UNITED STATES FLEET 
UNITED STATES NAVAL FORCES, GERMANY 
SENIOR U. S. NAVAL LIAISON OFFICER 
ATTN.: TECHNICAL SECTION (MEDICAL) 
Room 111, Headquarters 
Fourth Medical Laboratory 
APO 403, U.S. Army, c/o PM. 
NY/NY. 
File: P 3-l(c) 
Serial: 265-Med. 
7 April 1949 
From: 
U.S. Naval Forces, Germany, Office of the 
Senior U. S. Naval Liaison Officer, EUCOM Hq. 
Attn.: Technical Section (Medical) APO 403 
To: 
Chief of the Bureau of Medicine and Surgery, 
Department of the Navy, 
Via: 
(1) Technical Officer, U.S.Naval Forces, Germany 
(2) Chief of Naval Operations (0p-32-F2) 
Subject: 
Indexes - Geographical and General - for Atlas 
of Epidemiology - Forwarding of. 
Reference: 
Ja) Ltr. from this off* dtd.15 Dec.1948, File 
P 3-1(c), Serial 254-toed, to Chief. BUMED, 
(b) Ltr. from this off. dtd.21 Feb.1949, File 
P 3-1(c), Serial 260-Med, to Chief, BUMED. 
Enclosures: 
(A) Author Index to the Atlas of Epidemiology 
prepared by the Hygienists of the former 
German Armed Forces, 
(£) General Subject Index to the Atlas of Epi- 
demiology prepared by the Hygienists of the 
former German Armed Forces, 
(C) Geographic Index to the Atlas of Epidemio- 
logy prepared by the Hygienists of the former 
German Armed Forces. 
1* By references (s) and (b) translations of the Atlas 
of Epidemiology and introductory articles which subsequently be- 
came available were forwarded to various addressees. 
2. The Atlas referred to is now in the process of 
further development into a world atlas. In this connection de- 
tailed cross reference/indexes of the material in the Atlas 
were compiled for use in the future project. 
3. As the card index developed it became evident 
that it made accessible information otherwise more or less 
buried in the mass of the text of the Atlas. For that reason 
the card index has been placed on pages and is forwarded here- 
with as enclosures (A),{B) and (C) . It is believed that this will 
make a more accessible and useful work of the translation of 
the Atlas. 
Captain, U.S.N. 
Senior U. S. Naval Liaison Officer 
cc: 
| (see page 2) Page 2 of letter P 3-l(c), Serial 265-Med, dated 7 April *49 
from U.S.Naval Forces, Germany, Office of the Senior 
U.S. Naval Liaison Officer, to BUMED, Navy Department. 
cc: 
ONA, OMGUS, 
CNO (OP-32-F2) 
BUMED (Publications Division) 
BUMSD (Research Division) 
BUMED (Professional Division) 
BUMSD (Preventive Medicine Division) 
Army Medical Library 
N.M.R.I., Bethesda, 
Naval Medical School, Bethesda, 
Department of Army Surgeon General, 
Medical Intelligence Section 
Department of Air Force, 
Air Surgeon, Medical Intell♦Section. 
U.S. Public Health Service, 
Office of the Surgeon General 
U.S. Department of Commerce, 
Office of Technical Information. I 
FOREWORD 
by 
Dr. Handloser, General, MC, 
Chief Commanding Officer of 
the Medical Service of the 
Armed Forces 
Translation prepared by: 
U.S.Fleet, U. S. Naval Forces, Germany 
Technical Section (Medical) I 
INTRODUCTION 
by 
Dr. Zeiss, Colonel, M.C. 
Consultant Epidemiologist 
on the Staff of the Chief 
Commanding Officer of the 
Medical Service of the Army. 
Translation prepared by: 
U.S.Fleet, U.S. Naval Forces, Germany, 
Technical Section (Medical). II 
In no previous war during the entire history of 
Germany and the Germhn people have soldiers been re- 
quired to fight in such varied climates and countries 
of the earth as during the present war. As a result 
the diseases occurring in the countries occupied are 
great in number and therefore all the more important 
and dangerous for German troops. If one is to take 
precautionary measures against these endemic or epi- 
demic diseases, to control and if possible to extin- 
guish them, it is necessary to know their ”area of in- 
cidence”. This Atlas of Epidemiology is compiled to 
provide the information required. The medico-geographic 
maps exhibit the picture of static conditions. Its geo- 
graphical and medical, or geo-medical maps, show the 
picture of the dynamic progress of disease. By the 
closest cooperation of the Military Medical Academy 
and the Institute of Hygiene of the University of Ber- 
lin, the Atlas of Epidemiology has been completed. It 
will be a valuable contribution of medicine to strate- 
gic warfare. Simultaneously it is a most promising in- 
auguration of a new branch of research for German and 
European Epidemiologists. 
The exigencies of war prevent the Atlas from being 
made available to the general public at the moment. 
Therefore 'it is only intended to distribute it among 
the military circles and the German Universities, which 
are to employ it for the training of the medical stu- 
dents with regard to their future duties in the Armed 
Forces. 
DR. HAND LOSER, 
General, M.C. 
Chief Commanding Officer of the 
Medical Service of the Armed 
Forces. 
Headquarters of the 
Army, Autumn 1942. II 
Knowledge of the medical topography and the medical 
geography of an area or a country is just as important 
for the final development or the final outcome of a battle 
as is knowledge of its physical geography. The soil, the 
vegetation, the animals and men living in it, that means 
the entire biogeographic appearance of a country, deter- 
mine the strategic or tactical decisions. Whether the 
soldier invades a country in order to conquer it and hold 
it, or he merely overcomes it in battle and passes on 
through it to invade another country, he will always come 
into closest contact with the biology of the soil, its 
vegetation and the animals and men settled in it. He can- 
not escape them even during the most violent fighting, 
particularly not if he stages his preparations for battle 
in such an area or he occupies such an area after a vic- 
tory. Whether or not the soldier will advance or fight 
in a fThealthyn or a "diseased" area depends on the con- 
dition of the soil and its flora and faunae It is there- 
fore the task of epidemiology as a branch of military 
medicine to neutralize the noxious influences of the dis- 
eased area, or if this cannot be done to reduce them as 
much as possible. Both have to rely on medical geography 
and, just as strategic and tactical warfare will overcome 
and eliminate the obstacle of a mountain or a water course 
cleverly used by the enemy for defense in the "fighting 
area", so must epidemiology accomplish the same strategic 
work in overcoming and eliminating the epidemics existing 
or insinuating themselves in that area. Just as the sol- 
dier during combat often changes a landscape by his in- 
tervention, the epidemiologist must sometimes do the same 
to make the nature of the country his servant in the 
battle against epidemics. In every case he alters its 
biogeographic appearance and with that its map. Without 
a map such extensive accomplishments are impossible. 
