becam e of critical im port; for advising a patient to rest m ight condem n him to com plete idleness and his fam ily to poverty, the workhouse or starvation.

B u t upon what principles could he base an opinion?
H e d i d : not have D r. Briggs' " clinical instinct" , and had neither learnt in Edinburgh, nor could find in the literature any indications as to the prognostic significance of the signs and sym ptom s which his patients presented; he was sim ilarly disturbed to find that he knew nothing o f th e m echanism of these signs and sym ptom s.

MACKENZIE'S POLYGRAPH
M ackenzie is perhaps best known to under graduates as the co-inventor, w ith a Padiham watchm aker, of the In k Polygraph (the poor relation of the Electrocardiograph), w ith which he could sim ultaneously record arterial and venous pulsations.Y e t I feel that a prolonged description of this and earlier instrum ents and discussion o f interm inable polygraph traces would not really be a fitting tribute to Mac-K enzie's work.
In his practice, M acK en zie saw a great deal of cardiac failure which was largely of rheumatic origin, and a single case history w ill serve to illustrate his experim ental findings and his progression o f thought concerning his patients and-their traces.In 18 52, he attended a woman o f '42 years who had a history of four attacks of rheum atic fever; a presystolic m urm ur had followed and had becom e m ore pronounced, indicating progressive m itral stenosis.A t this time, the wom an suffered from weakness and some shortness of breath: on exam ination, her apex beat was in the 5th space, the neck veins were not raised and the liver was two fingerbreadths below the costal margin and pulsating, H er Kym ograph traces were largely normal: (Figure 1) T h is pattern continued for som e years until i n 1898, and with dram atic suddenness, she was seized w ith great breathlessness and dis tress, and was found to b e in marked failure and extrem ely ill.O n exam ination, her pulse was very rapid and irregular b oth in tim e and force; M acK enzie knew this pulse as the ."D angerous T yp e of Irregularity" .T h e apex b e a t was in the 7th space, and the liver was three, inches prom inent and pulsating; there w as-a large J.V .P ., and the ventricular form o f,th e jugular venous pulse (showing absence of " a-waves" ) was recorded: (Figure 2) 1.

RADIAL PULSE LIVER PULSE
1 r e g ular1 wave due to atrial systole.
wave corresponding in time to (la te ) ventricular systole.H owever, on auscultation, M acK enzie was perplexed to find that the presystolic murmur, which had persisted in this heart for over 18 years, was absent!H e discounted the possibility that the narrowed valve had opened up again, and dismissed the current view of the day that in failure, when the right ventricle dilated, it pushed the le ft ventricle away from the chest wall so that the m urm ur could no longer be heard.
T h en the truth cam e to him ; th e absence of the 'a-wave' in the J.V .P .indicated that the auricles had ceased to contract, this contraction against the resistance of the stenosed valve having form erly produced the presystolic m urmur.W h e n the wom an died a year later, M acK en zie found greatly distended, thin-walled atria at post-mortem .H e considered that the atrial distension precluded its rhythm ical con tractility and thus coined the term " auricular paralysis" ; however, lie could not explain the ventricular irregularity on the basis o f such a paralysis: full elucidation cam e from S ir T h om as L ew is' studies of junctional tissues in the heart, and from E .C .G .findings was evolved the term " atrial fibrillation" .
B y such investigations, then, M acK en zie showed that the inability o f the heart to m aintain the circulation m ay be due to a disorder of any of the factors upon which norm al heart action depends e.g. its rhythm , the condition of the valves, or inherent defects in the m yocardium .
N ow , M acK e n z ie 's investigation of heart failure was an extension of his work in the busy B urnley practice; all who enjoyed his hospitality at B ank Parade, including Osier, C ushny and W en kcb ach , m arvelled h ow this hardworked G .P .could fuse so successfully with the enthusiastic research-worker.H is discoveries resulted from the collection o f scientific experim ental data and the em ploym ent of sound reasoning; he always insisted that it is the analysis and consideration o f recordings that is im portant in research, and he w ould sit for hours thinking over his patients and th eir traces, often in the early m orning after a cold bath, or in the evening while his w ife played the piano to him .

WAIT AND SEE
In addition to recognising the m eaning of signs and sym ptom s, M acK en zie appreciated the im portance of know ing w hat bearing they m ay have on the p atien t's prognosis.H e had been m uch impressed by D r. B riggs' ability to foretell the outcom e of his patients' illnesses, but was dismayed that this knowledge could not be passed on to new generations of doctors.It then occurred to him that Dr. Briggs' m ysterious pow er was nothing m ore than accum ulated experience -every tim e his senior partner considered a new case, he rem em bered hundreds of old cases and how they had fared.T h u s M acK en zie began his " wait and see" m ethod of defining prognosis i.e. in order to assess the prognostic significance of any sym ptom s, patients presenting the sym ptom would be watched over a period of years to determ ine w hat happened to them.
B y this means, he began separating the dangerous from the benign form s of pulse irregularity; know ledge of the pulse had been " not m erely im perfect, but ch aotic" , he said, for though these irregularities were easy to recognise, their " significance was com pletely m isunderstood" .

