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a point in a Descartes scheme—in the Journal of the capillary tube of the refined Lippmann electrometer. In 1895
History of Medicine and Allied Sciences 1971, he published an illustration (Figure 1) that showed his
26:181. mathematically corrected curve superimposed on the uncor-
A note on Descartes seems appropriate because although rected curve made by the refined Lippmann capillary elec-
he was born in France in 1596 and died in 1650, he plays a trometer.5 Note that Einthoven’s purpose was to show how
major role in the story that unfolds.1 He invented analytical his mathematically corrected ECG, which contained more
geometry. He was the first scientist to state the law of waves, differed from the tracing made with the refined
refraction, and he labeled some of the points on the curves he Lippmann capillary electrometer. Because he used ABCD to
drew P and Q. As discussed later, Einthoven undoubtedly indicate the waves in the uncorrected tracing, he was forced
studied the work of Descartes, as did all serious students of to find other letters to label his corrected curve, which he
geometry and physics. superimposed on the uncorrected tracing. He chose PQRST.
The first human ECG, recorded by Waller2 in 1887 with One attractive hypothesis is that Einthoven chose these letters
Lippmann’s capillary electrometer, revealed only 2 deflec- because Descartes had used them to identify successive
tions. Being a physiologist, Waller labeled the waves as one points on a curve.
would expect a physiologist to do: he used letters that Henson’s magnificent article,6 cited by Burchell, supports
the idea that Einthoven used letters popularized by Descartes.
suggested the anatomic parts of the heart that produced them.
I have simply highlighted the reason Einthoven no longer
Accordingly, he labeled the 2 waves V1 and V2 to indicate
used ABCD; he had to change letters because in a single
ventricular events. Einthoven, using a Lippmann capillary
illustration he had to show how his corrected curve differed
electrometer, also obtained tracings with 2 waves made by the
from the uncorrected curve.
ventricles and labeled them A and B. When Einthoven later
Now let us look at Snellen’s account of the naming of the
recorded atrial excitation with an improved Lippmann elec-
waves in the ECG. It is reprinted here with permission.
trometer, Waller labeled the newly discovered deflection with
an A to indicate it was produced by the atria. Einthoven, who To eliminate confusion with the uncorrected trac-
had already used A to label the first ventricular event, used P ings and to allow space for possible later additions
to designate the record made by the electrical activity (such as later actually happened with the U wave) the
From the Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Ga.
Correspondence to J. Willis Hurst, MD, 1462 Clifton Rd NE, Suite 301, Atlanta, GA 30322.
(Circulation. 1998;98:1937-1942.)
© 1998 American Heart Association, Inc.
1937
1938 Naming the Waves in the ECG
Einthoven recognized, perhaps as an afterthought, that by Figure 3. The postage stamp issued by the Netherlands in
choosing PQRST he allowed space to add letters before P and 1993 in honor of Einthoven. The ECG imprinted on his forehead
after T. was made with a galvanometer. It had become standard to label
waves made by a galvanometer as PQRST. Note that Einthoven
Einthoven continued to use PQRST to identify waves in
reverted to the use of PAB to label the waves in this particular
the ECG recorded with the string galvanometer. PQRST, of ECG. Why he used an old, mixed rubric is unknown (see text).
course, is still used today (Figure 2).
Einthoven identified the U wave a few years later.7 The U Tracings made with Einthoven’s galvanometer were usu-
wave was detected only in ECGs made with the string ally routinely labeled PQRST. Why then did he use PAB to
galvanometer. label a tracing made with his galvanometer? Such labeling
In 1993 Einthoven’s country, the Netherlands, issued a harks back to an earlier period when the letters were used
postage stamp in his honor (Figure 3). Note that the tracing to identify waves in the tracing made by a slightly
used by the artist was made with a galvanometer and is improved Lippmann capillary electrometer. Why
similar to the ECG made by Einthoven and published as Einthoven used the same labeling in a tracing made with
Figure 58B in the biography of Einthoven by DeWaart.8 his galvanometer remains a mystery.
of a supplementary electrical deflection that we pro- All J-wave deflections do not look alike. Some are merely
pose to call D.” elevations of ST segments in leads V1 and V2,37 whereas
others are of the spike-and-dome variety.26 This leads to the
conclusion that different mechanisms may be responsible for
Genesis of the Delta Wave the size and shape of J-wave deflections.
