As the chief resident of Obstetrics in Vienna in the 1840s, Ignaz Semmelweis oversaw two maternity clinics.
But he had a problem.
One clinic had a maternal mortality rate of about 10%, while the other had a considerably lower maternal mortality rate of 4%. This gap was very well known to people outside the hospital as often, women would beg to be admitted to the Second Clinic due to the reputation of the first clinic.
Semmelweis struggled to determine why one mortality rate was significantly higher at one clinic than another. Semmelweis eliminated all known differences – including religious practices. After that, the only significant difference was the individuals who worked there. The First Clinic was a teaching hospital for medical students, while the Second Clinic was for the instruction of midwives only, but he couldn’t figure out how that could have mattered.
The breakthrough occurred following the death of a fellow doctor who had been accidentally poked with a student’s scalpel while performing a post-mortem examination. The Doctor’s autopsy showed a pathology similar to that of the women dying in the First Clinic. That’s when Semmelweis had his “aha” moment and connected the cadavers with the cause of death for women in the First Clinic.
He concluded that he and the medical students carried “cadaverous particles” on their hands from the autopsy room to the patients they examined in the First Clinic. This explained why the student midwives in the Second Clinic, who were not engaged in autopsies and had no contact with corpses, saw a much lower mortality rate.
The idea of germs (and germ theory) had not been accepted in Vienna. Thus, Semmelweis concluded some unknown “cadaverous material” caused the higher mortality rate. He then instituted a policy of using a solution for washing hands between autopsy work and the examination of patients.
This story is important to us for the following reasons:
- Sometimes we are the problem and don’t know it yet
- The answer to some challenges haven’t been identified yet
- The answers you seek may not be anything you’ve ever considered before
We must take Semmelweis’ learning experience into our next challenge. In the end, Semmelweis used data and an open mind to identify and resolve the problem. Thankfully what we do isn’t life or death. Still, let’s all keep washing our hands.
Originally posted February 13, 2018