James Mackenzie was born on 12 April 1853 in Scone, Perthshire, Scotland, and educated at the village primary school and then Perth Academy. At age 15 he left school, apparently at his own request, to become an assistant at a local chemist’s shop, then a chemist’s apprentice in Perth, qualifying as a chemist (pharmacist) at the age of 20 and working as a chemist in Glasgow. He began to study medicine at the University of Edinburgh at the age of 21.
He was tall and broad-shouldered demonstrating physical and mental strength. He mastered French and German, in both of which he was able to read medical literature. He read and published extensively. He even published novels. His non-medical interests included chess and sporting activities. His marriage, at the age of 34, was a happy one, lasting until his death from coronary artery disease on 25 January 1925. He had two daughters, one of whom died at the age of 16, which grieved him for life.
Medical training
In his medical school years, he observed two very distinct qualities of the human mind: memory and reasoning power. He considered himself to be endowed with the latter, which was his greatest insight into himself.
On graduating from medical school in 1879, he entered general practice in Burnley, Lancashire, where he took a great interest in local affairs. His great humility made a lasting impression on Dr William Briggs and Dr John Brown, his general practice seniors. In addition, he took an unpaid house job at the Edinburgh Royal Infirmary. He worked long hours daily, doing clinics and house calls, yet reserving one afternoon a week to play golf. His keep-fit routine included leaving the window open during sleep and having a cold bath every morning.
From his seniors he learnt a lot of what the medical school did not teach, and the literature did not provide. There were two specific questions that most patients asked but which he, his seniors and the literature could not answer: why people become ill in the first place and what the future holds for them once they are ill. This prompted him to investigate pathophysiological mechanisms and prognosis. To his disappointment, his search for information on disease prognosis was fruitless, even in his trusted encyclopaedia.
He reasoned that if one cannot foretell a disease’s future, one has no right to be called a doctor, and that it was unsafe practice to allow ignorance of a disease’s prognosis to lead to inability to prevent its occurrence.
Thus, from 1883, he decided to probe the unknown using a ‘wait and see’ methodology and applying the ‘accumulated experience’ of the profession. His quest for pathophysiology and prognosis led him to success in both clinical research and clinical practice.
The anguish of his personal witness of the sudden death of a woman during childbirth prompted him to develop the concept of ‘heart affliction’ and aim to become a heart specialist.
Subsequent observation of irregular pulses by the ‘wait and see’ method led him to propose two types of irregularities: dangerous and not dangerous. The, then advanced, instruments, the Dudgeon sphygmograph and the pulse writer, validated his idea of different types of heart irregularity. Later, his own invention, the polygraph, allowed him to describe three pulse waveforms originating from the right atrium, the left ventricle and an obscure source (later found to be from the carotid artery).
The polygraph
His polygraph invention was ingenious but initially was not well received by the profession, with opposition from some powerful peers. However, Mackenzie has since been recognised as a pioneer, and an architect of the future of cardiology, or, indeed, of clinical medicine.
With further observation using the polygraph applied to patients with irregular pulses, Mackenzie was able to identify ‘the youthful type irregularity’ (sinus arrhythmia) and ‘the adult type irregularity’ (ventricular ectopic). He later defined ‘auricular paralysis’ (atrial fibrillation), which formerly he had named ‘dangerous type of irregularity’. In 1899, he described the association of atrial fibrillation with heart failure, particularly with fast heart rates, 80% of patients with atrial fibrillation being found to have heart failure. He tried to keep the heart rate under 80 bpm by titrating the digitalis dose, thereby enabling patients with heart failure to remain employed for years, though at a lower intensity than previously, when healthy. He also found an association between angina pectoris and heart failure.
Causes and treatment of heart failure
He realised that heart failure was the final path to death in some conditions, even in women suffering from puerperal fever. He recognised that the onset of heart failure was due to a reduction in the ‘reserve force’ of the heart with the earliest symptoms, such as breathlessness and, less commonly, chest pain, provoked by effort. With long-term observation, he found that “a failing organ does not itself necessarily show its impaired efficiency”, in that heart failure presented with breathlessness and congestion in other organs. This led him to conclude that the early signs of heart failure were outside the heart and resulted in his pursuit of the “true scent”.
