The St Andrews Institute for clinical research: An early experiment in collaboration

Medical History

Volumn 46, Issue 4, 2002, Pages 549-568

  Macnaughton, Jane ^a  

^a DURHAM UNIVERSITY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HISTORY; HUMAN; MEDICAL RESEARCH; ORGANIZATION; UNITED KINGDOM;

ACADEMIES AND INSTITUTES; BIOMEDICAL RESEARCH; HISTORY, 18TH CENTURY; HISTORY, 19TH CENTURY; HUMANS; SCOTLAND;

EID: 0036782627     PISSN: 00257273     EISSN: None     Source Type: Journal    
DOI: 10.1017/s0025727300069738     Document Type: Article

References (102)

1. It is an indication of Mackenzie's fame that there have been two biographies of him. The first, The beloved physician (London, John Murray), was written by his admirer, Dr R MacNair Wilson (a physician and journalist with The Times newspaper) and was published in 1926, the year after Mackenzie's death. This book was so popular that it ran to three reprints within seven months. The later, more objective, account was published in 1973 by the second incumbent of the James Mackenzie Chair of Public Health and Social Medicine at the University of St Andrews, Professor Alex Mair: Sir James Mackenzie, MD, 1853-1925, general practitioner, Edinburgh, Churchill Livingstone, 1973.
2. It is an indication of Mackenzie's fame that there have been two biographies of him. The first, The beloved physician (London, John Murray), was written by his admirer, Dr R MacNair Wilson (a physician and journalist with The Times newspaper) and was published in 1926, the year after Mackenzie's death. This book was so popular that it ran to three reprints within seven months. The later, more objective, account was published in 1973 by the second incumbent of the James Mackenzie Chair of Public Health and Social Medicine at the University of St Andrews, Professor Alex Mair: Sir James Mackenzie, MD, 1853-1925, general practitioner, Edinburgh, Churchill Livingstone, 1973.
3. It is an indication of Mackenzie's fame that there have been two biographies of him. The first, The beloved physician (London, John Murray), was written by his admirer, Dr R MacNair Wilson (a physician and journalist with The Times newspaper) and was published in 1926, the year after Mackenzie's death. This book was so popular that it ran to three reprints within seven months. The later, more objective, account was published in 1973 by the second incumbent of the James Mackenzie Chair of Public Health and Social Medicine at the University of St Andrews, Professor Alex Mair: Sir James Mackenzie, MD, 1853-1925, general practitioner, Edinburgh, Churchill Livingstone, 1973.
4. Christopher Lawrence, 'Moderns and ancients: the "new cardiology" in Britain 1880-1930', in W F Bynum, C Lawrence, and V Nutton (eds), The emergence of modern cardiology, Medical History, Supplement No. 5, London, Wellcome Institute for the History of Medicine, 1985, pp. 1-33, p. 16. This paper gives an account of Mackenzie's significance to the development of cardiology. Further accounts are to be found in the biographies above.
5. Ibid., pp. 15-16. Mackenzie made frequent reference to this belief in his writings, such as his book The future of medicine, London, Henry Frowde, Hodder & Stoughton, 1919, p. 45. His view was that clinical specialism was retarding the advance of medicine by concentrating research on the end stages of disease, when it was too late to prevent death or serious illness.
6. Ibid., pp. 15-16. Mackenzie made frequent reference to this belief in his writings, such as his book The future of medicine, London, Henry Frowde, Hodder & Stoughton, 1919, p. 45. His view was that clinical specialism was retarding the advance of medicine by concentrating research on the end stages of disease, when it was too late to prevent death or serious illness.
7. Christopher Lawrence gives a general account of the development of clinical research in the UK and the USA in 'Clinical research', in J Krige and D Pestre (eds), Science in the 20th century, Amsterdam, Harwood Academic, 1997, pp. 439-59, pp. 444-5. Anne Digby, in her recent book on the history of general practice, The evolution of British general practice, Oxford University Press, 1999, shows the decline in MDs amongst GPs (p. 218).
