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Sir James Mackenzie
American
Heart Journal
VOL. 46
OCTOBER,1953
Original SIR
No. 4
Communications JAMES MACKENZIE 1853-1953
IAN STEVENSON, M.D. NEW ORLEANS, LA.
E
VERY physician concerned with the advance of medicine will be interested this year in the centenary of Sir James Mackenzie who did so much to promote that advance. Mackenzie was in a very real sense the first modern clinical investigator to apply the methods of science at the bedside. Many medical men before him had worked fruitfully with animals in laboratories and a number, such as Bright and Beaumont, had made important physiologic observations on human subjects. Mackenzie, however, was the first physician to dedicate himself wholeheartedly to clinical investigation, the first to make of it a life work. Those who have done this since are greatly indebted to his leadership. It is timely to review his life and work in order to enrich our own. The outward circumstances of Mackenzie’s early life deserve a brief recounting because of the shape they gave his personality. Mackenzie was born in 1853 in the town of Scone in highland Perthshire, Scotland. His father was a tenant farmer who succeeded and even prospered during a period of crop failures and general depression in farming. From him, no doubt, Mackenzie acquired some of the perseverance in adversity which distinguished him later. The stock was certainly capable of generating greatness. One of Mackenzie’s brothers, who became Sir William Mackenzie and later Lord Amulree, was a lawyer hardly less notable in his profession than Sir James Mackenzie in his. A third brother was a widely known and much beloved minister. Mackenzie received his early education in the schools around Scone, chiefly in the celebrated Perth Academy. The schoolsof Scotland, then, as many schools still do, attached undue importance to feats of memory and gave little opportunity for the exercise of reasoning and understanding. By these standards Mackenzie was judged an indifferent scholar and for many years accepted this opinion of La.
From the Department of Medicine, Louisiana Rt,ateTJnimrsity Fichoolof Medicinr, iVrw Orlnans, Received for publication July 6, 1953.
479
480
AMERICAN
HEART
JOURNAL
himself. And accepting it, he at first confined his ambitions to becoming a pharmacist. Soon he was stimulated by the company of the doctors in Perth to undertake the study of medicine himself, and so enrolled in the medical school of Edinburgh University. In the medical school the focus of learning was again on memory rather than on reasoning and understanding. Mackenzie was beset by the same feeling of incompetence which he had previously experienced. Although he did much better than average in his studies, he was graduated with a reinforced conviction of his own intellectual inadequacy. He had some aspirations to a career of teaching and research, but he felt himself unequal to such heights. After serving a year as a resident physician at the Edinburgh Royal Infirmary, he accepted an offer in 1879 of an assistantship to two general practitioners in the town of Burnley, Lancashire. There he spent the next twenty-eight years of his life engaged in a busy general practice. Mackenzie was evidently moved by the highest professional ideals, and when any of his patients became worse or died, he attributed this to his own ignorance. He became particularly impressed by his ignorance of prognosis, and his inability to pick out the important signs of danger from a miscellany of symptoms. Searching through the available textbooks and medical journals of the day, he discovered to his astonishment that the information he sought was not even known to others. Indeed there seemed little curiosity about such knowledge. The tradition of the day taught the physician to be preoccupied with structural changes but not with the subtler disturbances of function which are the earliest indications of more serious trouble. Out of this frustration and helped by his insatiable curiosity, Mackenzie began to observe his patients with a view to distinguishing the more from the less significant signs and symptoms. He reasoned that, if he followed his patients long enough, he would be able to correlate their symptoms and signs with their prognoses. The magnitude of this task soon obliged him to restrict himself largely to disorders of the cardiovascular system which thereafter became the center of his interest. In the midst of a busy general practice, he collected a mass of data from his own examinations of large numbers of patients studied over many years. He utilized whatever technical tools he could and even invented a new recording instrument--the polygraph-which could make simultaneous records of arterial, cardiac, and venous activity. It was characteristic of the age, but not a part of Mackenzie, that he became more famous for his polygraph than for the information which he was seeking with it. That information came to him slowly over the years, but in the end it came in abundance. With it Mackenzie wrought a’revolution in cardiology. To understand the magnitude of this revolution one need only recall that sinus arrhythmia and auricular extrasystoles were, prior to Mackenzie’s work, treated as signs of grave import demanding drastic restriction of activities and even a life of invalidism. Mackenzie’s long-term studies of his patients demonstrated that these signs were not followed by any serious heart disease and that they were, in fact, harmless. On the other hand, he was able to point out the serious significance of puleus alternans and of the arrhythmia now known as auricular fibrillation. He showed that in the latter condition the auricle is useless,
STEVENSON
:
SIR
