Historical Perspective

Woldemar Mobitz and His 1924 Classification of

Second-Degree Atrioventricular Block
Mark E. Silverman, MD, MACP, FRCP; Charles B. Upshaw, Jr, MD; Helmut W. Lange, MD
AbstractWoldemar Mobitz, an early 20th century German internist, analyzed arrhythmias by graphing the relationship
of changing atrial rates and premature beats to AV conduction. Through an astute mathematical approach, he was able
to classify second-degree atrioventricular block into 2 types, subsequently referred to as Mobitz type I (Wenckebach)
and Mobitz type II (Hay). Type I AV block was most often due to digitalis and was reversible. There were no associated
pathological findings. Type II AV block frequently progressed to complete AV block and was associated with seizures,
death, and pathological findings. (Circulation. 2004;110:1162-1167.)
Key Words: Mobitz arrhythmias conduction heart block
It may appear astonishing to the clinician that the
results presented here are seemingly based on purely
mathematical considerations. However, the idea that
all theoretical concepts of rhythm disturbances developed so far are derived from measuring the recorded
tracings, and correlating numerical data will give the
same approval for this method of reasoning in regard
to the field of clinical medicine as it has already been
given for the methods of pure chemistry and physics
in regard to other fields.
Woldemar Mobitz1
Woldemar Mobitz, an early 20th century German internist
with a mathematical inclination for analyzing arrhythmias, is
remembered eponymically for his 1924 classification of
second-degree atrioventricular (AV) block into 2 types,
subsequently referred to as Mobitz type I (Wenckebach) and
Mobitz type II (Hay).

Biography
Mobitz was born May 31, 1889, in St. Petersburg, Russia, the
son of a prominent surgeon. His family moved to Tbingen in
southwest Germany before his sixth birthday. His father had
died at a young age, and Mobitz was raised by his mother and
an uncle. He attended the Gymnasium at Meiningen, Saxony,
equivalent to high school and college-level study, graduating
in 1908. Mobitz began medical studies at the University of
Freiburg in Breisgau in southwest Germany, transferring to
the University of Munich, from which he graduated in 1914.
Initially, he worked in Berlin and Halle in surgical clinics,
and then he completed his internship at the first medical clinic
at Munich. His activities during and after World War I are
unknown. In 1921, he was a lecturer in the first medical clinic
at the University of Munich, directed by Professor Ernst von
Romberg. His interests included various internal medical

topics centering mainly on cardiovascular disease and

arrhythmia.2 4
In February 1922, Mobitz presented an example of AV
dissociation.5 Two months later, he lectured on the question
of automation of the AV node in a patient with AV
dissociation.6 He published a report on the effect of extrasystoles in humans with regard to their contribution to interference of the cardiac rhythm in 1923.7 Later that year, he
published his important article on automation of the AV node,
in which he introduced the term interference-dissociation.8
At the Medical Convention for Internal Medicine in Vienna
in April 1923, Mobitz spoke about the nature of time intervals
between atrial and ventricular action.9 In July 1923, at the
meeting of the Association of Munich Specialists of Internal
Medicine, he lectured on AV conduction disturbances in
humans.10 This was the occasion on which he first classified
second-degree AV block into type I and type II. He authored
his classic article on partial block of conduction between
the atrium and ventricle in human hearts in 1924, commenting on their pathophysiological differences.1 Between 1923
and 1930, Mobitz also published articles on congenital and
acute porphyria; heart failure due to primary pulmonary
arteriosclerosis; regulation of the circulation; enhancement of
action potentials; a valve for mechanical production of
alveolar air; and the correlation of respiration, circulation,
and oxygen consumption during physical work, as well as 6
articles on determination of the pulse volume of humans as
analyzed by inhalation of ethyl iodide.1117
Having achieved recognition for his medical accomplishments, Mobitz was invited in 1928 by Professor Hans
Eppinger, Jr, to join the faculty of the University of Freiburg,
where he remained for 15 years, becoming tenured in 1939.
Mobitz suffered from laryngeal tuberculosis, and there were
reservations about his health that led to quarrels with fellow

From the Department of Medicine (M.E.S., C.B.U.), Emory University, Atlanta, Ga; the Fuqua Heart Center of Atlanta at Piedmont Hospital (M.E.S.,
C.B.U.), Atlanta, Ga; and Heart Center Bremen (H.W.L.), Bremen, Germany.
Correspondence to Mark E. Silverman, MD, MACP, FRCP, 1968 Peachtree Rd NW, Atlanta, GA 30309. E-mail marksil@comcast.net
2004 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

