Heimlich's Maneuvers

by Henry J. Heimlich

  At the end of our date at Howard Johnson’s, I told her I would not be able to see her for a while because I was studying for the surgical board examinations. But then I called her the next morning and asked her out for dinner that night. When I arrived at the home of her parents, they were not there. Jane offered me a drink, and I asked for scotch and soda. It turned out Jane had never mixed a drink before and poured me a full glass of scotch with just a squirt of soda.

  A little while later, her parents walked in. I was so tipsy, I could not stand up to greet them. Once I was able to get on my feet, the four of us had dinner at a lovely French restaurant nearby. Throughout the evening, I observed Jane’s lovely way of addressing people and the sparkle of her eye, and I knew I was hooked. For the next four months, we went out every evening. To hell with the surgery board exams.

  After a month or two of dating, Kathryn and Arthur invited Jane and me to dinner at the Persian Room in the Plaza Hotel. Jane and I danced a few numbers, after which Kathryn asked me to dance. I was plenty nervous leading one of America’s most famous women known for dancing, but I’m pleased to say I held my own. When Kathryn and I returned to the table, she said delightedly, “Arthur, Hank is a natural dancer.”

  Figure 8.1. Son-in-law: By marrying Jane, I inherited her energetic and fun-loving celebrity parents, Kathryn and Arthur Murray.

  I turned to Arthur and said, “Arthur, you’d better treat me right, or I’ll tell everyone I never took a lesson in my life.”

  But my father-in-law was just as quick. “Just don’t tell them you took lessons at Arthur Murray’s,” he said in his usually wry manner.

  A PROPOSAL OF MARRIAGE

  That spring, I planned to ask Jane to marry me. She and I were to go skiing at a small resort in Massachusetts and stay at the home of my sister and her husband. In those days, a man and a woman going away together was unusual, but after a bit of convincing, Kathryn gave her approval. We had a wonderful time. When the moment hit me, we were making our way up the hill, each sitting on either side of a T-bar lift. The T-bar wasn’t that steady, so I held off, afraid the shock might cause Jane to fall off.

  Later that evening, as we were driving back to New York, I pulled off the highway so we could eat sandwiches Cele had packed for us. Within a few moments, I declared my love for Jane, and she told me she loved me, too.

  “Since we love each other, we should get married,” I said. And she agreed.

  “Do you think September would be a good time?” I asked.

  “That will be fine,” she said.

  I let out a big breath and started the car. As we continued driving down the parkway, I suddenly blurted, “Why wait? How about June?”

  “That will be fine,” she repeated.

  After dropping Jane off at her house, I rushed home and woke my parents to tell them the happy news. They had gotten to know Jane when she had come to our home for dinner a few times. In fact, they had grown so fond of her that my mother said, “Henry, don’t you ever hurt that wonderful girl. If you do, I will surely take her side.”

  Jane and I were married on June 3, 1951—exactly four months after our Howard Johnson’s date—in a Jewish wedding ceremony at the Plaza Hotel. I later found out that Jane had never been crazy about being a celebrity’s daughter, and she was content to have found a man who was “just a doctor.” She noted in her memoir that she was

  delighted to shed my celebrity maiden name for one of an anonymous doctor. Surely, the name “Heimlich” was not likely to appear outside of a medical journal. I felt secure in knowing that I would at last be an ordinary person.

  But the fates had something else in mind for me.2

  In fact, I was about to devise my first significant medical innovation—one that would become known throughout the world.

  Figure 8.2. Wedding day: Jane and I were married on June 3, 1951.

  Figures 8.3 and 8.4. Our early years together: After Jane and I were married, we lived in New York City and then Rye, New York. Neither of us anticipated that I would make a big splash in the medical world so early in my career.

  Soon after Jane and I were married, we moved in to an apartment in New York City on Madison Avenue near Fortieth Street. Jane then became pregnant with our son Philip, whom we named after my father. Philip was born in December of 1952, at a time when most obstetricians were giving patients anesthesia before they delivered. But when Jane went into labor and her doctor suggested he give her anesthesia, she fought him off. Even though it went contrary to medical trends of the day, Jane was interested in natural childbirth. (Decades later, she would make a name for herself in the field of holistic health by writing two books on the subject.)

  Despite the many evenings I spent with Jane instead of studying for my exams, I had passed the tests. This qualified me as both a general and a thoracic surgeon. Now I had to find work and put to the test what I had learned in medical school, China, and my residency programs. Unfortunately, nothing I could find in the way of employment paid very much, so I had to take on as many jobs as I could. I was a staff surgeon at Mount Sinai Hospital. In addition, the chief of thoracic surgery at Montefiore Hospital had offered me a job as his assistant at both Montefiore and Mount Sinai Hospital, where he also practiced. He was a good chest surgeon and a pleasant, kind man. I assisted him in surgery and looked after his patients postoperatively; in return, he gave me a percentage of his fees for each operation, which altogether earned me $2,500 a year. I earned extra money treating employees of a department store and hotel association. Fortunately, I had a car, a Chevrolet sedan I used to zip around New York City from one job to the next. Parking was not often a problem; my license plate designated that I was a medical doctor, which allowed me to park almost anywhere.

