The first intensive care unit in the world: Copenhagen 1953

Abstract

After an extensive survey of the medical literature we present compelling evidence that the first intensive care unit was established at Kommunehospitalet in Copenhagen in December 1953. The pioneer was the Danish anaesthetist Bjørn Ibsen. The many factors that interacted favourably in Copenhagen to promote the idea of intensive care therapy, half a century ago, are also described.

Full text

Review Article
The first intensive care unit in the world: Copenhagen 1953
P. G . B ERTHELSEN and M. CRONQVIST
Department of Anaesthesia, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
After an extensive survey of the medical literature we present
compelling evidence that the first intensive care unit was
established at Kommunehospitalet in Copenhagen in Decem-
ber 1953. The pioneer was the Danish anaesthetist Bjørn Ibsen.
The many factors that interacted favourably in Copenhagen to
promote the idea of intensive care therapy, half a century ago,
are also described.
Accepted for publication 4 September 2003
Key words: Critical care therapy; critical care unit; history;
intensive care therapy; intensive care unit; polio epidemic;
recovery room; respiratory insufficiency.
#Acta Anaesthesiologica Scandinavica 47 (2003)
‘Disease desperate grown —by desperate appliance
are relieved —or not at all.’ William Shakespeare,
Hamlet.
FOR the purpose of this investigation we have
defined an intensive care unit as a ward where
physicians and nurses observe and treat desperately
ill patients 24 h a day. The unit may serve patients
from all branches of medicine. The primary goal is to
restore and maintain the function of vital organs,
enhancing the chance of survival.
With this paper we present evidence that the
world’s first intensive care unit was established at
Kommunehospitalet, the Municipal Hospital of
Copenhagen, in 1953 by the Danish anaesthetist
Bjørn Ibsen.
Patient no. 1
December 21st, 1953
6.00 p.m.: A 43-year-old-man was admitted from the
medical ward to the Observation Room (Observa-
tionsstuen), at Kommunehospitalet in Copenhagen,
three days after he had attempted, unsuccessfully, to
hang himself. He was agitated, confused and cyanotic
with laboured respiration. Temperature 38.6Cand
pulse 136. An X-ray showed bilateral infiltrates and
oedema of the lungs. It was felt that fatal cardiopul-
monary failure was imminent.
Oxygen via a facemask and when the oxygen
saturation (monitored with a Milikan Oximeter)
decreased, with positive pressure ventilation from a
bag and mask, was started.
Furthermore, the patient was given one unit of
blood (500 ml), isotonic glucose (1000 ml) and an anti-
biotic (Aureomycin 250 mg four times a day).
December 22nd
7.15 a.m.: The condition of the patient had deteri-
orated. A tube with cuff was passed into his trachea
and manual positive pressure ventilation with 60%
oxygen in N
2
O was started. After the injection of
theophylamine (400 mg) and procaine (100 mg) his
condition stabilized.
10.25 a.m.: Blood pressure 140, pulse 120 and tem-
perature 39.8C.
00.45 p.m.: Oxygen saturation 80%. Increases to 86%
when 100%oxygen was used instead of the O
2
/N
2
O
mixture.
3.00 p.m.: An analysis of the patient’s arterial blood
revealed: bicarbonate 24.5, pH 7.51, pCO
2
31 mmHg,
and oxygen saturation 100%. Clinically the patient
was much improved. The respiration was sufficient
and he was extubated.
December 23rd
10.00 a.m.: The patient wasreturnedtothemedical
ward.
5.00 p.m.: Readmitted in a condition very much like
the one he was in when first admitted to the Observa-
tion Room.
7.55 p.m.: A tracheostomy was performed and posi-
tive pressure ventilation was resumed.
Acta Anaesthesiol Scand 2003; 47: 1190 —1195 Copyright #Acta Anaesthesiol Scand 2003
Printed in Denmark. All rights reserved ACTA ANAESTHESIOLOGICA SCANDINAVICA
ISSN 0001-5172
1190