Wolferth and Wood pointed out that the abnormal slurring of
the initial part of the QRS complex and prolongation of the
QRS complex were not due to bundle-branch block as Genesis of the Osborn Wave
proposed by Wolff, Parkinson, and White but were caused by Knowing the work of Wilson and Finch38 relating the effect of
an “actual acceleration of the passage of the impulse from the drinking ice water on T waves of the ECG, I assumed that
auricle to a section of the ventricle.”16 intense total body hypothermia somehow delayed and slowed
They also stated, “all the data so far obtained are in keeping depolarization of a portion of the left ventricle. In our
with the possibility that an accessory pathway of AV con- patients,39 the mean vector illustrating the Osborn wave was
duction such as described by Kent [Reference 18] between directed to the left and parallel with the frontal plane or
the right auricle and right ventricle could be responsible for slightly anterior. This led to the view that the left anterior
the phenomenon manifested by these cases.” portion of the left ventricle was cooled more than other parts
of the left ventricle.
In 1996 Yan and Antzelevitch40 wrote
Osborn Wave
Our results provide the first direct evidence in
support of the hypothesis that heterogeneous dis-
Naming the Osborn Wave
The scholarly article by Gussak and associates19 served as the tribution of a transient outward current-mediated
spike-and-dome morphology of the action potential
source for most of the information that follows.
across the ventricular wall underlies the manifes-
The J point in the ECG is the point where the QRS complex
tation of the electrocardiographic J wave. The
joins the ST segment.19 It represents the approximate end of
presence of a prominent action potential notch in
depolarization and the beginning of repolarization as deter-
epicardium but not endocardium is shown to pro-
mined by the surface ECG. There is an overlap of '10
vide a voltage gradient that manifests as a J
milliseconds.20 The J point may deviate from the baseline in
(Osborn) wave or elevated J-point in the ECG.
early repolarization, epicardial or endocardial ischemia or
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be useful in the search for AV dissociation in ven- alphabet, he would have other letters to label waves that
tricular tachycardia or to study abnormal atrial might be found before the P wave or after the T wave. He
rhythms when the P waves are too small on regular later discovered the U wave when he developed the string
leads. galvanometer. Why Einthoven mixed the old with the new
labeling in the tracing made with the string galvanometer
Naming the Epsilon Waves shown in the postage stamp created to honor him is
Fontaine named the epsilon waves. His personal account of his bewildering and unexplained.
discovery was described in his March 5, 1997, letter to me: Segers, Lequime, and Denolin named the delta wave. They
chose delta because 1 side of the slurred part of the QRS
. . . after discovering the first cases of late (or complex seems to parallel 1 side of the Greek letter delta.
delayed) potentials recorded at the time of surgery on Clinicians named the spike-and-dome wave caused by
the epicardium of patients with resistant ventricular hypothermia the Osborn wave in honor of Osborn. More
tachycardia. It was quite exciting to demonstrate that research is needed to determine the mechanisms responsible
these late potentials located on the free wall of the for the abnormal J deflections that appear in a diverse group
right ventricle of patients with arrhythmogenic right of conditions.
ventricular dysplasia could be recorded on the surface Fontaine discovered and named the epsilon waves. He
by signal averaging and in some circumstances by chose the epsilon because it follows delta in the Greek
increasing the magnification of ECG recording. alphabet and is the mathematical symbol for smallness.
As late potentials were supposed to be the result of
late activation of a limited group of fibers, the term
“post-excitation” looked logical, since it was ob- Acknowledgments
served after the main excitation of the ventricle, I wish to thank Dr Howard Burchell, Dr Charles Antzelevitch, Dr
Dennis Krikler, Dr Guy Fontaine, and Dr Clyde Partain for their help
leading to the QRS complex. The term “epsilon” was
in the preparation of this manuscript. This dissertation could not have
nice, because it occurs in the Greek alphabet after been written without their suggestions, but I wish to emphasize that
delta; thus, delta represents the preexcitation and any errors in the manuscript are mine and not theirs.
epsilon the post-excitation phenomenon. In addition,
epsilon is also used in mathematics to express a very References
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