JAMES
MACKENZIE
481
(although it is not, as he thought, paralyzed); and he pointed to the danger to health during auricular fibrillation when the ventricular rate becomes rapid and ventricular function ineffective. He was the first physician to achieve an understanding of the arrhythmias based on physiologic knowledge. He similarly extended our information on the significance of different murmurs. The integration of the different lines of Mackenzie’s work was dramatically demonstrated by his observations on one of his patients with rheumatic heart disease whom he followed for many years. One day when he was called to see this patient, he found that there had occurred simultaneously a disappearance of the a wave in the jugular pulse and of the presystolic murmur, while the ventricular rate had become rapid and the general condition much worse. This was the beginning of Mackenzie’s understanding of auricular fibrillation. Mackenzie would want it remembered today that the insight which he achieved from the examination of this patient came only because he had examined her on many occasions over many years. The clarification of the arrhythmias and murmurs was not Mackenzie’s only contribution to cardiology. After Stoke:, he was the first physician to draw attention to the primary importance of the state of the cardiac muscle in prognosis. He pointed out that signs of inadequacy are first revealed when an organ is under stress and its reserves are called into play. He established the response to effort as an index of these reserves. He thus became the great modern exponent of the forward failure theory of congestive failure. His contributions to therapy were hardly less notable than those to clinical physiology. His moFt important modification of therapy arose from his better understanding of the significance of different signs and symptoms. Thus he was able to free many patients from unnecessary restrictions of activity which had been imposed on them by other physicians. And he was equally able to warn other patients that a decline in their cardiac reserves warranted restriction of exercise within the bounds of comfort. In addition, he revived the use of digitalis which had become neglected in British medicine at this time. He demonstrated its particular value in slowing the rapid ventricles in auricular fibrillation and clarified the indications for its use. All this work and much else Mackenzie published throughout the middle years of his life. At first many of his articles were rejected by editors of medical journals because the facts he cited were too contrary to current theories. In 1902 he published The Study of the Pulse and with this his fame began to spread. The extraordinary diagnostic and prognostic acumen which he exhibited had already won him a large consulting practice around his section of Lancashire. But now, slowly, some leaders of the medical profession began to interest themselves in his studies. These at first were from abroad, and it was in Germany that his views on the arrhythmias and heart failure were first widely accepted. It is said that some German physicians who came to a meeting of cardiologists in England were annoyed when they did not find Mackenzie there and left the meeting to visit him. In the ensuing years they were gradually followed by a few and then by more and more of Mackenzie’s British colleagues as they learned about the richness of his experience and his remarkable powers of observation.
482
AMERICAN
HEART
JOURNAL
Throughout his life Mackenzie felt an understandable urge to place his studies before a larger public. To this end he published much. But in 1907 at the age of fifty-four he resolved to move from Burnley to London and there seek to widen his influence through the big hospitals and medical schools of the metropolis. The step was a bold one and at first it seemed fraught with failure. Mackenzie earned barely &lo0 during his first year in London. The next year, This work contained a distillate of 1908, he published his Diseases of the Heart. his long years of observations of cardiac patients. It provided a summary of the evidence on which he based his prognosis and his treatment, both so different from those prevailing. The book took hold rapidly so that Mackenzie’s practice increased and he was soon much in demand. Over the next fifteen years, other papers and books followed, such as his great monograph Angina Pectoris and the He also made significant contribuclassical Symptoms and Their Interpretation. tion&to the study of pain. Many honors came to him and were culminated in a knighthood. Despite his undoubted success in London, Mackenzie remained unsatisfied with his work on two counts. In the first place, he became increasingly aware that fame had come to him for what he considered his less important work, namely his technical discoveries. This was in keeping with the mood of the time. Everywhere there was enthusiasm for new technical aids in medicine. The invention of the electrocardiograph by Einthoven and its clever exploitation by Lewis captivated the medical world. Mackenzie almost alone at this time penetrated beyond the usefulness of these aids to see that they did not, that nothing ever could, replace the need for careful study of the individual patient as a whole. Secondly, it had always been part of his plan to search for underlying principles which apply throughout the whole of medicine. He had confined himself largely to cardiology because the wealth of observations to be made precluded his studying a larger field. But he had done so reluctantly and, in fact, only partially. He had always maintained a keen curiosity about events in all organs of the body. And he felt that the necessity of specializing had largely