A centennial note on waller and the first human electrocardiogram

A centennial note on waller and the first human electrocardiogram

HISTORICAL STUDIES A CentennialNote on Waler and the First HumanElectrocardiogram HOWARD B. BURCHELL, MD T he beginnings of human electrocardiograph...

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HISTORICAL STUDIES

A CentennialNote on Waler and the First HumanElectrocardiogram HOWARD B. BURCHELL, MD

T he beginnings of human electrocardiographystem from an article by A.D. Waller in the ]ournal of Physi-

of whether the electric potential of the heartbeatmight be observedwith the capillary electrometer:

ology of 1887l [Fig. 1). This volume also contains the reports of Sydney Ringer concerningthe influence of changing concentrations of the electrolytes on the heart, Gaskell on muscarin and vagal effects on the heart, and MacWilliam on ventricular fibrillation. Admittedly, the impetus for clinical work did not come until after the development of the string galvanometer in 19012and demonstration of its use in patients in 19063by Einthoven. Walleld in 1915,reminiscing about his initial experiments, statedthat he had explored the possibility

. * *so I dipped my right hand and left foot into a couple of basins of salt solution, which were connected with the two poles of the electrometer and at once had the pleasure of seeing the mercury .column pulsate with the pulsation of the heart. . *this first demonstration was made in St. Mary’s laboratory in May 1887 and demonstrated there to many physiologists and among others, to my friend Professor Einthoven of Leiden. . .

From the Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota. Manuscript received November $1986, accepted November 5,1986. Address for reprints: Howard B. Burchell, MD, Department of Medicine, University of Minnesota, Box 508, Mayo Memorial Building, 420 Delaware Street NE, Minneapolis, Minnesota 55455.

FIGURE I. Portralt of Wailer and his dog, Jimmy, taken In London. My copy was obtained there many years ago. This picture has been reproduced In several papers and Is In Burch and DePasquale: A History of ElecfrocardC ography, p 77.

Two years earlier, in 1913,in a historical review given beforethe Harvey Societyin New York,5Wailer mentionedthat “it was in 1889at the first International PhysiologicalCongressin Basle that I first introduced it to the attention of physiologists.”Whenever the first meeting with Einthoven occurred, Einthoven’s interestwas aroused,and indeed, he givesWaller credit for coining the term “electrocardiogram.”In 1912,Eintho-

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ven6concluded a lecture in England, “It gives me a specialpleasureto bring to remembrancehere that the human EKG was first recordedby a London physiologist, AugustusD. Waller who alsointroduced the term ‘electrocardiogram’into science.” Such credit has often been given to Einthoven. For example, the outstanding authority Snellen stated,7“By the way, the term electrocardiogramwas coined by Einthoven.” Whether Waller’s early recordings constituted a “real” electrocardiogram[Fig. 2)should allow friendly disputation,as no atria1potentialswere identified and the ventricular oneswere grosslydistorted. Concerning his early studieshe8stated,“The auricular contraction doesnot affect any electrometerI have used.”(He meantin human studies.]By 1894improvementsin the capillary electrometerallowed Einthoven to record in the human atria1 potentials and ventricular ones, which approachedmore clearly to their true values. (The “U” wave was added later, a product of string galvanometerstudiesin 1903.)Such thoughtsas these may have been the sourceof the statementby Professor Johansseng in his presentationaddressfor the Nobel award to Einthoven in 1924:“Einthoven can thus with full justification be named the discoverer of the real electrocardiogram.”While admitting the validity of such reasoning,I cannot escapethe conclusionthat if the Nobel prize had been awarded for developmentsin electrocardiographybefore Waller’s deathin 1922,he would have shared it with Einthoven. Waller called the deflections in the electrocardiogram, A, V1 and VZ; he never adopted the rubric of Einthoven: P Q R S T. To a physiologist,A, V1 and Va would be a rational nomenclature;to a mathematician, the P Q R S T rubric presumably would have had greaterattraction. In 1913,WallerlOstatedthat he had usedhis nomenclaturefor 20 years and defended his preference for it as it being “simpler and closer to facts.” A perennial surprise to readersof Waller’s papers with a historic bent hasbeen his false propheciesconcerningthe future value of electrocardiogramsin clinical investigation.He was candid and honestwhen re-

