- Email: [email protected]
Wilhelm His Jr. (1863–1934)—The man behind the bundle
Wilhelm His Jr. (1863–1934)—The man behind the bundle Ariel Roguin, MD, PhD From the Department of Cardiology, Rambam Medical Center, B. Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel. Wilhelm His Jr. (1863–1934) was a Swiss-born cardiologist and anatomist. In 1893, he discovered the bundle of His—the specialized tissue in the heart that transmits the electrical impulses and helps synchronize contraction. He pioneered studies in cardiac conduction and coined the term “heart block,” which he identified as the cause of Adams-Stokes disease. He was a professor of medicine at the University of Berlin, became the dean of medicine in 1918 and in 1928 was elected rector of the University of Berlin. Through his long clinical and teaching career he became better known for his work on gout and diseases of the joints. “Trench fever,” or Werner-His disease, was also named after him. This report presents the life and work of Wilhelm His Jr., who was described by his colleagues as “a master of his profession, a great physician, investigator, and a well cultured gentleman.” (Heart Rhythm 2006;3:480 – 483) © 2006 Heart Rhythm Society. All rights reserved.
The name His is a familiar one to every medical student, anatomist, physiologist, and clinician. There are two reasons for this popularity: the first is Wilhelm His Sr. (1831– 1904), professor of anatomy and physiology at the universities of Basel (1857–72) and Leipzig (1872–1904). Professor His Sr. developed many of the present day methods for the study of anatomy. In 1865, he invented the microtome, a mechanical device used to slice thin tissue sections for microscopic examination. He created the science of histogenesis, which is the study of the embryonic origins of different types of animal tissue, and is also one of the originators of the neuron theory. In 1886, he put forward the idea that the nerve-cell body and its prolongations form an independent unit. In 1889, he coined the term “dendrite” for some of the appendices in nerve cells. His Sr. wrote the best description of the development of the heart and brought to prominence the significance of the vestibular spine.1 The second reason is his son, Wilhelm His Jr., whose name is written in the human heart because of his discovery of an “embryonic muscle bundle which united the auricles with the ventricles which transmits the auricular beat to the ventricles and when disturbed or interrupted causes heart block.”2 Wilhelm His Jr. was primarily a clinican and not an
Address reprint requests and correspondence: Ariel Roguin, MD, PhD, Department of Cardiology, Rambam Medical Center, B. Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 31096 Israel. E-mail address: [email protected] (Received October 15, 2005; accepted November 16, 2005.)
anatomist as his father was. The work on the bundle was accomplished during the first few years after his graduation from medical school while he was an assistant in the Medical Clinic in Leipzig, Germany. The results of his study were published in 1893,3 but, as he himself put it, “very few people have read the article.”4 Through his long clinical and teaching career he became better known for his work on gout and diseases of the joints. Because of this, there has been a widespread misconception as to whether he or his father described the atrioventricular (AV) bundle. Actually, few people in more recent years realize that there were two men by the same name. This article describes the life of the man behind the bundle of His. Wilhelm His Jr. was a Swiss-born internist, anatomist, and cardiologist. He was born in Basel, Switzerland (December 29, 1863), the third of six children. His early childhood was spent in Basel where his father was then a professor of anatomy and physiology. In 1872, when he was 9 years old, the family moved to Leipzig, Germany, a worldrenowned cultural, social, political, and academic city. The local university was of the highest order, and his father was one of the leading figures there. In this atmosphere, Wilhelm His Jr. received his education; he mastered both German and French and also became a proficient violinst and talented painter.2 Wilhelm His Jr. obtained his early training in the Gymnasium at Leipzig and completed his last 2 years of high school in Basel, where he graduated in 1882. His family maintained Swiss citizenship, thus His Jr. took his military training there.
1547-5271/$ -see front matter © 2006 Heart Rhythm Society. All rights reserved.
doi:10.1016/j.hrthm.2005.11.020
Roguin
Wilhelm His Jr.