8. Christopher Lawrence gives a general account of the development of clinical research in the UK and the USA in 'Clinical research', in J Krige and D Pestre (eds), Science in the 20th century, Amsterdam, Harwood Academic, 1997, pp. 439-59, pp. 444-5. Anne Digby, in her recent book on the history of general practice, The evolution of British general practice, Oxford University Press, 1999, shows the decline in MDs amongst GPs (p. 218).
9. John Howie, 'Research in general practice: perspectives and themes', in I Loudon, J Horder, C Webster (eds), General practice under the National Health Service, London, Clarendon Press, 1998, pp. 146-64, p. 151.
10. Mair, op. cit., note 1 above, p. 36.
11. Ibid., p. 37. Dr John Brown had been Lister's demonstrator and dresser at Edinburgh Royal Infirmary and persuaded Mackenzie to apply for a residency at the Royal before he entered general practice.
12. Edinburgh University library special collections department (EUL), MS Gen. 1980, box 6: Sir James Mackenzie, 'Personal experiences'. Edinburgh University Library contains 10 boxes of miscellaneous material relating to Mackenzie. This material was given to the library by Professor Mair after he had completed his biography.
13. Lawrence, op. cit., note 2 above, p. 14.
14. Mair, op. cit., note 1 above, p. 96.
15. T Osborne, 'James Mackenzie, general practitioner', Sociology of Health and Illness, 1993, 15: 525-46, p. 527.
16. Lawrence, op. cit., note 2 above, p. 15.
17. Mair, op. cit., note 1 above, p. 242.
18. James Mackenzie, The study of the pulse: arterial, venous and hepatic, and of the movements of the heart, Edinburgh and London, Young J Pentland, 1902.
19. Book review in Br. med. J., 1902, ii: 250-1, p. 250. Mair (op. cit., note 1 above, p. 181) confirms that it was Allbutt who wrote the review.
20. Book review in Br. med. J., 1902, ii: 250-1, p. 250. Mair (op. cit., note 1 above, p. 181) confirms that it was Allbutt who wrote the review.
21. It was not until his second book, Diseases of the heart, was published in 1908 (London, Henry Frowde, Hodder & Stoughton) that Mackenzie's reputation in London was secure enough for him to make money in his private practice.
22. Lawrence, op. cit., note 2 above, p. 29.
23. Mair, op. cit., note 1 above, p. 258-9.
24. Mackenzie's relationship with Fletcher will be described later in this paper. For his dealings with Morant over record-keeping for GPs, see Frank Honigsbaum's account in The division in British medicine: a history of the separation of general practice from hospital care, 1911-1968, London, Kogan Page, 1979, pp. 94-100.
25. MacNair Wilson, op. cit., note 1 above, p. 275.
26. 'Sir James Mackenzie's last letter', The Times, 11 Feb. 1925.
27. Mair, op. cit., note 1 above, p. 295.
28. EUL MS Gen. 1980, box 8: 'First Annual Report of the St Andrews Institute for Clinical Research', Oct. 1920. In addition to the following aims, the Institute intended to provide postgraduate courses for training GPs in the methods of research which they could employ in their own practices.
29. An account of the importance of research into tuberculosis for the MRC is given in Linda Bryder, 'Tuberculosis and the MRC', in Joan Austoker and Linda Bryder (eds), Historical perspectives on the role of the MRC, Oxford University Press, 1989, pp. 1-21.
30. Public Record Office (PRO) FD 1/571, J Mackenzie to W Fletcher, 'Memorandum on some of the medical aspects of work under the National Health Insurance Act', from the section entitled, 'Methods pursued by the St Andrews Institute for Clinical Research'.
31. 'First Annual Report', op. cit., note 23 above, Director's report.