DOI: 10.1161/01.CIR.0000140669.35049.34

1162
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Silverman et al
staff member Siegfried Josef Thannhauser. Mobitz was promoted to senior assistant physician in March 1934;
Thannhauser, who was 4 years older than Mobitz, opposed
the promotion. Thannhauser was dismissed from the Freiburg
clinic on April 17, 1934, and Mobitz became the head when
it was determined that he did not present a health risk. For
uncertain reasons, Mobitz was replaced within 10 days by
Otto Bickenbach, a leader of the National Socialist party in
Munich. In 1943, Mobitz left the University of Freiburg and
was appointed Director of the State Medical Clinic in
Magdeburg, where he stayed until 1945, when Germany was
occupied by the combined American, British, and Soviet
Union military forces. In 1946, he returned to the University
of Freiburg, where he remained employed until his death on
April 11, 1951, after a long illness, at age 61 years. His
medical publications after World War II included a study of
the differential diagnosis of lung infiltrates and new uses of
isotopes in medicine.18,19
Mobitz was a quiet, scholarly man with a delicate sense of
justice, considered to be an excellent clinician and investigator though burdened by chronic illness. His mind was crystal
clear and endowed with mathematical precision, which he
applied brilliantly to his study of cardiac arrhythmias and
conduction disturbances. In spite of his important medical
achievements and high intellect, he never received any major
honors or attained his highest goal, a chair at a German
Medical University. This may have been owing to his chronic
illness or because of his personality, which brought him into
conflict with his peers. Described as lonely and introverted
(he lived alone and never married), he had difficulty with
interpersonal relations. Despite a thorough search, a picture
of him could not be found.

Prior Observations on Second-Degree (Partial)

AV Block
Walter Gaskell, a physiologist experimenting between 1879
and 1883 at the Cambridge Physiological Laboratory in
England, removed a portion of the atrial muscle of a tortoise
and noted . . .if the block is more severe, then, instead of
every contraction passing the blocking point, only every
second contraction is able to pass.20 He called this rhythmic
phenomenon partial block, and he was the first to differentiate partial from complete block. (George J. Romanes,
working at the same time at Cambridge, was the first to use
the term block in studies observing the contraction movements of the jellyfish.) In 1899, 4 years before the introduction of the ECG by Willem Einthoven, Karel Wenckebach of
the Netherlands reported a patient with a recurrent irregular
pulse.21,22 His analysis of the patients radial pulse showed
the following characteristics: (1) there were repeated groupings of beats with pauses; (2) the length of the pauses was less
than twice the interval between the preceding beats; (3) the
interval between the first 2 pulses after the pause was longer
than the other pulse intervals; and (4) there were no
extrasystoles.
Frog experiment recordings from 1893, provided to
Wenckebach by Theodur Engelmann, his mentor, exhibited a
similar pattern, with the interval between atrial contraction
and ventricular contraction being shortest after a pause.

Woldemar Mobitz and Second-Degree AV Block

1163

Crediting Luigi Luciani of Italy as the first to describe this

recurrent pattern in a frog heart preparation in 1873, Wenckebach called this form of group beating Luciani periods.22,23 In 1906, with the added advantage of the recently
introduced ECG, Wenckebach documented that the PR intervals progressively lengthened before the dropped beat.24 His
unraveling of this ECG phenomenon subsequently became
known as Wenckebach periodicity. That same year, Ludwig Aschoff and Sunao Tawara in Marburg, Germany,
discovered the AV node, thereby providing the anatomic
substrate to the conduction abnormality described by
Wenckebach.25,26