December 24th
The condition of the patient was unaltered. He
appeared dehydrated. A stomach tube was inserted
and an infusion of raw eggs and milk (2500 ml) was
started. He was given another transfusion of blood.
Positive pressure ventilation was continued.
Hyperthermia (41C) was combated by covering the
patient with wet blankets.
December 25th
The patient was somnolent with paralysis of the legs.
His respiration was still insufficient with large
amounts of secretions obstructing the airways. Ther-
apy was continued as outlined above and Penicillin
(2,000,000 IE) was added.
On December 26th the patient died from cardiopul-
monary failure.
The abstract from the medical charts illustrates
many aspects of intensive care even as we know it
today: the continuous recording of the function of
vital organs; the immediate intervention when
changes in the patient’s condition mandated it; moni-
toring of the effect of the intervention.
There is no doubt that what was described in the
records of this patient and in the records of several
others subsequently treated in the Observation Room
was bona-fide intensive care therapy.
Was the Observation Room, at the
Municipal Hospital in Copenhagen, the
first intensive care unit in the world?
‘In science, the credit goes to the man who convinces
the world, not the man (to) whom the idea first
occurs’. William Osler
When it is impossible to establish who did what,
where and when in medicine, priority is awarded to
the one who first publishes on the subject. Conse-
quently, we carried out a thorough search of the med-
ical literature (see Appendix A).
The first paper on intensive care therapy appeared
in Nordisk Medicin,September18,1958:‘Arbejdet pa
˚en
Anæsthesiologisk Observationsafdeling’(‘The Work in an
Anaesthesiologic Observation Unit’) (1). The authors
were the Danish anaesthetists Bjørn Ibsen (Fig. 1)
and Tone Dahl Kvittingen from Norway (Fig. 2). The
paper was in Danish but the English resume is shown
in Fig. 3.
The number of patients treated in the intensive care
unit increased from 1 in 1953 to 13 in 1954, 34 in 1955,
91 in 1956 and 120 in 1957. The average length of stay
also increased from 2.1 days in 1954 to 5.3 days in 1957.
Why was an epoch-making paper published in a
language few speak and understand? and why did it
take 5 years before Bjørn Ibsen first published on his
innovation and the results of establishing an intensive
therapy unit? Ibsen cannot, today, remember what
prompted him to publish in a journal with limited
circulation outside the Nordic countries. It is true
that he was the Danish coeditor of Nordisk Medicin
but he was also coeditor of the newly started (1957)
Acta Anaesthesiologica Scandinavica,wherehisideas
and results would have been presented in English.
‘What we did was just to use the principles and
techniques, which served us well in the operating
Fig. 1. Bjørn (Aage) Ibsen (1915—). Initiator of the first
multidisciplinary intensive care unit. Ibsen graduated from
medical school, University of Copenhagen, in 1940. From 1949
to 1950 he was Resident in Anaesthesia, Massachusetts General
Hospital, Boston. In 1951 he received his specialist diploma in
anaesthesiology. The turning point in his career came when he
became involved in the treatment of the most severely ill victims of
the 1952 poliomyelitis outbreak in Denmark. In 1954 Ibsen was
elected Head of the Department of Anaesthesiology,
Kommunehospitalet, Copenhagen (Photo c. 1955).
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1191

theatre, also on patients with medical diseases’, Bjørn
Ibsen told us when we interviewed him in February
2002. ‘Really we felt that it was not such a big deal and
therefore there was no hurry in publishing the results
of the treatment in the Observation Room.’
In line with this there was no official opening of the
unit. It started little by little in the hospitals newly
opened (July1953) postoperative recovery room(Fig. 4).
In the beginning, the doctors and nurses were on
duty when needed but from April 1954, when Bjørn
Ibsen was appointed Head of a new and independent
department of anaesthesia, the Observation Room
was staffed around the clock.
Bjørn Ibsen was not the first to envisage a special
unit for severely ill patients (2), but it is our contention
that he was the first to follow up on the idea. He
rejected the generally held views on the utility of
treating critically ill medical patients. Instead of the
prevailing fatalism and therapeutic nihilism, Ibsen
chose an aggressive and optimistic approach.
Many factors interacted favourably, in Copenhagen
in the early 1950s, to create a scene where Bjørn
Ibsen’s idea was accepted that critically ill patients
(medical as well as surgical) should be observed and
treated in a special ward by physicians and nurses
trained in restoring and/or maintaining the function
of vital organs. In the years following the Second
World War Danish physicians had contributed signifi-
cantly to the battle against tuberculosis in postwar
Europe. As an appreciation of this effort WHO
decided [at the suggestion of Erik Husfeldt (1901—85)
the first Danish cardio-thoracic surgeon] to establish
the so-called Anaesthesiology Centre Copenhagen in
May 1950. For 23 years, from all over the world, train-
ees came to Denmark for a 1-year course in anaes-
thesiology. And most importantly the teachers were
the leading anaesthetists from the UK, Sweden and
the USA. Among many others, Henry K. Beecher,
H. C. Churchill-Davidson, Stuart C. Cullen, Robert
Dripps, Francis Foldes, Olle Friberg, Torsten Gordh,
T. Cecil Gray, H. W. C. Griffiths, Martin Holmdahl,
R. R. MacIntosh, Eric Nilsson, Jackson Rees, John
W. Severinghaus, Leroy Vandam and Ralph M.
Waters. There is no doubt that the centre increased
the prestige of anaesthetists in Denmark and created
an international stimulating and fruitful professional
Fig. 2. Tone Dahl Kvittingen(1911—2001). Norwegian coauthor of
the seminal paper on intensive care therapy. After receiving her
medical degree from University of Oslo she completed her basic
training in anaesthesiology at Rikshospitalet in Oslo. In 1955—56
she attended the WHO-sponsored course on anaesthesiology in
Copenhagen. From 1959 she was Head of the Department of
Anaesthesiology, Trondheim Sentralsykehus [her career was much
more exciting than these few facts suggest: see Strømskag (4)].
Fig. 3. The resu
`me of the first paper on intensive care therapy.
P. G. Berthelsen and M. Cronqvist
1192