32. PRO FD 1/571, 'Memorandum upon medical records presented to the Medical Research Council', sent to Fletcher by Mackenzie, 2 Feb. 1922.
33. EUL MS Gen. 1980, box 4: 'Papers from the weekly staff meetings [of the Institute]', No. 1, May 1933, contains an article by G M Fyfe (a member of the medical staff) with the comment, "Mackenzie reckoned that thirty years would elapse before the work bore fruit".
34. 'First Annual Report', 'Report by the Director', op. cit., note 23 above.
35. Ministry of Health Consultative Council on Medical and Allied Services, Interim report on the future provision of medical and allied services (Dawson Report), HMSO, 1920, Cmd. (Great Britain. Parliament) 693.
36. Honigsbaum, op. cit., note 19 above, p. 64.
37. Dawson Report, op. cit., note 30 above, p. 14, para. 50.
38. PRO FD 1/571, 'Memorandum on some of the medical aspects of work under the National Health Insurance Act', by Sir James Mackenzie and the Staff of the St Andrews Institute for Clinical Research, 1919, p. 2.
39. Ibid.
40. Ibid., p. 2.
41. Sir James Mackenzie, The basis of vital activity, London, Faber and Gwyer, 1926. This work was significantly subtitled: being a review of five years' work at the St Andrews Institute for Clinical Research, indicating the importance of this side of the work in Mackenzie's mind.
42. Sir James Mackenzie (ed.), Reports of the St Andrews Institute for Clinical Research, vol. 1, London, Henry Frowde and Hodder & Stoughton, 1922, pp. 57-8. The Institute published three volumes of reports in book form, in 1922, 1924 and in 1926. In his article in vol. 1, Mackenzie gives an account of the development of his "theory of disturbed reflexes".
43. For the work of Charles Sherrington (and Henry Head) on the reflex see Ragnar Granit, Charles Scott Sherrington: an appraisal, London, Nelson, 1966, pp. 47-83.
44. PRO FD 1/571, H Head to W Fletcher, 19 July 1921.
45. Ibid., W Fletcher to H Head, 20 July 1921.
46. Ibid., J Mackenzie to W Fletcher, 27 June 1921.
47. 'First Annual Report', op. cit., note 23 above.
48. PRO FD 1/571, J Mackenzie to W Fletcher, 27 June 1921.
49. Ibid., W Fletcher to J Mackenzie, 29 April 1920.
50. PRO FD 1/572, J Mackenzie to W Fletcher, 18 Feb. 1924.
51. Ibid. This letter, written when Mackenzie was becoming increasingly "crippled" by his angina, reveals how much of his own financial resources Mackenzie was devoting to the Institute. He had intended to give up private consulting work when he founded the Institute but returned to it (despite his health problems) to help with funding.
52. EUL MS Gen. 1980, box 1: excerpts from minutes of meetings of University of St Andrews Court regarding the administration of the Carnegie grant.
53. EUL MS Gen. 1980, box 1: J Mackenzie to Mr Mitchell, 22 Dec. 1922.
54. PRO FD 1/572, W Fletcher to J Mackenzie, 13 May 1922: a letter containing details of this grant.
55. PRO FD 1/571, J Mackenzie to W Fletcher, 6 March 1922. Mackenzie's original request for a grant was for a total of £2300, and included a request for the part-time salaries of five GPs.
56. Ibid., J Mackenzie to W Fletcher, 29 March 1920.
57. Ibid., J Mackenzie to W Fletcher, 27 June 1921.
58. Ibid., W Fletcher to N Paton, 8 Dec. 1921. Paton and his colleagues published a report on child health and nutrition in 1926: D Noel Paton and Leonard Findlay, Child life investigations - poverty, nutrition and growth: studies of child life in cities and rural districts of Scotland, London, HMSO, 1926.
