EDUCATION AND PRACTICE History

...................................................................................................................................................

" Centenary of tele-electrocardiography and

telephonocardiography
N M Hjelm* and H W Juliusw
*Department of Clinical Biochemistry, St George’s Hospital, London, UK; wPutten, The Netherlands

Summary
In the history of electrocardiography the names of two physiologists stand out: Augustus Waller (1865–1922)
and Willem Einthoven (1860–1927). Waller was the first to show that the beating heart produces a weak electric
potential, which can be registered by a measuring device connected to electrodes attached to the skin. Einthoven
developed a ‘string’ galvanometer, which was much faster and more sensitive than the system used by Waller.
Einthoven’s electrocardiograph was ready for use in 1903. To facilitate investigations of patients Einthoven
connected his instrument to the Academic Hospital in Leyden, by a telephone line, as suggested by his
engineering colleague Johannes Bosscha in Delft. The first successful tele-electrocardiogram was transmitted
on Sunday 22 March 1905. The heart tones were registered by wiring a specially developed microphone
placed on the subject’s chest to another string galvanometer. The event was therefore a first both for
tele-electrocardiography and for telephonocardiography. We are still awaiting the full-scale implementation of
these achievements, 100 years later.

Introduction response time of this instrument was too slow to

....................................................................... generate an accurate representation of the ECG.2 He
succeeded in calculating the real shape of the ECG
In the history of electrocardiography, the names of two
physiologists stand out: Augustus Waller (1865–1922),
working at St Mary’s Hospital in London, and Willem
Einthoven (1860–1927), at the University of Leiden.
Waller was the first to show that the beating heart
produces a weak electric potential, which can be
registered by a measuring device connected to
electrodes attached to the skin. He recorded the first
documented electrocardiogram (ECG) of a human
being in 1887.1 He lectured both at home and overseas,
and often used his bull terrier Jimmy standing in front
of the audience with each paw in a glass pan filled with
saline, from which the electrical potentials were
transmitted to a ‘Lippmann capillary electrometer’,
generating an ECG.

ECG recording
.......................................................................
Willem Einthoven (Figure 1) also started his research
on the electrical phenomena of the heart using the
capillary electrometer. He soon realized that the

Correspondence: Professor N M Hjelm, 18 Neville Avenue, New Malden, Figure 1 Willem Einthoven. Drawing by his grand-niece, Lucie
Surrey KT3 4SN, UK Moonen Einthoven (1910–92) in 1924 (reproduced with kind
(Fax: þ44 20 8949 2055; Email: magnus_hjelm@hotmail.com) permission of her son, Paul M H Moonen)

Journal of Telemedicine and Telecare 2005; 11: 336–338

 N M Hjelm and H W Julius Tele-electrocardiography and telephonocardiography

from the distorted curve produced by the capillary First tele-ECG transmission
electrometer,3 but concluded that the approach could .......................................................................
not work in any practical situation (computers did not
exist at the end of the 19th century!). Einthoven The first successful tele-ECG was transmitted on
therefore developed a new type of galvanometer, Sunday, 22 March 1905.7 The trial involved a healthy
based on the French-designed mirror galvanometer. volunteer, who had his ECG registered in Einthoven’s
His brilliant idea was to reduce the number of windings laboratory for comparative purposes before going to
of the coil to one half, which he called a ‘string’. the hospital. Photographs of the volunteer (identified
This string, consisting of a quartz thread only a few as ‘d.J.’ on the ECG,7 probably Einthoven’s assistant C J
microns in thickness and coated with silver to make it de Jongh dressed up as a patient) sitting with his hands
conductive, was placed in a strong magnetic field. Its in the glass jars (Figure 2) and of his normal ECG
movements, perpendicular to the magnetic field, (Figure 3) are shown in Einthoven’s account of the
could be observed by using a microscope to project the event.7 He comments that the two ECGs were identical,
image of the string onto a photographic film. This except that the R deflection was larger on the
instrument, the string galvanometer,4 was much faster
and more sensitive than the system used by Waller,
producing ECGs identical to those Einthoven had
calculated from the capillary electrometer. Einthoven’s
electrocardiograph was ready for use in 1903.5 He
introduced the letters P, Q, R, S and T for the five main
deflections of the electrical potential during a heartbeat
and derived the mathematical relationships between
the magnitude of the deflections registered between
three electrodes placed in a triangular position (right
and left arm and left leg, Einthoven’s triangle). He
received the Nobel prize for his achievements in 1924.
Had Waller still been alive (he missed the event by
two years), he might have shared this honour with
Einthoven.
Einthoven’s new instrument with its many
components occupied a large room in his laboratory
and for practical reasons ECGs were initially only
recorded from healthy volunteers. However, to make
the string galvanometer useful as a clinical tool, there
was a need to investigate patients as well. Therefore, as
suggested by Johannes Bosscha (1831–1911), professor
of applied physics and director of the Polytechnic
School in Delft,6 Einthoven decided to connect his
electrocardiograph to the Academic Hospital in Leiden
by a telephone cable of about 1.5 km in length,
running partly under and partly above the ground.
In the hospital, the patient could be connected by
putting his/her hands, or one hand and one foot, Figure 2 The volunteer ready for the transmission of the first a
into two glass jars filled with saline solution and tele-ECG (Figure 14 in Einthoven7) with his hands in jars with
saline solution. The electrodes placed in the jars are also visible
containing electrodes wired to the cable. Einthoven
obtained a substantial grant of fl.500 for the project
(about h20,000 in today’s money) from the Dutch
Society of Science.6 The initial trials were fraught
with difficulties due to movements of the part of
the cable above the ground, swaying in the wind,
thereby interacting with the earth’s magnetic field.
This resulted in serious and unpredictable distortions
of the transmitted ECGs. The problem was finally Figure 3 The first tele-ECG (Figure 16 in Einthoven7 where the
overcome by insulating the overhead cable with initials d.J. appear in the legend). Note the excellent quality of the
lead. recording

