Heimlich and His Beagles

Today in History: June 1, 1974

According to various interviews given by Dr Henry Heimlich during his lifetime (he passed away in 2016 at age 96), the eponymous maneuver he championed in the 1970s is responsible for saving the lives of tens of thousands of people and a not insignificant number of dogs…

The genesis of the Heimlich maneuver can be traced back to 1972 when Dr. Heimlich, who was a Cincinnati-based thoracic surgeon at the time before getting fired a couple years later, read an article in the New York Times that revealed that over 3,000 people in the United States died from choking on food in that year alone.

At the time, the general consensus among medical professionals was that the best way for a layman to help a choking person was to slap them very hard on the back several times. Heimlich, being an expert on all things chest-related, reasoned that a better method would be to more directly leverage the air in the lungs to force the blockage out. Basically, if you put pressure on the lungs, the sealed balloon-like organ would naturally provide the force necessary to dislodge the food.

To test his hypothesis he couldn’t exactly go around getting humans to choke, so Heimlich started by doing this to beagles. Specifically, Heimlich and his team put small tubes in the dogs’ throats that made it difficult, though not impossible, to breathe.

Once the dogs were choking, initially he experimented with pressure to the chest itself to expel the tube, but found this ineffective. In further experiments, Heimlich noticed that if he pressed on the dog’s diaphragm just right, thus compressing its lungs, the tube would sometimes even violently be dislodged. In fact, he noted on some test runs that the tube would fly out of the dogs’ mouths and travel several feet across the room.

You might at this point be wondering if things ever went wrong in the experiment, resulting in significant harm or death of a dog; Heimlich claims none of the dogs suffered any lasting injury and removal of the tube was a straightforward process- you just grab the tube and pull it out if things got dicey.

After perfecting the technique for dislodging tubes, Heimlich then began a slightly more dangerous procedure, giving the dogs comically large chunks of meat to eat- meat the dogs occasionally choked on, allowing him to perform the technique under more realistic conditions. (Again, he claims no dogs were permanently hurt as a result of these experiments.)

After adapting the technique for humans, Heimlich felt this method needed to be widely disseminated to save lives immediately, rather than going through the normal medical research progression including publishing a peer-reviewed study. After all, it might have taken years to prove the efficacy of the technique over existing recommendations and then very likely many years more before any official medical body would recommend it to the public, if it all.

And so it was that on this day in history, June 1, 1974, Heimlich published an article titled, Pop Goes the Café Coronary, in Emergency Medicine. (For reference here, Café Coronary is just a bit of a slang way to say cardiac arrest as a result of choking on food.)

Heimlich also pulled some strings to have a friend who wrote for the Chicago Daily News get the article published there, with the friend explicitly noting, “Dr. Heimlich doesn’t know that his method will save a choking person…” but then going on to recommend trying anyway.

As to the original article, Heimlich does note, “It’s been tested only on dogs but I believe the logic of the concept and the favorable findings warrant public dissemination…”

He goes on:

Since aspiration must occur during inspiration in order for the bolus to be sucked against the laryngeal orifice, the victim’s lungs are expanded at the time of the accident – actually there is always residual air in the lung – so sudden forceful compression of the lungs will increase the air pressure within the trachea and larynx and thus eject the offending bolus like the cork from a champagne bottle. There, in short, are the dynamics of the procedure. And here’s how to do it:

Standing behind the victim, the rescuer puts both arms around him just above the belt line, allowing head, arms, and upper torso to hang forward. Then, grasping his own right wrist with his left hand, the rescuer rapidly and strongly presses into the victim’s abdomen, forcing the diaphragm upward, compressing the lungs, and expelling the obstructing bolus. The same effect can be obtained with the victim lying face down on the floor, the rescuer sitting astride the victim’s lower torso or buttocks.

If, however, the victim is already lying on his back, he needn’t be moved. The rescuer merely sits astride him and suddenly presses both hands – one on top of the other – forcefully into the upper subdiaphragmatic abdominal region…

We cannot be certain, of course, that the experimental results will be duplicated in humans. But when tracheostomy is not feasible, there is certainly no risk in recommending that the procedure be tried in actual cafe coronary emergencies since an unaided victim will die in minutes. Then, as experiences are reported, the method can be evaluated. Only by disseminating public information about this simple technique can we determine whether it will result in a significant reduction of what amounts to 3900 totally avoidable deaths every year.

This article, or snippets of it, quickly got re-published in hundreds of newspapers throughout the United States. Within weeks, reports began pouring in from people across the United States about how the technique was saving lives. Later that year, the Journal of the American Medical Association called Heimlich and told him they were going to name the technique after him. After vetoing the name The Heimlich Method, Heimlich settled on The Heimlich Maneuver, which he felt was “more appropriate”.

