A Ward of Rubber and Glass

The construction was not complete. In the first week of September 1952, Blegdam Hospital’s upper floor had become a factory for breathing, its former ward architecture dissolved into something unrecognizable to the nurses who had worked there in July. The sound of compressed rubber filled the corridors—a rhythmic, wet slap of Ambu bags being squeezed, released, squeezed again, twelve to fifteen times each minute, the rate varying with the arm strength and concentration of whoever held the bag. The bags were pale green, made of synthetic rubber, with a valve assembly of metal and glass that clicked faintly at the end of each compression. They cost little and broke often. When a seam split, a student ran to the supply closet for another while a nurse took over with both hands, her shoulders already aching from her own shift.

The ward had been transformed. Where twelve beds once stood in orderly rows, separated by white curtains, now twenty-four mattresses crowded the floor, pushed together so that a nurse could walk the narrow aisles only by turning sideways. Oxygen lines ran overhead in improvised bundles, rubber hoses dropping at intervals like vines, each terminating in a metal flowmeter mounted on a wooden bracket screwed into the wall. Suction apparatus sat on wheeled stands at the foot of every second bed, glass reservoirs and rubber tubing coiled and ready. The floor was linoleum, pale green like the bags, scuffed white where beds had been dragged back and forth as the census changed.

At the center of this rearrangement stood Poul Astrup’s blood-gas apparatus. It occupied a table once used for dressing changes, its surface now covered with the components of an analytical system: a glass electrode for measuring pH, a manometer for carbon dioxide tension, a tonometer for calibrating samples against known gas mixtures. The machine required constant attention. Blood drawn from an artery—usually the radial, sometimes the femoral in the smallest children—had to be analyzed within minutes before the dissolved gases shifted. Astrup worked here, or one of the physicians he had trained, moving from bed to bed with a tray of heparinized syringes, returning to the central station to run the determinations, then calling out numbers that determined how the students squeezed.

The numbers mattered. Before Astrup’s apparatus arrived in force, the students had worked by appearance. A bluish tint to the lips meant squeeze harder, faster. A flushed face meant ease off, give the carbon dioxide time to wash out. These signs were unreliable. Cyanosis could mean poor circulation rather than poor oxygenation. Flushing could mean fever rather than hypercapnia. Patients died while looking comfortable, or rallied briefly while looking moribund, and no one could say why. Now the blood spoke. A pH below 7.25 meant acidosis, the carbon dioxide accumulating faster than the kidneys could compensate. A pCO2 above 60 millimeters of mercury meant ventilation was inadequate, the squeeze must be deeper or more frequent. The students could not see these numbers, but the physicians who supervised them could, and supervision had tightened as the ward formalized.

The transformation had happened quickly. Blegdamshospitalet began August with its single Emerson iron lung and six cuirass respirators, the standard equipment for respiratory failure. By early September, that equipment had been superseded. The iron lung stood unused in its dedicated room downstairs, its motor still functional but its design obsolete for this particular crisis. The cuirass respirators hung on their hooks like diving equipment abandoned by a flooded expedition. The hospital had learned what Bjørn Ibsen demonstrated on Vivi Ebert: that positive pressure delivered through a tracheostomy could succeed where negative pressure failed, that the problem was not paralysis of the breathing muscles alone but the retention of carbon dioxide in blood made too acidic to sustain life.

The learning required reorganization. The tracheostomies created a new category of patient, one who could not be managed in the scattered fashion of the first weeks. Each patient needed a clear airway, which meant suctioning every fifteen minutes to clear accumulated secretions. Each needed humidified oxygen, which meant flowmeters and nebulizers and constant monitoring of the tubing for condensation. Each needed the bag, which meant a human being standing or sitting at the bedside, squeezing, counting, watching the chest rise and fall, listening for the subtle change in breath sounds that might indicate a plugged cannula or developing pneumonia.

The students provided the labor. They arrived by the hundreds, medical and dental students from the University of Copenhagen, summoned by telephone chains and bulletin board notices, organized into shifts that ran through the twenty-four hours. They were not volunteers in the sentimental sense. They were conscripted by a national emergency, by the understanding that their education would wait while they performed this service, by the simpler fact that no one else was available. The trained nurses were too few and too valuable for tasks that required only stamina and attention. Physicians were needed for procedures that required training—the tracheostomies, the arterial punctures. They also adjusted treatment based on Astrup’s numbers.

