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HISTORICAL STUDY

From Rebellious Palpitations to the Discovery


of Auricular Fibrillation: Contributions of
Mackenzie, Lewis and Einthoven
Mark E. Silverman, MD

“I know the truth will revail, when,


An hvegular pulse, referred to as rebellious palpi- if I am wrong my views wl71be forgotten,
and ifI am right, &me will vindicate them.”
tations, delirium cordis and pulsus hregularls per
petuus, was a cause of speculation by physicians -James Mackenzie
to Arthur Keith’
since early times. R was James Mackenzie, a
Scottish general practitioner in Bumley, England, ince early civilization, the arterial pulse has provid-
utilizing an ink-writing polygraph to record and
label jugular venous pulses, who would pioneer in
d=m-mi! normal and abnormal cardiac rhythms.
S ed physicians with a powerful digital insight into
the physiologic mysteries of the circulation.* Be-
fore the electrocardiographic identification of auricular
His key observation that the jugular “A wave” fibrillation in 1909, an irregular pulse was a cause of
was lost in a patient who went from a normal to great speculation by Senac,Corvisart, Hope, Bouillaud,
an irregular rhythm provided the Brst insight into Flint and others.3Known lirst as rebellious palpitations
the mechanism of auricular fibrillation. Similar and later as delirium cordis and pulsus irregularis per-
jugular venous and arterial pulse findings were petuus, an irregular pulse was often associatedwith mi-
discovered by Cushny, Edmunds and Lewis in di- tral valve diseaseand heart failure and observed to re-
rectly observed experimental auricular fibrillation. spond to digitalis and quinine. The introduction of the
In 1999 Lewis in England and Rothberger and Wiu kymographic method by Carl Ludwig in 1847 provided
terberg in Vienna, taking advantage of Einthe an opportunity for Bamberger and Marey in 1863, Po-
ven’s newly developed string galvanometer, were tain in 1868, and others to record venous and arterial
the first to establish electrocardio@aphically that pulses.4However, it was JamesMackenzie (Figure l), a
auricular fibrillation was the cause of pulsus irreg- tall, indefatigable Scotsman and general practitioner in
ularis perpetuus. the industrial village of Bumley, England from 1879 to
(Am J Cardiol19W,73:384-389) 1907,who would assiduously apply the graphic method
in a quest to decipher auricular fibrillation and other
rhythm disturbances.1,5Mackenzie was a keen and me-
thodical bedside observer who was initially frustrated to
learn that his patients rarely fit the textbook description.
He found that his partners, who had been practicing for
some time, were more often able to prognosticateaccu-
rately basedon their long experiencewith their patients.’
When a woman under his care unexpectedly died
during childbirth from a rhythm disturbance and con-
gestive heart failure, Mackenzie asked, “Would this
death have occurred if I had a better knowledge of heart
afllictions?“’ About 1883, he decided to study symp-
toms and findings on examination and to follow his pa-
tients by serial venous and arterial pulse recordings,hop-
ing to learn how to analyze and anticipate their prob-
lems.5%6 After trying the cumbersome kymograph, he
helped devise an ink-writing polygraph (Figure 2) which
he would take to the cottages of his patients where he
would inscribe lengthy pulse recordings.4Back home he
would scrutinize the tracings, trying to correlate the puz-
zling findings with the clinical presentation.’ The work
was tedious and discouraging and required precious mo-
ments snatchedfrom the incessanttime-demandsof his
busy general practice.
From Emory University School of Medicine, and Piedmont Hospital,
Atlanta, Georgia. Manuscript received July 6, 1993; revised manuscript
received August 9, 1993, and accepted August 10. “I got a sphygmograph and took records of the
Address for reprints: Mark E. Silverman, MD, 1968 Peachtree pulse, and spent much time measuring the height and
Road, NW, Atlanta, Georgia 30309. breadth of the waves, the depth of the notches, seeking

