Clin. Cardiol.
15,785-787 (1992)
Profiles in Cardiology
This section edited by J. Willis Hurst, M D.
Willem Einthoven-The Father of Electrocardiography
MARK E. SILVERMAN,M.D.
Emory University School of Medicine and Piedmont Hospital, Atlanta, Georgia, USA
The truth is all that matters, what you or I may think is
inconsequential.
- Willem Einthoven to
Carl Wiggers, 1926’
In 1856 von Kolliker and Miiller were the first to dis-
cover that the heart generated electricity.2Sixty-eight years
later the Nobel Prize was awarded to Willem Einthoven,
the Dutch investigator who transformed this curious phys-
iologic phenomenon into an indispensableclinical record-
ing.3
Einthoven was born May 21, 1860, in Semarang, Java,
in the Dutch East Indies (now Indonesia), the son of a mil-
itary physician and the descendant of Spanish Jews who
had fled to Holland at the time of the Spanish Inquisition.
His father died when he was only six, and four years later
his mother moved her six children to Utrecht. Einthoven
attended the University of Utrecht Medical School where
he was greatly influenced by Frans Donders, a physiologist
studying action currents of the heart, and Herman Snellen,
the ophthalmologist of optical chart fame. He was award-
ed his medical degree magna cum laude for his thesis,
“The Influence of Color Differences in the Production of
Stereoscopic Effects.” Initially, Einthoven intended a
career in ophthalmology in the East Indies to repay a gov-
ernment grant; however, with the support of Donders, he
was appointed in 1885 to the recently vacated chair of pro-
fessor of physiology at Leiden where he remained the rest
of his life.” His research interests were extensive;his 127
Address for reprints:
Mark E. Silverman, M.D.
1968 Peachtree Road, NW
Atlanta, GA 30309, USA
Received January 2,1992
Accepted: January 13, 1992
papers included the study of bronchial musculature, the
physiology of the eye, the function of the cervical sympa-
thetic nerve, radiotelemetry, and his fundamental work on
the electrocardiogram.
In 1887 Einthoven attended an International Congress
of Physiology in London where he observed Augustus D.
Waller demonstrate the use of the capillary electrometer to
record an “electrogram” of the heart using pan electrode
limb The capillary electrometer, invented in 1873
by Gabriel Lippmann (who won the Nobel Prize in 1908
for the principle of color photography), consisted of a glass
capillary tube partially filled with mercury and placed ver-
tically into a bath of sulfuric acid.2*8Electrical potentials
flowing through the glass tube would cause the mercury
meniscus to fluctuate sluggishly. The surface movements
were recorded by magnifying the shadow onto a moving
photograph, a technique devised by Marey in 1876.5 Using
this method, Marey, Burdon-Sanderson, Page, Gotch,
Burch, Englemann, Bayliss, and Starling had recorded the
electrical activity of an exposed animal heart.27J
Waller was the first to record an “electrogram” from a
dog and human (himself initially) using a lead system that
did not require opening the chest.
... so I dipped my right hand and left foot into a
couple of basins of salt solution, which were con-
nected 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 physiol-
ogists and among others, to my friend Professor
Einthoven of Leiden.. .6
Waller’s contributions also included the variability of
the electrogram, the dipole concept that led to isopotential
mapping a i d the vector concept, he angle of the manifest
vector in the frontal plane, a comprehensive textbook of
physiology published in 1891, and the measurements of
chloroform and other anesthetic gases.5 He is also remem-
bered because of his “famous bulldog, Jimmy”-so-called
786 Clin. Cardiol. Vol. 15, October 1992
FIG.1 Willem Einthoven, 1860-1927. Published with permis-
sion from the National Library of Medicine.
