The evolution of the pacemaker.

The evolution of the pacemaker device provides evidence of a truly international achievement which began around the turn of the 20th Century.   It is a testament to the persistence and commitment not only of the inventors and doctors who made the device possible, but also to the patients who were the guinea pigs for the initially cumbersome devices.  Frankly, I do not think I possess the fortitude that was demonstrated by the first patients, nor do I think I could have tolerated some of their challenges.

I found a number of items on websites providing timelines for the development and Implantation of the first pacemaker, such as medical journals and even obituaries.  The information below was gleaned from these sources, including items listed on a timeline found in the Daily Mail obituary for Wilson Greatbatch.  The side comments throughout the post, of course, are mine.
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In 1899 J.A. McWilliam reported to the British Medical Journal about experiments where he had used an electrical impulse on a human heart in asystole to cause a ventricular contraction.  He also reported that a 'heartbeat' could be evoked by impulses applied at spacings equal to 60-70 beats per minute.  (For the record, it appears that the term “in asystole” means the heart is in cardiac arrest). 

In 1926, Dr. Mark C. Lidwell of the Royal Prince Alfred Hospital of Sydney, Australia, and Edgar H Booth of the University of Sydney, constructed a portable heart apparatus that could be 'plugged into a lighting point'.  This apparatus generated a variable rate of 80 to 120 pulses per minute.

In 1932 Albert Hyman, a physiologist in the United States coined the term 'artificial pacemaker', to describe his electro-mechanical instrument.  The instrument was powered by a spring-wound hand-cranked motor.  (I realize that this was an advance in pacemaker technology, but it does bring to mind the image of a pacemaker device that is powered by a gerbil on a treadmill!) 

The next pacemaker contributor comes from what seems to me to be a non-medical background.  John Hopps was a Canadian engineer who studied the use of radio frequency reheating for pasteurizing beer in Ottawa in the 1940s. He was devoted to this project.  According to the British Columbia Medical Journal, Hopps was rather annoyed when he was assigned to assist cardiac surgeon Wilfred Bigelow and his research fellow John Callaghan at the Banting Institute. 

Bigelow and Callaghan were using hypothermia to slow the heart down enough to enable open-heart surgery.  Unfortunately, when cooled below a certain temperature, the perfectly functional heart became immobile due to lack of cardiac depolarization (okay – I don’t know what this term means but it sounds serious).  Bigelow’s team could not figure out how to induce cardiac contraction during hypothermia.  This is where Hopps provided some great assistance.  He observed that an electrical impulse would cause the heart to contract and that repetitive stimuli, (or what is now referred to as pacing), would allow this to occur over a prolonged time.

Hopps and others went on to refine the process for pacemaker-induced cardiac stimulation.  Hopps used the information he learned from these initial experiments, as he designed and built the first pacemaker prototype, which looked like a small table radio.  It measured 30 cm in length, used vacuum tubes to generate pulses, and was powered by a 60-Hz household current.   (Does the image of a Roomba robot rolling a vacuum through the heart chambers come to mind?)

Hopps also developed transvenous catheter electrodes, which could be passed through the external jugular vein and eliminate the need to open the chest for heart stimulation. These same catheter electrodes continue to be used in today’s modern implantable versions. 

Next in pacemaker history is a man named Wilson Greatbatch.  According to his obituary in the New York Times, Wilson Greatbatch, was a professed “humble tinkerer” who, working in his barn in 1958, designed the first practical implantable pacemaker.  His efforts to improve the pacemaker, as described in the Daily Mail, were perhaps the result of a lucky break:

“Like all great inventions, Mr Greatbatch's pacemaker came about by a happy accident.  While attempting to build a heart rhythm recording device in 1956, he installed a wrong-sized resistor into the circuitry - and found that it emitted regular electrical pulses. *** But there was a catch.  The equipment of the day was too large to make an implantable pacemaker.  So, Greatbatch spent the next two years trying to reduce the size of equipment and make it safe from bodily fluids.*** On May 7, 1958, doctors at the Veterans Administration hospital in Buffalo demonstrated that a version he had created, of just two cubic inches, could take control of a dog’s heartbeat.  The same year, 43-year-old Arne Larsson became the first human to receive an implantable pacemaker in Sweden.”
 