384 THE AMERICANJOURNALOF CARDIOLOGY VOLUME73 FEBRUARY15,1994


in these signs for light upon the subject of prognosis. resemblanceof myself to one of the characters depict-
In efforts of this kind I spent several years and felt in- ed by Bunyan in his Pilgrim’s Progress. He describes
clined to give up in despair. . I was struck with the a man earnestly engaged in raking the mud in search
of something he was not quite clear about, while above
his head shines the crown of glory which was the real
object of his research.”*

-.- .
FIGURE 2. Ink-writing polygraph, “consisting or a tamDour ar
tacked to a Dudgeon’s sphygmograph,” developed by James
Mackenzie. Fawn Mackenzie J. Diseases oftheHeart.Pnd
FIGURE 1. James Mackenzie. (Reprinted with permission of ed. Oxford Me&al Publicatii London, 1910. (Reprinted
thCihldiC&~sectionoftheNatianaluXayofMedidna) with permission of Dxfard University Press.)

JUGULAR 3

Fro. 17.-Simultaneous tracings of the jugular and the carotid pulses. The jugular pulse is
POW of the ventricular type. Note the irregularity and the small ripples in the tracing at the
long pause +. due in all likelihood to fibrillary contra&&n of the auricle.

FIGURE 3. Jugular venous pulse tracings taken by James Mackenzie in 1906 fnwn a patient similar to the one discussed.
l&e tracings illustrate that the jugular A wave, previously recoiled, is no longer present, the arterial pulse is iwe@ular, and
small oscillations are present between the Y and the C. From Mackenzie 1. TIN interpretatronS of the pulsations on the
ju@lar veins. Am I Med Sci 1907;134:30. (Reprinted with permission of the J. B. Lippin~dt Company.)

DISCOVERY OF AURICULAR FIBRILLATION 385


FlGURE 4. Thomas Lewis. (Reprinted with permission of the FlGURE 5. Willem Einthoven. (Reprinted with permission of
Medical History Section of the National Library of Medicine.) tllflRlSCk4HiStOly-dthS!NationalLibr;ayOfMSdll~.)

Eventually he was able to discern 3 major jugular ve- to support his view. Later, however,basedon further au-
nous waves which he lettered “A, C, and V waves,” topsy findings of auricular hypertrophy in a patient with
postulating that their genesis was auricular contraction, the same arrhythmia, and the restoration of the A wave
the carotid impulse, and overtilling of the right auricle in patients with intermittent irregular rhythms, he ques-
and/or regurgitation from the right ventricle.4 With this tioned his concept of auricular para1ysis.sFurthermore,
device and his intuitive analysis of venous and arterial his friend, Arthur Keith, the discoverer of the sinus node
pulses, Mackenzie pioneered a new approach to clinical (along with Martin Flack) in 1907found that the sinoa-
cardiac investigation and contributed importantly to the trial node and its artery were disordered in this condi-
fundamental understanding of cardiac excitability and tion. This evidence persuadedMackenzie to believe that
conductivity as well as to the prognostic implications of the pacemakerof the heart had shifted to the atrioven-
arrhythmias.’ tricular node, producing a “nodal rhythm.“s
His interest was particularly arousedby patients with Hering, in Prague in 1903,was apparently the lirst to
an irregular pulse, for some seemedto tolerate the ir- use the term “pulsus irregularis perpetuus” and sepa-
regularity surprisingly well while others did not. He rate it from other irregular pulses. He proposed that it
posed the simple question, “What are the auricles doing was “myogenic” in origin. lo In 1899 and 1906 Arthur
when the ventricle was irregular?“* From 1880 until Cushny,i1.i2 first in Michigan and later in London, re-
1897 he had followed a woman with mitral stenosis in ported that arterial tracings in open-chesteddogs with
whom serial recordings had always shown a regular directly observed “auricular delirium or fibrillary con-
rhythm and a presystolic jugular A wave. In 1897 she traction” were similar to the radial artery tracings from
suddenly developed an irregular, rapid rhythm at which a woman with delirium cordis. He was the first to sug-
time the jugular A wave could no longer be recorded gest that the 2 conditions might be the same.8In 1899
and the presystolic murmur had disappeareds9(Figure Cushny wrote,
3). In 1902,in his lirst book, “The Study of the Pulse,”
Mackenzie published this original observation conclud- “The clinical sphygmograms in these cases resem-
ing that it was due to “paralysis of the auricle.“8 Initial bles exactly that obtained from dogs when the auricle
autopsy findings of a thin and distended auricle seemed is undergoing $brillary contractions, which may be