cut him off from the wider observations which would have permitted him to generalize about the principles of medicine. Ruminating about these problems-the acceptance of his discoveries, but not of his ideas and methods, and his wish to seek the basic principles of medicine -Mackenzie resolved to return to general practice. He had always known that sick people come first to general practitioners and that the latter have therefore an unequalled opportunity for the study of the early signs of illness. Theirs is an opportunity denied the specialist who usually sees only advanced cases, yet this opportunity is all too little used for research which could be extracted from it. Mackenzie had used this opportunity richly before, and now he felt he must return to it for the attainment of his goal. And so, with courage verging on rashness, and at the advanced age of sixty-five, he closed his office in Harley Street and went to the Scottish university town of St. Andrews. For his ideal he left a consulting practice worth J%,OOO annually. He chose St. Andrews because it is a small town with a settled population so that patients could be easily followed over many years; it had, in addition, the facilities of a university medical school. In
STEVENSON
:
SIR
JAMES
MACKENZIE
483
St. Andrews he enlisted the assistance of the practitioners of the town and of some of the university staff and began a systematic study of the early signs and symptoms of all illnesses. He hoped to extend his study of the significance of symptoms to other organs besides the heart and to search for ever earlier (and more treatable) appearances of serious disease. The colleagues who joined him worked energetically at this task, constantly illuminated by the vigor and enthusiasm of Mackenzie himself. Although Mackenzie had for many years suffered from angina pectoris and became increasingly its victim during this period, he labored on without stopping. He made frequent trips around the country in order to earn large consulting fees which he used to subsidize the work of the St. Andrews Institute for Clinical Research. Before his death the work of the Institute had already shown not merely promise but sound results. The proceedings of the Institute can be read with profit today, not because their information is necessarily topical, though much of it still is. Rather they are profitable reading because of the method which they demonstrate, the method of patient watching, waiting, and studying, and because of the ideal to which they are dedicated, the discovery of the fundamental principles of medicine. Mackenzie himself summarized those principles which he felt to be established with sufficient security in a slender volume called The Basis 03’ Vital A&&y. This little book reached the public only after his death as a sort of a posthumous gift to those who wished to share his quest. That these principles were not merely isolated speculations was demonstrated by Mackenzie in his last revision of Diseases of the Heart. For this edition he completely tore down the old structure and rewrote the book to incorporate the newer knowledge he had achieved from his wider work. The result is indeed an extraordinary volume, a medical textbook in which the problems of one organ are related to general principles of health and disease. Though there have been many advances in cardiology since this publication, there has been no advance in the integration of cardiology with medicine which has carried us beyond this great work. Unfortunately after Mackenzie’s Institute at St. Andrews, without his The ideals for which he stood became minds of those who have studied his
death, which came in 1925, the work of the inspiration, weakened and finally perished. embodied not in an institution, but in the remarkable career.
From all accounts it appears that Mackenzie was, to use the simplest language, both a great and good man. Few physicians have ever given so much of themselves to their patients, and it is certain that none have done so while at the same time carrying out first-rate research. His richness in humility and gentleness made him deeply loved not only by his patients but by all his colleagues. Apart from the accuracy of his clinical knowledge of the heart, far ahead of that of any of his contemporaries, Mackenzie knew well the art of medicine. If he was often perplexed by clinical problems, he did not convey this to his patients. Rather he always maintained an attitude of firm optimism. “Doubt and indecision on the part of the physician,” he said, “hang like a cloud around the patient.”
484
AMERICAN
HEART
JOURNAL
It is altogether as he would have wished it that Mackenzie’s individual discoveries have now been incorporated in the body of factual medical knowledge, so that few today even know their discoverer’s name. And it is right that Mackenzie’s fame should now rest on his search for clarifying principles of medicine to guide the practitioner in all his work. It should, however, be of some concern that his remembrance in this respect is no greater. It is astonishing to notice that while the fame of Mackenzie’s contemporary, Sir William Osler, continues to grow with the years, there are many young physicians who are barely acquainted with Mackenzie’s name. It would be unfitting to exalt one of these great men at the expense of the other. Suffice it to say that as Osler deserves to be the ideal of the young clinician, Mackenzie should be that of the young investigator. If he is less well known today than he should be, this is perhaps because the goal towards which he worked, that of understanding the basic principles of medicine, is still to be attained. But it is largely through his work that such attainment has become a possibility.