After graduation from the Gymnasium, his father laid careful plans for his further medical training so that he would have contact with many great instructors. He received his medical education at the universities of Geneva, Leipzig, Bern, and Strasburg. At Leipzig, under his father, his anatomical knowledge was acquired. Here he became familiar with embryological technique and used this knowledge for his later research work. At Strasburg, he studied under the great chemical and pharmacological teacher Professor Schmiedeberg, who was the director of the world’s first pharmacological laboratory. He conducted research on the metabolism of pyridine. In 1887, he discovered, beyond all expectations, the body’s ability to methylate organic compounds by isolating Nmethyl pyridinium hydroxide from the urine of dogs dosed with pyridine acetate. He passed the state examination in Strasburg in 1888. He returned to Leipzig and became deeply interested in embryology and anatomy.2,5 In 1889, he obtained his medical doctorate in Leipzig and was appointed assistant to Heinrich Curschmann in the clinic at Leipzig. He first studied the acoustofacial region in man and the migration of ganglion cells. These embryological studies published in 1889 –90 show that he had remarkable ability and knowledge in the morphological field. He was habilitated in internal medicine in 1891 and in 1895 was appointed assistant professor of clinical medicine at the University of Leipzig.1,6 Wilhelm His Jr. is best remembered for his discovery in 1893 of the specialized muscle fibers, known as the “bundle of His,” which is the only direct connection between the ventricles and the atria that conducts impulses to the ventricular heart muscle. In his original article on the AV bundle, the development of the cardiac nerves is reviewed and the controversies regarding heart function are discussed at length, but of the 35 pages, only one page is devoted to the description of the AV bundle (translated by Bast and Gardner)3: After long search I have succeeded in finding a muscle bundle which unites the auricular and ventricular septal walls, and which, up to now, has escaped observation because of incomplete exposure, for it is visible in its entire extent only when the septa are cut exactly in their longitudinal direction. From such cuts, as well as in serial sections, I was able to recognize the course of the bundle and have demonstrated it in a grown mouse, a newborn dog, two newborn and one adult (30-year-old) human. The bundle arises from the posterior wall of the right auricle, near the auricular septum, in the AV groove; attaches itself along the upper margin of the ventricular septal muscle by means of numerous fiber exchanges; proceeds on top of this toward the front until near the aorta it forks itself into a right and left limb which latter ends in the base of the aortic cusp of the mitral valve. Whether this bundle really transmits the impulse from the auricle to the ventricle I am unable to say certainly since, up to now, I have not attempted any transection experiments of
481 it. Very likely its presence is an argument against the belief of those who, because of the lack of muscular continuity between auricle and ventricle, seek to prove the necessity of nervous conduction. The ensuing portion of the paper deals with his observations on the action of various poisons on the heartbeat in various animals and on the fetal heart. He finally reviews the various controversies regarding the myogenic and neurogenic concepts of the origin of the heartbeat. The paper was published in 1893 in the Arbeiten aus der medidizinischen Klinik zu Leipzig,3 a journal with limited distribution, of which his mentor was one of its editors. During the next years, His found that these filaments help communicate a single rhythm of contraction to all parts of the heart.4 –7 He experimented on rabbits and found that when the bundle was severed it caused “asynchronie in the beat of the auricle and ventricle.”4 He attempted to cut the AV bundle. In 21 attempts he was successful in producing AV dissociation in only three. All hearts were examined histologically. The bundle was severed only in those three cases where asynchrony occurred. He presented the results at the International Physiological Congress in Bern in 1895. He pioneered studies in cardiac conduction and coined the term “heart block,” which he identified as the cause of Adams-Stokes syncope.2,4,7 After his appointment as assistant professor of clinical medicine in 1895, his time became more and more occupied with clinical problems; he had a special interest in gout and related diseases of the joints. He made excellent use of his chemical knowledge and studied the metabolism of uric acid and xanthines by making serial tests. He formulated the law that, “always before the acute attack the uric acid level drops, during the attack it rises to abnormal levels.” He recognized the toxic inflammatory irritation and studied different ways for the removal of precipitated uric acid.2 In 1901, His took over as physician-in-chief of the department of internal medicine at the Friedrichstadt Hospital in Dresden. The following year he was called to Basel and became assistant professor of internal medicine. There he continued with the study of joint diseases. He made a large collection of bone sections and x-rays. He employed a new therapy—the application of radium emanations. In 1905 he began to study the “goiter heart” and started to consider metabolic diseases as basically endocrine disturbances and regulated their therapeutic treatment accordingly. In 1906 he moved to Gottingen. The following year—1907, at the age of 44 — he received the prestigious chair of internal medicine in Berlin and became director of the first medical clinic at the Charité. His inaugural address has been hailed as a classic and one of his best speeches.2 In Berlin, then the greatest social and cultural city of the world, he was in his glory amidst the social whirl, music, and other cultural pursuits. In September 1918, he became dean of the medical faculty in Berlin, and in 1928 was elected rector of the University of Berlin (Figure 1). During World War I, he enlisted in the German Army as
482
Heart Rhythm, Vol 3, No 4, April 2006
Figure 1
Wilhelm His Jr. (1863–1934).
