Historical Essay: The Heimlich Maneuver

Henry Heimlich MD

 

People often ask me, "How did you invent the Heimlich maneuver?  Were you in a restaurant and saw someone choking?  Did someone ask you to invent it?  Or did it just come to you one day?" 

 

One day in 1972 I was reading an article in the Sunday New York Times Magazine about accidental deaths.  What caught my eye was that choking to death was number six on the list.  Three thousand people a year died from choking in this country alone.  This particularly piqued my interest because, in the 1950's I had developed the Reversed Gastric Tube esophagus replacement operation and, through much of my career, had become involved in evaluating patients' swallowing problems.   

 

What was most striking was how choking usually occurred in the most ordinary circumstances.  The object on which most people choked was a piece of food or, with children, a toy, a coin, or any small object they happened to put in their mouth.  Yet you rarely heard of these deaths.  Only when a prominent person died - such as Ethel Kennedy's sister-in-law, Joan Skakel, who choked to death on a chunk of meat, did you read about it in the newspaper.  Two music stars, band leader Tommy Dorsey and pop singer Mama Cass Elliot, lost their lives to choking. I later learned that Claudius I, Emperor of Rome, had also choked to death accidentally - not strangled by a rival, as is commonly believed.

 

As always, the first step was to research the subject in the medical journals.  I discovered that since 1933, the American Red Cross had been teaching people to save choking persons by slapping them on the back.  As I read further, I realized there was no scientific basis for that recommendation.  In fact, all reports from 1854 (Gross SD: A Practical Treatise on Foreign Bodies in the Air-Passages. Philadelphia, Blanchard & Lea, 1854) to the present prove hitting a person on the back drives the object downward, lodging it more tightly in the airway.  Choking persons, who can still breathe, even with a piece of food in their throat, often die when back slaps cork their airway.

 

Of particular interest to the ABEA is the remarkable study from the Chevalier Jackson Clinic.  Beginning with a series of 612 cases in 1917, the Clinic recorded nearly 6,000 choking patient studies in 1973. The observations and cautionary comments by Chevalier Jackson and others are remarkably similar to each other as well as to the conclusions drawn by Gross.  All of these authorities describe the dangers of backslaps, probing the pharynx with a finger, or turning the patient upside down. 

 

In 1969, the journal Transactions of the American Broncho-Esophagological Association warned the Red Cross that back slaps were killing people.  As a result, the Red Cross changed its policy.  The 1970 Red Cross manual read: "Do not allow anyone to slap you on your back if you are choking and do not try to dislodge an object from another person's throat by this means except as a last desperate effort to save his life."  Strangely, after the Heimlich Maneuver emerged, the Red Cross again reversed itself and began recommending back slaps before performing the Heimlich Maneuver!  That surely did not justify the years of faulty advice. 

 

As I approached the problem, I decided that since back slaps caused deaths by forcing the object back downward in the airway the answer lay in creating a flow of air upward out of the lungs, using the lungs like a pair of bellows.  As a thoracic surgeon, I knew there is always a large amount of residual air in the lungs, even after breathing out.  To work up enough force to expel the object, I would have to find a way to compress the lungs sufficiently to create a strong flow of air out of the mouth. 

 

In 1973, I began researching the problem in my laboratory at Cincinnati's Jewish Hospital.  I used an endotracheal tube as the foreign body obstructing the airway.  I blew up the balloon at the lower end of the tube and closed off the upper end of the tube to prevent the flow of air through it.  I inserted the balloon into the airway of an anaesthetized beagle.  The balloon thus acted like a foreign object, such as a piece of meat, obstructing the airway.  If I could produce a large flow of air by compressing the lungs, the tube should move upward out of the airway. 

 

I pressed repeatedly on the dog's chest, but the tube did not move.  What was wrong?  I stopped to analyze the situation.  Simply pushing on the chest obviously did not compress the lungs sufficiently.  The problem was the rib cage.  It was evident pressing on the rigid chest did not compress the lungs at all..  In order to get the proper effect, you would virtually have to crush the ribs.  In fact, rib fractures and crushed chests are a common complication of chest compression during CPR --cardiopulmonary resuscitation.