  At the same time, I rented space in a doctor’s office in New York City, where I had begun a private practice. It was tricky trying to find patients. Unlike today, when surgeons of all ages can join an HMO or a partnership fairly quickly, building a practice in the early 1950s was like starting a business from scratch, and I would be competing for patients with older physicians with large practices. At that time, many patients had no insurance, and there was fierce competition among surgeons for patients who could pay. (Some surgeons engaged in fee splitting, where they would slip money, gifts, or other kickbacks to family practitioners who referred to them patients for surgery. One time, a physician referred a patient to me and expected some sort of payback. Being new, I did not understand the system and refused his request, after which he cursed me out and called me “tight.” Throughout my career, I have always loathed the negativity that surrounds the business of medicine.)

  TREATING PATIENTS WHO COULD NOT SWALLOW

  Almost immediately after I began my practice, I took a special interest in patients who were unable to swallow due to a damaged esophagus, or swallowing tube. The condition of not being able to swallow or having difficulty swallowing is called dysphagia.

  There are many ways that patients develop dysphagia. Some have an esophagus that is so inflamed, scarred, or ulcerated by chronic acid reflux from the stomach that their esophagus is blocked and useless. Other patients have cancer of the esophagus, and, in those cases, part or all of the esophagus must be removed. Some babies are born with an esophagus that is either closed off or connected to the trachea; in the latter case, any food or liquid swallowed enters into the airway, often causing death.

  Figure 9.1. My own practice: Beginning and building my own practice took time and patience.

  Back in the 1950s, when people were less aware of the dangers of caustic household cleaners, they would store lye under their sinks and keep the liquid, commonly used to open clogged drains, in glass soda-pop bottles. Children (and occasionally adults) often found the lye under the sink and, thinking the liquid inside was soda, drank it. Often this resulted in scarring or narrowing of the esophagus. Each year, thousands of children suffered with—or died from—a destroyed esophagus. Some adults intentionally drank lye to commit
suicide. When those attempts failed, they were stricken with the inability to consume food.

  In the cases where the esophagus has been severely damaged or destroyed, the outcome is the same: without a healthy esophagus, patients are denied the ability to swallow food and sometimes liquids. The life of a patient with dysphagia is extremely unpleasant. This was especially true back in the 1950s, when there was no adequate method to treat the condition. Since these individuals could not swallow saliva, they were condemned to a lifetime of drooling or constant spitting. To take in nourishment, patients had a tube with a funnel attached to it surgically inserted into the stomach. The funnel appeared outside the body. In order to “eat,” patients first chewed food and then spat it into the funnel, where it would move into the stomach and be digested. Liquids were poured directly into the funnel. Sometimes the stomach tube, which was made of rubber or plastic, was damaged by the stomach’s gastric acid and had to be replaced.

  Being afflicted with dysphagia was a source of embarrassment for most patients. Some went to great lengths to hide their condition from friends, even family, for decades, conducting their feeding rituals at home, when they were alone, or in public-bathroom stalls. Many avoided socializing at events where food would be present.

  Surgeons had been trying for years to devise an operation that would replace a defective esophagus. Researchers in this field were working largely on two methods. One consisted of first removing the part of the esophagus that was blocked or damaged and everything below it, ending at the junction where the esophagus meets the stomach. Then a hole was made at the top of the stomach of the same diameter as that of the esophagus. Finally, the dangling, remaining end of the esophagus was connected to the hole at the top of the stomach.

  Using this technique allowed patients to eat; however, it did not solve a dangerous problem: stomach acid could rise up into the esophagus, which is a condition we call acid reflux. Most healthy people don’t have to worry about acid reflux, because they have muscular tissue between the esophagus and stomach called the gastroesophageal sphincter. This sphincter acts as a valve to prevent acid from rising up into the esophagus and damaging it. But this first method surgeons were attempting, which pulled the stomach up to meet part of the esophagus, left the patient with no sphincter valve. As a result, acid reflux freely flowed upward and inflamed and ulcerated the esophagus, leading to bleeding ulcers and the scarring and closure of tissue. Sometimes, the ulcers bled and even perforated the stomach, allowing the organ to hemorrhage into the chest or abdomen, a condition that sometimes proved fatal.

  The second method researchers were attempting proved just as harmful. Here, lengths of the patient’s small or large intestine were used to replace the entire esophagus. As with the other procedure, this method left the patient without a sphincter valve, and so the rising stomach acid could cause the transplanted intestine to scar, close down, and bleed. In some cases, ulcers perforated the transplanted intestine, resulting in severe complications or death.

  All in all, there was no effective surgical procedure that could restore these patients’ ability to swallow. The only workable solution—however unpleasant—was the rubber feeding tube that had to be surgically inserted into the stomach. Seeing the agony that patients with dysphagia endured and the ineffective and dangerous treatments that were available in the 1950s made me determined to come up with a better way to replace someone’s missing or deteriorated esophagus so that patients could enjoy a good quality of life.

