WITHOUT ANIMALS: ADVANTAGES AND SAFETY OF CLINICAL RESEARCH
Henry Heimlich, MD.
Part 1 / Part 2The Heimlich Manoeuvre
Well, then, let's come to the Heimlich Manoeuvre for choking. There was great pressure to do animal experiments for this. But what we did was very simple. The manoeuvre is performed by pressing upward under the diaphragm. How did we prove it? Again, dogs were unnecessary! We put a tight-fitting mouthpiece in the subject's mouth, put a clip on the nose, attached the mouthpiece to an ordinary clinical respirometer, did the manoeuvre, and got flow charts from which we deduced the energy produced. We learned you can expel 215 litres of air per minute by doing the Heimlich Manoeuvre, pushing upward on the diaphragm and compressing the lungs. My associate, Dr. Edward Patrick, found that the energy produced by the Manoeuvre was sufficient to expel a choking object out of the mouth. It was as simple as that. We also know that the methods that were being used on choking victims - hitting on the back and putting a finger in the throat - were all driving the object tighter into the airway, whereas the flow of air resulting from the Heimlich Manoeuvre caused a choking object to always move towards the mouth, away from the lungs. But I have to tell you that for 35 to 40 years, doctors from the American Red Cross and Heart Association had been recommending putting a finger into the throat and using back-slaps on choking victims, and they weren't about to say they had been wrong all this time, even though all the medical literature said they were wrong. One of them took six humans and six baboons and anaesthetized them, and he said: "I put a piece of meat in their throats to test the Heimlich Manoeuvre and the other methods."And he said : "I tied a string to the meat to pull it out if it didn't work." Well, at least he gave the baboons and the human subjects even chances, but I'm sorry to say he also reported that one of the baboons had been fed before this was done and he vomited and aspirated and died. Totally useless!
We went through the other methods of doing the Manoeuvre that were obvious - no need to test them, except on people. If one can't reach around a choking person, then the rescuer places the choking person in the supine position (on the back) , which enables the rescuer to use his weight to perform the Manoeuvre. I'm going to take more time with this one because I think it's the perfect example of what we've heard this morning and what this meeting is about. I first described and published the Heimlich Manoeuvre in 1974, calling it "sub-diaphragmatic pressure". In three months it had saved enough lives that the editors of the Journal of the American Medical Association (JAMA) named it the "Heimlich Manoeuvre". I had published the method in a medical journal. Then I did something which at that time could have been considered unethical - I had the publisher notify the press of this procedure. Today, doctors in the States have advertisements in the newspapers, but at that time if your name was in the newspaper it was terrible. The purpose of the publicity was to discover whether it would be successful and not harm anybody. What was quoted in the newspaper was the same thing as in the scientific article: "We don't know if this method of pressing up under the diaphragm will work but your alternative is to let a person die when they choke or to slit open their throat on the spot and do a tracheotomy." It was thereby disseminated to millions of people - and that's the way a vaccine is tested - it was clinical research. The millions of people knew: "Either let 'em die or try this." And within a week, we started receiving reports resulting from these newspaper stories, of lives being saved with the Manoeuvre and those reports led the newspapers to say: "We have saved a life from our previous story". That's how the method became widely disseminated: another form of clinical research. We also got reports very shortly after the Heimlich Manoeuvre came out, within the first year, of the Manoeuvre saving drowning victims who had not recovered with the Red Cross/ Heart Association-recommended methods. They recommend doing mouth-to-mouth resuscitation as the first step in rescuing a drowning-victim. The reports we received were from top-notch "First Aid-ers". They said: "I did the Heimlich Manoeuvre and water from the lungs gushed out of the mouth and the person recovered." We finally got reports from the chief fire-surgeon of Washington, D.C., a fire-chief in Florida, authoritative people, showing that drowning victims were saved by the Heimlich Manoeuvre after mouth-to-mouth failed, by getting the water out of the lungs. I come back to the report we heard this morning. The typical thing was: "Well, those are anecdotal reports." If you want to belittle a report and say: "Go back and use animals," you say: "That is an anecdotal report." But it isn't anecdotal if it's the chief fire-surgeon of Washington, D.C., who's an advisor to the Red Cross on water safety. So we had to go on and collect more cases and look into why the Manoeuvre was saving lives, and what we found was that a mistake had been made in 1960, 30 years ago.