AGURE 6. The First Published Electro-


cedii of “Pulsus lneequelis et
Irregularis.” From Einthoven W. Le
telecardiogramme. Arct, Int Physio/
1906;4:132-163. (Reprinted with per-
mission of VaillanSarmanne Publish
-1

386 THE AMERICANJOURNALOF CARDIOLOGY VOLUME73 FEBRUARY15, 1994


continuedfor a long time without proving,fatal. I do not some initial rebuffs and difficulties in obtaining hospital
wish to assert that the clinical delirium cordis is iden- privileges, his unchallengeable clinical research and for-
tical with the physiological delirium auriculae, hut the midable personality soon brought him to the forefront
resemblance is certainly striking.” ’ ’ and he became the leader in the emerging new special-
ty of cardiology. His reputation was further enhanced by
Mackenzie commented in 1914, the publication of his influential book, “Diseases of the
Heart,” published in 1908, 1910 and 1918.
“Cushny was the first to suggest auricular fibvilla- In 1908 Mackenzie met Thomas Lewis, a brilliant,
tion might be a factor of clinical importance, and com- incisive 26-year-old Welshman working on animal ex-
paring the radial tracing from a human subject with the periments in Starling’s physiologic laboratory at Uni-
tracing fram a dog in which they produced experimen- versity Hospital I5516 - (Figure 4). Mackenzie recognized a
tal j%rillation of the auricles, it was agreed that auric- kindred spirit and stimulated Lewis to study cardiac ir-
ular fibrillation might be the cause of irregular heart regularities in the laboratory. Lewis induced experimen-
action.” I3 tal auricular fibrillation in dogs and demonstrated that
the arterial pulse was irregular and the venous pulse sim-
(Knowledge about fibrillary contraction of heart mus- ilar to Mackenzie’s patients.17q’8Mackenzie then urged
cle dates to the experiments of Hoffa and Ludwig in Lewis to visit Willem Einthoven in Utrecht to see if the
1850 who used repeated electrical shocks of the rabbit recently developed “electrocardiogram” might shed
ventricle to produce irregular and weak contractions some light on cardiac irregularities.19 Einthoven, who
which they called “Flimmem.” Vulpian, using direct was professor of physiology at Leiden, was striving to
faradization of the dog ventricle in 1874, described ir- develop a device that would improve the precision of
regular, incoherent, tremulous muscular movements recording the electrical forces emitted by the heart (Fig-
which then became fibrillary contractions - “fremisse- ure 5). After initial discouraging attempts using the slug-
ment fibrillaire.” The term “fibrillation” stems from gish capillary electrometer in the early 1890s he focused
that time. 14) his efforts on a different type of galvanometer, consist-
Although his reputation as an expert in arrhythmias ing of a silver-coated quartz thread suspended within a
had accorded him respect in Europe and the United magnetic field. The thread would move in direct re-
States, Mackenzie’s work was relatively unknown and sponse to the changing electric forces of the heart and
unaccepted in his own country.’ When his book, “The cast a shadow which was captured on a moving photo-
Study of the Pulse, ” received little attention, he decid- graphic plate. I9 He reported the use of this “string gal-
ed to leave general practice and move to London in 1907 vanometer” in 1901 followed by fundamental clinical
at the age of 54 to convince the medical community of papers in 1903, 1906 and 1908 describing the advantages
the significance of his methods and findings.1,5 Despite of the electrocardiogram. In his paper of 1906 Einthoven*O

FlGURE 7. Electrocardiograms recoded by Thomas Lewis showing sinus tiythm in a normal patient (top) and auriculsr fibriC
lation in eeother patient @ottomJ. Ftilleting (f) waves ere demonstrated. lhis is net from the original patii mentii in
the text. From Lewis 1. Evidences of auricular fibdlatii, treated historically. Br Med I 1912;13:59. (Reprinted with pemria
sion of the British Medical Association.)