milieu in Copenhagen that increased the public
awareness of the potential of this new speciality.
The 1950 report from the Second Commission on
the future organisation of the anaesthetic services in
the hospitals of the municipality of Copenhagen (3)
also helped pave the way. It was coauthored by two
influential professors of surgery [Jens Foged
(1897—1956), chief surgeon, Bispebjerg Hospital, and
Otto Mikkelsen (1895—1960), chief surgeon, Depart-
ment of Surgery I, Kommunehospitalet].
The report recommended that independent
departments of anaesthesia should be established
in all hospitals. The anaesthetists should care for
the patients during the operation and postopera-
tively ‘maintaining a sufficient circulation of blood
by transfusion of blood and plasma, and infuse salt
and water to restore the fluid balance and secure
the best possible oxygen delivery by an energetic
support of the respiratory function’ ... ‘These prin-
ciples for supportive therapy should also be
applied to patients with medical diseases and self-
poisoning’. Furthermore, the report suggested, for
financial and practical reasons, that it would be
prudent to design and designate a room where
patients could recover postoperatively.
Special wards for specific purposes were not
unheard-of in the early fifties. In 1949 Carl Clemmensen,
Head of the Department of Psychiatry at Bispebjerg
Hospital in Copenhagen, established a centre for the
treatment of patients with barbiturate poisoning (5).
Barbiturate poisoning was often lethal in those
days, but by intensive therapy of shock (serum
infusion, electrolyte replacement) and respiratory
insufficiency(lung physiotherapy, prophylactic
penicillin) the mortality rate decreased signifi-
cantly. Nobody, however, extrapolated these
favourable results to other patient categories.
In the late forties postoperative recovery rooms/
wards were established in many hospitals around
the world and also in Denmark. Usually the patients
were observed and treated in such units only for a few
hours postoperatively until the effects of the anaes-
thetic had vanished. In the medical literature we have
found no evidence that such a service was extended
also to patients with medical diseases before Ibsen
started doing so in December 1953.
The pivotal point came with Ibsen’s involvement in
the 1952 polio epidemic in Copenhagen.
When 27 out of 31 poliomyelitis victims, with
respiratory involvement, had died during the first
few weeks of the epidemic Professor H. C. A. Lassen
(1900—74), Head of the Medical Department, Bleg-
damshospitalet, condescended to ask Bjørn Ibsen’s
advice. It must be remembered that, in those days,
anaesthetists were not highly regarded by other phys-
icians. They were seen as technicians who knew a few
gimmicks. When Ibsen was consulted in August 1952
(6) he almost immediately realized that polio patients
died from respiratory insufficiency with carbon
dioxide retention and not from an overwhelming
virus infection of the brain as was generally believed
by the epidemiologists. Ibsen proposed to treat the
patients with tracheal intubation via a tracheostomy
and controlled or assisted manual ventilation with a
bag and a to-and-fro system with a Waters’ cannister.
He first proved his point when a 12-year-old para-
lyzed and cyanotic girl, Vivi, survived when she was
treated as Ibsen advocated (7, 8). In the following
months mortality decreased markedly to approxi-
mately 25%. It soon became clear that it was imprac-
tical to treat patients with respiratory insufficiency in
all the different wards in the hospital. When the
patients were concentrated in three specially desig-
nated wards, each of 35 beds, the quality and effi-
ciency of the treatment of respiratory insufficiency
and circulatory instability improved.
So although the special wards at Blegdammen
treated patients with the same modalities as was
later used in proper intensive care units, nobody
suggested that the concept should be broadened to
encompass all types of patients with critical illnesses.
An important side-effect of Ibsen’s contributions,
during the epidemic, was to increase considerably the
reputation of anaesthetists generally and Ibsen person-
ally. A fact that helped when a year later he needed to
Fig. 4. Kommunehospitalet i n Copenhagen. The ho spital was
inaugurated in 1863. The student nurses’ classroom turned into
the worlds first intensive care unit was on the first floor, right next
to the main entrance (Photo ca. 1980).
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1193