Prior to that time, the methods of saving lives were pressing on the lower back with the person lying out flat (called artificial respiration), rolling a person over a barrel, or draping a person over a horse. We now realize that each of these methods were crude Heimlich Manoeuvres. They were intermittently pushing up on the diaphragm. In 1960, the American Red Cross and American Heart Association came up with mouth-to-mouth resuscitation, and they said, "This is the best form of artificial respiration. This is the best way to get air into the lungs." That may have been true for heart attacks, but they forgot that the lungs of drowning victims are filled with water. And when the lungs are filled with water, you can blow all day and not get the air, the oxygen, down to the part of the lung where it will absorb into the bloodstream. We didn't have to do animal experiments. We didn't have to do expensive experiments. There's a logic in research. Again, as was mentioned this morning, you get the idea that is the solution and then you prove it. You've all done this experiment as children, I'm sure. You put a straw into a glass of fluid, and put your finger over the straw. Take the straw out of the fluid and the fluid remains in the straw, because as the fluid descends a little bit, it creates a vacuum above compared to the outside atmospheric pressure. That is why if a person has drowned or nearly drowned and you tilt their legs up, the water will not come out of the lungs. If you take that same straw with fluid in it and your finger covering one end and put the open end in your mouth, you can blow all day and the air is not going to get to your finger, or comparably to the lung. When you blow, you'll see the chest move, but your air is not getting into the lungs, just the water is moving. If you squeeze the straw, the fluid will come out. In the same way, if you do the Heimlich Manoeuvre and push up on the diaphragm, the fluid will come out of the lungs. That's why these people are recovering and why the Manoeuvre should be the first thing used to save a drowning victim. If they don't recover after the water stops flowing out of the lungs, then you can do mouth-to-mouth, but first you've got to squeeze the water out of the lungs.
You use the Heimlich Manoeuvre for drowning in the same supine position as for choking, with the victim lying on his or her back. Your hands are in the same position under the rib cage. For a choking victim, however, you leave the person's face as it falls naturally, face upward, because if you turn the head and there's a solid object in the throat, it can't get out of the twisted throat. For rescuing drowning persons, you turn the victim's head to the side so that the water that comes out of the lungs flows out of the mouth. I learned a lot this morning in finding out why people do animal experiments after clinical work has been completed. As I studied drownings, I found some terrible, terrible things.
I read to you from a paper by a Cleveland Clinic physician, published in 1987. It has long been known that sea-water drownings, if the person recovers, they have less lung-damage than after fresh-water drownings (fresh-water damages the lungs). So Dr. Orlowsky said, maybe if the tonicity of swimming-pool water could be altered to a solution less injurious to the lungs, improved survival of and ability to resuscitate near-drowning victims might result. He said, "We anaesthetized 33 mongrel dogs, then instilled the drowning fluid down the endotracheal tube using a hypotonic saline solution that would not inactivate or destroy surfactin and would move out into the alveoli." He said, "It would cost approximately $60.00 to convert an average 500,000 gallon swimming-pool to a .225% sodium chloride solution. However, the effects of the sodium chloride on metallic-pipe fittings, pumps and heaters would have to be addressed." Why not address the pumps and pipes before you drown 33 dogs? How ridiculous!
The following is from a paper by a Pittsburgh physician: "Resuscitation Following Fresh-water or Sea-water Aspiration". "Pilot experiments were performed on 13 unanaesthetized dogs whose lungs were flooded by pouring water through a funnel into a cuffed tracheostomy tube. In these well-oxygenated dogs, which were breathing normally, the lungs were flooded with sea-water and drained 60 seconds later. The dogs struggled, showed later some signs of pulmonary edema. Spontaneous recovery did not occur if flooding was continued until profound arterial hypotension had developed. Because of the "species variation", which you heard about from Dr. Gordon, we cannot tell whether the same pattern may occur in man. It is unlikely, however, that in man, breathing movements continue that long." After going through dozens of other dogs in the same study, and taking other people's studies, this is his conclusion: "These resuscitative data cannot simply be applied to man. They suggest, however, that resuscitative efforts in the rescuing of drowning victims must consist of more than just rescue breathing." If you look at these papers and many others, you'll find in the back of them references describing drownings of hundreds of dogs with similar ridiculous results!
This useless sacrificial research can be stopped if we use the press, which is very friendly. An article I wrote appeared in all the papers in Florida at the time when an anaesthesiologist at the University of Florida was preparing to drown 42 dogs in order to study the Heimlich Manoeuvre. This was AFTER the Manoeuvre had been approved for saving drowning victims by the Red Cross and American Heart Association, after many saves had been reported. These are some of the words I used:
"Firstly, let me state unequivocally, this experiment is unnecessary and it is cruel. Scientists are beholden to prevent unnecessary loss of life, both human and animal. To do otherwise is to jeopardize our right to do research."