porting his early views of the future of the technique. In a 1909address,ll he begins by mentioning that he had just returned from a visit to Leyden and emphasized that he had been greatly impressedwith Einthoven’s collection of human electrocardiograms“obtained with an extraordinarily sensitivegalvanometer he hasinvented.” Waller statesthat “I certainly had no idea that the electrical signsof the heart’sactionscould ever be utilized for clinical investigation” and even at the time of this lecture in 1909he stated, “I do not however imagine that the string galvanometer,however useful and even necessaryit may be in the physiological laboratory,is likely to find any very extensive use in the hospital.. .” This opinion astounded the growing number of disciples of the method; for example, BarkerI of Johns Hopkins stated in 1910 that “Waller admits and, to my surprise,despite his admiration of delicacy and accuracyof Einthoven’s string galvanometer,still fails to seeany or only a very slight clinical future for the procedure.”This may well have been an overreaction,foreign to Waller’s meaning. Waller was not the only scientist who opined that the electrocardiographhad little promise in clinical medicine. About the same time asWaller’s forecast,2 American workers, James and Williams,13 wrote in 1910“that the galvanometermay prove of great aid in the diagnosis of an occasional case, experience has shown:but consideredsimply asan aid to diagnosis,its cost and the time requisite to secure the necessary familiarity with its manipulation, will preclude its extensive use.” WallerlO reviewed his contributions to electrocardiographyin the Oliver-SharpeyLecturesin 1913,mentioning the earliest beginningsin 1885and reproducingsomeof thoseearliest records.Thesepioneering studies were reported by him and Reid in 188714and were the basis for his statement that the “moribund heartin the laboratory” was “an epitome of phenomena which may unfold clinically.” One of their tracingsshow atria1potentialsand heart block in an excised puppy’s heart very clearly. One of their physiologic conclusions was that the “excitatory changemust be practically simultaneousin all parts of

FIGURE 2. The often-reproduced first record of the electric potentials generated by the human heart beat, taken by Dr. Wailer. The black and whne Interface shows the top of the capillary mercury column, 2 downward movements relate to the excltatlon and recovery processes In the ventricles. The transthoraclc leads are noteworthy (chest lead, equlvalenl to dlatorted Inverted V,). Heart led off to electrometer from front and back of chest (front to Hg, back to H#O1.) e = electrometer; h = cardiograph; t = tlme In seconds.

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the ventricle and that such simultaneity postulatesthe existenceof nervouschannelsof conduction.” Edward Reid, his associatein the St. Marys Laboratoryat that time, continued in a physiologiccareer in Scotland, a brilliant but increasingly unhappy man,15apparently with a strong nostalgiafor London. Thomas LewisI took his first electrocardiogramin Dr. Waller’s laboratory on November 12,1908,with a “strong” galvanometer[I presume“string” was intended] in a caseof heart block. He also illustrated a paper on extrasystoled7with electrocardiogramstaken in the same laboratory. From the published recordsI could not be certain that they were taken by a string galvanometer or a mirror oscilloscope.Waller had used a much improved mirror instrument in his demonstrations, and Figures 1 and 2 in his Oliver-Sharpey Lecturesl” are labeled “from a string galvanometer” and from an “oscilloscope.” In the earlier (1909)lectureI he had praised Einthoven’s galvanometer as “by far the mostefficient and convenientinstrument for physiological purposescertain to displace all other forms.” In the correspondencein 1904pertaining to the arrangement being made for the Cambridge Scientific Instrument Company to manufacture the string electrocardiographunder the Einthoven label, it is recorded’* that “ProfessorWaller is most anxious to obtain one of your galvanometers and that he thinks that there would be a demand for them. . -and we believe he wishes us to make one for him.” Waller’s name, however, doesnot appearon the list of buyersof string galvanometersfrom the Cambridge Company in the period 1905to 1912.The preceding quotation comes from John Burnett’@ exhaustivestudy on “The Origins of the Electrocardiographas a Clinical Instrument,” which also contains a challenge to Waller’s priority in recording the first human cardiac poten-

