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Machines in Our Hearts: The Cardiac Pacemaker, the Implantable Defibrillator, and American Health Care. By Kirk Jeffrey. Baltimore: Johns Hopkins University Press, 2001. Pp. xiii+370. $48.
Although estimates vary, it is possible that in the United States 250,000 people had pacemakers or similar machines implanted in their hearts during the year 1997. By then the pacing industry was worth over a billion dollars. Kirk Jeffrey's fascinating book describes the history and technology of pacing from its humble beginnings to the far-from-humble enterprise it has become.
Pacemakers are implanted when the heart fails to beat in a normal rhythm or at a suitable rate. Cardiac malfunction is most commonly caused by a block in impulse transmission between the atria and the ventricles. The consequent failure of the heart to deliver sufficient quantities of blood can result in anything from fainting attacks to death. Jeffrey clearly explains how the sort of technologies we use to diagnose and manage cardiac disturbances are related to how we think of the heart. In the nineteenth century, pacemakers were, in a sense, unthinkable. Doctors mainly conceived of the heart in terms of anatomy. In the early twentieth century, drawing on physiology, clinicians began to think about the heart more in terms of its function.
They invented bedside devices that were noninterventive variants of machines used in experiments on animals. One of the most valuable was the electrocardiograph, which mapped out the heart's electrical pathways. Once this could be done, artificially stimulating or inhibiting those pathways became thinkable. Such technologies were part of broader social changes within the medical profession—for one, the creation of specialist [End Page 163] disciplines. Cardiologists, a new breed in the early twentieth century, cornered the market in heart disease.
Though conceptualized prior to World War II, working pacemakers were not developed until after 1945. Jeffrey largely confines his narrative to the American context, observing that postwar optimism in the United States gave rise to a belief that "through large organizations such as government and corporate labs and academic medical centers, teams of researchers could develop new technologies and treatments that would drastically improve people's health" (p. 46). The heart, once a no-go area, gradually became the focus of radical therapeutic intervention.
Physicians, sometimes in association with hospital engineers, initially developed bulky external devices delivering painful shocks and considered valuable only until the heart could, if possible, resume normal function. This concept changed in the aggressive surgical culture of the 1950s, the lead being taken in a few scattered centers by surgeons working with hospital engineers or sometimes with small medical manufacturing companies. Pacemakers were reconceptualized as machines that could be implanted in the chest, a surgical operation requiring considerable skill. Pacemaker technology and its social relations during this period largely partook of an older heroic approach. Many surgeons who implanted pacemakers seemed to take little interest in the devices after that: wires fractured, power sources failed, patients died.
Eventually this situation was transformed by two developments. The first was a transvenous approach by means of which a catheter could be inserted into a vein in the neck and gently nudged into the heart, after which a small battery could be implanted in the chest wall. This required no surgical heroics and gradually cardiologists took over pacemaker management as surgeons moved on to more adventurous things. Cardiologists seemed more concerned about the long-term management of patients, and in the 1970s and 1980s rigorous follow-up clinics were created. The second development was the industrialization of manufacture. Medicare money poured into technologies of all sorts. Companies made huge profits. Salespeople were accused of wining and dining physicians far in excess of ethical propriety, and physicians were in turn accused of accepting bribes. Inevitably, the government and the insurance companies became concerned about costs, and hospitals had to become more selective in choosing technologies.
The pacemaker, Jeffrey reminds us, was not some inert device to be prescribed when needed; rather, need...