DISCOVERY OF AURICULAR FIBRILLATION 387


published the lirst electrocardiogramillustrating ‘ ‘pulsus in Vienna using venous pulse tracings with electrocar-
inaequalis et irregularis”; however, he did not recognize diographic confirmation in experimental preparations.
its significance (Figure 6). Lewis visited Einthoven in The quest was over. The mystery of the irregular pulse
1908and returned to England eagerto use the string gal- that had eluded physicians for centuries was now
vanometer to analyze arrhythmias.6 From 1909 until solved- rebellious palpitations, delirium cordis and
1923 Lewis was the acknowledged leader in the appli- pulsus irregularis perpetuus were auricular fibrillation.8
cation of the electrocardiogramto the study of arrhyth- In addition to his work on auricular fibrillation, Mac-
mias and cardiac excitation. Einthoven wrote Lewis in kenzie also made important contributions in the area of
1911to show his appreciation: extrasystoles, sinus arrhythmia, digitalis, heart disease
and pregnancy, referred pain, the significance of signs
“An instrument takes it value not so much from the and symptoms,angina pectoris, and soldier’s heart.’ His
work that it might possibly do, but from the work that most important teaching was his insistence that physical
it really does. So your discoveries in the field of pathol- findings, such as heart murmurs and pulse irregularities,
ogy of the heart increase the value of the string gal- were not, by themselves,evidence for severe heart dis-
vanometer greatly. . . i easebut significant only when they were associatedwith
a limitation of responseto effort. With his concept, “A
For his work in developing the string galvanometer heart is, what a heart can do,” he revolutionized medi-
as an electrocardiographic recorder, Einthoven was cal practice, provided the basis for functional classifica-
awarded the Nobel Prize in 1924. He modestly ac- tion of heart disease, and liberated countless patients
knowledged that this would not have occurred without who had been advised to restrict activities or avoid preg-
Lewis: “But for the work of Thomas Lewis I would not nancy becauseof innocuous lindings.‘,5 Mackenzie re-
have the honour of standing here today.“13 mained loyal to his polygraph, never fully acceptingthe
In October 1909,Lewis applied his string galvanom- electrocardiogram, stethoscope,x-ray or blood pressure
eter to a patient with pulsus irregularis perpetuus and reading, for he believed that these instruments removed
was able to demonstrateirregular waves corresponding the clinician from the more direct information gained by
to the fibrillary movements seen in his experimentsr8~21 feeling and recording the pulse.7,18,24
(Figure 7).
“The sensitive index finger of the experienced doc-
“Electrocardiograms taken from patients exhibiting tor can give far more valuable information than all the
the irregularity [pulsus irregularis perpetuus] show a instrumental methods in the world. WhenI see the mod-
number of irregular waves, apart from the ventricular ern cardiologist getting his assistant to take an x-ray
curve; . . . They are found in no other disorder of the photograph of the heart and an electrocardiogram, and
heart’s action. They disappear when, in a paroxysmal even a blood-pressurereading, and then behold him sit-
case, the irregularity vanishes, and are therefore due to ting down to study these reports, I am truly amazed.I
a temporary and disorderly action of some part of the never could have realized that the practice of medicine
heart wall. . . , Fibrillation of the auricle yields curves could have become so futile and ineflective.”
which are identical in every respect. . . Further, the
waves on the experimental electrocardiograms can be In this regard, he remained close-minded and intol-
shown to correspond to the jibrillary movementsin the erant of the obvious advantagesof the exciting progress
auricle. . . The facts point clearly to the conclusion in diagnosis that would pass him by. His relationship
that the irregularity in question is the result of auricu- with Thomas Lewis soured somewhat in 1921 when
lar fibrillation.“2’ Lewis, who was the editor of Heart, refused to publish
Mackenzie’s paper on the effect of digitalis on the va-
When Lewis examined electrocardiogramson Mac- gus - a view that Lewis incorrectly opposed.‘,25In
kenzie’s patients with nodal rhythms the same fibrillat- 1918,having reached the pinnacle of his profession and
ing oscillations were present. Mackenzie, who was usu- receiving a knighthood, Mackenzie left London for
ally receptive to new ideas, later wrote, Scotland to start an Institute at St. Andrews to study
symptoms. He developed angina pectoris and died of a
“I had no hesitation in abandoning my views, and myocardial infarction on January 25, 1925.’
accepting thefact that these casesowed their abnormal Thomas Lewis continued his work with the electro-
actions to auricular fibrillation; and I now recognize cardiogram publishing classical studies on the spreadof
that the reason those evidencesof auricular activity, to excitation through the heart, the circus motion of atria1
which I have referred, disappear, is becausethe auricle flutter, aberration and some erroneous views on bundle
ceasesto act as a contracting chamber.” branch block.‘2,16,26His monograph on “The Mecha-
nism of the Heartbeat” (1911)becamethe bible of elec-
In fact, Mackenzie had already commentedin an ar- trocardiography. “Clinical Disorders of the Heartbeat”
ticle written in 1907 that he had found a series of small (1912)and “Clinical Electrocardiography” (1913)quick-
waves on one jugular recording (Figure 6) and had ly followed. During World War I, he collaboratedon the
shown these small movementsto Cushny who told him study of soldier’s heart with Mackenzie, Osler, Allbutt,
they were due to ‘ ‘fibrillary contraction of the auricle”22 Levine, and Wilson at the Colchester Military Hospi-
(Figure 3). Similar conclusions had already been reached tal - a remarkable juncture where some of the finest
independently in 1909 by Rothberger and Winterberg minds of 19th and 20th century American and British

