The Greatest Killer: Smallpox in History.

Donald R. Hopkins, 2002. Chicago, The University of Chicago Press. 80 pages, soft cover, plus illustrations. ISBN 0-226-35168-8.

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  • 1 Division of Infectious Diseases, University of Michigan Health System, Ann Arbor, MI, E-mail:

The Greatest Killer is a comprehensive monograph that traces the history of smallpox from its origins in antiquity until the present day. In this encyclopedic book, Donald Hopkins provides a thorough account of the disease’s devastating impact on a variety of cultures—ancient Egypt, medieval to 20th century Europe, China, India, Africa, and the Americas, and, as a consequence, the course of history. For example, he meticulously shows how smallpox committed a “regicidal rampage”, killing a “queen of England, an Austrian emperor, a king of Spain, a tsar of Russia, a queen of Sweden, and a king of France in the 80 years before 1775.” Furthermore, by not restricting his focus to western civilizations alone, he allows readers to compare general ideas about smallpox across cultures, such as those regarding disease causality (i.e., supernatural, naturalistic, etc.), and how they served as a basis for various therapies. He successfully places these ideas in their particular social and historical context, and shows the impact each epidemic has had on that individual culture. He meticulously shows, for example, how individual religious practices have been aimed at propitiating a particular god thought to control the outcome of smallpox—Sekmet (Egypt), T’ou-Shen Niang Niang (China), Shapona (Yoruba), etc. He also illustrates how commercial interests in 19th century America favored a sanitationist view of smallpox, since they preferred measures that did not require quarantining goods and people (i.e., measures advocated by contagionists).

Hopkins vividly shows the horror that this terrible disease has caused societies throughout history. His descriptions of how smallpox decimated certain societies, using such words as “unpredictable grotesque torture” to describe its demolition of Incan and American Indian societies, perhaps is a reflection of his own personal experience with the disease. He was a physician who treated smallpox victims in the Sierra Leone in the late 1960s, an experience that few practicing physicians have had today. In spite of his appropriate focus on the gravity of his topic, he nonetheless manages to artfully weave in more lightheaded, entertaining examples of how the disease has influenced certain societies. Mentioning how a fanciful hairstyle, pouf a l’inoculation, was used to celebrate successful inoculation of the wife of Louis XVI in 1774, he provides the reader a welcome, although brief, respite from his otherwise sober topic.

The chapter on erythrotherapy is a particularly strong demonstration of how certain practices may persist, rather than be completely replaced by widespread belief in newer ideas and therapies. For example, he traces the therapeutic efficacy of red objects from Avicenna to European royalty, and shows how these ideas persisted even into the 1930s, when a Viennese doctor vaccinated his patients in rooms illuminated with red light, then covered the vaccinated area with red bandages. The doctor’s claim of excellent results is a nice example of how beliefs in old therapies are not abolished when new ideas are introduced, but may continue in parallel with new beliefs.

The shortcomings of this book, some of which the author acknowledges, do not detract from its great value. His attribution of Athenian plague to smallpox (Chapter 1), for example, does not account for Thucydides’ acknowledgement that animals as well as humans were inflicted with the plague. Also, primary sources are sparsely used, which is understandable, given the broad territory he covers. Additionally, references to past ideas as “curious beliefs” and practices revealing the “pathetic price of ignorance” (Chapter 8) suggest he is basing his views of these practices on information that is believed to be true today. Finally, his account gives a disproportionate amount of attention to “important people”, such as monarchs, Marcus Aurelius, and Mozart.

This is an authoritative, encyclopedic monograph on the history of smallpox, and it is well written. In addition, this is a timely book, given the concern that smallpox could be used as a weapon by terrorists. For these reasons, I highly recommend it as a useful reference for those interested in bioterrorism, history of medicine, and, in particular, in the history of epidemics and medical experimentation. It provides a coherent perspective to the current dilemma regarding whether to vaccinate the U.S. population in the face of a perceived terrorist threat. The 19th century controversies between the provaccinators and antivaccianationist objections he reviews are highly relevant to today’s controversy.