Commentary: James Mackenzie 1921, still relevant in 2012

The son of a tenant farmer from Scone, James Mackenzie was a remarkable example of social mobility in Victorian and Edwardian Britain. After initial schooling and an apprenticeship as a dispensing chemist, he entered medical training, and shortly after completing his course, he became a general practitioner in Burnley in 1879. In general practice, he became one of the leading researchers of heart disease of his generation, and by 1907, had advanced to lead the new cardiac department of the London Hospital. He went on to become a knight, Fellow of the Royal Society and honorary physician to the king. In 1921, he was nominated for a Nobel prize, and given his ground-breaking work in heart failure, mitral stenosis, atrial fibrillation and the role of digitalis, his case for a prize may appear strong, but perhaps because of the primacy of laboratory methods against which he furiously railed in his article in the BMJ, his work, although of great clinical value, was not rewarded with a prize. In the 91 years since he published his lecture delivered at St Mary’s Hospital, medical practice has transformed. The laboratory methods that so frustrated him have produced an abundance of riches in both clinical investigations and therapeutic interventions that even Mackenzie would be forced to marvel at. Our understanding of cardiac physiology and function, our ability to investigate the heart in the living subject and the pharmacological and surgical therapies now at our disposal would surely be sufficient to cause Mackenzie to reverse his opinions, and acknowledge with almost everyone else that laboratory methods are patently more complex and more rewarding than the role of the humble clinical observer—the doctor, most commonly a general practitioner, who records in detail the symptoms and signs that may be the initial features of disease or risk of disease, and follows up the people in his care for several years. However, wait a moment—perhaps, he would not change his mind, but instead stubbornly would remind us once again not to overlook the importance of the frequent opportunities that present to observe, record and monitor clinical details. The clinical observer and the early detection of disease