                               

I decided to start again.  I considered if you pushed the diaphragm upward into the chest, you would markedly reduce the volume of the chest cavity, which would compress the lungs in a very even manner.  Moving below the rib cage, I pressed my fist above the dog's belly button and just under the rib cage, thereby pushing the diaphragm upward into the chest..  Instantly the tube shot out of the animal's mouth!  Repeating this procedure, I found the same result every time.  I was extremely excited!  With only a little bit of exertion, I found that pushing upward on the diaphragm drove air out of the lungs, creating a sufficient flow of air to carry the object away from the airway and out the mouth.. 

 

I quickly sent my assistant to the hospital cafeteria for a piece of meat.  Putting the meat into the animal's larynx or trachea, I again pressed the chest repeatedly.  Nothing happened.  Then I pressed upward on the diaphragm.  The meat shot out of the dog's mouth!  I repeated the procedure over and over.  Each time it worked.  At first, I thought the object would have to be stuck tightly in the windpipe, like a champagne cork, in order to create enough pressure to pop it.  As I experimented, however, I found that even with a partially obstructing object like a chicken bone, the flow of air past the object was enough to push it upward and out of the mouth.  It was the flow of air, as in a small hurricane, not pressure, that carried the object away.

 

What was the actual measure of airflow?  I soon discovered that by carrying out a series of tests with ten of my fellow doctors and hospital residents, the air flow was fairly easy to calculate. 

 

One at a time, each of us was fitted with a mouthpiece that connected by tubing to a machine that measured the flow of air passing out of our mouths when the diaphragm was forced upward with a fist.  Today, of course, the results would be measured by computer but in our day it was measured by a graph on a rotating drum.  The figures were astounding.  The average flow generated was 205 liters/minute, more than enough to drive a trapped object out of the throat.  The pressure was minimal, in keeping with the engineering saying, "The higher the flow, the lower the pressure."

 

But how to administer this effort?  The technique had to be simple.  When a child chokes on something, the parent has less than four minutes to save him from death or permanent brain injury.  You couldn't depend on a household instrument because you might not be able to locate it.  You certainly couldn't call 911; it would take emergency teams too long to respond.  It had to be a procedure that could be performed by anyone.  Furthermore, it had to be simple enough to be disseminated throughout the population, since you never know where or when the next choking incident would occur.

 

There were several choices.  You could brace the victim's back against a wall and push with your fist against his or her upper abdomen.  You could lay the victim on the ground and push with your hand or foot on the upper abdomen.  However, after many tests and trials, it became obvious that the best technique was to stand behind the victim and reach around the choking person's waste with both arms.  Make a fist.  Place the thumb side of your fist below the rib cage, just above the belly button, grasp the fist with the other hand and press it the fist inward and upward.  Perform it firmly and smoothly and repeat until the choking object is dislodged from the airway.  In most reports the object flies out of the mouth and sometimes hits the wall or even the ceiling.  I called this method "sub-diaphragmatic pressure."  It can be mastered in one minute from a poster.  To learn it, you do not even need to take a first-aid course.

 

Still, there were other considerations.  Suppose a person faced a choking victim of such large stature that the rescuer could not reach around the victim's waist?  Suppose a small woman or child was trying to save a large man?  What happens if the victim has lost consciousness and fallen to the floor?  Was it necessary to lift the victim to a standing position?  What if he or she were too heavy?

 

To plan for these contingencies, I also developed an alternate lying-down position for the Maneuver.  With the victim lying down on his back, the rescuer kneels astride the victim's thighs, facing him.  Then she places one hand on top of the other and puts the heel of the bottom hand on the same spot, just above the belly button and under the rib cage.  The rescuer can use her body weight to overcome the size differential.  This has made it possible for any diminutive individual to save a large or overweight person or even the youngest child has saved a parent. .

 

By 1974 I believed my research was complete.  I had enough evidence to introduce the technique to the public.  I was anxious to get started because people were choking to death every day.  It was necessary to educate the entire population as soon as possible. 

The Heimlich Maneuver is not designed as a professional practice; it is something that can be performed by anyone.  I knew it would save lives.  

 

But how were we to go about this?  Setting up controlled experiments in hospital emergency rooms would be useless if not impossible.  Yet without some sort of data, most medical journals were not likely to accept anything for publication.  Even then, the public wouldn't necessarily learn about it.  It often takes a long time for articles in medical journals to filter down to the public.