388 THE AMERICANJOURNALOF CARDIOLOGY VOLUME73 FEBRUARY15, 1994


Medicine intermingled.15,24*27 Like Mackenzie, whom he brary Staff; the National Library of Medicine Medical
always greatly admired, Lewis preferred the ink poly- History Section; the Wellcome Institute for the History
graph in analyzing clinical arrhythmias because it pro- of Medicine; Albert Kuhfeld, PhD, of The Bakken, A
vided an easily obtained, instantly interpretable bedside Library and Museum of Electricity in Life; Albert L.
tracing of physiologic eventscomparedwith the difficult- Waldo, MD; and Joel L. Silverman.
to-use electrocardiogram with its delicate thread always
susceptible to breaking, delayed photographic images,
and electrical waves that seemedto belong more on the 1. Mair A. Sir James Mackenzie, M.D. 1855-1925 General Practitioner, The Royal
laboratory side of medicine.6 The illustrations in his College of General Practitioners, London, 1986.
“Clinical Disorders of the Heartbeat” through the sev- 2. Scherf D, Schott A. Historical remarks. In: Extrasystoles and Allied Arrhyth-
enth edition in 1933 are all pulse tracings - no electro- mias. 2nd ed. chap I. Chicago: Year Book Medical, 1973.
3. McMichael 1. History of atrial fibrillation 1628-1819: Harvey-de Senac-Laennec.
cardiograms are shown -though electrocardiograms Br Heart J 1982;48: 193-7.
4. Mackenzie J. The venous and liver pulses, and the arrhythmic contraction of the
are used in some of his other books. He remained an in- cardiac cavities. .I Path Bact 1894:2:84-154.
timidating, uncompromising, often aloof man who 5. Smith C Sr, Silverman M. A letter from Sir James Mackenzie to Dr. Carter
would refuse to admit error or countenanceintellectual Smith, Sr. Circulation l975;5 I:21 2-16.
debate when his strongly entrenched beliefs ran counter 6.farction.
Howell JD. Early perceptions of the electrocardiogram: from arrhythmia to in-
Bull Hist Med 1984;58:83-98.
to new evidence.1,24In striking contrast to his focused 7. Lawrence C. Modems and ancients: the “New Cardiology” in Britain 188&1930.
laboratory mood which tolerated no idleness or small Med Hist Suppl 1985;5:1-33.
talk, his summer months were more relaxed, filled with Br8. Mackenzie J. Observations on the process which results in auricula fibrillation.
Med .I 1922:2:71-73.
his hobby of photographing birds, and, at these times, 9. Mackenzie J. The inception of the rhythm of the heart by the ventricle. Br Mrd
he could be charming and approachable.Declaring that .I10.1904;2:529-36.
Hering HD. Analysis of the pulsus irregularis perpetuus. Prq Med Wchnschr
“the cream is off the top,” Lewis left the field of elec- 1903;28:377-381.
trocardiography in 1923 and overlooked the potential of 11. Cushny AR. On the interpretation of pulse-tracings. J Exp Med 1899;4:327-47.
