Publications speculating on the bio-electric nature of the cardiovascular system appeared. The first reference to external electrical stimulation of the heart in the Registers of the Royal Human Society of London. The physician was Squires and the patient was a young girl. The Danish physicist Nickolev Abildgaard conducted the first studies on the effects of electrical energy when applied to the body. He placed electrodes on the sides of a hen's head and applied an electric discharge which caused it to fall dead.
Application of electrodes over various parts of the hen's body failed to reanimate the bird, until they were placed across the chest. In this position they presumably defibrillated the heart after which the hen staggered onto its feet and walked away Fig.
Luigi Galvani Fig. He published the experimental findings of electrical phenomena in frog muscles and frog hearts making a fundamental contribution to modern cardiac electrophysiology.
There was general agreement that electricity had a pronounced effect on the heart Fig. Alexander von Humboldt found a dead bird in his garden and placed a blade of zinc in the beak and a shaft of silver into the rectum.
An electric shock caused the bird to flap its wings and attempt to walk. He also tried the experiment on himself with unpleasant consequences. Rudimentary forms of electrical stimulation were used by physicians sporadically to treat cardiac disease in numerous ways without any standardisation. The crude technology was however far ahead of the understanding of heart disease and a very wide range of effects were documented. The Italian physicist, Alessandro Volta Fig. For the first time, electricity could be produced by means other than through electrostatic machines.
He also gave his name to one of the basic physical units of electricity: the Volt, unit of electromotive force. Marie Francois Xavier Bichat Fig. They had no shortage of experimental material during the French Revolution.
Aldini - Fig. Duchenne de Boulogne - , successfully resuscitated a child who had drowned by attaching one electrode to a leg while rhythmically tapping the precordium with another electrode. A golden opportunity for clinical and scientific experimentation arose in A year old female patient arrived in the clinic of Hugo Von Ziemssen Fig. A chest tumour had been excised together with the left anterior part of her thoracic wall thus exposing her heart, which could be seen through a thin layer of skin.
Von Ziemssen stimulated her heart using electric current and could change her heart rate at will. The recordings Fig. Medicine had its first integrated theory of cardiac pacing yet another 20 to 30 years had to elapse before this theory resulted in effective therapy. In particular it had to await significant further medical discoveries cardiac structure, physiology and conduction pathways and technical progress the electrocardiogram, lab stimulators.
Marcus Gerbazius - , a Slovenian physician, described the symptoms of bradycardia due to complete atrio-ventricular block. The Irish surgeon Robert Adams - described a patient with repeated apoplectic attacks and a slow pulse.
He was the first to realise that cerebral symptoms may be caused by cardiac rhythm disorders. William Stokes - Fig. Karel Frederik Wenckebach Fig. John Hay Fig. He utilised simultaneous tracings from the radial artery and the jugular venous pulse. Woldemar Mobitz provided the classification of second degree atrio-ventricular blocks utilising the electrocardiogram, hence documenting Wenckebach's and Hay's findings.
Over the late 's — early 's, cardiology witnessed a great technological breakthrough that was to have a major effect on the understanding of arrhythmias and hence on the development of specific therapy including pacing: the invention of the electrocardiograph. Mary's Hospital, London, recorded the first human surface electrocardiogram using the Lippmann capillary electrometer to deflect a light beam Fig. Alexander Muirhead may have been the first to record a human electrocardiogram but Waller was the first to do so in a clinico-physiologic setting, publishing reports and acquiring extensive experience.
The clinical significance of the electrocardiogram Fig. It can at most be of rare and occasional use to afford a record of some rare anomaly of cardiac action.
He would often use Jimmie as the subject when he demonstrated his method at lectures by dipping his legs in pots of saline, which served as the electrodes Fig.
Waller is said to have been quite informal and loved entertaining and dashing around with the newly invented motor car. Another physiologist, Willem Einthoven — Fig. Einthoven recorded the first human electrocardiogram in Europe on April 11 th , using the Lippmann capillary electrometer. In , he made the first direct recording of the true human electrocardiogram using a modified string galvanometer Fig. This slot allows only a point of the shadow to pass through to a moving photographic plate or film, on which the point of shadow writes in a continuous curve.
