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CHAPTER 2 THE WAR ON HEART DISEASE AND THE INVENTION OF CARDIAC PACING As a doctor, Paul M. Zoll had a two-track career: he did laboratory research at the Beth Israel Hospital in Boston and he also maintained a large general practice, even making house calls. The medical world took notice when Zoll announced in 1952 that he had successfully kept a patient alive through numerous episodes of ventricular standstill using a bedside device that delivered electrical pulses to the heart.1 Zoll’s external pacemaker had imperfections, but these lacks inspired heart researchers to improve on the original design—and put cardiac pacing on a path of continuous technological change. By the end of the 1950s, pioneer open-heart surgeons and a handful of tiny manufacturing firms were also paying attention to cardiac pacing. These new participants began to reshape the pacemaker and redefine its uses; in the process, they drove pacing a considerable distance from what Paul Zoll had originally had in mind. Even at this early point in its history, ‘‘cardiac pacing’’ had a quicksilver quality: the meaning of terms like pacing and pacemaker began to undergo a process of redefinition that has never yet stopped. A NEW ERA IN HEART MEDICINE Medical thinking about diseases of the heart changed rapidly during the 1930s and 1940s. Electrostimulation of the heart, largely ignored in the early 1930s, reemerged in an era of intensified research and high expectations for new treatments. The idea of attacking acute maladies of the heart by getting inside the heart and putting instruments and devices into it came into favor after World War II.2 This shift in outlook occurred in a number of fields of heart medicine: in techniques of diagnosis, in surgery of the heart, and in the treatment of rhythm disturbances like fibrillation and heart block. The announcements of laboratory discoveries or successful new procedures in one field of heart medicine aided and challenged researchers in every related field by answering some questions, raising still more, and conjuring new possibilities. The momentum of research and discovery depended, in HEART DISEASE AND THE INVENTION OF PACING 37 turn, on funding from the federal government and private sources. The policy of encouraging medical research expressed ordinary Americans’ high hopes and enlarged expectations; these were nourished throughout the 1940s and 1950s by the incontestable achievements of wartime medicine and by a stream of popular accounts about medical breakthroughs. The new postwar treatments required new facilities and complex equipment that could only be maintained and put to use in the hospital. As mortality from childhood infectious diseases declined rapidly in the 1940s, hospitals began to redefine themselves as care centers for heart disease, stroke, and cancer—diseases of middle age that, by 1945, had already become the leading causes of death in the United States. In this context of hospital-based coronary care, the modern invention of cardiac pacing took place. Paul Zoll’s external pacemaker of 1952 did not invade the human body, but later pacemakers certainly did. By an interesting irony, the pioneer of clinical cardiac pacing specialized in internal medicine rather than surgery, always viewed implantation with unease, and eventually revealed himself as a man of deeply conservative instincts.3 Albert Hyman had not invented his pacemaker to treat heart block with Stokes-Adams attacks but to restart healthy hearts that had stopped because of injury from a fall or an electric shock. The background scientific knowledge needed to build and use Hyman’s invention had been minimally adequate by the 1920s. But beginning in the late 1930s, specialists in cardiac electrophysiology made important discoveries about the behavior of the heart during a Stokes-Adams attack.4 Around the same time, improved knowledge of ventricular fibrillation led to new attempts to terminate this lethal arrhythmia with electric shocks. From a somewhat bizarre practice associated with eighteenth-century Leyden jars and nineteenth-century quackery, electricity came to hold a place, admittedly still tenuous, as a possible treatment for heart-rhythm disorders. These developments were crucial for Zoll’s invention of the external pacemaker in 1952 and the diffusion of pacing into U.S. hospitals. NEW THINKING ABOUT STOKES-ADAMS ATTACKS In the decade after Hyman’s pacemaker, cardiologists refined their ideas of what happened in a Stokes-Adams attack, although today’s understanding of the underlying causes did not emerge until the 1960s. A group in London led by John Parkinson (1885-1976) proposed in 1941...

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