 

And so I decided to approach Emergency Medicine, which had published some of my previous work and I knew the editor.  The magazine often included accessible digests of recent research that had appeared in technical journals.  I called the editor.  "I have devised a method for saving the lives of choking persons," I told him.  "I'm sure it will work.  If you publish it, I'd like you to alert a certain medical reporter."  After reading the article, he agreed. 

 

At the time, doctors generally considered it unethical to talk to the press.  Today, doctors, hospitals, clinics, and drug companies advertise themselves and their products on television, full pages in newspapers, and through the mail.  I don't know whether the old way or the present way is right.  The best way is obviously the one that saves most lives. 

 

"Pop Goes the Cafe Coronary" (the editor's title) appeared in Emergency Medicine in June 1974.  The term "CafÈ Coronary" had emerged to describe the frequent situation where a person chokes to death on food in a restaurant.  More often than not, horrified onlookers thought the person was having a heart attack.  (This was before a universal symbol for choking that I designed - hold your hand around your throat - was widely popularized.)  Even the best doctors didn't know what to do about choking.  In my article, I described one incident where a physician had tried to perform a tracheotomy with a kitchen knife on his choking wife.  He literally slit her throat, cutting her carotid artery in the process, and she died of a hemorrhage.  Yet, one of the recommendations, before the Heimlich maneuver came along, for saving choking victims was to slit open the trachea in the neck with a knife.

 

Arthur Snider, a medical reporter on the Chicago Daily News who had reported on my esophagus operation twenty years before, wrote a syndicated column that appeared in several hundred newspapers on June 16, 1974.  It repeated what I had said in my scientific article: Dr. Heimlich doesn't know that his method will save a choking person, but the alternative is to let a choking person die.  We did not have to wait long for results. 

 

A week later, the following article appeared on the front page of the Seattle Times:

 

News article helps prevent a choking death

 

A Hood Canal woman is alive today because of an article in some Sunday editions of The Seattle Times. . . Isaac Piha . . . said he read the article twice Saturday night . . . while in his cabin on Hood Canal.  It told of Dr. Heimlich's method of forcing a piece of food out of the windpipe.

           

Piha . . a retired restaurateur, . . . was interested . . . because of the number of instances patrons have choked to death on pieces of meat. . . .   Piha . . and members of his family were enjoying a Father's Day gathering Sunday afternoon when Edward Bogachus ran from his nearby cabin calling for help for his wife, Irene.  Piha, his son, David, 26, and his niece, Diane Rood, 20, ran to the Bogachus cabin and found Mrs. Bogachus slumped at the dinner table and beginning to turn blue.  "I thought about heart attack and about that article in The Times while I was running to the cabin."  Piha said.  "When I saw that they'd been eating dinner, I knew it was food lodged in her throat . .." 

 

Mr. Piha became the first person to perform what was soon known as the "Heimlich Maneuver."  He dislodged a large piece of chicken from Irene Bogachus's throat and she quickly recovered.

 

A similar story was soon reported over and over around the country and abroad.  What was particularly gratifying to me was how in each case people expressed enormous pride at having personally saved a life.  

 

The Director of Medical Services at Albert Einstein Medical Center in Philadelphia told me how his wife started choking on a chicken bone at a dinner party.  After two applications of the maneuver, the bone - one and a half inches long and pointed at both ends - flew out of her mouth.  This report confirmed what our studies had shown: it isn't necessary for the object to be stuck in the throat like the cork in a champagne bottle.  Even an object like a bone, which allows a flow or air around it, can be dislodged by the Maneuver. 

 

Finally, one woman told how, while at her summer cottage in Wisconsin, she was putting some leftover roast beef in the refrigerator when she broke off a piece and tossed it in her mouth.  In an instant, she was choking.  She ran out on the porch, waving to her husband who was down by the lake, but could make no sound because a choking person cannot speak or breathe.  Unable to get his attention, she thrust her upper abdomen against the porch railing.  The meat popped out.  She had performed the maneuver on herself. 

 

From this report and others, we soon realized that people could save themselves by pressing their abdomen against a table, the back of a chair, the edge of a sink or any other firm object.  In another instance, a woman saved herself by pushing her abdomen with her own fist.  The self-administered maneuver became part of the instructions.