Naturally, given a lack of hard evidence supporting his method in favor of existing recommendations, institutions such as the American Red Cross chose not to initially recommend the Heimlich maneuver, which in turn caused Heimlich to decide to market it himself, including selling shirts and posters, and even going on The Tonight Show to demonstrate it on Golden Globe award winner Angie Dickinson.

At this point you might be wondering if this method actually is superior to the former widespread recommendation of just hard back slaps. It turns out this is remarkably difficult to say, though perhaps that shouldn’t be unexpected given to study the matter in a scientifically rigorous fashion on humans isn’t really ethically possible.

As for statistics, when Heimlich first got his bright idea a little over 3,000 people per year died from choking in the United States. In the two decades following the widespread use of the Heimlich, the number of choking deaths in the U.S. stayed approximately the same as it was before…

Later, in 2000, there was a rather curious sudden jump from 1995’s 3,185 to 2000’s 4,313 deaths.

The number stayed mostly stable until 2010 when it further jumped to 4,570, with it rising a bit since, with the high mark here on choking deaths in the United States occurring in 2015 at 5,051 people.

Given the lack of hard evidence supporting the Heimlich over back slaps, starting in 2006, the American Red Cross, besides still recommending first encouraging the person to cough if they can and having someone call 911, they actually switched to recommending back slaps before trying the Heimlich and then alternating between the two at five times each.

As for the reason for adding the back slaps back in, according to American Red Cross representative Mike Higgins, Red Cross officials determined that, to quote, “the body of scientific evidence now states that the use of more than one method [is] most effective in helping a person who has an obstructed airway…”

Of note here is that the American Red Cross (while being a very reputable organization) is not part of ILCOR (The International Liaison Committee on Resuscitation)- basically, the group most all trained emergency medical providers throughout the world use when recommending guidelines for treating people in emergency situations.

On that note, the American Heart Association is part of ILCOR and recommends in choking situations that both medical professionals and laymen perform the Heimlich on a conscious person and chest compressions (the same ones as in CPR) on an unconscious person. If this is unsuccessful at dislodging the blocking object, medical professionals are then trained to perform a cricothyrotomy (cutting a hole in the neck), which, of course, is not something untrained individuals should try.

Should you be the one choking and you’re by yourself, researchers at the Royal Brompton Hospital found that self-administered abdominal thrusts produced just as much intrathoracic pressure as when someone else does it. And for maximum effect, they found doing the abdominal thrusts via forcibly collapsing your abdomen on the back of a chair produced the highest intrathoracic pressure of all.

Going back to back slaps and the Red Cross’ recommendations, Heimlich stated, “I have no desire to diminish the good work that the American Red Cross has done, such as in times of natural disasters, but telling people to hit a choking person on the back could potentially lead to death. The Red Cross should do what the American Heart Association does—recommend the Heimlich Maneuver…”

He then elaborated, “It’s been scientifically proven that hitting a choking person on the back can drive an object that is partially blocking the airway more deeply into the throat.”

It is not entirely clear as to what studies he’s referring to that supposedly scientifically proved this is the case.

That said, at least when talking comparing the two with regard to internal pressure, a 1982 Yale study, Choking: The Heimlich Abdominal Thrust vs Back Blows: An Approach to Measurement of Inertial and Aerodynamic Forces, determined the Heimlich produces significantly more intrathoracic pressure than back slaps. It is noted, however, that this study was partially funded by the Dysphagia Foundation Inc. of Cincinnati Inc., later renamed the Heimlich Institute.

That said, just because Heimlich helped fund the study, doesn’t necessarily mean the results were inaccurate, and the three Yale researchers involved, Richard L. Day, Edmund S. Crelin and Arthur B. DuBois, would later state that their research was completely independently performed with no oversight or pressure from Heimlich. DuBois further stated the experiment was rather straightforward and easily verifiable by others, simply measuring air pressure out of the mouths of subjects when the researchers performed back blows and abdominal thrusts.

In response, representatives from the Red Cross noted that the point of the back blow is more for the jarring effect to dislodge the stuck object, rather than creating an artificial cough using air pressure to dislodge it as in abdominal thrusts- hence their recommendation to do both methods.

As for one Dr. Roger White of the Mayo Clinic and American Heart Association, he states of his opinion of Heimlich and his work, “There was never any science here. Heimlich overpowered science all along the way with his slick tactics and intimidation, and everyone, including us at the AHA, caved in.”