a voluntary soldier and served as an advisory internist. He did not belong to the German Army, as his family remained Swiss citizens, although in 1905 at Leipzig he became a citizen of Saxony as well and in 1906 accepted naturalization in the state of Prussia. His visited all theaters of the war, both in the west and in the east. In 1916, he described “Volhynia fever,” named after a district in Russia. Professor Werner, a corps hygienist, called it “5-day fever.” On the Western front it did not appear until later and was then called “Trench fever” or “Werner-His disease.” Trench fever is a moderately serious disease caused by Bartonella quintana, an unusual rickettsial organism that multiplies in the gut of the louse. Trench fever (also called Volhynia fever, shin bone fever, 5-day fever, His disease, and His-Werner disease) infected more than a million soldiers during World Wars I and II. The disease is classically a 5-day fever. The onset of symptoms is sudden with high fever, severe headache, back pain and leg pain, and a fleeting rash. Recovery takes a month or more. Relapses are common. The disease persists today and is seen endemically in Mexico, Africa, and elsewhere. Urban trench fever occurs among the homeless and people with alcoholism, and outbreaks are still reported periodically. Wilhelm His Jr. was a sophisticated conversationalist, as well as a musician and painter. Besides his medical research
he also occupied himself with medical history, publishing “The History of the Medical Clinic at Leipzig” and in 1931 a biography of his father. In 1932, he decided to retire. During a farewell gathering with an intimate circle of friends, he admitted that age was creeping up on him rapidly and that his emphysematous dyspnea caused him regretfully to set a time limit for the completion of numerous projects that he had begun. He presented himself to his colleagues as a patient. He told them the nature of his illness and stated that he had only 2 years more to live. His clinical prediction was exact. He spent his last years in Brombach in Wiesental. Here he completed his final scientific and historic account of the structure and function of the AV bundle, telling the story of its discovery and recording results of experiments on the bundle that had not been presented in detail before.4 Interestingly, in 1893, the same year that His reported the bundle, Stanley Kent (1863–1958), a British physiologist, reported that there were multiple muscular pathways crossing the insulating AV junctions of the normal heart.8 We now know that Kent’s concept is incorrect, although these “nodes” do exist, and in certain circumstances they can give rise to specialized bundles that produce the so-called Mahaim variant of preexcitation.9 In the 1933 summary, His gives credit to Kent for noting the AV bundle in part, and also other connections, although he states that Kent “did not follow its course and, besides this, he described not only other direct bridges from the atrial to the ventricular musculature but also peculiar isolated cells which he likewise ascribed conduction. These latter could not be found by later investigators.”4
Discovery of the conduction system A frequently quoted paradox states that the elements of the cardiac conduction system were discovered in the reverse order of cardiac excitation, which is generated in the sinus node (discovered 1907) and transmitted to the AV node (1906), then to the His bundle (1893), and finally to the Purkinje fibers (1839). However, when scrutinized, this interesting paradox does not correctly reflect all facts because the role of the left and right bundle branches was reported by Tawara in 1906, 13 years after His reported the bundle that bears his name. In addition, although Purkinje was the first to describe the fibers, Tawara was the one who discovered their true function. Knowledge of the conduction system of the heart was greatly advanced by Sunao Tawara (1873–1952), a Japanese pathologist who actually came to study cardiac failure in Ludwig Aschoff’s (1866 –1942) pathological laboratory.10,11 After his two and a half years of strenuous work in Marburg, as a result of careful histological studies of serially sectioned human hearts, Tawara established the link between the His bundle and the Purkinje fibers by discovering the role of the left and right bundle branch and the
Roguin
Wilhelm His Jr.