because a concern was raised in the House of Commons
that Waller’s experiments, in which Jimmy’s feet were
immersed in salt solutions, might constitute a cruelty to
animals ~ f f e n s eWaller
.~ failed to see any clinical value in
his experiments,commenting later, “I certainly had no idea
that the electrical signs of the heart’s actions could ever be
utilized for clinical investigation.”6In part, this was due to
the aggravation related to using the capillary electrome-
ter-poor frequency response due to inertia, viscous drag
through the capillary tubes, sensitivity to vibration, and
hours required to obtain a decent tracing.“
In the early 1890s Einthoven turned his attention to re-
cording electricity from the heart using the capillary elec-
trometer of L i p ~ m a n n .Because
~?~ of vibration produced
by horse-drawn vehicles rumbling over the cobblestone
street in front of his wood frame laboratory, Einthoven
constructed a platform of rocks in a hole cut into the floor
of his laboratory to provide stability for his experiments.“
By improving the frequency response and correcting for
distortion mathematically, Einthoven enhanced the fideli-
ty of the instrument and, in 1895, was able to report recog-
nizable waves that he labeled “P, Q, R, S , and T,” a nota-
tion disliked by Waller.2-3.5.6 The origin of this nomen-
clature is uncertain; it probably was from the geometric
convention of Descartes that straight lines are labelled
beginning with A and curved lines starting with P.8
Frustrated by the inherent technical problems of the cap-
illary electrometer, Einthoven began to work on a different
type of galvanometer, a string galvanometer, developed
independently in 1897 by Clement Ader, a French electri-
cal e n g i ~ ~ e eThe
r . ~ ?string
~ galvanometer, which would be
the basis of future electrocardiography, consisted of a sil-
ver-coated quartz thread suspended within the magnetic
field of two poles of a large, water-cooled electromagnet.
The electrical current flowing from the subject through the
silverized thread would cause the thread to move at right
angles to the line of the magnetic field in proportion to the
strength of the current. This fluctuating movement could
be magnified by a lens and its shadow projected by a car-
bon arc lamp onto a photographic plate moving at 25
mm/s. The quartz thread was created by a unique form of
archery in which the quartz was attached to the tail of an
arrow and heated until it released the arrow from a drawn
bow.* As it shot across the lab, the thread would be drawn
into a fine filament so light that it would float and be cap-
tured by his able assistant, Van der Woerd. The original
equipment, all developed by Einthoven, was very large,
weighing 270 kg, occupying two rooms, and requiring five
people to operate. It was the most elaborate and ingenious
diagnostic instrument as well as electrical measuring
device invented up to that time.9 In addition to laboratory
experiments, the equipment was connected from the labo-
ratory to patients in the hospital by a 1.5 km cable, a tele-
cardiogram, in order to gain clinical information.
With this technique, originally suggested by Bosscha8
and reported by Einthoven in 1901, he standardized the
tracing and described extra systoles, complete heart block,
auricular and ventricular hypertrophy, atrial fibrillationand
flutter, the U wave, the effects of heart rate and respira-
tion, and examples of various heart diseases in his impor-
tant papers published in 1903, 1906, and 1908.2.3The first
commercial machine was made by Edelmann and Sons in
Munich. Apparently, Einthoven was to receive a royalty
of $25.00 for each machine; however, Edelmann claimed
to develop a superior machine and refused further payment
of any royalties.2
In 1908, Thomas Lewis, on the urging of James Mac-
kenzie, visited Einthoven’s laboratory to see if the string
galvanometer might advance the study of arrhythmia^.^
Through Horace Darwin, the son of the great biologist and
founder of Cambridge Scientific Instrument Company,
Einthoven arranged for Cambridge to manufacture electre
cardiographic equipment. Using this equipment, Lewis
began his pioneering work that would establish the elec-
trocardiogram as a useful clinical t e ~ t . ~In, ’191
~ 1 Eint-
hoven, in a letter to Lewis, showed his appreciation: “An
instrument takes its value not so much from the work that
it possibly might do, but from the work that it really does.
So your discoveries in the field of pathology of the heart
increase the value of the string galvanometer greatly.. .”