FIGURE 3. The first human have an electrocardiogram, Thomas Goswell, a technician the laboratory, dlagrammed as was connected to a capillary electrometer In 1887 and years later, connected wlth string galvanometer.lO

to In he 25 a

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tials: “The first successfulattempt to record a human electrocardiogramseemsto havebeenmade at St.Bartholomew’s Hospital, London by Alexander Muirhead in 1869-70.” The source is unavailable to me and my credulity will remain strained until records are republished. Lewis had ordered a string galvanometer from Edelmann in January1908.’In the first issueof Heart, July 1, 1909,his paper on paroxsymal tachycardiaincluded recordstaken “with an Einthoven’sinstrument in the Physiological Department, University of London,” presumably Waller’s laboratory. In the fourth issueof Heart, March 30, 1910,Lewis’ epic paper on atria1fibrillation appearedand at this time it is stated the “the electrocardiogramshave been obtainedwith Edelmann’slargepattern of the stringgalvanometerof Einthoven.” In this period (1906to 1912)there was controversy in England as to whether the His bundle constituted the sole conductingtissuebetweenatrium and ventricle, asclaimed by Keith and supportedby Lewis. Wallerll espousedand expressedthe contrary view that thereseemedto be multiple pathwaysandAV conduction was not dependenton the integrity of the central His bundle, thereby supporting the views of Stanley Kent, although not mentioning him by name. Lewis,lgin his classic text, statesin a brief historic introduction that “AD Waller first showedit is possible to register the human heart beat” but credits Bayliss and Starling “with the first satisfactoryrecordings of the mammalian heart in 1892.” The latter comment may reflect a loyalty to Starling, with whom he had worked in 1907and 1908.To me, the publishedrecords of Bayliss and Starling20are not superior to those of Waller’s. In the published correspondencebetween Lewis and Einthoven7there is a dearth of referenceto

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Wailer’s studies:he apparently was politely ignored. In the available correspondencethere are no clues as to how Wailer may have been involved in arrangements for Einthoven’s visit to London in 1912.Osler played a role as one of the hosts. How Osler’s and Waller’s lives might have interfaced seemsunknown: Did they know they sharedthe samebirthday (JulyX4? As a footnote to an obituary,21Lewis did praise Waller’s work highly-“a milestone in the history of this branch on knowledge”-although mentioning that others “could not always see eye to eye with him.” In the Oliver-Sharpey LectureslOWaller included illustrations of many clinical conditionsbut dwelled at greater length on the nature of lead systemsand the angle of the manifest vector in the frontal plane. One illustration in this paper showing a diagram of the human torso with isopotential lines (mapping)has always titilated electrocardiographers.It was from this paperthat the illustration showingthe first personpresumably to have an electrocardiogram[a “primitive record,” in Waller’s own words),hasbeenreproduced [Fig. 3). One illustration of the first electrocardiograms in that 1913 lecture was stated to be from his 1887 paper,but it is not exactlythat; the black and white are reversed,and the contour of the tracing shows the V1 and Vz peaksupright. Waller explained these differences“by reasonof reversedpole connections.”In his lectures,Waller often included demonstrationsof the heart’s electrical activity, and as mentioned abovein the 1913 Oliver-Sharpey Lectures he used a mirror galvanometer,“a minute mirror fixed to a stirrup of fine platinum wire in a strong electromagneticfield.” In his New York lecture5in the sameyear,the apparatus that he had brought was smashedin transit. This gavehim the opportunity to praisethe Columbia string galvanometer,which had been built by Hindle under the direction of Dr. Williams. Wailer’s penchant for teaching is reflected by his choice of topics in his general university lecture in 1887,22 his subjectbeing his recentdiscoverythat electric currentscould be recordedfrom the human heart. The latter part of the lecture related to undergraduate education and the burden and the necessityto both student and teacher of examinations. In any study involving Waller and of Einthoven, one is presentedwith a seeming paradox. Waller, a physiologist,a dedicatedteacherand popular lecturer, with his laboratory in a hospital-basedschool, was apparently not greatly interestedin the application of his discoveryto the sick, whereasEinthoven, although a physician,more a physicist,with a university-based laboratory over a mile from a hospital, was intensely interested.It is not what one would have predicted. The style of these 2 great pioneers of electrocardiographic science were certainly different. Waller, in his lectures, was informal, fond of metaphors and “folksy,” and in his records apparently content with technical mediocrity. In contrast,Einthoven,in his lectures, was formal and methodical: in his records,demanding of technical perfection. Wailer’s lectures seemeddesignedto be entertaining and witty; Einthoven’s presentationswere more matter-of-fact. Eintho-