Observations by Mobitz on Second-Degree

(Partial) AV Block
In 1924, Mobitz reported a 40-year-old woman with an
irregular cardiac rhythm whose ECG showed irregular atrial
activity, P waves with different morphologies, and variations
of the PR and RP intervals.1 His mathematical analysis
demonstrated that there was a systematic relation between
the length of the PR interval and the distance of the atrial
activation to the preceding ventricular beat [ie, the RP
interval]. . . The shorter the latter, the longer lasting is the
conduction [ie, the PR interval]. He stated that the ventricular beats with normal ECG complexes must be conducted
even though the conduction time varies between 0.12 and
0.31 sec. The corresponding preceding RP intervals varied
between 0.15 and 0.44 seconds. He continued, . . . the fact
that the conduction has different velocity or the latency has
different length . . . is based on different degrees of recovery
either in conductivity as measured in conduction velocity, or
reactivity measured as latency of that precise portion of the
heart to which the stimulus is being transmitted. Postulating
that there was variable anterograde AV conduction velocity
as a result of a variable recovery time of the AV node and
bundle, as initially described by Hermann Straub of Munich
in 1918, Mobitz showed that the speed of recovery during
diastole can be depicted as a steady curve like all analogous
phenomena in nature. He demonstrated this graphically by
plotting the curvilinear relationships of both anterograde and
retrograde conduction (Figure 1).
Mobitz believed that his insight into PR/RP reciprocity
could contribute to the understanding of periodicity of AV
block as described earlier by Wenckebach.1 He observed that
the PR interval and the following RP interval were constant
provided that the atrial rate remained unchanged. By graphing
the relationship of changing atrial rates to AV conduction, he
found that the PR interval lengthened as the atrial rate
increased (Table). The PR interval remained constant and
normal at a steady atrial rate of 105 bpm (Figure 2, graph A).
At a regular atrial rate of 154 bpm, he observed that the
[straight] line no longer intersects the curve. [Figure 2, graph
B.] This means that the atrium has exceeded the highest rate
which the Aschoff node can follow. Wenckebach periodicity
developed at an atrial rate of 154 bpm with increased dropped
systoles at 162 bpm (Figure 3, graph C) and at 176 bpm. At
projected atrial rates of 231 and 300 bpm, (Figure 3, graph
D), he surmised that greater degrees of AV block would
develop with 2-to-1 AV conduction. Modern atrial pacing

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Figure 1. Mobitzs theory of variable latency (PR interval is

related to preceding RP interval and results in a steady curve).
Numbers are in hundredths of a second; PR intervals are on ordinate; preceding RP intervals are on abscissa. Figure has been
lightly retouched for clarity. Reprinted from Figure 2 of Mobitz,1
with permission from Springer-Verlag. Springer-Verlag.

studies have shown that this is the usual response of the AV

node when it is challenged by a progressively increased atrial
pacing rate.

Classification by Mobitz of Second-Degree

(Partial) AV Block Into 2 Types
Mobitz classified Wenckebach periodicity as a type I form of
partial [AV] block, commenting that it had been produced
experimentally in animals with digitalis, strychnine, and
asphyxia and by cooling the cardiac ventricle. In humans, it
was reported to most commonly be due to digitalis intoxication. He noted that type I conduction impairment was reversible, and that human autopsy studies did not usually disclose
significant disease of the AV node or the bundle of His.
Mobitz also observed that the QRS duration is usually normal
with this type of AV block. Those kinds (type I) which we
interpret as purely functional impairments, normally do not
show [changing] ventricular complexes.
In the same paper, Mobitz also discussed the less common
but more serious form of AV block as first described by John
Hay of Liverpool, England, in 1906 and again later that year
by Wenckebach.24,27,28 Hay kymographically recorded simul-

taneous jugular venous and radial arterial pulses of a 65-yearold man with a slow pulse. He observed that the a-to-c
intervals of the jugular venous waves remained constant until
an a wave occurred that was not followed by the c wave or a
radial pulse. The pause was equal to 2 atrial pulse-wave
intervals.27,28
Mobitz termed this form of abnormal conduction type II
AV block (Figure 4) and noted the following features: (1)
normal, fixed PR intervals that were present independent of
the length of the preceding RP intervals; (2) random dropping
of ventricular complexes that occurred without prolongation
of the PR interval; (3) the pause resulting from the nonconducted P wave equaled 2 P-P intervals; and (4) the PR interval
did not change after a pause. He reviewed the medical
literature, commenting that type II AV block often progresses
to complete AV block and is associated with Stokes-Adams
attacks and death. From autopsy reports, Mobitz believed
that conduction disturbances of Type II are very likely an
expression of a structural injury to the bundle. He included
the AV node as a part of the His bundle. Although bundlebranch block was not recognized electrocardiographically in
humans until 1925,29 Mobitz described ventricular complexes
that suggested the presence of bundle-branch block in his
patients with type II AV block: (1) Quite unique was the
behavior of the ventricular complexes. They showed, although originating without exception from a supraventricular
source, multiform changes in shape. (2) In view of the
profound deviation from normal shape shown by the various
types of ventricular EKGs, larger territories involving several branches of the atrioventricular system must have been
affected. (3) The profound variety of ventricular complexes
in this case. . . suggesting a failing ventricular muscle.
Describing the 2 types of AV block, Mobitz observed that
daily clinical experiences teaches that in transient conduction disturbances apparently due to toxicitymost often, we
see them as a consequence of high-dose digitalization
exclusively those kinds of partial block are being observed,
which we can derive from our curve and call Type I. By way
of contrast, he stated, We recognize in Type II a structural