M acK en zie cam e across m any children dem onstrating the " Y o u th fu l T y p e o f Irregul arity" (sinus arrhythm ia)
, where the heart rate varies with the phase of the respiratory cycle.H is " wait and see" m ethod proved to him that the condition was physiological -he found the irregularity distinct in p erfectly healthy children, and in w atching them grow into adulthood, noted that they never showed any signs o f cardiac weakness.H ow ever, he was dismayed to find that outside his practice, such children were variously treated, and when these failed to rem ove the supposed affliction, the children were labelled as " incurables" and told to restrict all physical activities.
T h e benign nature of sinus arrhythm ia is now a standard part of m edical know ledge, yet the discovery o f this is seldom attributed to Mac-Kenzie 's m ethod; this 'negative aspect' of hi? work has been considered less valuable than his polygraph traces, but surely, as M acK en zie h im self once rem arked, his " greatest contribution was to have freed a large num ber of people from fear" .H ence the saying -" C u p id never broke hearts so fast as M acK en zie mended them " .
Sim ilarly with regard to the " A d u lt T y p e of Irregularity" , (the prem ature systole), he was again confronted with the " universal idea in the m edical m ind that som ething m ysterious is very m uch am iss with the heart that presents an irregular rhythm " .H e dem onstrated that the prem ature systole indicates ventricular stim ulation prior to the term ination o f normal disastolc, such stim ulation being either m om entary (giving rise to a single missed-beat) or lasting for longer period (producing a " stum b lin g" pulse).A nd after years of observation of hundreds of patients, his m ethod of " wait and see" proved to him that " the irregularity is perfectly consistent w ith good health . . .and a sound heart" .T h a t is not to say that no significance should be attached to this sign: it is com m only present in patients who are dangerously ill e.g. with valvular heart disease or chronic nephritis, and who died from congestive failure, but " then it is only one of the m any sym ptom s that testify to the weakness of the heart" , he said, " and is o f no serious significance in itself" .
As a result o f this work, he propounded his " law of associated phenom ena" i.e. " a serious prognosis should not be given on the evidence of a single sym ptom or sign " .T h u s, the pre-m ature systole has no consequence when it is the only abnorm al sign or occurs in mild cardiac failure.

BELOVED PHYSICIAN
A lthough M a c K enzie 's findings were very slow to be accepted (and on occasion were actively resisted) in the great centres of m edical learning, the doctor was loved and revered by his patients in the Burnley practice.T h ere was no " hush of self-im portance" about him as he travelled about the town in the first m otor car to be seen there, and he always explained his m ethods to his patients and the reasons behind his diagnosis.A bove all he con sidered it a duty to tell every patient (or those responsible for him ) the likely outcom e of his illness.His colleagues m arvelled at the confid ence in him which the dying and distressed displayed; small wonder he cam e to be known as the " beloved physician" .

PRINCIPLES OF PROGNOSIS
A lthough M acK enzie had defined th e m ech anism of various pulse irregularities -sinus arrhythm ia, prem ature systoles and auricular paralysis -his wait and see m ethod had only dem onstrated that the form er two were benign; of auricular paralysis, he knew that som e patients die soon after the com m encem ent of the irregularity w hile others go on fo r years w ith little trouble; he was thus still unable to recognise the earliest signs of heart failure, and thereby foresee danger in the p atient's future.
A bout this tim e, he was pondering over the contrasting prognoses of a patient w ith prem ature systoles as the only abnorm al sign, and another showing no abnorm ality on clinical exam ination yet who would be seized w ith a spasm o f anginal pain on walking 100 yards.H e conceived that the earliest sym ptom s of heart failure are shown in a response to effort, and thus evolved his great principle that " the first sign of heart failure is a dim inution in the reserve force o f the heart m uscle" .T h e extent o f the response to effort offers the m ost valu able aid in judging the efficiency of the heart and circulation and hence in assessing the patient's prognosis.
H e thus taught that attention m ust be paid to sym ptom s as a guide to prognosis, the " com m onest being shortage of breath, occurring on such exertion as the patient was w ont to undertake w ithout discom fort" .
A rtificial tests like asking a patient to hop about a room and then counting his pulse or taking his blood pressure, are of little value; the inform ation required to m ake an estim ate of the am ount of reserve force is obtained from the p atient's own experience of responses to exertion e.g.w alking up a hill after a meal or into a wind.
A story is told of a visit by M acK en zie to the Royal Infirm ary of E dinburgh, during which he was asked to opine on th e circulatory condition of a wom an aw aiting cholecystec tomy.She had been found to have anom alous heart-sounds, and the surgeon doubted the wisdom of operating (for as with irregularities, murmurs, o f w hatever nature, were consid ered to be of serious significance at that time).M acK en zie talked to the wom an before a crowd of onlooking staff and students, and soon learnt that she lived in a top flat and shopped for a fam ily of six, finding no diffi culty with the stairs.H e straightaway told the surgeon to operate w ith confidence so far as the function of the heart was concerned.T h e crowd drifted away, disappointed at seeing nothing of the fam ous m an's skill in exam ining a patient, and largely unappreciative o f the im portant lesson which he had taught them.

CONCLUSION
So M acK en zie, hailed as the inventor of the polygraph and a leader am ong research scient ists of his day, always m aintained that bedside evidence, particularly the p atient's history, was always of prim ary im portance over instrum ental and laboratory evidence at second hand.H e taught that pulse irregularities and m urm urs achieve significance entirely by virtue o f their relationship to, or effect on, the heart's effic iency as a pum p (as reflected b y a p atien t's sym ptom s during responses to effort).
As a fam ily doctor, M acK en zie knew his patients in health as well as disease; it was only while working am ong the people of B urnley that he learned the need for the inform ation which his researches were to give him , and it was only in general practice that he could carry out these studies, for there he saw his patients throughout the whole course o f their illnesses.

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JAMES MACKENZIE : RESEARCH IN GENERAL PRACTICE" by DAVID McLEOD, B.Sc. F rom a dissertation read before th e Society on F riday, 20th O ctober, 1967.