The principal value of every war map is implied in 
the fact that it also constitutes a basis for considering 
the situation. Just as tactical planning for a military 
operation employs the map of the unknown area for the 
prognosis of the outcome of the battle using physical 
geography as well as the proper disposal of men and arms, 
so must the epidemiologist provide from medical geography 
and from the information concerning endemics and epidemics 
on a historical basis the prognosis for fighting the epi- 
demics. Only then can the real epidemiological situation 
be recognized distinctly. Ill 
The decisions in strategic warfare are not in- 
frequently influenced by such an epidemiological map 
showing the results of medical scientific studies and 
research work* The publication of the Atlas of Epidemi- 
ology is therefore compiled with the intention of contri- 
buting to the protection of the German forces from any 
damage through invisible enemies. 
DR. ZEISS, 
Colonel,MG, 
Consultant Epidemiologist 
on the Staff of the Chief 
Commanding Officer of the 
Medical Service of the Army. 
High Gommand of the Army, 
Medical Service of the Army, 
Berlin, in the Autumn, 1942, 1 
MEDICAL CARTOGRAPHY AND CONTROL OF EPIDEMICS 
Lecture given during the II Conference of the Medical 
Consultants (Eastern Theater) of the German Armed For- 
ces in Berlin (2 December 1942), before the German 
Military Medical Society in Berlin (IS February 1943), 
and before the German Cartographic Society in Berlin 
(17 March 1943). 
Translation prepared by: 
U. S.Fleet, U.S. Naval Forces, Germany 
Technical Section (Medical) Any study of medical cartography must be based upon 
the knowledge and a clear picture of the two elements 
from which it has arisen, that is medical geography and 
geographic medicine or, in short, geomedicine* For the 
develbpment of medical geography which relies upon medi- 
cal topography, and which can be traced back as far as 
the times of Hippocrates, numerous most interesting 
documents of German medical science are available. How- 
ever, these have not yet been evaluated completely for 
the practical and theoretical use of modern epidemiology. 
Valuable material on many regions of Germany is still 
concealed in them. In cooperation with the geographers, 
the geologists and the cartographers, epidemiologists 
will often be surprized how many forgotten or unnoticed 
sources are to be found. The same applies to the medi- 
cal geography of all other countries in which material 
frequently has been found which has been available for 
decades without having been evaluated, as I just dis- 
covered in a certain country where the practical value 
of the material for the field of epidemiology was not 
recognized sufficiently. The same may happen in other 
countries too, as one discovers when investigating 
foreign sources to complete German research work. This 
fact applies particularly to the medical topographies 
which were developed principally in Germany in the course 
of the 18th century. These have been collected for many 
years in the Institute of Hygiene of the University of 
Berlin and detailed studies on them are being prepared. 
Some of them have already been published. In the "Archiv 
fuer Bevoelkerungswissenschaft und Bevoelkerungspolitik" 
Vol. 5, page 175 (1935) I made reference to them as a very 
important source of information for ethnology, and it was 
JUSATZ who recently outlined their significance for geo- 
graphic research in "petermann»s Geographischen Mitteilun- 
gen,f 1943, page 159* Even though these medical topographies 
are usually concerned with only one certain town or dis- 
trict, as they were compiled by the local medical officer, 
sometimes more accurate remarks are found referring to 
military matters, because mention is made of losses 
through infectious diseases and other hazards during 
military action in the respective places and districts 
regarding the population and troops operating in the area* 
Later on the former Prussian and Imperial Austrian Ministry of War recognized the value of the topographic descrip- 
tions of the medical experience of garrisons, though 
these were published only in a limited number and short- 
ly afterwards were abandoned. 
Contrary to this the Russian authorities continued 
the research work which was initiated by the classical 
medical dissertation of K.E. von BAER about the Estonians 
(Dorpat 1814) , who in his turn followed the G-erman model 
and created an exemplary work. Thus two collections of 
medical topographies were published during the seventies 
of the 19th century which were completed according to the 
systematic plan usually employing the authorship of dis- 
ciples of the Military Medical Academy in Petrograd. 
These collections revealed glimpses of military medicine. 
Here again, German medical officers serving in the Russian 
forces during the Crimean War made remarkable observations 
which could even have been published in our days. I am 
thinking principally of the old descriptions of the medical, 
geographic and topographic situation in the Inkerman Valley, 
and of the most severe type of malaria which was prevalent 
even at that time. Though in the following years these 
efforts were not continued, the interest in medical topo- 
graphy remained alive. New impulse was given by the ex- 
pansion of Russia towards Central Asia, Alaska, and to 
the Far East before the conflict with Japan. That was 
especially promoted by World War I, and by the decisive 
importance of the Caucasus mountains during the war a- 
gainst Turkey. During that time numerous very detailed 
topographies accompanied by maps were compiled by Russian 
medical officers. In these we find a most accurate des- 
cription of the geographic significance of the strategical- 
ly most important areas of the Caucasus mountains, and with 
that considerations of the epidemiological importance re- 
garded from the military point of view. According to the 
sources available to me, the Soviet regime continued those 
topographies with special consideration of malaria occur- 
ring in the Caucasus mountains. In view of the consider- 
able accuracy with which they handled all these military 
topics one may expect valuable contributions to the medi- 
cal topography of the Caucasus mountains in general and 
concerning malaria in these mountains in particular, even 
if one relies exclusively upon the abstracts made from 
them. The evaluation of the Russian medical topographies 
which so far has been made for 120 of them is carried through in a common investigation by Professor RODEN- 
WALDT and several associates. 