59. Paton, unlike many of the London based clinical scientists, would have shared Mackenzie's view of the importance of close working relationships with clinicians for the success of clinical research. See David Smith and Malcolm Nicolson, 'The "Glasgow School" of Paton, Findlay and Cathcart: conservative thought in chemical physiology, nutrition and public health', Soc. Stud. ScL, 1989, 19: 195-238, pp. 206-7.
60. PRO FD 1/571, N Paton to W Fletcher, 8 Feb. 1922.
61. St Andrews University Library Special Collections George Steedman Riddell Collection, MS 380009 box 3/3, Annual reports of the Clinical Institute, St Andrews Fife, 3 vols, 'Sixth Annual Report', 1925.
62. PRO FD 1/572, Dr Thomson (of MRC) to Professor Macwilliam (Dundee), 10 Jan. 1927.
63. Annual reports of the Clinical Institute, op. cit., note 56 above.
64. Ibid.
65. Mackenzie's original ideas about the physiology of symptoms were expounded in his book, Symptoms and their interpretation, London, Shaw and Sons, 1909.
66. The third and final volume of Reports of the St Andrews Institute was published in 1926 (London, Humphrey Milford and Oxford University Press), and although the eighth annual report suggests that a fourth volume was in preparation, it was never published. The rate of publication fell off dramatically after Mackenzie's death. Mackenzie published a series in the Lancet on 'The principles of symptomatology: an introduction to a new outlook in medicine' in an attempt to gain recognition for his theory of disturbed reflexes: Lancet, 1923, ii: 963-8, 1020-4, 1069-74.
67. Lawrence, op. cit., note 2 above, p. 29. For an account of Mackenzie's significance in Lewis's career see Arthur Hollman, Sir Thomas Lewis: pioneer cardiologist and clinical scientist, London, Springer, 1997, pp. 21-2.
68. Lawrence, op. cit., note 2 above, p. 29. For an account of Mackenzie's significance in Lewis's career see Arthur Hollman, Sir Thomas Lewis: pioneer cardiologist and clinical scientist, London, Springer, 1997, pp. 21-2.
69. J B Morrell, 'The chemist breeders: the research schools of Liebig and Thomas Thomson', Ambix, 1972, 19: 1-46. Gerald L Geison developed Morrell's idea into a checklist in his later article, 'Scientific change, emerging specialties and research schools', Hist. Sci., 1981, 19: 20-40, p. 26.
70. J B Morrell, 'The chemist breeders: the research schools of Liebig and Thomas Thomson', Ambix, 1972, 19: 1-46. Gerald L Geison developed Morrell's idea into a checklist in his later article, 'Scientific change, emerging specialties and research schools', Hist. Sci., 1981, 19: 20-40, p. 26.
71. PRO FD 1/571, H Head to W Fletcher, 19 July 1921.
72. EUL MS Gen. 1980, box 4: 'Papers from the weekly staff meetings', No. 1, May 1933.
73. EUL MS Gen. 1980, box 1: W Mackenzie to F Mackenzie, 26 April 1941. Sir William Mackenzie (Mackenzie's brother, by this time Lord Amulree) reported to Frances Mackenzie (Mackenzie's widow) that the Council of the Institute were unwilling to give up laboratory and X-ray facilities for the sake of focusing work on the records.
74. Sir Thomas Lewis papers, Archives and Manuscripts, Wellcome Library for the History and Understanding of Medicine (Wellcome), PP/ Lew/A.1/460-483, J Mackenzie to T Lewis, 3 Feb. 1921.
75. Wellcome, PP/Lew/A.1/460-483, T Lewis to J Mackenzie, 5 Feb. 1921.
76. Wellcome, PP/Lew/A.1/460-483, J Mackenzie to T Lewis, 15 Feb. 1921.
77. Christopher Lawrence, 'Incommunicable knowledge: science, technology and the clinical art in Britain 1850-1914', J. contemp. Hist., 1985: 20: 503-20, p. 507.
