The Doctors' Plague is a concise, compelling narrative that Nuland wrote for the informed public. Its eight chapters and brief afterword deftly cover the following topics: the ravages of childbed fever; various erroneous but strongly held beliefs circa 1850 about its causes; a comparison between the high rates of death from childbed fever in the Vienna hospital's first maternity clinic, which was staffed by physicians, and the lower rates of the second maternity clinic, staffed by midwives; Semmelweis's insight that physicians were infecting patients by introducing into the wounds of the birth canal decomposed organic material from cadavers they had dissected and from patients ill with childbed fever; Semmelweis's requirement that all physicians and students wash and scrub their hands in chlorine before examining their patients; Semmelweis's inability to establish firmly these ameliorative procedures even in his own institutions in Vienna and in Pest; his struggle to write The Etiology, Concept, and Prophylaxis of Childbed Fever, a book presenting his theory and defense of it; and his mental breakdown, incarceration in a mental hospital, and death triggered by the staff's brutal treatment.
Understanding a person as complex as Semmelweis, who was subject to the social and political forces of the medical faculties and facilities of the University of Vienna, may require some psychological interpretation, which Nuland freely offers (pp. 94-95, 168-75). To explain why Semmelweis left Vienna, Nuland emphasizes the psychological attractions of Pest, rather [End Page 232] than the ugly politics that pushed him away from Vienna: "He ran back to Hungary because it was safe and it was home; he made himself believe in the fantasy of his rejection because it gave him the rationalization he needed to rush back to that protective cocoon" (p. 174). The political pushes were strong, however. Semmelweis had solved the puzzle of childbed fever and instituted procedures that would reduce its occurrence. However, Johann Klein, the head of obstetrics and Semmelweis's immediate supervisor, did not renew his two-year position as assistant, even though Semmelweis's elite allies—Rokitansky, Skoda, and Hebra—supported his reappointment. Klein had allowed Semmelweis to require the chlorine washing that reduced the death rates but resisted his explanation because it implied that changes Klein had instituted in obstetric education—autopsy of cadavers and invasive examinations—were responsible for the deaths, thus putting his conscience and job at risk.
Semmelweis did receive an alternative appointment in Vienna, but one that was humiliating: It required him to use a female mannequin to teach medical students rather than dissection of cadavers, which was state-of-the-art. He declined. His career in Vienna blocked, he abruptly departed Vienna for Pest without informing his supporters, who then withdrew their sponsorship. The political intrigues pushing Semmelweis to leave cosmopolitan Vienna for provincial Pest were real.
Counterfactual models of causality enable statistical scientists to make causal inferences from observational data. Nuland's use of counterfactuals, however, limits the importance of Semmelweis's achievements by shifting the frame of reference from what Semmelweis did do, which was significant, to what he might have done, which would have been even more significant. He (pp. 114-16, 149, 180) explicitly faults Semmelweis for failing to ask his colleague Joseph Hyrtl in Vienna—and implicitly, his colleague Ign·c Hirschler in Pest—to examine pus from the victims of childbed fever under their microscopes, a tool whose use was then being perfected. Had they done so, Nuland suggests (p. 115), they might have identified the bacteria that caused the infection, anticipating Pasteur. Why fault only Semmelweis for this lost opportunity? Given the potential relevance of microscopy to Semmelweis's controversial theory, why did the two microscopists not suggest its use to their colleague or themselves carry out the examination of pus?
Although Semmelweis did conduct laboratory experiments in which he convincingly induced childbed fever in three rabbits (p. 113), Nuland (pp. 111-14) faults him for not conducting more and better laboratory experiments on animals. Semmelweis probably thought...