Turning to medical geography we observe that it 
consists either of several medical topographies of 
single places or districts or that it comprises the 
medico-geographic description of a country as a whole, 
of continents, or of the whole earth. The topic varies 
between the description of all endemic or q)idemic dis- 
eases occurring in the respective territory, and the 
medico-geographic presentation of a certain disease. 
Such a medical geography usually is a kind of "instan- 
taneous design of the epidemiological area" of a geo- 
graphic unit. The single stages cf the design are 
presented in the varying development and very frequent- 
ly they encompass the adjoining healthy area. In any 
case borderline areas play their part, as they are recog- 
nizable as a barrier against an infectious disease or as 
a medico-geographic border against the endemic form of a 
disease, according to whether or not one is confronted 
with traveling or stationary diseases of parasitic or 
non-parasitic origin. Particularly during the 19th cen- 
tury we owe a number of results to medico-geographic in- 
vestigations. 
The synoptic evaluations of medical topographies 
cf the 18th and 19th centuries sometimes are voluminous 
compilations of more or less critically digested material. 
Within these range the well known German works of FINKE, 
ISENSEE, FUCHS, HIRSCH, MUEHRY, SCHNURRER and the French 
authors BORDIER, LAURENT, LOMBARD, POINCARE, the Italian 
author MUZIO and others. 
A review of the cartographic methods according to 
which the various investigators recorded their results, 
and endeavored to present them in a lucid geographic 
form in the synopses on medical geography or infectious 
diseases - I just mention SCHEUBE, MENSE, KOLLE-WASSER- 
MANN, and many others in foreign countries - reveals 
very primitive concepts which do not attain the high 
level of the methods used by the geographers, nor can 
they be compared with them. The cartographer as well 
as the epidemiologist has so far overlooked the medico- 
geographic map and in the course of one century they made only weak attempts to create a medical cartography; 
for even LOMBARD’S work and his’Pathological Atlas or 
the Presentation of the Geographical Distribution of the 
Principal Diseases” is the only heretofore known attempt 
at an Atlas of Diseases and Epidemics, which after all 
was a complete failure. Other scientists also tried to 
attempt various methods of the geographical presentation 
of diseases on maps, and cartographers such as August 
PETERMANN and Hermann BERGHAUS contributed more or less 
successful studies. These noteworthy preliminary studies 
and attempts were reviewed by JUSATZ in the ’"Mitteilungen 
des Reichsamts fuer Landesaufnahmen” 1939* 
Therefore until recently we have been confronted with 
a great variety of medico-topographic and geographic maps 
among which the topographic presentation sometimes was bet- 
ter than others, as it was restricted to regional maps or 
very simple drawings, which as in a military sketch showed 
the actual situation. 
A strong impulse was given to medical cartography by 
the creation of the concept and method of geomedicine. 
When I first (1931) made this suggestion which was initi- 
ated by my extensive expeditions and travels in southeast 
Russia I postulated entirely new medico-geographic and 
geomedical maps and Atlases and a special geomedical meth- 
od . 
I postulated the prognosis as one of the principal 
tasks of geomedicine, which is as dynamic as geopolitics. 
From this the development of geomedicine was induced un- 
der the influence of Karl HAUSHOFER to whom I owe practioal- 
ly the entire concept of an establishment of geomedicine 
in accordance with his method of geopolitical research. 
Geomedical research work is based upon two premises: 
1. The knowledge of the geographic structure 
of the territory to be investigated with 
the geomedical method, that means its bor- 
ders, its surface structure, its soil and 
its paleontology, its zones of ’’particular 
sensitivity”, its general climate as well 
as its special local climatic conditions, 
its symbiosis, its civilization, its urban 
landscapes and many other things. 2. The knowledge of the medical and medico- 
historical events in the territory to 
be investigated. 
Briefly described, geomedicine is that branch of 
medical science which is concerned with the investiga- 
tion of the spatial and chronological relations of the 
progress of disease in concurrence with the progress of 
other events. For many years HAUSHOFER and his school 
of thought have been wotking on the theoretical and 
practical aspect of dynamic maps. They have developed 
special methods of describing geopolitical events and 
progress which are generally known from the geopolitical 
literature or at least from the newspapers. However, 
the German geographers too have recently subjected the 
dynamic map to critical and systematic discussions. 
The difficulties of presentation frequently apply by 
more to the topic than to the method. The two prob- 
lems, however, cannot be discussed separately and their 
solution will be all the more difficult because in the 
dynamic map in geopolitics as well as in medicine the 
progress in time and space have to be presented in only 
two dimensions. The difficulties are not present if on- 
ly attempts to outline the actual distribution of a cer- 
tain disease throughout a geographical entity are made 
if this distribution of the disease is a matter of the 
past or of slow changes. Matters are different as soon 
as one desires to display the progress of an epidemic 
on a map; We undertook this with a typical migrating 
epidemic, cholera, and we described for a period of many 
years the various appearances of cholera in Germany. 
Russia, Great Britain, Austro-Hungary. The descriptions 
of cholera in Poland, Switzerland, Belgium, France and 
Greece are being prepared* In this we employed a method 
heretofore unknown in medical cartography and with great 
success. We used the method of geography and cartography 
which draws isohemeres, such as isobars, isotypes, iso- 
therms and many others. OLZSCHA, for instance, when 
studying cholera in Russia called his lines indicating 
the incidence of the disease isodates, that means he 
connected all these places in which cholera occurred 
on the same day and in this way he studied the invasion 
of cholera in Russia. In one place he marked the in- 
vasion as an eruption and he followed the progress of 
cholera in the country. This method provided entirely new results and supplied new information on the migra- 
tion of a bacterial disease which is not spread by- 
wandering rodents as for instance plague and tularemia. 
This geomedical method does not mean the final 
stage of development. The contrary is true, the geo- 
medical method stands at the beginning of its develop- 
ment. It permits a large number of other valuable com- 
binations such as, for instance, including the density 
of population, the botanic and the zoologic geography 
of animals transmitting the disease and the areas where 
they find their food, and in addition it permits con- 
sidering simultaneously the most important geological 
condition of the soil upon which the settlement of man 
and animals always depends. 