ven was not without a senseof humor, asdocumented by Samojloff’s remiscences,z3but this did not appear in Einthoven’s lectures. The two had similar dress codesfor portraits(frock coats),but in lecturesWaller’s dresswas quite informal. Einthoven was emotionally moved at the time of Waller’s death in 1922from a stroke,possiblyrelating it to his knowledgeof his own hypertensive risk and eventual mortality.7 Bestermanand Creese24 point out that there is scant knowledge of Wailer as a person.His bulldog, Jimmy, often pictured with him, alleged to have been the first dog specifically mentioned in the Houseof Commons, has attained immortality as a witness for antivivisectionists. It had a countereffect.“The leatherstrap with sharpnails wound aroundhis neck” waspointed out to be a leather collar with brassstuds,the “salts in solution in which the feet were immersed,” saline solution like seawater. Jimmy alsofigured in Waller’s explanation of his differenceswith Einthoven concerningaxis data, pointing out that Einthoven used “long dogs,” while he usedshort ones.Waller alsoapparentlyliked cats;onewas pictured with him in Snellen’sHistory of Cardiology.25Zachary Cope26lists his contributions to physiology,e.g.,he was treasurerof the Physiological Society for 25 years,at the time when it was changing from an exclusive dining club to an open society of thosewith physiologicinterests.To seeWaller’s handwriting and obtain a glimpse of his sometimesmischievous nature, a facsimile of a letter is available.27Waller was appointed consultant to the Heart Hospita12* when it was founded in 1913,but apparentlyhad trouble operatingthe galvanometerthere. More recently, Sykes2ghas published a short account of his life with illustrations of the bustsmade of him and his family. Of interest is the fact that Wailer had a laboratory in his home aswell asat the University. In the former, he carried on investigations on exercise and emotional states.His researchthere was the forerunner to the lie detector technologyof later decades. All in all, the name AugustusDesireWaller belongs to an electrocardiographichall of fame. Waller was a pioneer in human electrocardiography,a physiologic investigatorand stimulating teacher.His range of interestwas wide in the physiologic world and his contributions manifold. These have been outlined in the obituaries in the British Medical JournaL21Lancet30 and Proceedingsof the Royal Society.31A summary of his electrocardiographicinvestigationsand viewpoints was published in a monograph32edited by his son in 1922,the year of his father’s death.I hope and expect that the centennial of Waller’s landmark paper will alsobe appropriately recognizedin his home country, England.

References 1. Wailer. AD. A demonstration on man of electromotive chorines accompanying the heart’s beat. 1 Physiol 1697;6:2~7-234. 2. Einthoven W. Un nouveau galvanometre. Arch Neerlond. des SC Ex et Nat 1901;2:40-42.