 

Two months after the first article appeared, I received a phone call from an editor of the Journal of the American Medical Association (JAMA).  "Dr. Heimlich, your procedure has saved so many choking victims in just two months," he said.  "We feel it should be named after you."  "That's wonderful," I replied. 

 

In an editorial in the August 12, 1974 JAMA, the editors described the procedure for the first time as the "Heimlich Maneuver."  A short time later I received a letter from JAMA's editor-in-chief asking me to write an article describing my discovery.  I submitted it a few months later.

 

On October 27, 1975, my first scientific article on the Heimlich Maneuver, "A Life Saving Maneuver to Prevent Choking," appeared in JAMA.  To my surprise there was an accompanying editorial stating that the Heimlich Maneuver had been officially endorsed by the American Medical Association Commission on Emergency Medical Services.  This set the Maneuver on the path toward world use.

 

Over the years, people have come up to me time after time to tell of their experience with the Heimlich Maneuver.  "I know you've heard a lot of stories," they always say, "but I want to tell you how grateful I am for what you did."  I am always particularly thrilled to receive pictures of children saved by their parents.  On a wall in my home I have a large frame holding dozens of photographs.  I used to be able to tell visitors the name of each child but today there are far too many.  Even now, after thousands of such reports, I am deeply moved when hearing about a new case.

 

One of the most moving reports came in a letter dated November 11, 1975, from Frank P. Wicher, an attorney in Sioux City, Iowa:

 

Dear Dr. Heimlich:

Last June, my wife and I were attending a steak dinner in a nearby community.  There were about ten people at our table.  She and I were seated directly opposite each other at about the center.  I am blind.  There appeared to be a little commotion across the table from me and the folks informed me that my wife was choking (she was not coughing) and she hadn't been breathing for nearly a minute, as far as they could tell me.  I whipped around that table as fast as a man might who could see.  In a few seconds I had her by the guts and gave her a swift jab.  That failed to do the trick so I gave her two more, and lo, the chunk of unchewed steak was ejected and she was breathing once again.

 

I know full well, Dr. Heimlich that had I not read of your procedure I would have buried my wife six months ago.  From the bottom of our hearts my wife and I thank you.  My six daughters thank you, as do our eleven grandchildren.

 

Gratefully yours,

Frank P. Wicher

 

A short time later Mr. Wicher arranged for me to go to go to Sioux City and we had lunch in the restaurant where he saved his wife.

The following declaration firmly established the Heimlich Maneuver as the only method for saving choking victims: 

 

U.S. Department of Health and Human Services Declaration: 1985

 

Surgeon General C. Everett Koop today endorsed the Heimlich maneuver, not as the preferred, but as the only method that should be used for the treatment of choking from foreign body airway obstruction.

 

Dr. Koop also urged the American Red Cross and the American Heart Association to teach only the Heimlich Maneuver in their first aid classes.  Dr. Koop urged both organizations to withdraw from circulation manuals, posters and other materials that recommend treating choking victims with back slaps and blows to the chest.... 

 

The American Red Cross and the American Heart Association 

Concluded during a July 11-13 conference held to establish first aid

Standards for both organization that methods other than the Heimlich Maneuver can be dangerous and that only the Heimlich Maneuver should be used to treat a choking victims.        

 

"Millions of Americans have been taught to treat persons who are choking with back blows, chest and abdominal thrusts," Dr. Koop said.  "Now, they must be advised . . . and I ask for the participation of the Red Cross, the American Heart Association and public health authorities everywhere . . . that these methods are hazardous, even lethal." 

 

A back slap, the surgeon general said, can drive a choking object even deeper into the throat.  Chest and abdominal thrusts, because they refer to blows to unspecified locations on the body, have resulted in cracked ribs and damaged spleens and livers, among other injuries.  "The best rescue technique in any choking situation," Dr. Koop said, "is the Heimlich Maneuver"..."The Heimlich Maneuver is safe, effective and easily performed by the average person," Dr. Koop said.  "It can be performed on standing or seated victims and on persons who have fallen to the floor.  It can be performed on children and even on one's self." (Entire declaration available on request)