Heimlich’s son, Peter Heimlich also had less than glowing reviews of his father’s assertions, stating, his father was “a spectacular con man and serial liar…” Peter has since dedicated years of his life to debunking many of the things Dr. Heimlich would say publicly.

That said, it is almost universally thought among medical professionals that the Heimlich maneuver is a fantastic tool to help choking victims until medical professionals arrive. And, as noted, even those medical professionals will usually start by attempting the Heimlich or chest compressions before moving on to other methods at their disposal for saving a choking person.

But while the Heimlich Maneuver itself has been a boon to the world of choking victims, earning Heimlich more than a little positive fame, Heimlich’s later career was marked with controversy owing to doing things like publicly championing the Heimlich maneuver to help people suffering from asthma attacks, heart attacks, and cystic fibrosis, as well as advocating its use with drowning victims.

The last one there caught on somewhat, owing to seeming to make sense on the surface- trying to force the water out of the lungs. However, the American Red Cross Advisory Council notes, “Studies have shown that there is no need to clear the airway of aspirated water. Only a modest amount of water is aspirated by the majority of drowning victims and it is rapidly absorbed into the central circulation. Therefore, it does not act as an obstruction in the trachea… An attempt to remove water from the breathing passages by any means other than suction… are unnecessary and potentially dangerous.”

With the danger here noted as potentially causing physical injury, vomiting and potential subsequent aspiration, and the fact that doing this delays the gold standard recommendation to the public here in cases of an unconscious drowning victim who isn’t breathing- CPR until professional medical aid arrives or the person is revived. (Although, to be fair here, proper administration of CPR is guaranteed to also cause physical injury via breaking the cartilage that attaches the ribs to the sternum in an attempt to compress the heart, but in this case actually for a proven effective purpose.)

As with its use in aiding choking victims, it doesn’t appear as if Heimlich took the time to do the necessary research to definitively show the Heimlich maneuver is actually more helpful than standard recommendations in these cases before widely publicizing it as such in the media. This was succinctly pointed out by cardiologist Dr. Joseph Ornato, who stated of the controversy, “Dr. Heimlich is trying to force the medical community to adopt a measure that is lacking in adequate scientific foundation. But if studies show he is right, I’d be the first one to want to apply it.”

Later, much more controversially, Heimlich, in conjunction with the Heimlich Institute and doctors from China and Ethiopia, were intentionally infecting people that had AIDS with malaria and then not treating them for the malaria until the disease had progressed to a critical state… Known as malariotherapy, the idea here was to try to cure the person of HIV by raising the body temperature to extreme levels via a malaria induced fever for an extended period. These extreme high fevers potentially would be allowed to be maintained even for weeks without treatment, with the hope that the HIV would not survive such a scenario.

Not without precedent, in 1927 this was a Nobel Prize winning treatment for syphilis, but in this case the experiments the Heimlich Institute were involved with were considered too dangerous, unethically administered, and with little hope that it would actually do anything beneficial. Heimlich’s response: “If all of your peers understand what you’ve done, you haven’t been creative.”

If you liked this article, you might also enjoy our new popular podcast, The BrainFood Show (iTunes, Spotify, Google Play Music, Feed), as well as:

Bonus Fact:

  • The International Liaison Committee on Resuscitation (ILCOR) in part chose that name because “cor” is Latin for “heart”- hence “ill heart”.
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  • Of course the current death rate by choking has stayed very close in the face of Heimlich saving lives, the population continues to rise…

    • Daven Hiskey

      True, but that doesn’t really explain the sudden sustained jump in a 5 year span from 1995 to 2000.

  • I saved two lives in this manner. My father who died in 1988 from an actually choking to death on a small piece of steak once was choking but being to large of a man to get my arms around him enough to perform the maneuver I place against a wall and used the heel of my hand thrust in the proper spot resulting it dislodging the piece of meat. Once I was having dinner with my brother who died in 2009 and his family and he began to cough in a manner to inform me he was choking. He suddenly rose from his chair and began to move off struggling to breath. I immediately recognized what was happening and performed the maneuver several times. A small piece of pork soon flew from his mouth. Yet I kept performing the maneuver not sure he had extracted all of the meat. I knew he was alright when he stammered “You’re breaking my ribs.” As a side note after my father’s death I became paranoid of choking. And some years later I suffered a great deal from Girt. I sometimes had the feeling of choking. Once called 911 and had the operator to tell me to see if I could swallow water and if so I wasn’t choking. Also I was informed if you can talk you are not choking. I was successfully treated for the Acid Reflux and haven’t felt the sensation since or am even as paranoid of it as I once was.