Prolongation of AV Conduction as Related to Increasing Atrial Rate (Calculated by Mobitz)

P-P
Atrial Rate,
Interval*
bpm

PR Interval After a Pause*

PR Interval Before
a Pause*

AV Conduction

57

105

13

1:1

42

149

16

1:1

40

150

39

154

13 with Wenckebach periodicity

25

10:9

37

162

13 with Wenckebach periodicity

23

5:4

34

176

13 with Wenckebach periodicity

28

4:3

30

200

13 with Wenckebach periodicity

23

3:2

28

214

13 with Wenckebach periodicity of 3:2 conduction

29

3:2; alternate 3:2/2:1

28

214

16

2:1

26

231

13

2:1

300

19

2:1

20

*In hundredths of a second.

No pause present at this P-P interval.
Atrial rate at which type I AV block develops.

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Silverman et al

Figure 2. Graphs A and B drawn by Mobitz illustrate the effect of

changing atrial rates on AV block as related to (1) his curves of
reciprocity of PR and preceding RP intervals and (2) tangential
straight lines with different P-P intervals. Curve is derived from his
40-year-old patient (see text) and is identical in Figures 1, 2, and 3.
The tangential straight lines of the PR and following RP intervals in
Figures 2 and 3 depict hypothetical regular atrial activity at various
rates. The sum of the PR and the following RP is constant due to
the regular atrial period. Tangential lines intersect ordinate and
abscissa at 45 degree angle relative to them. Beneath each graph
are laddergrams with 3 tiers drawn by Mobitz: [A] indicates atrial
tier showing P-P intervals; [AV], junctional tier showing PR intervals; and [V], ventricular tier showing R-R intervals. Numbers are in
hundredths of a second. On graphs, PR intervals are on ordinate,
RP intervals are on abscissa, and P-P intervals are on both coordinates. In graph A, P-P interval is 0.57 second; the 2 lines intersect
at PR interval of 0.13 second on ordinate and RP interval of 0.44
second on abscissa. Atrial rate is constant, and AV conduction is
1:1. In graph B, P-P interval on both coordinates decreases to
0.39 second. AV block develops as P-P interval decreases, corresponding to increase in atrial rate. Wenckebach periodicity is
present, and AV conduction is 10:9. Curve and tangential line
do not intersect, which indicates that increased atrial rate has
exceeded refractory period of AV node. To obtain shortest PR
interval, a line is dropped to the curve from the upper
abscissa at 0.39 second, the P-P interval. From this point,
Mobitz draws a stepwise rectangular line horizontally and
vertically connecting the curve and the [tangential] lines. Initial intersection point on line indicates PR interval of 0.13
second on ordinate. Further stepwise lines indicate subsequent PR intervals and ventricular intervals. If the stepwise
line does not cross the curve anymore, an omission in systole
follows. Mobitz then constructed laddergrams from graph
data, showing P-P intervals, AV conduction, and nonconducted beats. Figure has been lightly retouched for clarity.
Reprinted from Figure 8 and Figure 10 of Mobitz,1 with permission from Springer-Verlag. Springer-Verlag.

Woldemar Mobitz and Second-Degree AV Block

1165

Figure 3. In graphs C and D, drawn by Mobitz, P-P intervals

decrease to 0.37 second (C) and to 0.20 second (D), respectively. AV block increases as P-P intervals decrease, corresponding
to increase in atrial rates. Wenckebach periodicity is present in C,
and AV conduction is 5:4; AV block is greater than AV block of
Figure 2B. In D, AV block is greater still, with PR interval increased
to 0.19 second, and AV conduction is 2:1. See Figure 2 for explanations of graphs and laddergrams. Figure has been lightly
retouched for clarity. Reprinted from Figure 11 and Figure 16 of
Mobitz,1 with permission from Springer-Verlag. Springer-Verlag.

process affecting the cross-sectional area of the bundle as the

decisive element of the ventricular cessation.

Current Understanding of Second-Degree

AV Block
Since the 1924 article by Mobitz, studies have confirmed the
pathological and prognostic differences between type I and
type II AV block.30,31 Type I AV block has been associated
with digitalis, inferior myocardial infarction, heightened venous tone (as seen in sleep, vomiting, and highly trained
athletes), sclerodegenerative disease affecting the AV node,
congenital AV block, and myocarditis.32 His bundle studies
have localized the site of the conduction block to the AV
nodal or upper junctional region (supra His) as manifested by