In his opinion, identification of the true scent of disease in a heart required observation of the response of the heart to effort, physical, emotional or other stimuli, which enables detection and/or prediction of the ‘heart’s inefficiency’. This is akin to the modern concept of cardiopulmonary stress testing in early heart failure. But even today, a cardiopulmonary stress test is not routinely performed in patients with suspected heart failure, which reminds us how advanced was Mackenzie’s thinking.
One of his treatments for heart failure was individually tailored exercise in the fresh air. This was not imitated until decades after his death. Fortunately, exercise is now an integral part of heart failure rehabilitation programmes.
His fame reached far and wide, except in his own country. His international admirers focused mainly on his polygraph invention, rather than on the man himself or on his clinical work. They each invested in a polygraph. Mackenzie maintained that the most reliable method of clinical research was ‘wait and see’, keeping to this principle throughout his entire clinical practice. His ‘wait and see’ method has subsequently turned out to be a real and solid service to humanity.
He paid great attention to patients’ sensations, often the earliest symptoms of illness. He took pains to record patients’ symptoms in their homes or at their bedside, preferring the former. With extensive observation and research on other organs, particularly those in the abdomen, and on cutaneous pain, Mackenzie concluded that “bodily organs do not have pain except under excessive demand”. Mackenzie was convinced that true clinical research should focus on three aspects, wait and see, mechanism of symptoms and response to effort.
Later life
After much productive work in London and beyond, Mackenzie became satisfied that his work on the heart had been accepted. He was no longer interested in maintaining a fashionable practice in London. He also perceived a trend, within the medical profession, of the human mind and reasoning power being replaced by instruments. So, he planned to return to Scotland to pursue ‘clinical research’, which, in his opinion, was best carried out in general practice where doctors could observe their patients in their own environment in the long term. He decided in 1917, “If nobody else will go, I must go myself”.
However, the first world war delayed his plans. He became a key player in dealing with service men who were deemed unfit for active service because of alleged heart disease. Along with others, including his loyal assistant Thomas Lewis, he developed the concept of ‘soldier’s heart’ and its effective management with rehabilitation, enabling most service men with a ‘soldier’s heart’ to return to the front.
He then returned to general practice in Scotland and initiated clinical research at St. Andrews University, which he continued for the rest of his life. There he established the research institute that is now known as the Sir James Mackenzie Institute for Early Diagnosis, and his legacy continues.
Legacy
Mackenzie inspired many talented men in cardiology, including Thomas Lewis and John Parkinson, thus laying the foundations for a group of eminent British cardiologists, the Cardiac Club formed in 1922, the forerunner to the British Cardiac Society (now British Cardiovascular Society), the oldest cardiological society in the world. His influence and inspiration extend well beyond the British Isles.
His contribution to cardiology was truly fundamental. It is not an exaggeration to call him the father of cardiology. He made thorough and long-term observations on the then common cardiac conditions, heart failure, atrial fibrillation, rheumatic valve disease and angina pectoris. His invention of the polygraph and his teaching in both general practice and hospitals influenced greatly the medical profession, both in the UK and abroad.
He was honoured with many titles, Doctor, Inventor, Head of Heart Department at the London Hospital, Fellow of the Royal College of Physicians (RCP), a Knighthood (knighted 1915) or sobriquets, such as The Burnley Man, The Man of Polygraph, The Man of Tracings, The Father of Neo-Cardiology, and The Beloved Physician. Of them all, that which he liked best, and probably the most appropriate was ‘the beloved physician’, bestowed by the people of Burnley.
Conflicts of interest
None declared.
Funding
None.
Further reading
McNair Wilson R. The Beloved Physician, Sir James Mackenzie; A Biography. New York: The Macmillan Company, 1926.
Mackenzie J, Orr J. Principles of Diagnosis and Treatment in Heart Affections. Third edition. London: Henry Frowde and Hodder & Stoughton, 1927. Available from: https://ia802907.us.archive.org/14/items/in.ernet.dli.2015.547836/2015.547836.Principles-of_text.pdf
Parkinson J. Sir James Mackenzie, the centenary of his birth. Br Heart J 1954;16:125–7. https://doi.org/10.1136/hrt.16.1.125