convince the health authorities of Copenhagen and his
colleagues at Kommunehospitalet that anaesthetists
were indeed proper doctors and could take care of
patients also outside the operating theatre.
In April 1953 Ole V. Secher (1918—95) became the
first Head of an independent Department of Anaes-
thesia in Denmark at Rigshospitalet in Copenhagen.
Rigshospitalet was the most prestigious hospital in
Denmark at the time. The appointment of Secher
was a wise choice but it was at the expense of Ibsen
who was both older and more experienced. This rejec-
tion was a disappointment to Ibsen, but there is little
doubt that it also acted as an incentive. He became
determined to show the Professors at Rigshospitalet
that they had taken the wrong view. So, in April 1953
when Ibsen became Senior Resident (anaesthetist) in
the Department of Surgery I at Kommunehospitalet
his fighting spirit had been roused. and he needed it
right away. In the surgical department there was dis-
agreement between the surgical senior residents as to
the best postoperative volume replacement therapy.
To solve this problem, Otto Mikkelsen, Chief of the
Department, asked Ibsen to supervise and direct how
surgical patients should be treated in the recovery
room (and the wards) (9). This controversy between
his surgical colleagues allowed Ibsen to take charge of
the recovery room and subsequently made it possible
for him on 21 December 1953 to change a purely
surgical recovery ward into a unit where all types of
patients could receive professional help.
In conclusion, it is beyond reasonable doubt that the
first intensive care unit in the world was established
in the Observation Room at Kommunehospitalet in
December 1953. and that Ibsen, as the initiator, must
be counted as one of the people who were instru-
mental in laying the foundation of our profession.
Acknowledgements
Five (alphabetical order) colleagues have contributed with their
first-hand knowledge and impressions of the events leading up
to the establishment of the first intensive care unit in the world.
Elieser Arge: Senior House Officer (Reservelæge) from August
1953 to September 1955, Departments of Surgery and Anaesthe-
siology, Kommunehospitalet (later Chief Surgeon, Thorshavn,
Faroe Islands).
Bjørn Ibsen: 1 April 1953 to 1 April 1954, Senior Resident
(1. Reservelæge) (anaesthesiology), Department of Surgery I,
Kommunehospitalet. From 1 April 1954, Chief, Department of
Anaesthesiology. Professor of Anaesthesiology, University
of Copenhagen, 1971.
Carl Jørgen Carlsen: Senior Resident from September 1951 to
December 1954, Department of Surgery I, Kommunehospitalet
(later Chief Surgeon, Thisted Sygehus, Denmark).
Ole Juhl: Senior House Officer from April 1953 to December
1956, Departments of Surgery I and Anaesthesiology, Kommune-
hospitalet (later Chief Anaesthetist, Aalborg Kommunehospital,
Denmark).
Hans Heugh Wandall: Senior Resident, Department of
Surgery I, Kommunehospitalet 1950—56 (later director of the
Institute for Experimental Medicine and Surgery, University of
Copenhagen).
Very useful background material has been provided by Niels
Fjeldborg, former Chief of the Department of Anaesthesiology,
Aarhus Amtssygehus, and Henning Sund Kristensen, former
Chief Anaesthetist, Blegdamshospitalet, Copenhagen.
We obtained useful ground plans and pictures of Kommune-
hospitalet from Erik Dauv-Pedersen (Senior Pharmacist) and
Jørgen Wiedemann (Hospital Manager).
Kjell Erik Strømskag, Molde, Norway, provided data on Tone Dahl
Kvittingen — coauthor of the first report on intensive care therapy.
References
1. Ibsen B, Kvittingen TD. Arbejdet pa
˚en anæsthesiologisk
observationsafdeling. Nordisk Med 1958; 38: 1349—55.
2. Kirschner M. Zum Neubau der chirurgischen Universita
¨tskli-
nik Tu
¨bingen. Der Chirurg 1930; 2: 54—61.
3. Betænkning II. Afgivet Af Den Af Magistraten Under 28. Februar
1944 Nedsatte Hospitalskommission. København: J.H. Schultz
Universitetsbogtrykkeri, 1950.
4. Strømskag KE. Et fag pa
˚søyler. Anestesiens historie i Norge.
TanoAschehoug 1999.
5. Nilsson E. On treatment of barbiturate poisoning. A modified
clinical aspect. Acta Med Scand 1951; 139 (Suppl.): 89—98.
6. Ibsen B. The anaesthetist’s viewpoint on the treatment
of respiratory complications in poliomyelitis during the
epidemic in Copenhagen, 1952. Proc Royal Soc Med 1954; 47:
72—4.
7. Wackers GL. Modern anaesthesiological principles for
bulbar polio: manual IPPR in the 1952 polio-epidemic in
Copenhagen. Acta Anaesthesiol Scand 1994; 38: 420—31.
8. Kristensen HS. Comment on the description of the polio
epidemic in Copenhagen 1952. Acta Anaesthesiol Scand 1996;
40: 134—5.
9. Ibsen B. From anaesthesia to anaesthesiology. Personal experi-
ences in Copenhagen during the past 25 years. Acta Anaesthe-
siol Scand 1975; 61 (Suppl.): 29—33.
Address:
Preben G. Berthelsen,MD
Department of Anaesthesia
Gentofte Hospital
University of Copenhagen
Niels Andersens Vej 65
DK-2900 Hellerup
Denmark
e-mail: prbe@gentoftehosp.kbhamt.dk
P. G. Berthelsen and M. Cronqvist
1194