In additi on the method considers the alteration of 
a landscape by man, which is effected during peace and 
war, the alteration of a landscape by natural events 
which through the forceful action of a flood, of a vol- 
canic eruption, of an earthquake changes the appearance 
of whole areas, or it has to take into account the slow 
development of changes in the coast line, of swamps, the 
rise and fall of the subsoil water level be it through 
man or the persistent influence of naturee The extent 
to which geomorphological analysis as "diagnosis" and 
’’therapy" is apt to provide clarity and remedy in geo- 
medicine has been repeatedly outlined by RODENWALDT, 
most recently in his lecture "Geomorphological Analysis 
as a Means of Epidemic Control", held in the Eastern 
Theater of Operations (12/2/42). I want to point out 
that the prognosis is the final objective and the highest 
point of development of geopolitics and geomedicine. 
This may be demonstrated by a significant example. 
Before the war the investigations of MARTINI revealed 
in his book "The Route of Epidemics" suggestions con- 
cerning the geographic distribution of tularemia which 
were followed up by JUSATZ. The following results 
were obtained: 
The principal area of distribution of 
tularemia in Russia, that means of the ro- 
dents transmitting the disease, shows a 
precipitation of 250 to 500 mm. This appears 
in the areas of Voronesh, Kaluga, Rostov and 
Orel. Our prognosis indicated that these areas would certainly become areas of dis- 
ease, The expectations were fully confirmed 
by the occurrence of tularemia during the 
war years 1941-1943Even though tularemia 
did occur in previously healthy areas it did 
not become lodged there as the biological con- 
ditions for the rodents were unsatisfactory. 
However, if we look at the remaining foci on 
the map, we recognize that there are areas of 
Germany which are threatened by tularemia, 
since all biological conditions are probably 
fulfilled and even the rodents transmitting 
the disease are to be found in these districts., 
But apart from this valuable preliminary work in the 
field which transforms geographical topography to medical 
topography, there is no methodical cartography of epi- 
demics, in short an Atlas of Epidemics. 
The gap is to be filled by this Atlas. According 
to the wishes of the medical officer who defined the 
task, General (MC) Professor Dr. med. S. HANDLOSER, 
Chief of the Medical Services of the German Armed For- 
ces, the regions treated in the present war edition of 
the "Atlas of Epidemiology” shall be restricted to an 
area comprising continental Europe, the Mediterranean 
Basin, the Near East, the Transcaspian Region and East- 
ern Europe as far as the Ural Mountainsa The concepts 
upon which this work is based have been outlined by me 
in the introduction to the Atlas of Epidemiology to which 
I here refer. 
Thus the medical map becomes a prognostic instru- 
ment in the hands of the epidemiologist if he makes use 
of it with common sense and critical experience. If he 
disregards this restriction and instead attempts to read 
things out of the maps which are not there and if he pays 
no attention to the bacteriological and clinical diag- 
nosis of the epidemics, he is merely a crystal gazer. 
It is not permissible to use the geomedical method 
of the diagnostic and prognostic map exclusively, but 
it must be employed only in the closest association 
with all other facts. Every faulty use will yield the 9 
same detrimental results as in geopolitics. The powerful 
force of the medical map will then turn against those 
who use it and from a scientific means of research it 
becomes a poison causing an euphoric attitude whose 
sequelae may hit the population for which the epidemi- 
ologist is responsible, be they soldiers or civilians. 
H. ZEISS 
(Institute for General and 
Military Hygiene of the Mil- 
itary Medical Academy and the 
Hygienic Institute cf the 
University of Berlin). I 
FOREWORD 
to the 
TRANSLATION 
of the 
ATLAS OF EPIDEMIOLOGY. The age of the airplane, jet-propulsion and the rocket have 
brought to man's attention more forcibly than ever before, the fact 
that all men live on one globe. No longer is it acceptable to think 
of the world as a collection of continents separated from each other 
by the various seas and oceans. A new galaxy of subjects has' de- 
veloped on this basic concept of one world. It would perhaps be more 
exact to say that eaoh of the sciences has taken on a "one world" 
facet that is more or less new to it. Geo-medicine is that new facet 
on the healing arts. Yet even here, as with a number of ether sciences, 
this is not a new concept in the sense of original discovery, but rather 
it is new in the sense of general recognition of its importance. 
Geo-medicine, or medical geography if you prefer, can safely be 
described as a field of science that is certain to grow tremendously. 
Despite the intense interest of a number of pioneers in this field and 
the fact that the early works are quite old, there is yet so much left 
undone and untouched that it is almost as though the field was new. 
When the German political jmchine set out on its campaigns of 
conquest, the opportunity for the realization of a long time ambition 
of two men was presented. During the First World War two young doctors 
stationed in the Balkans discussed and talked about one day making an 
atlas of the world to show the various diseases along with the geo- 
graphic and climatic factors having .an influence on them. The senior 
of these was Ernst RODENWALDT and the junior was H. ZEISS* At the war's 
end circumstances and events shaped the course of their individual lives 
differently and each went his separate way, maintaining contact and never 
losing the dream, but they were unable to do anything about it directly. 
The magnitude of the problem and the tremendous research necessary for 
its completion were tasks they could not undertake as individuals and 
still make their way in life, Wieh the outbreak of the Second World War 
these two were again brought in contact, this time the senior being Zeiss 
and the junior Rodenwaldt. In an atmosphere of expansive schemes of all 
sorts it was not too difficult for the idea of the atlas to be put con- 
vincingly before the high command. In due time orders were given and it 
became one of the major tasks of the epidemiologists of the German Armed 
Forces. It was only by mobilizing the resources of the wartime expanded 
economy of the nation and the availability of whatever manpower was 
needed that it could be undertaken with reasonable certainty of carry- 
ing it through. As armies advanced field representatives were able to 
enter areas previously somewhat inaccessible in some cases and, in the 
course of reestablishing some sort of public health control to obtain 
valuable information from local sources. It was in this manner that 
much of the information concerning southeast Russia was obtained. Some 
of their findings may be read in the translations of the Reports of Ill 
the conferences of the Medical Consultants to the Medical Services 
of the German Armed Forces, another translation project of the Naval 
Technical Unit, Enrope (Medical section). 