interposed components between them and by identifying the Purkinje fibers as the terminal ramifications of these components. By adding another component, the AV node, he enabled the understanding of these components as a system, that is, the conduction system of the heart. In his monograph, The Conduction System of the Mammalian Heart, published in 1906, Tawara also theorized about the velocity of the excitatory process in the conduction system and the mode of ventricular contraction. Tawara’s anatomic findings and physiological assumptions provided the theoretical basis to Eindhoven for interpreting the electrocardiogram, resulting in rapid popularization of electrocardiography. At the same time, Arthur Keith (1866 –1955), an anatomist from London, was unable to find the purported AV bundle.12 Keith’s skepticism reached such a degree that he decided to write a letter to the Lancet regarding his failure and his doubt as to the existence of the His bundle. By the time the Lancet returned a proof of the letter, he had read the paper by Tawara and Aschoff. Supported by Tawara’s descriptions in his monograph, Keith was able to find the His bundle and the conduction system of Tawara. Tawara’s discovery of the AV node stimulated Keith and his young assistant Martin Flack (1882–1931), then a medical student at the London Hospital, to search for such a peculiar tissue in another region of the heart, as it was believed at that time that the heartbeat was initiated in the musculature surrounding the terminal part of the superior vena cava. Indeed, in 1907, Keith and Flack were the first to report the existence of the sinoauricular node in the vertebrate heart. Wilhelm His Jr. died on November 10, 1934, at the age of 71 and was buried in his native city of Basel. Petow, one of his students, summed up his characteristics in the following words: “He was a master of his profession, a great physician, investigator and a well cultured gentleman.”13
483
References 1. Anderson RH, Webb S, Moorman AFM, Brown NA. Morphological correlates of atrial development. John Keith Lecture. Cardiol Young 2004;14:239 –254. 2. Bast TH, Gardner WD. Wilhelm His, Jr. and the Bundle of His. J Hist Med Allied Sci 1949;4:170 –187. 3. His Jr. W. Die Tätigkeit des embryonalen herzens und deren bedeutung für die Lehre von der Hezebewegung beim Menschen. Arbeiten aus der medidizinischen Klinik zu Leipzig, 1893:14-49. Bast TH, Gardner WD trans.: J Hist Med Allied Sci 1949;4:289318. 4. His, Jr, W. The story of the Atrioventricular Bundle with remarks concerning Embryonic Heart Activity. Klin Wschr 1933:12:569574; Bast TH, Gardner WD trans.: J Hist Med Allied Sci 1949; 4:319-333. 5. Fye WB. Disorders of the heartbeat: a historical overview from antiquity to the mid-20th century. Am J Cardiol 1993;72:1055– 1070. 6. Wilhelm His Jr.(1863–1934). JAMA 1964;187:453– 454. 7. Hardewig A. Wilhelm His Jr., 1863–1934. Action of the embryonal heart. A case of Adams-Stokes disease with asynchronous beats of heart atrium and ventricle (heart block). Internist (Berl) 1969;10:87– 91. 8. Anderson RH, Becker AE. Stanley Kent and accessory atrioventricular connections. J Thorac Cardiovasc Surg 1981;81:649 – 658. 9. Anderson RH, Ho SY, Gillette PC, Becker AE. Mahaim, Kent and abnormal atrioventricular conduction. Cardiovasc Res 1996;31:480 – 491. 10. Anderson RH, Ho SY.The morphology of the specialized atrioventricular junctional area: the evolution of understanding. Pacing Clin Electrophys 2002;25:957–966. 11. Suma K. Sunao Tawara: a father of modern cardiology. Pacing Clin Electrophysiol 2001;24:88 –96. 12. Keith A, Flack MW. The auriculo-ventricular bundle of the human heart. 1906. Ann Noninvasive Electrocardiol 2004;9:400 – 409. 13. Keith A, Flack M. The form and nature of the muscular connections between the primary divisions of the vertebrate heart. J Anat Physiol 1907;41:172–189.