The students slept where they could. The hospital requisitioned classrooms, a gymnasium, the basement of a nearby church. They arrived for their shifts in street clothes, changed into white coats that might be theirs or borrowed, took their places at the assigned beds. The assignment was not permanent. Patients died, or improved enough to wean from the bag, or deteriorated and were moved to beds nearer the nursing station where supervision was tightest. The students moved with them, or moved to fill gaps, learning to read the quick briefings that accompanied each handover. One patient needed deeper breaths, his carbon dioxide climbing. Another was fragile, requiring gentler pressure after a pneumothorax the previous day.

The ward developed its own temporality. Outside, September advanced toward autumn. The days shortened, the temperature dropped, the epidemic continued its exponential spread through Copenhagen and beyond. Inside, time was measured in breaths. Four seconds each. Fifteen per minute. Nine hundred per hour. The students learned to count without counting, to fall into the rhythm as into a kind of walking, the mind free to wander while the hands maintained their mechanical task. Some reported a dissociation, a sense that the patient and the bag and their own aching shoulders had become a single system, the boundary of self expanding to include the rubber and glass and the struggling lungs.

Others found the intimacy unbearable. The tracheostomy site, visible at the throat, a hole ringed by sutured skin, the plastic or metal cannula protruding, the bag connecting to it with a click of the fitting. The patient’s eyes, usually open, usually conscious, following the student’s face with a look that might be gratitude or accusation or simply the fixed stare of someone who cannot blink. The smell of the secretions, sweet and foul, that the student must suction away without gagging. The occasional patient who could still speak, whispering through the cannula, asking questions the student was not qualified to answer: whether they would walk again, how long this would continue, whether their mother had been told where they were.

The physicians developed new routines. Bjørn Ibsen moved through the ward several times each day, less visible now than in the first experimental days, his presence concentrated in the difficult cases and the teaching moments. He had argued for this system against the skepticism of colleagues who preferred the iron lung, who found the tracheostomy invasive and the manual ventilation primitive. The mortality figures were beginning to support him. Where bulbar polio had killed more than ninety percent of patients managed with negative pressure devices, the new approach was achieving survival rates that would eventually reach eighty percent. The transformation was technical, but it also demanded a different medical attention: continuous rather than episodic, quantitative rather than impressionistic, collective rather than individual.

Poul Astrup’s apparatus made this attention possible. The blood-gas measurements provided an objective language for what had been subjective guesswork. They allowed comparison between patients, between treatments, between the outcomes of different students’ techniques. They revealed patterns that no single clinician could have perceived: the patient whose ventilation looked adequate but whose pCO2 crept upward through the night; the patient who tolerated weaning attempts better in the morning than the evening; the correlation between secretions and acidosis that pointed to the importance of suction timing. Astrup published nothing during the epidemic itself. His data accumulated in handwritten ledgers, in the heads of the physicians who learned to interpret them, in the gradual refinement of protocols that would emerge only later as formal knowledge.

The physical arrangement of the ward expressed these intellectual changes. The central station, with its blood-gas apparatus, became the functional heart of the space. The beds radiated outward from it in rough rows, the most unstable patients closest, the more stable toward the periphery. This geography was not static. Patients migrated inward as they deteriorated, outward as they improved, their movement tracked on a chalkboard that someone updated hourly. The oxygen lines and suction apparatus followed similar logic, the infrastructure concentrated where need was greatest, extended to new beds as the census expanded.

The expansion continued. Through the first week of September, new patients arrived at rates that would have seemed catastrophic a month before but now registered as routine. The admitting office had developed a triage protocol: respiratory symptoms, bulbar signs, immediate transfer to the upper ward; spinal paralysis without respiratory involvement, lower floors; uncertain cases, observation. The protocol was not perfect. Some patients deteriorated in the lower wards and arrived in the upper only after their blood gases had already turned dangerous. Others were transferred unnecessarily, occupying beds that others needed. The system strained at every joint.