78. MacNair Wilson, op. cit., note 1 above, p. 179.
79. Lawrence, op. cit., note 70 above.
80. Lawrence, op. cit., note 2 above, p. 9.
81. Christopher Lawrence,. 'A tale of two sciences: bedside and bench in twentieth-century Britain', Med. Hist., 1999, 43: 421-49, p. 421. (Most of the discussion in this section is based on the work of Lawrence in this field.)
82. Roger Cooter, Surgery and society in peace and war: orthopaedics and the organization of modern medicine, 1880-1948, Basingstoke, Macmillan in association with the Centre for the History of Science, Technology and Medicine, University of Manchester, 1993, p. 5.
83. Sir Walter Fletcher, 'Medical research: the tree and the fruit', Br. med. J., 1929; ii: 993-6, p. 994.
84. Sir Thomas Lewis, 'Observations on research in medicine: its position and its needs', Br. med. J., 1930, i: 479-83. Christopher Booth gives an account of this discussion in his chapter entitled 'Clinical research', in Austoker and Bryder (eds), op. cit., note 24 above, pp. 211-14.
85. Sir Thomas Lewis, 'Observations on research in medicine: its position and its needs', Br. med. J., 1930, i: 479-83. Christopher Booth gives an account of this discussion in his chapter entitled 'Clinical research', in Austoker and Bryder (eds), op. cit., note 24 above, pp. 211-14.
86. Lewis, op. cit., note 77 above, p. 481.
87. Wellcome, PP/Lew/A.1/460-483. Correspondence between J Mackenzie and T Lewis, Feb. to March 1921.
88. Osborne, op. cit., note 11 above, p. 527.
89. Lawrence, op. cit., note 2 above, p. 14-15.
90. Mackenzie, op. cit., note 3 above, p. 45.
91. PRO FD 1/571, J Mackenzie to W Fletcher, 9 Aug. 1920.
92. Ibid., W Fletcher to J Mackenzie, 30 July 1920. Mackenzie's "henchmen in the press" refers to the support given to his views by his biographer, MacNair Wilson in The Times.
93. EUL MS Gen. 1980, box 5: Recollections of Sir James Mackenzie sent to Alex Mair (Mackenzie's later biographer).
94. PRO FD1/571, H Head to W Fletcher, 19 July 1921. The view of Newman is reported in Honigsbaum, op. cit., note 19 above, p. 95.
95. EUL MS 1980, box 7: J Mackenzie to Miss Haldane (secretary to a trustee of the Carnegie UK Trust), 3 July 1922. Mackenzie writes threateningly: "If we fail, as I expect we will, then it will be on record that the CUK Trust refused to help a scheme which came within their purview."
96. Wellcome, PP/Lew/A.1/460-483, J Mackenzie to T Lewis, 19 Jan. 1924.
97. Smith and Nicolson, op. cit., note 54 above.
98. PRO FD 1/571, 'Memorandum on some of the medical aspects of work under the National Health Insurance Act' by Sir James Mackenzie and the Staff of the St Andrews Institute for Clinical Research, 1919. Honigsbaum's book gives an account of Rolleston's committee, op. cit., note 19 above, p. 97.
99. Honigsbaum, op .cit., note 19 above, p. 96.
100. This study, called the 'Mackenzie Record Study', is ongoing under the direction of Professor Charles du V Florey at the Department of Epidemiology and Public Health at the University of Dundee.
101. A number of articles have been published on this work, the most recent of which is S O Shaheen, JAC Sterne, J S Tucker and C du V Florey, 'Birth weight, childhood lower respiratory tract infection and adult lung function', Thorax, 1998, 53: 549-53.
102. In the Institute's first annual report, Mackenzie noted that the results of their preliminary enquiry into "The present state of medical knowledge regarding the diseases common among the people" (Reports, note 56 above, vol. I, pp. 30-48) showed that over 90 per cent of cases met with in general practice were undiagnosable.