another group of researchers were combing the available litera- 
ture for reports concerning areas which were more accessible* The 
project was a matter of considerable pride to the high level medical 
command* And it was so very justifiably. The compilation of the 
Seuchen Atlas was a monumental task. Although undertaken in war-time, 
and presumably advanced to the military as a strategic necessity, this 
atlas will find its uses and its place in peacetime just as widely 
appreciated* 
The Medical Section of the Naval Technical Unit, Europe, recog- 
nizing the value of this work as a scientific undertaking, spurred 
on efforts to locate copies of the Atlas and when they were available 
began the chore of its translation* Ofher projects of higher priority 
made progress slow at first but during the course of 194# it- became 
the project of highest priority and its completion is in sight* The 
major portion of this work has been translated in Germany by a German 
group. The preliminary translations were then sent to the United 
States for editing. They were then returned to Germany for further 
inquiry and editing before they were prepared in their present mimeo- 
graphed form. Although cooperation has been of the highest order 
this wide separation has made impossible much of the close collabo- 
ration that is so important to this kind of work. Professor R®den- 
waldt, although not a member of the translating group, has been a- 
vailable in Heidelberg for consultation on the points of obvious un- 
certainty. He has given his assistance in a generous and kindly way. 
Although primarily an undertaking of the Medical Corps of the 
U. S. Navy the possibility of carrying this work through to completion 
has been very materially aided by the cooperation and sympathetic en- 
couragement of Major General A. E, NOYES, Theater Chief Surgeon of the 
European Command, U. So Army. Always ready with his personal assistance 
and the resources and personnel of his organization has been Lt. Col. 
Carl J* LIND, (MC.) u. S* Army, Commanding Officer of the Fourth Medical 
Laboratory. At a. time when the project was at a critical state he gave 
inestimable help in housing and logistic support for the personnel of 
the translators organization. That the translation is completed at all 
is an example of the finest kind of cooperation between the medical 
corps of the Army and the Navy. Acknowledgement must be extended to 
those more distant from the immediate scene who gave unfailingly their 
personal approval and support for the continuance of the translation 
work of the section. Outstanding among these were Rear Admiral IV 
C, A* SWANSON, Surgeon General of the Navy and Captain A* R. BEHNKE 
Research Executive of the Naval Medical Research Institute, 
HARRY J. ALVIS, 
Commander, Medical Corps, 
U. S* Navy, INDEX 
TO THE 
ATLAS OF EPIDEMIOLOGY 
Translation prepared by: 
U.S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical). INDEX 
FOLIO I 
Foreword 
Index 
Objectives and Methods of Medical Cartography. 
Section I 
Survey Maps 
1/1 Plague Foci of 1st and 2nd Order in Europe, 
Near East, and North Africa. 1921 - 1941. 
"1/2 Epidemics of Tularemia in Europe, Western Asia, 
and North Africa. 1921 - 1941 
1/3 Pandemic Distribution of the Indian Cholera. 
1934 - 1943. 
1/6 Paratyphoid A in Europe, 1902 - 1939* 
1/7 Paratyphoid C throughout Europe and the 
Mediterranean Basin. 
l/8 Distribution of the Sandflies (Genus Phlebotomus) 
in Europe. 
Section II 
Near East 
Il/l Occurrence of Plague in the Near East 
1917 - 1941. 
II/2 Distribution of the Fever Mosquitoes in Western 
and Central Asia. 
Il/2a Occurrence of Malaria and Distribution of 
Anopheles in Turkey. 
II/3 Arthropoda as Vectors of Diseases (except 
Anopheles) in the Near East. Il/4 Amebic Dysentery throughout the Near East. 
II/5 Leishmaniases in the Near East. 
Il/6 Leprosy in Iran. 
II/7 Ankylostomiasis and Bilharziasis in the 
Near East. 
II/9 Density of Population in the Near and Middle 
East. 
Section III 
TransCaspian Region 
IIl/l Occurrence of Malaria and Distribution of 
Anopheles in the Transcaspian Region. 
III/2 Sandflies and Ticks as Vectors of Diseases 
in the Transcaspian Region. 
III/3 Leishmaniases in the Transcaspian Territory. 
IIl/L Density of population in the Transcaspian Area. 
FOLIO II 
Section IV 
Eastern Europe 
IV/l Plague in Southeast Russia. 1877 - 1927. 
rv/la Incidence of Plague and Distribution of Ground 
Squirrels West of the Lower Volga, the Sig- 
nificance of the Steppe Rodents of Southeastern 
Russia for the Epidemiology of the Plague. 
IV/2 Occurrence of Malaria and Distribution of 
Anopheles in Caucasia. 
IV/4 Epidemic Distribution of Tularemia in the Area 
of Eastern Europe. 
IV/4a Epidemics of Tularemia in South East Russia. 
1926 - 1942. IV/5 Exanthematic Typhus in the Eastern Territories 
of Europe. 
IV/6 Leprosy in Southeast Russia and in the Trans- 
caspian Area. 
IV/8 Worm Infestation of the Population of Caucasia* 
IV/9 Precipitation and Isotherms in the Eastern 
European Territories. 
IV/10 Density of Population in the European East. 
Section V 
Baltic Area 
V/l Epidemics of Acute Anterior Poliomyelitis in 
the Baltic Countries. 1930 - 1941« 
V/2 The Distribution of the Bornholm Disease (Myalgia 
acuta epidemica SYLVEST) in the Region of the 
Baltic Sea. 
V/3 Leprosy in the Baltic Countries. 
V/4 Precipitation and Isotherms in the Baltic Area. 
V/5 Density of Population in the Baltic Area. 
Section VI 
Central Europe 
Vl/l Distribution of Trachoma in Central Europe. 
FOLIO III 
Section VII 
Mediterranean Region 
VII Geomedical Review of the Mediterranean Countries. 
VIl/l Mediterranean Fever (Melitensis-Brucellosis) in 
the Mediterranean Region. 
VIl/2 Malaria in Spain and Portugal* IV 
VIl/3 Occurrence of Malaria and Distribution of 
Anopheles in Italy. 
VIl/4 Occurrence of Malaria and Distribution of 
Anopheles in South East Europe. 
VIl/4a Occurrence of Malaria and Distribution of 
Anopheles in Greece. 
VIl/4b Occurrence of Malaria in Albania 
VIl/5 Leishmaniasis in the Mediterranean Basin. 