Heart Journal
VOL. 46
OCTOBER,1953
Original SIR
No. 4
Communications JAMES MACKENZIE 1853-1953
IAN STEVENSON, M.D. NEW ORLEANS, LA.
E
VERY physician concerned with the advance of medicine will be interested this year in the centenary of Sir James Mackenzie who did so much to promote that advance. Mackenzie was in a very real sense the first modern clinical investigator to apply the methods of science at the bedside. Many medical men before him had worked fruitfully with animals in laboratories and a number, such as Bright and Beaumont, had made important physiologic observations on human subjects. Mackenzie, however, was the first physician to dedicate himself wholeheartedly to clinical investigation, the first to make of it a life work. Those who have done this since are greatly indebted to his leadership. It is timely to review his life and work in order to enrich our own. The outward circumstances of Mackenzie’s early life deserve a brief recounting because of the shape they gave his personality. Mackenzie was born in 1853 in the town of Scone in highland Perthshire, Scotland. His father was a tenant farmer who succeeded and even prospered during a period of crop failures and general depression in farming. From him, no doubt, Mackenzie acquired some of the perseverance in adversity which distinguished him later. The stock was certainly capable of generating greatness. One of Mackenzie’s brothers, who became Sir William Mackenzie and later Lord Amulree, was a lawyer hardly less notable in his profession than Sir James Mackenzie in his. A third brother was a widely known and much beloved minister. Mackenzie received his early education in the schools around Scone, chiefly in the celebrated Perth Academy. The schoolsof Scotland, then, as many schools still do, attached undue importance to feats of memory and gave little opportunity for the exercise of reasoning and understanding. By these standards Mackenzie was judged an indifferent scholar and for many years accepted this opinion of La.
From the Department of Medicine, Louisiana Rt,ateTJnimrsity Fichoolof Medicinr, iVrw Orlnans, Received for publication July 6, 1953.
479
480
AMERICAN
HEART
JOURNAL
himself. And accepting it, he at first confined his ambitions to becoming a pharmacist. Soon he was stimulated by the company of the doctors in Perth to undertake the study of medicine himself, and so enrolled in the medical school of Edinburgh University. In the medical school the focus of learning was again on memory rather than on reasoning and understanding. Mackenzie was beset by the same feeling of incompetence which he had previously experienced. Although he did much better than average in his studies, he was graduated with a reinforced conviction of his own intellectual inadequacy. He had some aspirations to a career of teaching and research, but he felt himself unequal to such heights. After serving a year as a resident physician at the Edinburgh Royal Infirmary, he accepted an offer in 1879 of an assistantship to two general practitioners in the town of Burnley, Lancashire. There he spent the next twenty-eight years of his life engaged in a busy general practice. Mackenzie was evidently moved by the highest professional ideals, and when any of his patients became worse or died, he attributed this to his own ignorance. He became particularly impressed by his ignorance of prognosis, and his inability to pick out the important signs of danger from a miscellany of symptoms. Searching through the available textbooks and medical journals of the day, he discovered to his astonishment that the information he sought was not even known to others. Indeed there seemed little curiosity about such knowledge. The tradition of the day taught the physician to be preoccupied with structural changes but not with the subtler disturbances of function which are the earliest indications of more serious trouble. Out of this frustration and helped by his insatiable curiosity, Mackenzie began to observe his patients with a view to distinguishing the more from the less significant signs and symptoms. He reasoned that, if he followed his patients long enough, he would be able to correlate their symptoms and signs with their prognoses. The magnitude of this task soon obliged him to restrict himself largely to disorders of the cardiovascular system which thereafter became the center of his interest. In the midst of a busy general practice, he collected a mass of data from his own examinations of large numbers of patients studied over many years. He utilized whatever technical tools he could and even invented a new recording instrument--the polygraph-which could make simultaneous records of arterial, cardiac, and venous activity. It was characteristic of the age, but not a part of Mackenzie, that he became more famous for his polygraph than for the information which he was seeking with it. That information came to him slowly over the years, but in the end it came in abundance. With it Mackenzie wrought a’revolution in cardiology. To understand the magnitude of this revolution one need only recall that sinus arrhythmia and auricular extrasystoles were, prior to Mackenzie’s work, treated as signs of grave import demanding drastic restriction of activities and even a life of invalidism. Mackenzie’s long-term studies of his patients demonstrated that these signs were not followed by any serious heart disease and that they were, in fact, harmless. On the other hand, he was able to point out the serious significance of puleus alternans and of the arrhythmia now known as auricular fibrillation. He showed that in the latter condition the auricle is useless,
STEVENSON
:
SIR
JAMES
MACKENZIE
481