3. Einthoven W. “Le telecardiogromme” Arch Internat d Physiol1906;iv:132164. 4. Wailer AD. (unpublished] Quoted from Besterman and GreeceWeller, pioneer of electrocardiography. Br Heart 1 1979:42:61-64. 5. Wailer AD. A short account of the origin and scope of electrocardiography. The Harvey Lectures 191%1914;6:17-33.

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W. The different forms of the human electrocardiogram and their signification. Lancet 1912;1:853-681. 7. Snellen HA. Two pioneers of electrocardiography. The correspondence between Einthoven and Lewis form 1908-1926, Donkers Acad Publ1983:lO. 8. Waller AD. On the electromotive variations which accompany the beat of the human heart. Nature i888;619-621. 9. Johansson JE. Physiology or Medicine 1924. Nobel Lectures 1922-1944. Nobel Foundation, EJsevier:89. 10. Waller AD. The Oliver-Sharpey Lectures on the electric action of the

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11. Waller AD. The electrocardiogram of man and of the dog as shown by Einthoven’s string galvanometer. Lancet 1989;1:144&145Q. 12. Barker L. Electrocardiography and phonocardiography. A collective review. Bull \ohns Hopkins Hosp 1910;21:358-389. 13. James WB, Willams HE. The electrocardiogram in clinical medicine. Am 1 Med SC 1910;140:644-669, 14. Waller AD, Reid EW. On the action of the excised mammalian heart. Phil Trans B 1687;178:215-256, 15. Cathcart EP, Garry RC. Edward Wymouth Reed 1862-1948 Obituary Notices, Royal Society of London 1948-1949:213-218. 16. Lewis T, Macnalty AS. A note on the simultaneous occurrence of sinus and ventricular in man. J PhysioJ 1908;37:445-448. 17. Lewis T. Single and successive extrasystoles. Lancet 1909:1:382-385. 18. Burnett J. The origins of the electrocardiograph as a clinical instrument. Medical History Supplement 5: 1985, 53-76. Published as monograph. The Emergence of Modern Cardiology. Bynum WF, Lawrence C, Nutton V, eds.

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Wellcome Institute for the History of Medicine:1985. 19. Lewis T. The Mechanism and Graphic Registration of the Heart Beat. New York: Paul Hoeber. 1920:30. 20. Bayliss WN. Starling EH. On the electromotive phenomena of the mammalian heart. Mon Int r Anat and PhysioJ 1892;9:256-261. 21. Obituary (anonymous] addendum by Sir Thomas Lewis-Augustus D. WalJer. Br Med r 1922;1:458-459. 22. Waller AD. Introductory address on the electromagnetic properties of the human heart. Br Med 1 1888;2:751-754. 23. Samojloff A. Reminiscences of the late Professor William Einthoven. Am Heart 1 1930;5:545-548. 24. Besterman E, Creese R. WaJler-pioneer of electrocardiography. Br Heart f 1979;42:61-64. 25. Snellen HA. History of cardiology. Amsterdam: Donker Acad 1984:115. 26. Cope Z. Augustus Desire WaIJer 1656-1922. Med Hist 1973;17:380-386. 27. Nobel D. The early minute books of the physiological society. J PhysioJ 1976;263:29P-38P. 28. Marshall R. Early days in Westmoreland Street. Br Heart )1964;26:140145. 29. Sykes AH. AD Wailer, a biographical note. St. Marys Gazette 1985; 91(3):19-20. 30. Obituary (anonymous). Augustus Desire WaJJer. Lancet 1922;1:555. 31. Halliburton WD. Obituary. Augustus Desire WaIJer. Royal Society Proc 1922;93:xxvII-xxx. 32. Waller AD, ed. The Electrical Action of the Human Heart. London: University of London Press, 1922.