But it held. The students kept squeezing. The bags kept hissing. Astrup’s apparatus kept generating its numbers, and the physicians kept adjusting treatment in response. The ward that resulted was something new in medical history: a space organized entirely around the maintenance of a single physiological function, staffed by workers whose sole task was to perform that maintenance continuously, supervised by specialists who interpreted quantitative data to optimize its performance. The space had no precedent in the hospital’s architecture or in medical tradition. It possessed instead the particular smell of rubber and antiseptic, the particular sound of compressed air and clicking valves, the particular sight of young people leaning over beds in attitudes of sustained, repetitive labor.

The new respiratory ward was now operational, locking in a relentless system of manual ventilation and monitoring that would define the coming months of the epidemic. The students had learned to sleep in any available corner, to eat standing up, to continue squeezing through the tremor of exhausted muscles. The physicians had learned to trust Astrup’s numbers, to intervene before crisis rather than in response to it. The hospital had learned that its space was fungible, that walls could be moved and beds crowded and corridors converted to clinical use when the need was sufficient.

By the second week of September, the pattern was set. The morning shift arrived at seven, the evening at three, the night at eleven. Each shift began with a conference at the central station, the outgoing supervisor presenting the overnight blood gases, the incoming team receiving their bed assignments. Then the squeezing resumed, the bags rising and falling in their mechanical rhythm, the students counting their breaths, the physicians moving among the beds with their syringes and stethoscopes, the ward maintaining its strange equilibrium between chaos and control.

Yet even as the system locked in, its physical form revealed the strain of its own success. The beds pushed together, the oxygen lines snaking overhead, the central station with its glass electrodes and clicking manometers—this arrangement had never been planned, only accumulated, each addition a response to the previous day’s crisis. The ward breathed through the hands of its student workforce, but it also breathed through its own improvised infrastructure, and both were being asked to perform beyond their designed capacity.

The blood-gas numbers that guided the physicians came slowly, one patient at a time, while the queue of new admissions grew faster than the queue of analyzes. The students who squeezed the bags learned to recognize the particular sound of a patient whose breathing had suddenly worsened, the particular stillness of a chest that had stopped moving, but they could not act on what they saw without calling for supervision, and supervision was spread thin across twenty-four beds and counting.

The physicians had begun to understand that they were managing a system whose outputs depended on inputs they did not fully control. The rate of tracheostomies, the availability of suction equipment, the calibration of Astrup’s electrodes, the stamina of the student workforce—all of these variables interacted in ways that no one had mapped. They worked from clinical intuition and from the numbers that accumulated at the central station, but the numbers described what had already happened, not what was happening now, and the intuition of even the most experienced physician could not encompass the simultaneous needs of two dozen paralyzed patients.

What emerged from this pressure was a form of medical attention the physicians themselves did not yet have language to describe. It was not the episodic care of traditional hospital medicine, the rounds at appointed hours, the treatment of discrete problems as they arose. It was not the continuous but undifferentiated vigilance of the night nurse, watching for any change in any patient.

It was something more focused and more systematic: the continuous monitoring of specific physiological parameters, the immediate adjustment of treatment based on quantitative data, the delegation of routine tasks to workers who need not understand their full significance. The physicians who practiced this attention did not yet know that they were inventing a specialty. They knew only that it seemed to work, that patients who would have died in August were surviving into September, that the numbers from Astrup’s apparatus correlated with outcomes in ways that justified the labor they required.

The students, meanwhile, inhabited a different understanding. For them, the ward was not a system but a place, not a protocol but a series of beds, each with its particular patient and its particular rhythm. They learned the names of the patients they squeezed, or the names that the patients whispered through their cannulas, or the nicknames that other students had given to patients whose real names they never learned. They learned to read the subtle signs of deterioration—the change in breath sounds, the shift in skin color, the particular quality of stillness that preceded crisis—but they learned also that these signs were not theirs to act upon. Their role was to maintain the rhythm, to keep the bag moving, to call for help when something changed. The judgment belonged to others.

This division of labor, this separation of execution from decision, was not new in medicine, but its extension to the fundamental act of breathing was unprecedented. The students who squeezed the bags were not assisting physicians; they were replacing a physiological function that the patient’s own body could no longer perform, and they were doing so under conditions of continuous supervision rather than periodic intervention. The physicians who supervised them were not prescribing treatment; they were adjusting that treatment in real time, based on data that described the immediate state of the patient’s internal chemistry. The ward that contained them both was not a hospital space; it was a machine for maintaining life, its parts human and mechanical, its operation dependent on the coordination of hundreds of individual actions.

