History of fibrillation and defibrillation

Igor R. Efimov, Washington University

Introduction

The research focus of our laboratory is the fundamental mechanisms of shock therapy, also known as defibrillation. This research field has a long and exciting history, involving several giants of the 19^th and 20^th century. This WEB-page is dedicated to the history of fibrillation and defibrillation. Our research laboratory started and worked on investigation of mechanism of defibrillation for 10 years in Cleveland (Cleveland Clinic Foundation (1994-2000) and Case Western Reserve University (2000-2004), which is the birthplace of clinical defibrillation, a result of the pioneering work of the great American physiologist Carl J. Wiggers, MD and the great American surgeon Claude S. Beck, MD.

Working at Case Western Reserve University Allen Memorial Medical Library and Museum I was fascinated to find direct evidence of how different generations of scientists and clinicians from many countries contributed to the success of shock therapy, which then culminated in the recent worldwide application of implantable defibrillators and external defibrillators, saving hundreds of thousands of lives in all countries around the world.

Scientific tradition does not know national boundaries. Physiology has been developed by many national schools, which share the same principles of scientific integrity, curiosity, passion for discovery, and the careful attention to perpetuation of the research field by raising future generations of scientists. Recently, I discovered striking similarities among several major physiology research laboratories, which have made a profound impact on physiology from Carl J. Wiggers in Cleveland Ohio to Ivan Pavlov in St. Petersburg, Russia. As it turned out, both have proudly adhered to a tradition originated in Carl Ludwig’s laboratory in Austria and Germany.

I discovered two pages of Carl J. Wiggers’s proofs of particular interest. These are starting pages from a chapter XVI of his book “Reminiscences and Adventures in Circulation Research”, published in 1958. In these two pages Carl J. Wiggers describes his personal experiences as a young investigator who learns Carl Ludwig’s tradition through interaction with his mentor W.P. Lombard, a former trainee of C. Ludwig. These are the pages: [page 1][page2].

Ventricular fibrillation

A single rotor produced by electrical stimulus, can lead to ventricular fibrillation

Nearly a quarter of all human deaths is attributed to sudden cardiac death, which results from disturbances in electrical impulse propagation throughout the heart. Such disturbance leads to a lethal breakdown of cardiac rhythm known as arrhythmia. There are numerous types of arrhythmias with ventricular fibrillation being the most dangerous one. It starts from a single of several tornado-like sources of electrical activity, which disorderly propagate throughout the heart, rapidly breaking up into numerous wavelets. These tine wavelets excite cardiac fibers without synchrony and lead to cessation of the blood flow. Death is imminent within minutes unless the shock therapy is applied.

Carl Ludwig (1816-1895) and his discovery of electrical stimulus-induced ventricular fibrillation. (M. Hoffa & C. Ludwig Einige neue Versuche uber Herzbewegung. Zeitschrift Rationelle Medizin 9:107-144, 1850)

19^th century discoveries and first studies of fibrillation and defibrillation

Written history of fibrillation and defibrillation goes back to the pioneering work of Carl Ludwig’s laboratory. In 1849, Ludwig’s student M. Hoffa was the first to witness and, most importantly, to document the onset of ventricular fibrillation, which he induced by electrical stimulus. This picture from their paper shows rapid contractions produced by electrical stimulation, which resulted in cardiac arrest.

A. Vulpian

Many investigators of the second half of the 19^th century attempted to resolve this mystery. Why is the heart suddenly in arrhythmia? Originally, most of the physiologists favored neurogenic theory of fibrillation, which suggested that irregular contractions of the heart muscle and are produced by an abnormal impulse generation and conduction within the nerve fiber network. Swiss physiologist from Lausanne, A. Vulpian was the first to suggest the myogenic theory of fibrillation. (A. Vulpian , Note sur les effets de la faradisation directe des ventricules du coeur le chien. Arch de Physiol., i:975, 1874). In other words, heart muscle itself sustains this irregular propagation of impulses and resulting mechanical disarray. In order to emphasize the myogenic nature of the observed arrhythmia he coined the term FIBRILLATION (“mouvement fibrillaire”). He also described ventricular fibrillation as a progression of at least 3 distinctly different phases.

John A. MacWilliam

Observations of A. Vulpian were independently confirmed by British physiologist John. A. MacWilliam, who arrived at similar conclusions regarding the myogenic nature of fibrillation. (J.A. MacWilliam, Fibrillar contraction of the heart. Jour. Physiol. 8: 296, 1887). He also made numerous observations, which became a part of commonly accepted paradigm. To name a few, he found that (1) ventricular fibrillation and atrial fibrillation are different phenomena, which can be inducible separately by stimulating the ventricles or atria, respectively; (2) vagus stimulation has no effect on VF, but can check or arrest AF. As A. Vulpian, MacWilliam concluded that fibrillation has myogenic nature, and it is not due to injury or irritation of nerves that pass over the ventricles

J.-L. Prevost and F. Battelli, La Mort Par Les Déscharges Électriques, Journ. de Physiol., 1: 1085-1100, 1899

20^th century advancement of defibrillation

Further experiments with “faradization” of the heart were conducted by two physiologists from University of Geneva, Switzerland, J.-L. Prevost and F. Batelli. They discovered that, while a weak stimulus can produce fibrillation, a stimulus of higher strength applied to the heart could arrest ventricular fibrillation and restore normal sinus rhythm. This discovery was made in 1899. Unfortunately, unlike discovery of contemporary electrocardiogram, defibrillation did not enjoy similar attention and success.

Carl J. Wiggers, The Mechanism and Nature of Ventricular Fibrillation, Am. Heart Journal, 20: 399-412, 1940

The discovery of Prevost and Batelli was confirmed and advanced by the subsequent work in many countries, most prominently by the research laboratory of Carl J. Wiggers from Western Reserve University in Cleveland, Ohio. Using a state of the art experimental methodology of his time, cinematograph, Carl Wiggers was able to advance original observations of Vulpian, describing several stages of ventricular fibrillation produced by a stimulus, which now are known as Wiggers stage I, Wiggers stage II, etc. Carl Wiggers provided the first mechanistic explanation of the induction of ventricular fibrillation within the framework of the concept of vulnerable window. He also perfected defibrillation procedure in an animal model of defibrillation.

Claude S. Beck and his first defibrillator

Courtesy to Allen Memorial Medical Library, CWRU

Work of Carl J. Wiggers in the Department of Physiology of Western Reserve University was well known to the thoracic surgeon Claude S. Beck from the University Hospitals in Cleveland, which are adjacent to the Western Reserve University. In 1947, Dr. Beck successfully applied defibrillation therapy and saved the first human life by this method (C.S. Beck, W.H. Pritchard, H.S. Feil, Ventricular fibrillation of long duration abolished by electric shock. Jour. Amer. Med. Assoc. 135: 985, 1947). His success triggered the immediate acceptance of this method by the clinical community and started a wide front of basic and clinical research of fibrillation and defibrillation.

Naum L. Gurvich (1905-1981) N.L.Gurvich, N.A. Negovsky, B. Storey, Baltimore, 1962. Courtesy to M.S. Bogushevich

The work of Prevost and Batelli was independently continued by the Russian physiologists N.A. Negovsky and N.L. Gurvich in Moscow. N.L. Gurvich was trained by the director of the Institute of Physiology in Moscow L.S. Schtern, who graduated from the University of Geneva and was an associate of J.-L. Prevost for many years. Naum L. Gurvich made many important discoveries and advancements in defibrillation, including an advent of the biphasic waveform, use of a capacitor for shock delivery and the introduction of the stimulatory theory of defibrillation.