(although it is not, as he thought, paralyzed); and he pointed to the danger to health during auricular fibrillation when the ventricular rate becomes rapid and ventricular function ineffective. He was the first physician to achieve an understanding of the arrhythmias based on physiologic knowledge. He similarly extended our information on the significance of different murmurs. The integration of the different lines of Mackenzie’s work was dramatically demonstrated by his observations on one of his patients with rheumatic heart disease whom he followed for many years. One day when he was called to see this patient, he found that there had occurred simultaneously a disappearance of the a wave in the jugular pulse and of the presystolic murmur, while the ventricular rate had become rapid and the general condition much worse. This was the beginning of Mackenzie’s understanding of auricular fibrillation. Mackenzie would want it remembered today that the insight which he achieved from the examination of this patient came only because he had examined her on many occasions over many years. The clarification of the arrhythmias and murmurs was not Mackenzie’s only contribution to cardiology. After Stoke:, he was the first physician to draw attention to the primary importance of the state of the cardiac muscle in prognosis. He pointed out that signs of inadequacy are first revealed when an organ is under stress and its reserves are called into play. He established the response to effort as an index of these reserves. He thus became the great modern exponent of the forward failure theory of congestive failure. His contributions to therapy were hardly less notable than those to clinical physiology. His moFt important modification of therapy arose from his better understanding of the significance of different signs and symptoms. Thus he was able to free many patients from unnecessary restrictions of activity which had been imposed on them by other physicians. And he was equally able to warn other patients that a decline in their cardiac reserves warranted restriction of exercise within the bounds of comfort. In addition, he revived the use of digitalis which had become neglected in British medicine at this time. He demonstrated its particular value in slowing the rapid ventricles in auricular fibrillation and clarified the indications for its use. All this work and much else Mackenzie published throughout the middle years of his life. At first many of his articles were rejected by editors of medical journals because the facts he cited were too contrary to current theories. In 1902 he published The Study of the Pulse and with this his fame began to spread. The extraordinary diagnostic and prognostic acumen which he exhibited had already won him a large consulting practice around his section of Lancashire. But now, slowly, some leaders of the medical profession began to interest themselves in his studies. These at first were from abroad, and it was in Germany that his views on the arrhythmias and heart failure were first widely accepted. It is said that some German physicians who came to a meeting of cardiologists in England were annoyed when they did not find Mackenzie there and left the meeting to visit him. In the ensuing years they were gradually followed by a few and then by more and more of Mackenzie’s British colleagues as they learned about the richness of his experience and his remarkable powers of observation.
482
AMERICAN
HEART
JOURNAL
Throughout his life Mackenzie felt an understandable urge to place his studies before a larger public. To this end he published much. But in 1907 at the age of fifty-four he resolved to move from Burnley to London and there seek to widen his influence through the big hospitals and medical schools of the metropolis. The step was a bold one and at first it seemed fraught with failure. Mackenzie earned barely &lo0 during his first year in London. The next year, This work contained a distillate of 1908, he published his Diseases of the Heart. his long years of observations of cardiac patients. It provided a summary of the evidence on which he based his prognosis and his treatment, both so different from those prevailing. The book took hold rapidly so that Mackenzie’s practice increased and he was soon much in demand. Over the next fifteen years, other papers and books followed, such as his great monograph Angina Pectoris and the He also made significant contribuclassical Symptoms and Their Interpretation. tion&to the study of pain. Many honors came to him and were culminated in a knighthood. Despite his undoubted success in London, Mackenzie remained unsatisfied with his work on two counts. In the first place, he became increasingly aware that fame had come to him for what he considered his less important work, namely his technical discoveries. This was in keeping with the mood of the time. Everywhere there was enthusiasm for new technical aids in medicine. The invention of the electrocardiograph by Einthoven and its clever exploitation by Lewis captivated the medical world. Mackenzie almost alone at this time penetrated beyond the usefulness of these aids to see that they did not, that nothing ever could, replace the need for careful study of the individual patient as a whole. Secondly, it had always been part of his plan to search for underlying principles which apply throughout the whole of medicine. He had confined himself largely to cardiology because the wealth of observations to be made precluded his studying a larger field. But he had done so reluctantly and, in fact, only partially. He had always maintained a keen curiosity about events in all organs of the body. And he felt that the necessity of specializing had largely cut him off from the wider