Appendix A
The following sources were searched to find the first article on the
treatment of patients in an intensive care unit:
Index Medicus, 1950—60
Web of Science (www.wos.isiglobalnet.com). In this database it is
possible to search for author names and words in the titles of 1.5
million papers published between 1945 and 1960. We used the
following search string: icu or sicu or care unit or recovery room
or intensive care or critical care or observation ward.
Ugeskrift for læger (Journal of the Danish Medical Association),
1950—60
Nordisk Medicin, 1950—60.
Acta Anaesthesiologica Scandinavica, 1957—63.
Anaesthesia, 1955—60.
Der Anaesthesist, 1955—60.
Anaesthesia and Analgesia, 1950—67.
Anaesthesiology, 1952—69.
British Journal of Anaesthesia, 1955—63.
Journal of the American Medical Association, 1950—60.
Lancet, 1950—60.
New England Journal of Medicine, 1950—60.
Surgery, Gynecology and Obstetrics, 1950—60.
Proceedings of the Third Congress of the Scandinavian Society of
Anaesthesiologists. Copenhagen, 11—12 June 1954 (even though
the main topics were respiratory insufficiency and respirators
the concept of an ICU was not mentioned).
Abstracts from the First World Congress of Anaesthesiology.The
Netherlands, 5—10 September 1955 (again no mentioning of
an ICU).
Rushman GB, Davies NJH, Atkinson RS. A short history of anaes-
thesia. The first 150 years. Butterworth and Heinemann, 1996.
Rendell-Baker L, Mayer JA, Bause G. Pioneers and Innovators in
Anaesthesia. In: The History of Anaesthesia. The Fourth Inter-
national Symposium on the History of Anaesthesia. Lu
¨beck:
Verl a g Dr a
¨ger-Druck, 1997.
Atkinson RS. Bjørn Ibsen and his contribution to the start of
intensive therapy as a part of the speciality of anaesthesia
and intensive care. Current Anaesthesia and Critical Care.
1997; 8: 184—186.
Evans TW. Hemodynamic and Metabolic Therapy in Critically
Ill Patients. N Engl J Med, 2001; 345: 1417—18.
Webel N, Harrison B, Southorn P. Anaesthesia origins of the
intensive care physician. In: Proceedings of the 5th International
Symposium on the History of Anaesthesia.Amsterdam:Elsevier
Science, 2002.
Safar P. Development of cardiopulmonary-cerebral resuscita-
tion in the twentieth century. In: Proceedings of the 5th Inter-
national Symposium on the History of Anaesthesia.Amsterdam:
Elsevier Science, 2002.
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