Resuscitation (2007) 74, 403—405
The Holger Nielsen method of
Thomas F. Baskett∗
Department of Obstetrics and Gynaecology, Dalhousie University, 5980 University Avenue,
Halifax, Nova Scotia B3J 3G9, Canada
Received 20 March 2007; received in revised form 20 March 2007; accepted 20 March 2007
Widespread teaching and application of manual
techniques of artificial respiration for both lay
people and medical personnel developed in the
last half of the 19th century and into the early
20th century. One of the first methods to achieve
acceptance was that of Hall,1followed by the tech-
niques of Silvester,2Howard,3and Shafer.4Until
the early 20th century the two most commonly
used methods were those of Hall and Silvester. Both
the Hall and Silvester techniques suffered from
the fact that the tongue was likely to fall back
and obstruct the airway and similar criticism was
levelled against the Howard technique. In 1904,
the prone pressure method developed by Shafer
was increasingly accepted, although it was shown
subsequently to be the least effective of all the
In Copenhagen, Colonel Holger Louis Nielsen
(1866—1955), who was a physical fitness instructor
in the Danish Army and an experienced teacher of
life saving methods, began to work on an improved
technique of artificial respiration6
Nielsen had taught both the Silvester and Shafer
methods to his students. However, he felt that
neither of these techniques was ideal: the supine
position of the Silvester method with its poten-
tial for airway obstruction by the tongue, and the
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prone pressure method of Shafer which lacked an
active inspiratory phase component. He thus devel-
oped his method in which the victim was placed
prone with the elbows bent and the hands placed
under forehead. The expiratory action was the
same as Shafer’s with prone pressure on the pos-
terior part of the chest and the inspiratory phase
was accomplished by lifting the elbows.7,8Initially
Nielsen proposed two operators, one each for the
inspiratory and expiratory phases, respectively. He
presented this proposal to the Danish Red Cross
in 1930 but they rejected it on the grounds that
it was impractical to expect two operators to be
present.6The answer to the one-man approach
came to Nielsen fortuitously when he attended a
masseur seeking relief from muscular pain in his
shoulders. During the massage, while Nielson lay on
his stomach he noted that when the masseur, who
was positioned at the head of the table, pressed
down on his shoulder blades it caused a forced
expiration.6,9Nielsen had the answer: he placed
one rescuer at the head of the victim with instruc-
tions to press down on the shoulder blades then
pull up on the bent elbows (Figure 2). The method,
which became known as the ‘push—pull’ technique,
was described as follows8:
‘The victim’s arms are folded and his face turned
sideways and placed on his hands. The operator
kneels about 6 inches from the head...he places the
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404 T.F. Baskett
Figure 1 Holger Nielsen (1866—1955).
heels of his hands on the upper edge of the shoulder
blades with the fingers spread out obliquely. He
slowly rocks forward on straight elbows until his
arms are nearly vertical, exerting steady pressure
on the chest; then rocks back slowly, sliding his
hands to the victims arms, just above the elbow,
grasps the arms and continues to rock backward,
raising the arms until tension is felt, and then
draws them slightly towards himself; finally, he
lowers the arms, completing the cycle. The whole
cycle should take about six seconds, so that it is
carried out at a rate of about 10 times a minutes.
Two seconds should be allowed for pressure on the
back and two seconds for traction on the arms,
allowing one second for every change of the hand
As Nielsen developed his technique he sought
assured him that the amount of pulmonary ventila-
tion with his manoeuvre was equal to or superior to
other techniques.10He then published his method
in the Danish literature11(Figure 3).
In 1933 the Danish Red Cross accepted and
endorsed Nielsen’s one-man method. The Holger
Figure 2 The Holger Nielsen method of resuscitation.8
The Holger Nielson method405
Figure 3 Nielsen’s original paper.11
Nielsen method of artificial respiration was rapidly
accepted in Scandinavian countries and in Europe
by the late 1930s. In 1935 Nielsen introduced his
technique at the 4th International Congress for
Live-saving and First Aid in London. Acceptance of
his method spread throughout Europe and North
America and by 1953, at the International Red
Cross Conference in Toronto, Nielsen’s technique
was officially adopted as the method of choice for
first-aid teaching.12However, by the late 1950s
the evolution of cardio-pulmonary resuscitation
with mouth-to-mouth respiration rendered obso-
lete Nielsen’s and the other techniques of manual
artificial respiration that had been developed over
the previous 100 years.
Conflict of interest
1. Hall M. On a new mode of effecting artificial respiration.
2. Silvester HR. A new method of resuscitating still-born chil-
dren, and of restoring the persons apparently drowned or
dead. BMJ 1858;2:576—9.
3. Howard B. The more usual methods of artificial respiration.
With demonstrations of the ‘‘direct method’’ of the author.
4. Shafer EA. Description of a simple and efficient method of
performing artificial respiration in the human subject espe-
cially in drowning to which is appended instructions for
the treatment of the apparently drowned. Med Chir Trans
5. Gordon AS, Fainer DC, Ivy AC. Artificial respiration: a new
method and comparative study of different methods in
adults. JAMA 1950;144:1455—64.
6. Karpovich PV. Adventures in Artificial Respiration. New York:
Association Press; 1953. p. 63—6.
7. Garland TO. Artificial respiration: with special emphasis on
the Holger Nielsen method. London: Faber and Faber Ltd.;
8. Resuscitation drill—–the Holger Neilson method. The Royal
Life Saving Society’s handbook of instruction. 22nd ed.;
9. Eisenberg MS. Life in the Balance. New York: Oxford Univer-
sity Press; 1997. p. 82.
10. Asmussen E, Nielsen M. Efficacy of artificial respiration. J
Appl Physiol 1950;3:95—102.
11. Nielsen H. En oplivningsmetode (method of resuscitation).
Ugesk f Laeger 1932;94:1201—3.
12. Gentle HW. A new method of artificial respiration. Natl
Safety News 1935;32:34.