The photographic material was later developed to produce the image Fig. The signals were obtained from the two arms and left leg modern Lead I. To enhance conduction, hands and foot were bathed in saline solution with the tubs wired to the input of the electrocardiograph Fig. It is interesting to note that the signals were collected from a patient in the University Hospital and transmitted to the physiology lab quite a good distance away where the actual recording was made.
An early example of telemedicine! There was wide scepticism by the contemporary scientific community against his methods. But Einthoven continued publishing and in described the Einthoven triangle as the basis for calculations of electrocardiograms and introduced the bipolar electrode system. Classic rhythms were obtained and published.
Einthoven was formal, methodical and demanded technical perfection. He was keen to apply the modality to clinical problems. In , he was awarded the Nobel Prize for Physiology and Medicine for his electrocardiographic work in developing the string galvanometer.
The extremity bipolar electrode system the standard electrocardiogram lead system was expanded in by F. Wilson who introduced the unipolar chest wall electrodes. Goldberger introduced the unipolar amplified augmented extremity leads. The lead electrocardiogram as we know it today was now complete!
Several manufacturers to produced commercial versions of the electrocardiograph Fig. The Cambridge Scientific Instrument Co. The string galvanometer for electrocardiography was superceded by direct writing equipment after the Second World War.
Electrocardiography was of paramount importance in the understanding of cardiac rhythm and hence in the further development of pacing. Credit for the first external cardiac pacemaker has been shared by two doctors: the Australian anaesthesiologist Mark Lidwell and the American physiologist Albert Hyman.
Working independently on opposite sides of the world they developed the first cardiac pacing machines. Lidwell's device ran on alternating current and required a needle to be inserted into the patient's ventricle. In he used intermittent electrical stimulation of the heart to save the life of a child born in cardiac arrest.
The child apparently recovered completely and survived but not much else is known of Lidwell's efforts. Initially this therapy consisted of the intra-cardiac injection of stimulant drugs such as epinephrine although he soon realised that it was not really the drug that restarted the heart but the needle that set up an action current of injury as it punctured the cardiac wall.
Hyman's device, described in Fig. The clockwork drove a DC current generator whose electrical impulses were directed into the patient's right atrium through a bipolar needle electrode introduced via an intercostal space Fig.
Pacing could be delivered at rates of 30, 60 or per minute. None of the three models of this device build in the 's survives today and only two photos can be traced. He faced considerable opposition, including that of the Journal of the American Medical Association and did not report his experiments. No one agreed to manufacture it locally although a battery-operated version lost to history was eventually manufactured by Siemens-Halske in Germany and their American subsidiary Adlanco Fig.
The Hymanotor, as it was called, was tested but found ineffective and again unfavourably reported upon. During the Second World War, Hyman unsuccessfully urged the US Navy to support his device for use in resuscitation of dying servicemen. It is important to note that Hyman intended the pacemaker to restore a normal heartbeat in patients whose heart had stopped accidentally or in stillborn infants rather than in those with heart block.
In the mid's, the connection between Stokes-Adams disease and pacing had not yet been made. Mains-powered pacemakers were developed in the early 's and were large bulky boxes filled with vacuum tubes that could not of course be implanted. They had to be wheeled around on carts and plugged into wall mains socket outlets to obtain their alternating current power. They were portable only in name since they could only go as far as the nearest electrical outlet!
Re-warming could not however restore cardiac contraction sufficiently rapidly and so the surgeons started experiments with sino-atrial node stimulation. In , during an experimental operation on a dog, the heart suddenly stopped. All four chambers of the heart responded. Further pokes clearly indicated that the heart was beating normally with good blood pressure.
During the 's and early 50's the principle device available to generate a variety of electrical impulses, potentially capable of stimulating the heart was a physiological stimulator manufactured by Grass Manufacturing Co for clinical and physiology lab application Fig. It used a thyratron rectifier tube to convert alternating current into direct current suitable for stimulation of biologic tissue. The stimulation rate, voltage output and pulse width could be varied monophasic rectangular pulse of ms duration.
