Pacing the Heart: Growth and Redefinition of a Medical Technology, 1952–1975

Abstract

Pacing the Heart: Growth and Redefinition of a Medical Technology, 1952-1975 KIRK JEFFREY A cardiac pacemaker delivers electrical impulses to the heart so as to coordinate the pumping action of the upper and lower chambers (atria and ventricles) and speed the heart up from standstill or an unduly slow rate.1 Between 1952 and the mid-1970s, the practice of cardiac pacing grew from “promising report” to “standard proce­ dure” and then kept on growing.2 The earliest devices stimulated the heart from outside the patient’s body, but implanted pacemakers made their appearance at the end of the 1950s. The number of pa­ tients relying on pacemakers in the United States expanded to more than 150,000 by 1975.3 In the 1990s, estimating conservatively, 500,000—600,000 Americans carry pacemakers; more than 110,000 pacemakers are implanted annually in the United States by about Dr. Jeffrey is professor of history at Carleton College. He thanks Carleton College for research support through the Faculty Development Endowment. Professor Clifford E. Clark, Jr., and the Technology and Culture referees offered helpful criticism. 1 Its focus on slow heart rates (bradycardia, rates below sixty beats per minute) distin­ guishes the pacemaker from devices that use electrical shocks to halt unduly rapid heart rates (tachycardia) and random electrical behavior with consequent loss of orga­ nized beats (fibrillation). My definition of the pacemaker is time bound: as Victor Parsonnet and Alan D. Bernstein have observed, “The definition of a pacemaker is imprecise, because now that word is applied to electrical stimulators that treat either slow or fast rhythms. In this computer age, a ‘pacemaker’ is essentially an implanted microcomputer that can be adapted noninvasively to any type of stimulation or sensing that is required.” See Victor Parsonnet and Alan D. Bernstein, “Cardiac Pacing after 25 Years: A Practical Approach to Growing Complexity,” in Modem Cardiac Pacing, ed. S. Serge Barold (Mount Kisco, N.Y., 1985), pp. 959-72, at 959. Cardiac electrostim­ ulation is employed diagnostically (e.g., in an electrophysiology workup) as well as therapeutically, but this article limits its scope to therapeutic uses of pacing. 2John B. McKinlay, “From ‘Promising Report’ to ‘Standard Procedure’: Seven Stages in the Career of a Medical Innovation,” Milbank Quarterly 59 (1981): 374-411. 3Victor Parsonnet and Marjorie Manhardt, “Permanent Pacing of the Heart: 1952 to 1976,” American Journal of Cardiology 39 (1977): 250—56.© 1995 by the Society for the History of Technology. All rights reserved. 0040-165X/95/3603-0004$01.00 583 584 Kirk Jeffrey 8,000 physicians.4 Pacing-related hardware, facilities, and services have cost Medicare well over $1 billion annually in recent years.5 A symbol in its early years of the fabulous promise of medical technology, pacing in the early 1980s became a lightning rod for doubts and concerns about the American system of health care. To­ day, in a time of national debate about the cost and distribution of health care, a review of a success story involving high-tech medicine may help us understand one important underlying dynamic in the health-care system: the reciprocal and interactive process by which technological change and new concepts of disease stimulate each other, thereby creating a powerful momentum for growth. A technological device draws us toward the outlook and aspirations of its sponsors, the groups that introduced it and shape its ongoing development and social meaning.6 Hence, this article speaks ofpacing 4 Because no national pacemaker registry existed during the period covered by this article, these and other figures must be taken as approximations. Here I follow the estimates of Parsonnet and his associates, who have conducted national surveys of pacing practices every few years since 1971: Alan D. Bernstein and Victor Parsonnet, “Survey of Cardiac Pacing in the United States in 1989,” AmericanJournal ofCardiology 69 (1992): 331-38. Their figure of 110,500 pacemakers implanted in 1989 (apparently misprinted as 117,000) included 89,445 primary (first-time) implantations and 21,055 replacements. But another set of observers suggests a figure of 250,000 implantations per year: Nicholas J. Stamato et al., “Permanent Pacemaker Implantation in the Car­ diac Catheterization Laboratory versus the Operating Room,” PACE (Pacing...