The name His is a familiar one to every medical student, anatomist, physiologist, and clinician. There are two reasons for this popularity: the first is Wilhelm His Sr. (1831– 1904), professor of anatomy and physiology at the universities of Basel (1857–72) and Leipzig (1872–1904). Professor His Sr. developed many of the present day methods for the study of anatomy. In 1865, he invented the microtome, a mechanical device used to slice thin tissue sections for microscopic examination. He created the science of histogenesis, which is the study of the embryonic origins of different types of animal tissue, and is also one of the originators of the neuron theory. In 1886, he put forward the idea that the nerve-cell body and its prolongations form an independent unit. In 1889, he coined the term “dendrite” for some of the appendices in nerve cells. His Sr. wrote the best description of the development of the heart and brought to prominence the significance of the vestibular spine.1 The second reason is his son, Wilhelm His Jr., whose name is written in the human heart because of his discovery of an “embryonic muscle bundle which united the auricles with the ventricles which transmits the auricular beat to the ventricles and when disturbed or interrupted causes heart block.”2 Wilhelm His Jr. was primarily a clinican and not an
Address reprint requests and correspondence: Ariel Roguin, MD, PhD, Department of Cardiology, Rambam Medical Center, B. Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa 31096 Israel. E-mail address: [email protected] (Received October 15, 2005; accepted November 16, 2005.)
anatomist as his father was. The work on the bundle was accomplished during the first few years after his graduation from medical school while he was an assistant in the Medical Clinic in Leipzig, Germany. The results of his study were published in 1893,3 but, as he himself put it, “very few people have read the article.”4 Through his long clinical and teaching career he became better known for his work on gout and diseases of the joints. Because of this, there has been a widespread misconception as to whether he or his father described the atrioventricular (AV) bundle. Actually, few people in more recent years realize that there were two men by the same name. This article describes the life of the man behind the bundle of His. Wilhelm His Jr. was a Swiss-born internist, anatomist, and cardiologist. He was born in Basel, Switzerland (December 29, 1863), the third of six children. His early childhood was spent in Basel where his father was then a professor of anatomy and physiology. In 1872, when he was 9 years old, the family moved to Leipzig, Germany, a worldrenowned cultural, social, political, and academic city. The local university was of the highest order, and his father was one of the leading figures there. In this atmosphere, Wilhelm His Jr. received his education; he mastered both German and French and also became a proficient violinst and talented painter.2 Wilhelm His Jr. obtained his early training in the Gymnasium at Leipzig and completed his last 2 years of high school in Basel, where he graduated in 1882. His family maintained Swiss citizenship, thus His Jr. took his military training there.
1547-5271/$ -see front matter © 2006 Heart Rhythm Society. All rights reserved.
doi:10.1016/j.hrthm.2005.11.020
Roguin
Wilhelm His Jr.
After graduation from the Gymnasium, his father laid careful plans for his further medical training so that he would have contact with many great instructors. He received his medical education at the universities of Geneva, Leipzig, Bern, and Strasburg. At Leipzig, under his father, his anatomical knowledge was acquired. Here he became familiar with embryological technique and used this knowledge for his later research work. At Strasburg, he studied under the great chemical and pharmacological teacher Professor Schmiedeberg, who was the director of the world’s first pharmacological laboratory. He conducted research on the metabolism of pyridine. In 1887, he discovered, beyond all expectations, the body’s ability to methylate organic compounds by isolating Nmethyl pyridinium hydroxide from the urine of dogs dosed with pyridine acetate. He passed the state examination in Strasburg in 1888. He returned to Leipzig and became deeply interested in embryology and anatomy.2,5 In 1889, he obtained his medical doctorate in Leipzig and was appointed assistant to Heinrich Curschmann in the clinic at Leipzig. He first studied the acoustofacial region in man and the migration of ganglion cells. These embryological studies published in 1889 –90 show that he had remarkable ability and knowledge in the morphological field. He was habilitated in internal medicine in 1891 and in 1895 was appointed assistant professor of clinical medicine at the University of Leipzig.1,6 