So who is Arne Larsson and where did his pacemaker come from?  According to an obituary in the New York Times, In 1958 Mr. Larsson was a 43-year-old man who had suffered from a viral infection that caused his heart to beat as slowly as 28 beats per minute.  He would suffer fainting spells and those around him would thump on his chest 20 – 30 times a day to revive him. 

(I have to stop the account of the history of the pacemaker for a moment.  I can’t imagine having to have my family, friends and medical team on standby throughout the day to jump start me with thumps to the chest.  I’m not sure that I would have been able to endure this.  At the very least, I would have had a very colorful chest because I bruise at the drop of a hat.  I also recall seeing a trivia fact that the stethoscope was developed to avoid the rather intrusive practice of the doctor putting his or her ear against the patient’s chest to hear the heartbeat.  Well I don’t know about you, but it seems to me that thumping someone on the chest 20 – 30 times a day is the epitome of intrusive!) 

Clearly Mr. Larsson needed a permanent solution to his heart problem.  Unfortunately, the only pacemakers available at that time were just for temporary use.  Enter engineer Rune Elmqvist and Dr. Ake Senning who were experimenting with making a permanent pacemaker from silicone transistors.  Elmqvist and Senning did not think the device was ready for prime time.  Despite their hesitation, Mrs. Larsson begged them to make one for her husband.  I edited this post on Valentine’s Day, and to me, Mrs. Larsson's advocacy on behalf of her husband is a very touching example of true love.

As you have probably guessed, Mrs. Larsson’s pleas were successful.  Dr. Senning implanted a device about the size of a hockey puck in Larsson’s chest.  Eight hours later, the device failed.  The doctor implanted the only backup, one with batteries that had to be recharged every few hours. The pacemaker worked, on and off, for three years.  After that time, there were 25 more operations over the course of Larsson’s life to replace the pacemaker.  Each replacement was smaller, smarter, safer and more durable and versatile.

As the result of the pacemaker devices, Mr. Larsson was able to travel throughout the world supervising the repair of electrical systems aboard ships. Larsson outlived Elmqvist, who died in 1996, and Senning, who died in 2000. Larsson lived over 40 more years after the first implan, and he eventually underwent a total of 26 pacemaker replacement procedures, until his death in 2001 from skin cancer at the age of 86.  Since skin cancer is a disease unrelated to his heart, I think it is safe to conclude that Larsson’s experience with pacemakers was a resounding success.

As for Rune Elmqvist, I found interesting stories regarding his work on pacemakers.  Apparently at one point, Mr. Elmqvist developed a pacemaker that consisted of two transistors and was assembled in a mold of an empty British Kiwi shoe polish tin.  I am not making this up.  I saw it in a 2007 article in the Journal of the American Heart Association.  For someone like me who was born way before the dawn of the iPhone, I cannot help but think of kids in the 1950s and 1960s who made telephones out of tin cans and strings!

The reality is that if we didn’t have the resourcefulness and innovation of people like Greatbatch and Elmqvist and Hoppes, and I am sure many many others, there would be scores of people from 1958 till the present day who struggled with slow hearts and challenging lives.  Happily, struggles are not part of our lives.  We now have a fairly easy time with our pacemakers.  Implanting a pacemaker no longer requires the chest surgery that Mr. Larsson underwent.  It is a relatively short procedure that only involves an overnight hospital stay (absent extenuating circumstances). 

The most inconvenient aspect of the current pacemaker device is probably the monitoring system by the patient’s bedside and the eventual need for a new battery or device.  Some might think these are intrusions.  But I believe they are extremely small prices to pay to make sure the device is working and assuring that the device is earning it’s keep by pacing my heart.  It certainly beats being thumped on the chest throughout the day!  So thanks to all the people who have made my life, and that of many other heart patients, longer and much, much more tolerable.