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N M Hjelm and H W Julius Tele-electrocardiography and telephonocardiography
tele-cardiogram ‘caused by the volunteer having to
cycle from the laboratory to the hospital’. The initial
reactions among the clinicians at the Academic
Hospital and among Einthoven’s oversees colleagues
were very positive. Contemporary British cardiologists
are said to have paid their compliment by calling the
connection the ‘Leyden mile’, perhaps with the Royal
Mile in Edinburgh in mind.8 However, Einthoven soon
became a better expert than his clinical colleagues in
diagnosing heart conditions, as a result of seeing many
more ECGs than they did. He began to offer diagnostic
advice, which was not appreciated. As a result,
the communication line between the Academic
Hospital and the laboratory ceased to be used after
some years.
First telephonocardiographic
transmission
.......................................................................
Soon after having registered his first ECG with the
string galvanometer5 in the 1890s, Einthoven became
aware of the importance of being able to relate
electrical and mechanical myocardial functions. Using
his string galvanometers, he succeeded in recording the
ECG and the heart tones simultaneously.9 The heart
tones (Figure 4) were registered by wiring a specially
developed microphone placed on the subject’s chest to
another string galvanometer. Einthoven used this
equipment on 22 March 1905.7 The event was there-
fore a first both for tele-electrocardiography and for
telephonocardiography. However, Einthoven’s interest in
the clinical application of electrocardiography soon
became the main focus of his research and
phonocardiography took a backseat. This was perhaps
also because clinical data transmitted along the Leyden
mile dried up.
Conclusion
.......................................................................
Einthoven suggested that his tele-electrocardiographic
– and telephonocardiographic – systems could be used
338 Journal of Telemedicine and Telecare Volume 11 Number 7
Figure 4 A telephonocardiogram (Figure 6 in Einthoven and
Geluk9). Registration over the apex. A1 and B1, first tone, A2 and
B2, second tone. P represents the pulse wave over the left carotid
artery. S is the time axis. Hg represents the movement of the
mercury meniscus. Again, note the impressive quality of the
recording
over a wider area.7 We are still awaiting the full-scale
implementation of this excellent idea, 100 years later.
Acknowledgements: HWJ is related to Willem
Einthoven.
References
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accompanying the heart’s beat. J Physiol 1887;8:229–34
2 Einthoven W. Niewe methoden voor clinisch onderzoek [New
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3 Einthoven W. Über die form des menschlichen Elektrocardiogramms
[The shape of the human electrocardiogram]. Pflug Arch Ges Phys
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4 Einthoven W. Un noveau galvanometer [A new galvanometer]. Arch
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5 Einthoven W. Galvanometrische registratie van het menschilijk
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registration of heart tones]. Pflug Arch Ges Phys 1894;57:617–39
2005