Wilhelm His Jr. is best remembered for his discovery in 1893 of the specialized muscle fibers, known as the “bundle of His,” which is the only direct connection between the ventricles and the atria that conducts impulses to the ventricular heart muscle. In his original article on the AV bundle, the development of the cardiac nerves is reviewed and the controversies regarding heart function are discussed at length, but of the 35 pages, only one page is devoted to the description of the AV bundle (translated by Bast and Gardner)3: After long search I have succeeded in finding a muscle bundle which unites the auricular and ventricular septal walls, and which, up to now, has escaped observation because of incomplete exposure, for it is visible in its entire extent only when the septa are cut exactly in their longitudinal direction. From such cuts, as well as in serial sections, I was able to recognize the course of the bundle and have demonstrated it in a grown mouse, a newborn dog, two newborn and one adult (30-year-old) human. The bundle arises from the posterior wall of the right auricle, near the auricular septum, in the AV groove; attaches itself along the upper margin of the ventricular septal muscle by means of numerous fiber exchanges; proceeds on top of this toward the front until near the aorta it forks itself into a right and left limb which latter ends in the base of the aortic cusp of the mitral valve. Whether this bundle really transmits the impulse from the auricle to the ventricle I am unable to say certainly since, up to now, I have not attempted any transection experiments of
481 it. Very likely its presence is an argument against the belief of those who, because of the lack of muscular continuity between auricle and ventricle, seek to prove the necessity of nervous conduction. The ensuing portion of the paper deals with his observations on the action of various poisons on the heartbeat in various animals and on the fetal heart. He finally reviews the various controversies regarding the myogenic and neurogenic concepts of the origin of the heartbeat. The paper was published in 1893 in the Arbeiten aus der medidizinischen Klinik zu Leipzig,3 a journal with limited distribution, of which his mentor was one of its editors. During the next years, His found that these filaments help communicate a single rhythm of contraction to all parts of the heart.4 –7 He experimented on rabbits and found that when the bundle was severed it caused “asynchronie in the beat of the auricle and ventricle.”4 He attempted to cut the AV bundle. In 21 attempts he was successful in producing AV dissociation in only three. All hearts were examined histologically. The bundle was severed only in those three cases where asynchrony occurred. He presented the results at the International Physiological Congress in Bern in 1895. He pioneered studies in cardiac conduction and coined the term “heart block,” which he identified as the cause of Adams-Stokes syncope.2,4,7 After his appointment as assistant professor of clinical medicine in 1895, his time became more and more occupied with clinical problems; he had a special interest in gout and related diseases of the joints. He made excellent use of his chemical knowledge and studied the metabolism of uric acid and xanthines by making serial tests. He formulated the law that, “always before the acute attack the uric acid level drops, during the attack it rises to abnormal levels.” He recognized the toxic inflammatory irritation and studied different ways for the removal of precipitated uric acid.2 In 1901, His took over as physician-in-chief of the department of internal medicine at the Friedrichstadt Hospital in Dresden. The following year he was called to Basel and became assistant professor of internal medicine. There he continued with the study of joint diseases. He made a large collection of bone sections and x-rays. He employed a new therapy—the application of radium emanations. In 1905 he began to study the “goiter heart” and started to consider metabolic diseases as basically endocrine disturbances and regulated their therapeutic treatment accordingly. In 1906 he moved to Gottingen. The following year—1907, at the age of 44 — he received the prestigious chair of internal medicine in Berlin and became director of the first medical clinic at the Charité. His inaugural address has been hailed as a classic and one of his best speeches.2 In Berlin, then the greatest social and cultural city of the world, he was in his glory amidst the social whirl, music, and other cultural pursuits. In September 1918, he became dean of the medical faculty in Berlin, and in 1928 was elected rector of the University of Berlin (Figure 1). During World War I, he enlisted in the German Army as
482
Heart Rhythm, Vol 3, No 4, April 2006
Figure 1
Wilhelm His Jr. (1863–1934).