VIl/6 Leprosy in the Mediterranean Basin. 
FOLIO IV 
Section VII continued 
Mediterranean Region 
VIl/7 Ankylostomiasis and Bilharziasis in the 
Mediterranean Basin. 
VII/8 Distribution of the Yellow Fever Mosquito 
(Aedes AQgypti) as Vector in the Mediterranean 
Region. 
VIl/9 Part I Distribution of Ticks as Vectors of 
Diseases in the Mediterranean Region. 
VII/9 Part II Relapsing Fever in the Mediterranean 
Region. 
VII/10 Distribution of Rickettsial Diseases throughout 
the Mediterranean Basin. 
Vll/lOa Exanthematic Typhus in Spain. 1939 - 1942. 
VIl/ll Typhoid Fever in Spain and Portugal. 
VIl/12 Trachoma in the Mediterranean Area. 
VIl/l2a Distribution of Trachoma in Spain. V 
VIl/13 Distribution of Poisonous Snakes in the 
Mediterranean Area. 
YIl/14 Precipitation and Isotherms in the Mediterranean 
Basin. 
Section VIII 
North and West Africa 
VIIl/l-3 Yellow Fever in Africa. 
VIIl/4 Density of Population in the Countries of 
the Atlas Mountains. 1 
OBJECTIVES AND METHODS OF MEDICAL CARTOGRAPHY. 
Translation prepared by; 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical)® I. 
Medical Cartography as an applied medical and geographical 
science is considerably older than is generally known. Even Max 
ECKERT made a mistake when he wrote in the End volume of his "Kar- 
tenwissenschaft" (Cartographic Science) published in 1925: "Two 
decades more and medical geography will be a century old. It was 
in 1853 that Caspar Friedrich FUCHS wrote the first "Medizinische 
Geographie" (Medical Geography) and in 1856 it was Ad. MJEHRY who 
wrote "Die geographischen Verhaeltnisse der Krankheiten" (Geo- 
graphical distribution of diseases). The maps illustrating this 
distribution are referred to as "disease maps" or "nosological 
maps" • 
In reality, however, the first German text book was written, 
as I could prove, 60 years before, in 1792, by Leonhard Ludwig FINKE, 
though it must be granted that it did not include medical maps. A 
map illustrating the geographical distribution of diseases was sub- 
mitted as early as in 1827 to an assembly of natural scientists and 
medical doctors by Friedrich SCHNURRER. The decisive impetus for the 
edition of disease maps according to my investigations came in the 
beginning of the past century from a medical event of world historic- 
al importance, namely the first appearance in Europe of Asiatic Cholera 
(1830). In connection with this event a great number of maps were 
published illustrating the spread of cholera from India t© Europe and 
its incidence in the different European countries. 
The presentation of the methods used at that time t® fight 
epidemics, that is by the establishment of sanitary cordons may also 
count among the early rudiments of medical cartography» 
The most impressive example is a map of the year of 1831 represent- 
ing the unfettered spread of cholera into the provinces of Eastern 
Prussia in spite of the five different cordons which are also shown 
on this map. The Preussische Staatsbibliothek treasures several hand- 
colored maps of the years 1739> 1750 and 1770 representing the pestil- 
ence cordons at the Eastern borders of Prussia and the Southern bor- 
ders of the Reich which may be considered as early precursors of this 
type of medical maps. Thus it may be said that medical cartography 
even in its early beginnings served important practical purposes be- 
sides purely scientific research. 
II. 
Since these early attempts it is the main objective of medical 
cartography to show the geographic distribution of diseases and epi- demies in the different countries and continents, so as to give in 
the final result a survey of their distribution on the gl?be3 These 
attempts to give a geographic display of medical phenomena by means 
of a plani-globular projection and to divide the earth into different 
zones with typical diseases, which were probably first carried through 
by BERGHAUS in his "physikalischer Atlas" published in 1848 and re- 
cently by PETERMANN in 1921 (Geographische Mitteilungen, Map 4 to 7) 
and by M* SORRE in his book: "Les fondements biologiqiBs de la Geo- 
graphie humaine" (1943) require, however, an exact inventory of all 
incidences of diseases and epidemics on the globe* Similar to the 
objective of geography to give a true display of the dimensional 
aspect of the earth (SORRE), medical geography and cartography in 
the above definition will be an equally important science along with 
morphology and climatology. 
If considering a map as a source of information on the one hand, 
and as a means of description on the other hand, the medico-geographic- 
al maps which have been published so far must be placed under the first 
category ana they constitute valuable sources for further research work* 
They are medico-historical evidence of former medical conditions* 
H0 ZEISS attributes to the maps representing the spread of 
cholera in the beginning of the last century tile status of documents. 
The task of medical cartography is, however, by no means con- 
fined to a cartographic synopsis of all diseases and epidemics on the 
globe* It might be of great value in tending to clarify the question 
whether the differentiated incidence of diseases and epidemics has a 
correlation with the particular character of the landscape and other 
geographic conditions* It is incumbent to the field of geomeaical 
research work, the necessity of which has been first emphasized by 
HEINZ ZEISS in 193lj to give an exhaustive answer to this question. 
August PETERMANN in the introduction of the text part of his 
"Cholera Map of the British Isles" ef the year 1848 appreciates this 
second task of medical cartography as well as the outstanding import- 
ance of the map for that part of medical research dealing with the 
causes of diseases with the following words: "The present work, that 
is the edition of cholera maps, is intended to supply an insight in- 
to the areas of distribution of this devastating disease and to dis- 
cover the local conditions which are susceptible to influence its pro- 
gression and severity. The geographic representation is particularly 
valuable for this purpose ana cannot be dispensed with. The represen- 
tation of figures and symbols - no matter how diligently these may 
be tabulated - will not fix in the mind the relative importance, the space relation and the distances. Only the geographical map can 
help t® acquire correct impressions of relative size and importance 
in connection with the existence and development of all kinds of 
medical phenomena. 
If the task of medical cartography has been confined up to 
now to providing a geographic synopsis of all diseases and epidemics 
in the service of medical geography, to allow for comparisons of the 
different diseases in various spaces of the globe and to trace com- 
mon factors as to the form of progression, this task will have to be 
extended in the sense of ZEISS in that the map will in the hands of 
the geo-medical scientists become a scientific means in the research 
of the causes of diseases and epidemics. 