the electrocardiogram to diagnose infarction and other 12. Cushny AR, Edmunds CW. Paroxysmal irregularity of the heart and auricular
fibrillation. Am J Med Sci 1907:133:66-77.
cardiac problems, leaving this grand prize for Smith and 13. McMichael J. A Transition in Cardiology: The Mackenzie Lewis Era. London:
Herrick and later Wilson.6*19Instead he turned his at- Royal College of Physicians of London, 1976.
14. Gay WE. Auricular fibrillation. Physiol Re 1924;4:215-250.
tention to the mechanism of referred pain, Raynaud’s 15. Drury AN, Grant RT. Thomas Lewis 1881-1945. Obituary Notices of Fellows
disease,angina pectoris and the vascular responseof the of the Royal Society 1945;5:17%202.
15. Holhnan A. Thomas Lewis-the early years. Br Heart J 1981;46:233-244
skin to injury - “the triple responseof Lewis” -for 17. Hoff HE, Geddes LA, McCrady JD. The contributions of the horse to knowl-
which he was again considered for the Nobel Prize.13,15 edge of the heart and circulation 111.James Mackenzie, Thomas Lewis, and the na-
Coronary diseasewas also his fate. After his second in- ture of ahial fibrillation. Corm Med 1966;30343-48.
farction, he said, “another arrow from the same quiver 18. Lewis T. Evidences of aunculw fibrillation treated historically. Br Med J
1912;13:57-60.
and one will get me in the end.“27 He died of his third 19. Silverman M. Willem Einthoven - the father of electrocardiography. C/in Car-
myocardial infarction on March 17, 1945. diol 1992;15:785-787.
20. Einthoven W. Le telecardiogramme. Arch Intwnar Physiol l906;4: 132-163.
As for auricular fibrillation, along the way it became 21. Lewis T. Auricular fibrillation, a common clinical condition. BI- Med J
“atria1 fibrillation” or “atria1 fib” and sometimesis re- 1909;2: 1528.
22. Mackenzie J. The interpretation of the pulsation of the jugular veins. Am J
spectfully referred to as the grandfather of arrhythmias. Med Sci 1907; 134: 12-34.
Though it was unable to hide from the electrocardio- 23. Rothberger CJ, Winterberg H. Vorhoffummem und Arhythmia Perpetua. Wien
gram and is now easily diagnosed, atrial fibrillation re- Klin Wochenschr 1909;22:839-44.
mains a rebellious treatment problem for the patient and 24. Wooley CF, Stang JM. Samuel A. Levine’s First World War encounters with
Mackenzie and Lewis. Br Heart J 1990:64:166-170.
the clinician. 25. McMichael J. Sir James Mackenzie and atria1 fibrillation - a new perspective.
J R Co// Gen Pmct 198 I :3 1:402~06.
26. Lewis T. Nature of flutter and fibrillation of the auricle. Lancet
1921;1:845-848.
Acknowledgment: I appreciate the following for 27. Hollman A. Thomas Lewis: physiologist, cardiologist, and clinical scientist.
their valuable contributions: the Piedmont Hospital Li- C/in Card& 1985;8:555-559.

DISCOVERYOF AURICULARFIBRILLATION 389