a voluntary soldier and served as an advisory internist. He did not belong to the German Army, as his family remained Swiss citizens, although in 1905 at Leipzig he became a citizen of Saxony as well and in 1906 accepted naturalization in the state of Prussia. His visited all theaters of the war, both in the west and in the east. In 1916, he described “Volhynia fever,” named after a district in Russia. Professor Werner, a corps hygienist, called it “5-day fever.” On the Western front it did not appear until later and was then called “Trench fever” or “Werner-His disease.” Trench fever is a moderately serious disease caused by Bartonella quintana, an unusual rickettsial organism that multiplies in the gut of the louse. Trench fever (also called Volhynia fever, shin bone fever, 5-day fever, His disease, and His-Werner disease) infected more than a million soldiers during World Wars I and II. The disease is classically a 5-day fever. The onset of symptoms is sudden with high fever, severe headache, back pain and leg pain, and a fleeting rash. Recovery takes a month or more. Relapses are common. The disease persists today and is seen endemically in Mexico, Africa, and elsewhere. Urban trench fever occurs among the homeless and people with alcoholism, and outbreaks are still reported periodically. Wilhelm His Jr. was a sophisticated conversationalist, as well as a musician and painter. Besides his medical research
he also occupied himself with medical history, publishing “The History of the Medical Clinic at Leipzig” and in 1931 a biography of his father. In 1932, he decided to retire. During a farewell gathering with an intimate circle of friends, he admitted that age was creeping up on him rapidly and that his emphysematous dyspnea caused him regretfully to set a time limit for the completion of numerous projects that he had begun. He presented himself to his colleagues as a patient. He told them the nature of his illness and stated that he had only 2 years more to live. His clinical prediction was exact. He spent his last years in Brombach in Wiesental. Here he completed his final scientific and historic account of the structure and function of the AV bundle, telling the story of its discovery and recording results of experiments on the bundle that had not been presented in detail before.4 Interestingly, in 1893, the same year that His reported the bundle, Stanley Kent (1863–1958), a British physiologist, reported that there were multiple muscular pathways crossing the insulating AV junctions of the normal heart.8 We now know that Kent’s concept is incorrect, although these “nodes” do exist, and in certain circumstances they can give rise to specialized bundles that produce the so-called Mahaim variant of preexcitation.9 In the 1933 summary, His gives credit to Kent for noting the AV bundle in part, and also other connections, although he states that Kent “did not follow its course and, besides this, he described not only other direct bridges from the atrial to the ventricular musculature but also peculiar isolated cells which he likewise ascribed conduction. These latter could not be found by later investigators.”4
Discovery of the conduction system A frequently quoted paradox states that the elements of the cardiac conduction system were discovered in the reverse order of cardiac excitation, which is generated in the sinus node (discovered 1907) and transmitted to the AV node (1906), then to the His bundle (1893), and finally to the Purkinje fibers (1839). However, when scrutinized, this interesting paradox does not correctly reflect all facts because the role of the left and right bundle branches was reported by Tawara in 1906, 13 years after His reported the bundle that bears his name. In addition, although Purkinje was the first to describe the fibers, Tawara was the one who discovered their true function. Knowledge of the conduction system of the heart was greatly advanced by Sunao Tawara (1873–1952), a Japanese pathologist who actually came to study cardiac failure in Ludwig Aschoff’s (1866 –1942) pathological laboratory.10,11 After his two and a half years of strenuous work in Marburg, as a result of careful histological studies of serially sectioned human hearts, Tawara established the link between the His bundle and the Purkinje fibers by discovering the role of the left and right bundle branch and the
Roguin
Wilhelm His Jr.
interposed components between them and by identifying the Purkinje fibers as the terminal ramifications of these components. By adding another component, the AV node, he enabled the understanding of these components as a system, that is, the conduction system of the heart. In his monograph, The Conduction System of the Mammalian Heart, published in 1906, Tawara also theorized about the velocity of the excitatory process in the conduction system and the mode of ventricular contraction. Tawara’s anatomic findings and physiological assumptions provided the theoretical basis to Eindhoven for interpreting the electrocardiogram, resulting in rapid popularization of electrocardiography. At the same time, Arthur Keith (1866 –1955), an anatomist from London, was unable to find the purported AV bundle.12 Keith’s skepticism reached such a degree that he decided to write a letter to the Lancet regarding his failure and his doubt as to the existence of the His bundle. By the time the Lancet returned a proof of the letter, he had read the paper by Tawara and Aschoff. Supported by Tawara’s descriptions in his monograph, Keith was able to find the His bundle and the conduction system of Tawara. Tawara’s discovery of the AV node stimulated Keith and his young assistant Martin Flack (1882–1931), then a medical student at the London Hospital, to search for such a peculiar tissue in another region of the heart, as it was believed at that time that the heartbeat was initiated in the musculature surrounding the terminal part of the superior vena cava. Indeed, in 1907, Keith and Flack were the first to report the existence of the sinoauricular node in the vertebrate heart. Wilhelm His Jr. died on November 10, 1934, at the age of 71 and was buried in his native city of Basel. Petow, one of his students, summed up his characteristics in the following words: “He was a master of his profession, a great physician, investigator and a well cultured gentleman.”13
483
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