In analyzing the activities of medical geography, emphasis is not 
only placed upon the relation of medical and geographical factors, spe- 
cial attention is devoted to the possibility of establishing, on ac- 
count of the knowledge so acquired, a prognosis with regard to the 
behavior and progression of a specific disease in a given geographical 
space. The disease maps thus serve the causes of socialized medicine 
and hygiene. A mere tabulation of diseases as was practiced up to now 
could not possibly cope with these prospects. Geomedical maps must in- 
dicate the possible trends of the development of a specific disease or 
epidemic in the different areas of the world. A new task has thus been 
given to geo-medicine which is comparable to the studies of maps for 
the exploration of space as brought forward by Walter GEISLER in his 
report to the Deutsche Kartographiscne Gesellschaft on 29 March 1941* 
To apply the cartographical methods as a means of research in 
the geo-medical field it will be necessary to classify the statistical 
material according to geographical points of view on the basis ©f a 
physical map. Similar conditions prevail in the exploration of space. 
Diseases and epidemics do not respect political or administrative 
boundaries, their incidence and spread is ruled by the law of nature 
substantiated by geograpnical conditions. Only by entering every 
case of a disease or fatality relevant to geo-medical studies as well 
as all the factors that may favor that type of disease, such as the 
fauna and flera into a physical map, will it be possible to arrive 
at a general appreciation of the spread of diseases and epidemics in 
correlation with geographical conditions. A survey on the medical 
maps which are now available will give the best idea as to the pos- 
sibilities of which medical cartography disposes for the solution of 
this problem. Ill, 
As set forth in the history of medico-geographical maps which 
I have outlined in the "Mitteilungen des Reichsamtes fuer Landesauf- 
nahme" (Bulletin of iieiQh Surveys and Maps) 1939> Part I, there is a 
long standing desire of all who are interested in medical science 
for cartographic material to impart a better presentation of the sub- 
ject matter. Simple black and white maps without an underlying topo- 
graphical color scheme aid not receive much favor because they were 
not very legible. This type of map is merely a descriptive survey 
of the recorded diseases. The entering of simple symbols for the 
different diseases ana fatalities into black and white maps is hard- 
ly more than a makeshift solution at the expense of legibility and as 
Max ECKERT put it, these maps are not half as legible as they would 
be if a color scheme had been used. 
In such cases where we have to deal with a presentation by means 
of circles, sectors and columns illustrating the recorded diseases 
and fatalities, as is for instance the case in the regular report on 
diphtheria and scarlet fever in the "Reichsgesundheitsblatt" (Bulletin 
of the National Office for Public Health) and which means "replacing 
the sequenee of a statistic by the parallelism of a map" (W. GEISLER) 
one should not speak of maps. Siegfried ROLLER calls that type of 
representation "Geo-statistical Charts". These presentations, as is 
the case with all cartograms, are a result of the desire to present 
the dry figures of statistics in a more communicative and impressive 
form. 
The medical maps properly speaking may be divided according to 
the method into the following categories: 
1. Locator Maps, 
2. Distribution Maps, 
3* Progression Maps. 
1. Locater Maps: All types of cartographical records of a sporadic 
or accumulated incidence of certain diseases or fatalities - possibly 
including an indication of the number of cases expressed by size or 
color of the legend - are referred to as locator or position maps. 
These maps reveal in the most simple manner the local incidence as 
well as the distribution over a certain area but they do not furnish 
any clue as to the boundaries of the respective disease area and do 
not allow for any prognosis whatsoever because they only reflect the 
investigated conditions in that particular area. The best example of 
a lecator map is the presentation of G. SCHLIEPER of the "Ankylostomiasis in Italy 18S2 to 1932” (Map VIl/7a). By using different colors and 
symbols it is perfectly possible to present several related or op- 
posed diseases with sufficient accuracy on one and the same map* 
(See: ,lParatyphus C in the Mediterranean Basin" by H* HABS, Map l/7)* 
Locator maps furnish the elements for any research work in the 
bialogic-ecologic field* With regard to medical cartography these 
maps indicate the places where certain diseases or causative agents 
ef diseases have been discovered and they are very suitable for the 
presentation of diseases or epidemics with a rather rare occurrence, 
such as leprosy in Europe* The incidence at certain epochs can be 
marked by slight variations of the legends or by different colors if 
the same symbols are to be used. The following examples are men- 
tioned in this connection: "Leprosy in fiicily 1867 - 1924" by H. J. 
JUSATZ (Map VIl/6a) and "Leprosy in the settlements at the mouth ©f 
the Volga River" by Th. BERSIN -and H.J. JUSATZ (Map IV/6a). 
The relation of insects and other arthropods to disease is al- 
so preferably presented on locator maps which suit the purpose better 
than the formerly used distribution maps (See BERGHAUS "Physical At- 
lasfj). Locator maps have actually been used for the distribution of 
anopheles, aedes aegypti, and ticks (see Maps Il/3, IIl/2, VIl/7 and 
VIl/8). The different types of insects can be indicated by specific 
symbols or signs in different colors which are marked at the place 
where they are found* For the sake of a more accurate indication 
the respective localities are marked by numbers and the respective 
names are on the margin of the map* The use of several legends 
next to each other did not turn out satisfactory in distribution maps 
for insects as was seen in a presentation of that kind of the different 
types of anopheles in the Near East (map Il/2). 
2* Distribution Maps cannot be prepared exclusively by the absolute 
method, as is the case with locator maps, but it is advantageous t* 
use the relative method at the same time. In this relative method, 
the number of cases is brought in relation to the number of inhabit- 
ants, certain lines of research also on the density of the po- 
pulation and only in very exceptional cases to the size of the area* 
The distribution maps of either method constitute an inventory for 
one or several diseases in a given geographical space. They thus re- 
present medical maps with a statistical feature which reflect the dis- 
ease or health condition at a definite time, one might call them 
"snapshots of a definite disease condition" (ZEISS)* In some in- 
stances they present the predisposition for diseases or epidemics in 
a certain geographical space, in other words, the medical phenomena 
are brought into relation to the geographical factors such as they appear in the map. This type of geo-medical map reflects the de- 
velopment of a disease or epidemic in the geographical space by a 
systejmtic evaluation of detailed observation which allows for a 
determination of the general trend. These maps have a dynamic 
feature and enable us to establish certain prognostic conclusions. 