 M.E. Silverman: Willem Einthoven
With the help of physicists and mathematicians at
Leiden, Einthoven studied the spread of action potentials
through tissues, introduced the three standard limb leads,
and formulated the concept of the equilateral triangle by
mathematically relating the three leads (Lead III = Lead II
- Lead I).3 For his monumental contribution in develop-
ing the string galvanometer to be used as an electrocardio-
graphic machine, Einthoven received the Nobel Prize in
1924. In characteristic manner, he felt that half of the
$40,000 prize should be shared with Van der Woerd, his
invaluable laboratory assistant, who had retired years
before. When Einthoven learned that Van der Woerd was
deceased and had two sisters living in poverty, he gave
them the $20,000 instead! In his Nobel address he credit-
ed the many investigators who had preceded him:
A new chapter has been opened in the study of
heart diseases, not by the work of a single investiga-
tor, but by that of many talented men, who have not
been influenced in their work by political boundaries
and, distributed over the whole surface of the earth,
have devoted their powers to an ideal purpose, the
advance of knowledge by which, finally, suffering
mankind is helped.3
Einthoven was considered a modest genius with a sense
of humor, a natural curiosity, a zeal for work, and a devo-
tion to search for the truth.24 He would ride his bicycle to
his laboratory each day, remove his coat, tie, and collar,
put on slippers, and work methodically and tirelessly, hav-
ing to be reminded repeatedly by his assistant, on Mrs.
Einthoven’s instructions, when it was time to go home.
Einthoven would acknowledge him but continue working,
often until as late as 8:OO P.M. He was known for pro-
longed deep thinking. One time he lapsed into such deep
thought that he told an assistant at the last minute to deliv-
er his lecture so that he could continue his thinking. In the
laboratory he applied his knowledge of physics to solve
problems in physiology. His friend and colleague,
Samojiloff,wrote “His mind was like an instrument of pre-
787
cision. He worked only on what could be measured and
his measurements reached the limit of precision possible
under the circumstance^."^ Though clumsy with his hands,
he was graceful in his mannerisms and speech and fluent in
three languages. His warm hospitality and generosity to
younger colleagues and visitors were remarked upon and
he enjoyed international respect and admiration.’ The
“father of electrocardiography”died from cancer on Sep-
tember 28, 1927, at the age of 67.
In his lifetime, his quest for an improved electrical re-
cording led to the single most important advance in the
diagnosis of heart disease-the electrocardiogram. It
would eventually make possible coronary care units, am-
bulatory monitors, pacemakers, exercise testing, intracar-
diac and fetal recordings, ablation, automatic implanted
defibrillators, signal averaging, and other tests and treat-
ments essential to the modern diagnosis and treatment of
heart disease.
References
1. Wiggers CJ: Willem Einthoven (1860-1927): Some facets of
his life and work. Circ Res 9,225-234 (1961)
2. Burch GE, DePasquale Np:A History OfElectrocardiograph.
Year Book Medical Publishers, Chicago (1964)
3. Snellen HA: Selected Papers on Electrocardiography. Leiden
University Press (1977)
4. Erschler I: Willem Einthoven-the man. Arch Int Med 148,
453-455 (1988)
5. Rantaharju PM: A hundred years of progress in electrocardio-
graphy. 1: Early contributions from Waller to Wilson. Canad J
Cardiol3,362-374 (1987)
6. Burchell HB: A centennial note on Waller and the first human
electrocardiogram.Am J Cardiol59,979-983 (1987)
7. Besterman E, Crease R: Waller-pioneer of electrocardiogra-
phy. Br Heart J42,61-64 (1979)
8. Cooper J: Electrocardiography 100 years ago: Origins, pioneers
and contributions.N Engl JMed 315,461-464 (1986)
9. Burnett J: The origins of the electrocardiograph as a clinical
instrument. Med Hist 5,53-76 (1985)
10. Barron SL: The development of the electrocardiograph in Great
Britain. Br Med J 1,720-725 (1950)