John Hopps Fig. It was an external unit driven by vacuum tubes. The electrical impulses were transmitted via a bipolar catheter electrode to the atria using a transvenous approach.
Atrial pacing was readily achieved and heart rate could be controlled with no uncomfortable chest wall contractions Fig. Paul Zoll Fig. He had read the work done by Callaghan, Bigelow and Hopps and developed an external tabletop pacemaker that was successfully applied to the treatment of heart block Fig.
The electrodyne PM pacemaker, designed by Zoll, comprised an electrocardiograph to monitor the cardiac rhythm and an electric pulse generator to pace the heart. The pulse generator was a modification of the electric stimulator used in physiology laboratories. It delivered periodic electric impulses at 2 ms pulse width and 50 to volts alternating current pulse amplitude through a pair of 3 cm 2 metal electrodes strapped to the patient's chest directly over the heart.
The electrodes irritated the skin and the patients of course found the repeated electric shocks painful. The mains-powered unit was bulky and heavy and was carried on a cart. It could only go as far as the extension cord would allow Fig. In , he reported on two patients suffering from recurring prolonged ventricular standstill whom he treated with this external device Fig. In St. At St. George's, Leatham asked Davies to develop the first demand circuit device which was published in This mains-powered device stimulated the heart through the intact chest wall utilising volts and was commercially manufactured by Firth-Cleveland in the UK.
The commercial version contained several modifications: duration of asystole permitted, sensitivity controls to sense the electrocardiogram, two output ranges and a battery for independent operation.
These events had far-reaching consequences and opened up the field to the future. Earl E. Bakken, electrical engineer, TV repairman and co-founder of Medtronic Inc. Bakken Fig. The company had led a precarious existence as a repair service for hospital electrical equipment and regional distributor for other manufacturers. They would build new equipment on order or customise standard instruments for laboratory or clinical researchers.
They would hang around hospital surgical suites setting up equipment, training personnel in its use and troubleshooting and repairing it as necessary. Meanwhile they forged working relationships with physicians and their staff. Walton Lillehei Fig. Techniques had been developed to enter the heart and correct congenital defects while the circulation was supported.
By , Lillehei had performed over open-heart operations on young adults and children. This rapidly evolving field of open heart surgery was to be a major driving force towards the development of cardiac pacing. Despite successful repair of the congenital defect, about 1 patient in 10 developed post-operative complete heart block due to damage of the conducting system while the surgical repair was being performed.
Stimulant drugs such as adrenaline, atropine, or the newly developed isoprenaline, were helpful in the short-term but proved disappointing over a longer time frame and could not prevent sudden recurrence of heart block. Another solution had to be found! It was thought that temporary rhythm support via pacing would keep the patient alive until recovery of the conducting system occurred. The technology developed by Zoll was clearly inappropriate as the high voltage pacing stimuli delivered trans-thoracically would be far too traumatic on these young children.
The physiologist John Johnson proposed the utilisation of the Grass stimulator that was used in the physiology labs to activate hearts. After several experiments, Vincent Gott and William Weirich concluded that a cardiac rhythm could be restored in animal hearts in which heart block had been surgically created by means of a wire inserted into the wall of the right ventricle and connected to the external stimulator.
Low voltage pulses at the desired rate could easily stimulate these hearts. Lillehei and his co-workers developed the myocardial wire: a multi-stranded, braided stainless steel wire in a Teflon sleeve Fig. One end of this was implanted directly into the myocardium and the other end was exteriorised via a stab incision and connected to the physiology lab stimulator. An indifferent electrode was buried under the skin to complete the circuit. Effective pacing needed only 1. There was no rejection and no damage to the beating heart and the wire could be removed easily by tugging once normal conduction resumed.
The first myocardial wire was implanted on the 30 th January in a 3-year old girl in whom heart block had complicated the repair of Fallot's tetralogy. Pacing was successful and the little girl soon regained sinus rhythm and survived. Principal Investigators: William Chardack, M.
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Accessed 28 October
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