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Figure 4. Laddergram drawn by Mobitz showing Cessation of

systole as in Type II (despite preceding uninterrupted conduction,
no stepwise prolongation in conduction time prior to the cessation). High-grade AV block is also present, with 2 consecutive
nonconducted P waves. Numbers are in hundredths of a second;
P-P interval of 75 corresponds to atrial rate of 80 bpm. Figure has
been lightly retouched for clarity. Reprinted from Figure 19 of
Mobitz,1 with permission from Springer-Verlag. Springer-Verlag.

a prolongation of the A-H interval. The block is usually

reversible and may or may not require permanent pacing,
depending on the presence of symptoms. The ECG criteria for
type I AV block have not changed significantly from Wenckebachs original observations, although frequent variations
are known.33,34 These include (1) sequences with a high AV
ratio; (2) frequently changing AV ratios; (3) variations in
sinus rate; (4) presence of atrial echoes, concealed impulses,
or an accelerated junctional rhythm; (5) a widening of the
final cycle before the pause due to a large increment in AV
nodal transit time preceding the dropped beat; (6) effects of
abrupt changes in autonomic tone; (7) incremental changes in
conduction too small to measure at the usual recording speed
of 25 mm/s; and (8) AV block at more than 1 level.
As originally pointed out by Mobitz, type II AV block
indicates permanent structural damage to the bundle branches
and is associated with extensive anterior myocardial infarction or widespread sclerodegenerative conduction disease.
The location of type II AV block is below the His bundle
(infranodal), as demonstrated by a prolonged H-V interval.
High-degree or complete AV block can be anticipated, and
permanent pacing is usually indicated to prevent dizziness,
syncope, and death.35 The criteria initially developed by
Mobitz were redefined in 1956,36 which led to some confusion, as discussed by Barold and Hayes.37 As they point out,
Mobitz also included higher degrees of AV block, ie, 3-to-1
and 4-to-1 conduction, in addition to a single dropped P wave
followed by a conducted P wave with a normal PR interval.
The current definition of type II AV block includes the
following: (1) The sinus rate (or the P-P interval) is constant,
and there are at least 2 consecutively conducted P waves. (2)
The PR interval may be normal or prolonged but remains
constant. (3) There is a single nonconducted P wave associated with a constant PR interval before and after the blocked
impulse. (4) The QRS interval is usually prolonged, although
it can be normal. (5) The site of the AV block is infranodal.
ECGs that display a fixed 2:1 AV block cannot be easily
classified; Wenckebach periodicity is suspected when the
conducted P wave is associated with a borderline or prolonged PR interval and the QRS complex is narrow or when
typical 3:2 AV conduction is also present. ECGs showing 3:1
and 4:1 or greater conduction ratios are now properly classified as high-grade AV block.
In 1968, Richard Langendorf and Alfred Pick wrote an
editorial in Circulation as a plea for clinical distinction
between type I and type II A-V block, especially in recent
myocardial infarction.31 They credited Mobitz for recognizing the functional nature of type I block and the organic

nature of type II block, pointing out that the distinction had

become blurred over the years. This editorial by highly
respected electrocardiographers served to reintroduce and
popularize the Mobitz classification. This was further sanctioned by a committee that revised the nomenclature and
concepts of AV and intraventricular conduction in 1970 (not
published until 1973), which was then redefined in 1978 by
the World Health Organization. This classification of seconddegree AV block, initially proposed by Mobitz, has been
accepted and widely applied since that time.38,39 His important contribution endures as a helpful eponym, and he is also
honored by the German Society for Cardiology, which
awards The Woldemar Mobitz Research Prize for studies
concerning cardiac arrhythmias.

Acknowledgments
We thank Professor Berndt Lderitz, University of Bonn, Bonn,
Germany, Professor Dr H. Lllgen and Astrid Kohlstdt-Klapper,
Ruhr University of Bochum, Bad Oeynhausen, Germany, and Dr
Edith Schipper, Munich, Germany, for their kind assistance; Hiltraud
Finger Culpepper, BA, of Warner Robins, Ga, for German translations and helpful advice; and the librarians of the Sauls Memorial
Library of Piedmont Hospital, Atlanta, Ga.

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zwischen Vorhof und Kammer des menschlichen Herzens [On the partial
block of impulse conduction between atrium and ventricle of human
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2. Vaughn Williams EM. Syndrome der Kardiologie und ihre Schpfer.
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12. Mobitz W. Die klinische Diagnose der schweren durch eine isolierte
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Woldemar Mobitz and His 1924 Classification of Second-Degree Atrioventricular Block

Mark E. Silverman, Charles B. Upshaw, Jr and Helmut W. Lange
Circulation. 2004;110:1162-1167
doi: 10.1161/01.CIR.0000140669.35049.34
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