  CREATING A NEW ESOPHAGUS FROM THE STOMACH

  In January 1950, I attended a thoracic surgical conference in San Francisco. Researchers gave presentations outlining the various methods, including the partial-esophagus-removal technique and the one that involved replacing the esophagus with part of the intestine, and the problems that stomach acid caused. However, one group of surgeons caught my attention; they reported that they had devised an approach that overcame the stomach-acid problem.

  It had long been known that the upper third of the stomach, called the cardia, and the middle third of the stomach, or the body, both secrete acid. However, the lower third of the stomach, called the antrum, neutralizes acid, thereby preventing acid from entering the small intestine. Evolution explains why this is so: Our stomachs need the acid to digest food, but once the digested food is ready to leave the stomach and move into the small intestine, the acid must be gone. Otherwise, it would destroy the intestine. That is why the lowest part of the stomach shuts down acid secretion.

  The researchers at the conference explained how they made use of this knowledge in experiments on dogs. First, the scientists removed the upper three-quarters of a dog’s stomach, including the gastroesophageal sphincter. They then connected the remaining lower portion of the stomach—the part that does not secrete acid—to the lower end of the esophagus. For six months, the animals remained free of ulcers and other complications, even after they were injected with acid-stimulating drugs.

  It was not an ideal solution, for the remaining stomach was quite small and the animals could eat food in only very small amounts. Also, each of the dogs that underwent these experiments still had a complete, healthy esophagus. Would the results be duplicated in patients whose esophagi were unhealthy or partially missing? It certainly did not offer a solution for patients who were missing their esophagus altogether.

  But hearing about the dog experiments got me thinking: What if I replaced the esophagus using the lower portion of the stomach that neutralizes acid? I thought about how I would leave the upper, acid-producing part of the stomach in place but make a tube from the lower part of the stomach. This tube would be the same diameter as that of the esophagus. One end of the tube would remain attached to the stomach, leaving the other end free. I would then lift the free end of the tube within the chest or through a tunnel under the skin and attach it to the remaining esophagus or the pharynx. Thus, the gastric tube would become the patient’s new esophagus.

  And here’s the beautiful thing: the new esophagus could not be damaged by acid because it would have been made from the stomach, which tolerates acid. What’s more, the upper portion of the esophagus would further resist acid because it was made from the acid-neutralizing antrum.

  I thought of this method as a reversed gastric tube operation. “Reversed,” because the tube created from the stomach would replace the esophagus by being brought upward, so it essentially functions in reverse.

  Figure 9.2. Reversed gastric tube operation: To treat a patient with severe swallowing problems, a tube is created from the stomach and brought up to replace part or all of the esophagus. (Illustration © Christy Krames 2013.)

  As I visualized the method of making use of the stomach’s lower region, I began to see that it could offer numerous advantages: First, the tube created from the stomach would come from the antrum, the lower, nonacidic part. This would eliminate the chances of stomach acid damaging the newly created “esophagus.” Second, the lower part of the stomach offers more organ to work with, allowing for a sufficiently long, new esophagus. Third, three-quarters of the stomach would remain in the abdomen, so the stomach could function quite normally.

  The fourth advantage concerns blood supply. I knew the blood supply to the newly created esophagus had to accompany it into the chest. Otherwise, the organ would die. Blood supply is also a critical component of replacing organs in children, for without a blood supply, the organ cannot grow as the child ages. A normal stomach has two blood supplies—one that supplies blood to the right side, and one that supplies blood to the left. The left side is the place from which the gastric tube would be cut. Creating the tube from the left side would ensure that the new organ maintains its own blood supply while the right side’s blood supply would not be disturbed.

  There was a fifth benefit—one I could not have fully realized at the time. Back in the 1950s, surgeons had not yet begun to replace human organs in patients using either transplanted organs from other individuals or artificially made ones. Th
ere was no artificial heart, for example. What we learned as we began doing organ replacement was that the body often rejects the new organs, and they stop working. Because my reversed gastric tube method was designed to use the patient’s own organs, there was little chance of rejection.

  I set about carefully analyzing my procedure to determine if it could work. I had many questions: Would the length of the gastric tube be adequate? Would its blood supply be sufficient? Would the parts be sufficiently mobile to extend to the neck? After studying the size of the organs involved and how they behaved, I determined that the procedure had strong potential and wanted to try it out on animals. But what medical college would allow a thirty-three-year-old doctor who had done no known scientific work to date to conduct research in its laboratories? My only solid contacts were at Montefiore Hospital, but it had no research laboratory or college. Mount Sinai Hospital started an animal-research laboratory in 1953, but when I inquired, I was turned down because the head of surgery was interested only in heart-surgery experiments.

  Then I thought about New York Medical College and decided to pay the director of surgery a visit. It was impulsive. I did not know his name, nor did I try to make an appointment. I simply walked into the hospital and asked if I could speak to the director of surgery at the information desk. The woman there said his name was Dr. James Winfield and told me where his office was. When I got to his office, I explained to the secretary that I was a surgeon with a promising new idea, and I asked if I could see Dr. Winfield. Amazingly, he agreed to see me on the spot.