Then, on February 12, the University of Florida Committee on Care and Use of Laboratory Animals (in the usual peer-review, with peers reviewing each other) approved the plan to drown the 42 dogs. After pressure came from animal-rights groups, suddenly the experiment didn't need 42 dogs to prove the research goal, it was reduced to 22 dogs, in order to test the use of the Heimlich Manoeuvre to remove water from the lungs of drowning victims. Why, then, were 42 dogs needed originally? Please note that the Committee does not address the question: "If the researchers are allowed to drown 42 dogs, will this produce significant results of value to human beings?" I made the following statement in the press:
- Drowning 42 dogs is unlike human accidental drownings and will not yield significant results for the following reasons: Dr. Modell's dogs are to be anaesthetized. People who drown are not anaesthetized. Anaesthesia diminishes the heart rate and depth of respiration and causes other physiological changes.
- It has not been explained how a dog's breathing and heartbeat will be arrested, as occurs in drowning.
- Dr. Modell intends to put water into the lungs and stomachs of dogs through a tube. People, when drowning, cough, gasp and inhale deeply, flooding the lungs with water. The situations are entirely different.
- How much water will Dr. Modell put into the dog's lungs? A small amount of water will not endanger a dog's life and may not be expelled by the Heimlich Manoeuvre. An extra large volume of water in the stomach will cause vomiting, with or without the Heimlich Manoeuvre. The result will therefore be based on the experimenter's bias.
- How do you perform mouth-to-mouth resuscitation on dogs? If done through a tube inserted into the windpipe, it bears no resemblance to human resuscitation. In humans, much air goes into the stomach during mouth-to-mouth, even to the extent of bursting the stomach, especially in drowning victims, because water blocks portions of the lungs.
And we beat them!
Is it easier to obtain research funds for animal-related research? I know people think, for some reason, that our Institute has all sorts of research funds; we don't. We get them mostly from private and semi-public foundations around the United States. I've had one government research grant. The problem is that if you're creative or innovative and have something that has not been tried before, it's very difficult to get government funds. If you're not a huge university institution, it's difficult. The reason is that they will give large grants to the so-called "safe" procedures, the ones they've been working on for years, like injecting all kinds of junk against cancer into animals.
I intended to apply to the National Cancer Institute for a procedure for otherwise inoperable cancer that I know has some merit. They invited me to present the project, after which the head of the committee turned to me and said: "If you do this in animals, I'm sure we'll be able to give you some money for it." It was that quick and that was it. Instead, we are using this procedure in two or three other countries, and it has merit.
I'd like to tell you about another piece of research we're doing, and, again, with a certain type of thinking, you can convince people, I'm sure, that animal research is not necessary. You won't convince those who get the big grants for using animals! I don't know how many of you know about Lyme Disease. It is the fastest-spreading disease in the world today. It's caused by the bite of a tick. Lyme Disease has been present in Scandinavia and northern parts of Europe, but unknown as an isolated disease, as a definitive disease, for 100 years. It is the fastest-growing disease throughout Europe, Asia and the United States, particularly. In all the northeastern United States, this tick is present in the lawns. This particular tick is spreading by being carried on birds and other animals. The tick-bite injects spirochetes, corkscrew-shaped bacteria. The spirochete is identical morphologically to the spirochete that causes syphilis. The DNA of each is different. The symptoms of the disease are identical. It infects the skin first and then there are two later stages, wherein it gets to the brain and spinal chord. It's a horrible disease that causes mental changes, severe headaches, joint pains, paralysis, blindness and total disability. If you catch it in the first stage, you can cure some patients with massive doses of antibiotics, but you can't catch it early in 50% of infected people because there's no visible evidence of it after the tick bite. You pick this tick up off your lawn or from your dog, who carries it. It affects adults and children and it's congenital, it passes on through the placenta. I'm fortunately old enough to have recalled that neuro-syphilis, syphilis of the brain and spinal chord, was frequently incurable, both with the arsenical drugs prior to antibiotics and with antibiotics, because the drugs cannot get into the nerve cells to destroy the spirochetes, and the spirochetes survive for months and years, with acute exacerbations that eventually destroy the person's life. In 1917 a paper was published by Wagner-Jauregg, a Hungarian in Vienna. He gave Plasmodium Vivaxto, a curable form of malaria - benign tertian malaria - to neuro-syphilis patients, and let the malaria fever run every other day for two to three weeks. That cured the neuro-syphilis; killed all the spirochetes. Then the malaria was cured with quinine within a few hours. He won the 1927 Nobel Prize for that discovery. Malaria therapy continued for 20 to 30 years after antibiotics, until 1960-1970, at which time it had wiped out neuro-syphilis.
