Sepsis history

During the “pre-antibiotic” era surgery was the dominating medical discipline. Because of a lack of knowledge of hygiene, wound infections during this period were a feared and common complication post-surgery and it was believed wound rot was the cause.

Despite the term sepsis being closely associated with modern intensive care, it is a very old term. The word “sepsis” was originally introduced by Hippocrates (460-370 B.C.) and means decay in classic Greek.

Ibn Sina (979-1037) observed that the blood’s rot (septicemia) is compatible with fever. The term “sepsis” which was introduced during Antiquity was used into the 1800s. Little was known about

Ignaz Semmelweis

Ignaz Semmelweis (1818-1865)

pathophysiology, so the physician Herrman Boerhave (1668-1738) from Leyden believed sepsis was caused by damaging particles in the air. At the beginning of the 1800s the chemist Justus von Liebig further developed this theory by claiming that sepsis was caused by oxygen.

A modern view of sepsis was first developed by Ignaz Semmelweis (1818-1865). Semmelweiz was a gynaecologist at the maternity clinic at Vienna General Hospital. A common complication during this period was childbed fever which caused high mortality in sepsis among newly delivered women. Especially Semmelweis’s division had mortality as high as 18 percent. In this clinic, it was common that the medical students went directly, after having performed an autopsy on a corpse, to the maternity clinic to examine the women. Hygienic procedures such as washing the hands or wearing gloves were not common. Semmelweis assumed that small cadaverous particles “ending up in the blood vessels” were responsible for women falling ill. By letting students and midwives wash their hands with bleaching powder before examining the women he managed to reduce mortality to around 2.5%.

Despite his medical success, Semmelweis did not manage to enforce his hygienic measures. Instead, his medical colleagues spoke derogatorily of him. Not until 1863, 15 years after his discoveries did he publish his work: The childbed fever’s ethology and prophylaxis. Due to his failed efforts to achieve professional recognition he eventually became mentally ill and needed to be remitted to a psychiatric clinic.

Louis Pasteur

Louis Pasteur (1822-1895)

It is the irony of fate that he there died of … specifically wound infection/sepsis.

When the French chemist Louis Pasteur researched rot and the putrefactive process he discovered that these processes were caused by minimal unicellular creatures which he designated as bacteria and microbes. He correctly assumed already then that these microbes could induce illness.

Joseph Lister was a surgeon at Glasgow Royal Infirmary during the latter part of the 1800s. When he took over the management of the surgical division he could ascertain that around 50 percent of the amputated patients died of sepsis. Lister managed to find a connection between Semmelweis’s observations and Pasteur’s discoveries and the deaths in his clinic.

Joseph Lister

Joseph Lister (1827-1912)

With more or less modern methods he examined which effects disinfection by carbolic acid on skin and surgery tools had, first on animals and then on humans. In that way, Lister managed to reduce mortality dramatically after amputations. Contrary to Semmelweis, Lister managed to persuade his colleagues about the importance of antiseptic methods. Robert Koch (1843-1910) further developed Lister’s discoveries by introducing steam sterilization.

Hermann Lenhartz (1854-1910), medical director at the general hospital in Eppendorf, managed in Germany to enforce the idea that “putrefaction” could be a bacterial illness. It was however his student, Hugo Schottmüller who, in 1914 laid the foundation of the modern sepsis definition:

“Sepsis occurs when a core has formed within the body from which bacteria constantly or periodically end up in the bloodstream so that subjective or objective disease symptoms are triggered.”

Hugo Schottmüller

Hugo Schottmüller (1867-1936)

With this, for the first time, the core of an infection was formulated as a fundamental cause of sepsis. Lennhartz said that the doctor’s efforts must therefore focus on the free bacterial toxins and not on the bacteria “moving” in the blood. With this position he was far ahead of his time.

These major medical breakthroughs and an increased quality of life with less starvation and overcrowding had a major impact on mortality from infectious diseases and sepsis.

Despite this, there were still many patients who fell ill and died of sepsis. It was found that these patients often had low blood pressure. This condition was called septic shock.

In 1918, the world was hit by a very extensive flu epidemic, the Spanish flu. Estimates show that 500 million people became infected and that 50-100 million people (about 4% of the world population at the time) died of sepsis caused by bacterial “superinfections”, such as Staphylococcus aureus in the aftermath of the viral infection. This happened in four different waves in the years 1918–20 (Johnson and Mueller 2002). The number of deaths in the Spanish flu was thus higher than the number of deaths in both the First and Second World Wars combined. Unlike common flu strains, which mainly affect children and weak, elderly people, the Spanish flu mainly affected healthy individuals of working age. The Spanish flu also caused strong long-term effects on the economy of the survivors, with a 25% decline in capital income expected for them.


The Spanish flu swept over the world 1918-20 and an estimated 100 people were killed. Here is an image of a camp in American Camp Funston, Kansas, in 1918.
Image: National Museum of Health and Medicine, AFIP (Washington D.C.)

That it was called the “Spanish flu” is not because it originated in Spain, but because it was in Spain that it was first discovered, and this was due to the First World War. Spain, like the Nordic countries, was neutral in the First World War and therefore did not have the same strong need to keep bad news away from the mass media.

Staphylococcus aureus (SA) mentioned above is an example of one of many bacterial species that have plagued humanity since the dawn of history. In fact, an outbreak of staphylococcal skin disease may even have been mentioned in the Bible. Exodus, chapter 9, tells of the sixth plague in Egypt, when Moses and Aaron were

Staphylococcus Aureus

Staphylococcus Aureus

commanded by God to take two handfuls of soot from an oven and then spread the ashes to heaven. Both Egyptian men and cattle had developed purulent growths, so-called shhin, a term that can be translated as “boiling boils” which was a skin infection that was extremely difficult to heal. Sir Alexander Ogston, a Scottish surgeon and early advocate of antiseptic treatment, first described a bacterial organism in 1881 as the cause of “acute warts.” He named the organism, “Staphylococcus pyogenes aureus”, based on microscopic morphology, purulent nature, and tendency to form golden colonies on culture plates. In 1941, during the “pre-antibiotic” era, the mortality rate of patients treated for Staphylococcus aureus septicaemia was as high as 82 percent.

Only with the introduction of antibiotics after World War II could mortality in sepsis be further reduced. With the beginning of medical advances, intensive care also began to develop. The sepsis patients would become a significant group in the intensive care units.

Roger C. Bone

Roger C. Bone (1941-1997)

1967 Ashbough and his colleagues described a severe lung disease where patients suffered severe respiratory distress and lung failure. This was named Adult Respiratory Distress Syndrome (ARDS) – an often deadly complication. It quickly became apparent that especially patients with sepsis often suffered from this complication.  It also became apparent that the origin of ARDS was a consequence of an inflammatory reaction activated by the body’s own substances. In the 80s it was discovered that the inflammatory reaction not only existed in the lung but the whole body. It was obvious that sepsis not only would depend on the focus of infection but also on the body’s own reaction to this infection.

This was described in 1989 by the American intensive care Doctor of Medicine Roger C. Bone using the definition of sepsis that still applies today. “Sepsis is defined as an invasion of microorganisms and/or their toxins in the blood along with the organism’s reaction to this invasion.”