The physical form of this machine continued to evolve. By mid-September, the oxygen lines had been reorganized into a more systematic distribution, the suction apparatus standardized, the central station expanded to accommodate additional analytical equipment. The beds remained crowded, the aisles narrow, but the chaos of early August had given way to something more orderly, more predictable, more sustainable. Or so it appeared. Beneath the surface of this order, the same pressures continued to operate: the arrival of new patients, the deterioration of old ones, the attrition of the student workforce as exhaustion and illness took their toll. The ward breathed, but its breathing was labored, maintained by effort that could not continue indefinitely.

What sustained it was not the efficiency of its organization but the urgency of its purpose. Every patient in the ward represented a life that would have ended without this intervention, a family that would have mourned, a future that would have been erased. The students who squeezed the bags, the physicians who interpreted the numbers, the nurses who managed the secretions and the tubing—all of them operated within this awareness, even when they did not speak of it. The ward was a workplace, but it was also a site of rescue, a place where the ordinary categories of medical care had been suspended in favor of a more fundamental obligation: to keep breathing, to keep living, to maintain the possibility of recovery against the pressure of a disease that would otherwise be fatal.

This obligation shaped every aspect of the ward’s operation. The decision to push beds together, to run oxygen lines overhead, to establish a central station for blood-gas analysis—all of these had been made in the name of efficiency, but they had been made also in the name of survival, of the belief that more patients could be saved if only the space could accommodate them. The same belief drove the students to continue squeezing through the tremor of exhausted muscles, the physicians to work through the night interpreting numbers, the administrators to requisition more space and more equipment than the hospital’s budget was designed to provide. The ward was expensive in every currency: human labor, material resources, institutional flexibility, professional tradition. No one had yet calculated the total cost, or determined who would pay it, or asked whether the result justified the expenditure.

What they knew, in the second week of September 1952, was that the system worked. Patients arrived paralyzed, their blood gases deteriorating, their breathing failing, and they survived. Not all of them, but many more than would have survived in August, more than would have survived in any previous polio epidemic, more than the iron lung or the cuirass respirator could have saved. The numbers from Astrup’s apparatus confirmed this survival in the only language that the physicians fully trusted: pH, pCO2, bicarbonate, the chemical parameters of life maintained within viable ranges by the continuous effort of human hands. The ward had become a demonstration that breathing could be sustained indefinitely, that the failure of one physiological system need not mean the failure of the organism, that medicine could intervene at the most fundamental level of biological function and maintain that intervention for days or weeks rather than hours.

This demonstration had consequences that extended beyond the immediate crisis. The physicians who practiced in the ward, the students who labored there, the administrators who organized its resources—all of them were learning something that would not be unlearned when the epidemic ended. They were learning that continuous physiological monitoring was possible, that quantitative data could guide real-time treatment decisions, that a dedicated space with dedicated staff could achieve outcomes that scattered, episodic care could not match. They were learning, in short, the elements of what would eventually be called intensive care, though that name did not yet exist and would not be applied to this ward for several years.

What they did not know, what they could not know, was how long this learning could continue under current conditions. The student workforce was finite, the University’s tolerance for its diversion uncertain, the physical space of the hospital already stretched to its limits. The epidemic showed no signs of abating. Each day brought new patients, new demands, new crises that required immediate response. The ward operated in the present tense, its attention focused on the next breath, the next analysis, the next shift change. The future was a terrain it had not yet begun to map.

And yet the future was being shaped by every action in the ward, every decision made in the name of immediate survival. The blood-gas measurements that Astrup accumulated, the protocols that the physicians refined, the physical arrangement of beds and equipment and central stations—all of these would outlast the epidemic, would be transmitted to other hospitals, other countries, other crises.

The ward of rubber and glass was a response to the polio epidemic of 1952, but it was also the prototype of a medical space that would be replicated and modified and formalized until it became so familiar that its origins in improvisation and emergency would be forgotten. For now, it remained what it was made to be: a place where young people squeezed rubber bags in shifts, where glass electrodes measured the chemistry of survival, where the continuous labor of human hands maintained life against the pressure of paralyzed lungs.

The sound of compressed rubber filled the corridors. The blood-gas numbers accumulated at the central station. The construction was not complete, but what had been built would not be dismantled.