Since Lyme Disease and syphilis are both caused by spirochetes, have the same three stages, and cannot be cured with antibiotics after the first stage, it logical to conclude that Lyme Disease may be cured using malaria therapy. After peer review, I published this method in the April 26, 1990 New England Journal of Medicine. The first Lyme Disease patients are being treated with malaria therapy. All were severely disabled with painful arthritis and neurological disorders for up to nine years, despite years of intravenous antibiotics. Remission of symptoms, temporary or prolonged, has occurred, indicating that further studies are warranted to determine how malarial therapy has produced these favourable results.
Questions and Answers:
Question: Why wasn't the Heimlich Manoeuvre developed and accepted 100 years ago?
Answer: I don't know. I guess no one thought of it. There were interesting things. After I came out with it, I received a letter from a police-chief, who mentioned that thirty-some-odd years before, his six-year old son was choking and he was rushing to get help and he fell on the child and it popped the object out. As a matter of fact, the Heimlich Manoeuvre, by the way, again, for your interest, is saving a lot of animals. It does work on animals. We have reports of dogs and cats who were choking, who have been saved.
Question: In the artificial esophagus, what happens to the gastric mucosa and the hydrochloric acid?
Answer: I was at a medical meeting in 1959, and they were describing that the method of removing a cancer of the lower esophagus and enabling them to swallow was to bring the stomach up and anastomose it, join it to the esophagus in the chest. They reported that the acid from the stomach regurgitated up into the esophagus and caused severe inflammation, and eventually stricture, bleeding and ulceration. At that moment I recalled that the upper part of the stomach, the cardia, secretes acid. The lower part does not secrete much acid. It is a non-acid-secreting part of the stomach. So my original concept was to replace the non-acid-secreting part of the stomach, to join it to the esophagus, rather than using the cardia which secretes all the acid. The method I desired turned out to enable replacement of the esophagus - the first time in history an organ had been totally replaced.
Just as an aside, I was at a medical meeting when I first considered this possibility. I had lunch with the chief of our chest surgical department and drew a diagram of the operation for him on a napkin. He said, "Ah, I don't know if that's so good, if that'll do anything." The usual reaction. So I went to another institution and got permission to do the procedure.
Question: In the Israeli Army they teach paramedics how to introduce a trocar catheter on dogs. What would be your response to that, Dr. Heimlich?
Answer: I don't know what the trocar catheter is for. Is that for oxygen? I might just say, I had a wonderful experience in 1977. I came at the invitation of the Israeli Army because they had used my valve so much. Every place they took me, to the underground bunkers, to the Sinai, every First Aid kit had the Heimlich valve on top. Certainly, they're going to learn a lot more by waiting until the patient comes in who needs the valve. If they're there long enough, they're going to see it put in. But I can tell you that without any training at all, corpsmen in Vietnam simply knew to put it in and put a dressing around it. They had no training at all, and certainly not on animals. There wasn't time for that. And a doctor one time wrote me that of 34 men shot in the chest on "Hill 881", 32 got off alive with the Heimlich Valves draining chest wounds. So, I just think the use of animals is an exercise that can be avoided. I don't think it has great value. During the course of the conference, I met with the Senior Medical Officer of the Israeli Army to discuss the use of animals in military training. He agreed to eliminate inserting chest-tubes into healthy dogs as a training exercise for paramedics. Instead, alternative methods will be used.
Regarding training of the military, several things have happened in the States. They had been shooting goats through the thigh to teach military doctors to repair such bullet wounds. This newspaper article was about the fact that such methods had now been eliminated at one of these centres and it was just a matter of time before it would be eliminated at the other. In particular answer to your question, I saw a television program just a couple of weeks ago and they showed that at the Pentagon the military surgeons and nurses are now being attached to civilian emergency-rooms in hospitals, particularly in Washington, where, it showed, it's like a battlefield anyway.
References:
1. Heimlich HJ: Oxygen delivery for ambulatory patients: How the Micro-Trach increases mobility. Postgraduate Medicine 84:68-79, 1988.
2. Heimlich HJ and Patrick EA: The Heimlich Manoeuvre: Best technique for saving any choking victim's life. Postgraduate Medicine 87:38-53, 1990.
3. Heimlich HJ and Patrick EA: Using the Heimlich Manoeuvre to save near-drowning victims. Postgraduate Medicine 88:62-73, 1988.
4. Orlowsky JP: Effects of tonicities of saline solutions on pulmonary injury in drowning. Critical Care Medicine 15:126-130, 1987.
5. Safar P: Resuscitation following fresh-water or sea-water aspiration. Acta Anaesthesialogica Scandinavia (Suppl.) 3:99-107, 1961.
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