observations which would have permitted him to generalize about the principles of medicine. Ruminating about these problems-the acceptance of his discoveries, but not of his ideas and methods, and his wish to seek the basic principles of medicine -Mackenzie resolved to return to general practice. He had always known that sick people come first to general practitioners and that the latter have therefore an unequalled opportunity for the study of the early signs of illness. Theirs is an opportunity denied the specialist who usually sees only advanced cases, yet this opportunity is all too little used for research which could be extracted from it. Mackenzie had used this opportunity richly before, and now he felt he must return to it for the attainment of his goal. And so, with courage verging on rashness, and at the advanced age of sixty-five, he closed his office in Harley Street and went to the Scottish university town of St. Andrews. For his ideal he left a consulting practice worth J%,OOO annually. He chose St. Andrews because it is a small town with a settled population so that patients could be easily followed over many years; it had, in addition, the facilities of a university medical school. In
STEVENSON
:
SIR
JAMES
MACKENZIE
483
St. Andrews he enlisted the assistance of the practitioners of the town and of some of the university staff and began a systematic study of the early signs and symptoms of all illnesses. He hoped to extend his study of the significance of symptoms to other organs besides the heart and to search for ever earlier (and more treatable) appearances of serious disease. The colleagues who joined him worked energetically at this task, constantly illuminated by the vigor and enthusiasm of Mackenzie himself. Although Mackenzie had for many years suffered from angina pectoris and became increasingly its victim during this period, he labored on without stopping. He made frequent trips around the country in order to earn large consulting fees which he used to subsidize the work of the St. Andrews Institute for Clinical Research. Before his death the work of the Institute had already shown not merely promise but sound results. The proceedings of the Institute can be read with profit today, not because their information is necessarily topical, though much of it still is. Rather they are profitable reading because of the method which they demonstrate, the method of patient watching, waiting, and studying, and because of the ideal to which they are dedicated, the discovery of the fundamental principles of medicine. Mackenzie himself summarized those principles which he felt to be established with sufficient security in a slender volume called The Basis 03’ Vital A&&y. This little book reached the public only after his death as a sort of a posthumous gift to those who wished to share his quest. That these principles were not merely isolated speculations was demonstrated by Mackenzie in his last revision of Diseases of the Heart. For this edition he completely tore down the old structure and rewrote the book to incorporate the newer knowledge he had achieved from his wider work. The result is indeed an extraordinary volume, a medical textbook in which the problems of one organ are related to general principles of health and disease. Though there have been many advances in cardiology since this publication, there has been no advance in the integration of cardiology with medicine which has carried us beyond this great work. Unfortunately after Mackenzie’s Institute at St. Andrews, without his The ideals for which he stood became minds of those who have studied his
death, which came in 1925, the work of the inspiration, weakened and finally perished. embodied not in an institution, but in the remarkable career.
From all accounts it appears that Mackenzie was, to use the simplest language, both a great and good man. Few physicians have ever given so much of themselves to their patients, and it is certain that none have done so while at the same time carrying out first-rate research. His richness in humility and gentleness made him deeply loved not only by his patients but by all his colleagues. Apart from the accuracy of his clinical knowledge of the heart, far ahead of that of any of his contemporaries, Mackenzie knew well the art of medicine. If he was often perplexed by clinical problems, he did not convey this to his patients. Rather he always maintained an attitude of firm optimism. “Doubt and indecision on the part of the physician,” he said, “hang like a cloud around the patient.”
484
AMERICAN
HEART
JOURNAL
It is altogether as he would have wished it that Mackenzie’s individual discoveries have now been incorporated in the body of factual medical knowledge, so that few today even know their discoverer’s name. And it is right that Mackenzie’s fame should now rest on his search for clarifying principles of medicine to guide the practitioner in all his work. It should, however, be of some concern that his remembrance in this respect is no greater. It is astonishing to notice that while the fame of Mackenzie’s contemporary, Sir William Osler, continues to grow with the years, there are many young physicians who are barely acquainted with Mackenzie’s name. It would be unfitting to exalt one of these great men at the expense of the other. Suffice it to say that as Osler deserves to be the ideal of the young clinician, Mackenzie should be that of the young investigator. If he is less well known today than he should be, this is perhaps because the goal towards which he worked, that of understanding the basic principles of medicine, is still to be attained. But it is largely through his work that such attainment has become a possibility.