2a. Medico-geographic aistribution naps: The first type of dis- 
tribution maps may be successfully used if General-Survey Maps of a 
large area or continent are required with a scale of 1:15 millions 
or less. For large areas or continents it will answer the purpose 
if the respective diseases or epidemics are entered by large open 
colored hatching. It will be possible to enter different diseases 
or epidemics by using different types of hatching or cross hatch- 
ing as is demonstrated in Map IJ./7 and VIl/7 an the incidence ©f 
schistosoma haematobium, schistosoma japonicum and hookworms. It 
must, however, be avoided to enter too much into one map. Even the 
best cartographic presentation will become illegible by accumulating 
too many colors and different types of legends. In these cases it 
will become necessary to list the diseases in special cartograms and 
to provide the reference by printing small numbers at the respective 
places of the map. It is a general rule in medical cartography to 
adopt the same size relation for all indications entered int© the 
same map. Older maps often present the disadvantage of using dots 
for one disease - dots are used in modern maps to indicate locali- 
ties only - and shades or hatchings for other diseases, whereas a 
third disease finally is simply marked by colored contour lines, 
thus mixing up the methods which are now reserved to indicate the 
distribution or to mark geographical areas respectively. 
The intensity of the infection may be simultaneously indicated 
in a rough approximation in the distribution maps as is shown in map 
IV/6 "Leprosy in South East Russia" by H, J. JUSATZ and endemic areas 
by cross hatching (see plague Centers of 1st and 2nd degree in Europe 
etc. by H. J. JUSATZ* Map i/l). 
The simple method of presenting the distribution of diseases 
allows at the same time to mark sporadic occurrences of the disease 
in addition to the hatched areas by encircling the names of the lo- 
calities (see map VIl/5) and to stress those areas where the disease 
is particularly frequent (see "Amebic Dysentery in the Near Last" by 
G. PIEKARSKI, map ll/4)<> In any case, the meaning of the respective 
signs must be explained in a legend. These general distribution maps have only little value for the 
more frequent, so called ubiquitous, diseases which occur more general- 
ly, at least in certain climatic zones, such as tuberculosis, typhoid 
fever, syphilis, pox, malaria, ana rheumatism. Nor are they suitable 
for presentations on a larger scale than 1:5 millions. In that case, 
the agglomeration areas must be made apparent and simple hatching of 
different width does not prove satisfactory. Only one, perhaps two 
diseases may be presented in one map. The colored impressions must 
either be made by hatches of different size, in some instances tc the 
aensity of a screen or colored shade,as was done in the presentation 
of the Distribution of trachoma in the Mediterranean basin (map VIi/ 
12 by W. ROHRSCHNEIDER) and in Spain (&ap VIl/l2a by H.J.JUSATZ) or 
still better by the use of a gliding color scheme which may include 
two different colors in order to obtain a maximum of contrast (Oc- 
currence of Malaria in Spain and Portugal by E, MARTINI and H.J. 
JUSATZ VIl/2 and in Italy VIl/3)* These maps present a maximum of 
legibility as regards the intensity and distribution with which a 
aisease or epidemic has invaded the different areas (malaria, cholera 
or influenza) or as to the repeated occurrence of typhoid fever and 
trachoma. The color scheme must be chosen so as to ensure that the 
underlying physical map will not become illegible. 
Distribution maps of this category should as a rule be made ac~ 
coraing to the relative method and the frequency of the disease will 
be related to the number of the indigenous population• Thinly or non- 
populated areas must be left out in the color impression (see Polio- 
myelitis in the Space of the Baltic Sea by G. FtNGER, map V/l). The 
layout of all maps shoule be such that they can*always be used as a 
source for the numerical statistics which were used for their pro- 
duction. 
In case that the distribution of a disease during a certain 
period of time is to be represented one may also have recourse to the 
dot method which was introduced by N* KREBS (1921) in surveys on the 
density of the population but which had been used before in the year 
1848 by August PETERMANN for the above mentioned plague map (see 
PETERMANNfs Geographische Mitteilungen - Geographical Magazine - 
1940, Table 23). In spite of the perfect presentation »>f these maps 
from a cartographic point of view, they are of little appeal with 
respect to their legibility as has been pointed out by W» BEHRMANN 
in the Jahrbuch der Kartographie - Year Book of Cartography - 1941* 
2b. Geomedical distribution maps: The second objective of medical 
cartography, namely the presentation of the distribution of diseases and epidemics in their correlation to the local conditions of the land- 
scape) the soil ana the climate, in short the establishment of geo- 
medical maps as a tool for research concerning the causes of diseases, 
makes it unavoidable to turn away from the statistical rigidity of the 
map presentation which W. GEISLER has already proposed with respect to 
the planning maps of the space explorers and to favor a more versatile 
fixation according to the natural factors such as flora and fauna. The 
topic of each medical map reads as follows: The behavior of a disease 
in the landscape and its relation to the peculiar factors of this land- 
scape, the development, relation to the structure of the population, 
the natural extinction of this disease or elimination as a result of 
control measures. 
Geomedical research in its present state confirms that the spread 
of epidemics is dependent on topographic conditions and certain geo- 
meoical barriers which cannot yet be accounted for, rather than en ad- 
ministrative boundaries. It may, therefore be said that medical maps 
are only suitable for geomeeical research if the result of the investi- 
gations obtained community by community is entered into such a type of 
map which set forth all topographic details of the landscape as well 
as the conditions of the soil. In this case a collection of these 
maps will permit certain conclusions with regard to the correlation and 
coincidence of certain topographic conditions with specific epidemics 
and diseases. If such a coincidence can be observed over an extended 
period ©f time in certain areas, the local or endemic character of that 
particular disease or epidemic will become obvious and conclusions as 
to the conditions favoring this state will be possible. Very illustra- 
tive examples in this respect are the very careful Swiss investigations 
in some villages of the cantons of Zurich and Aargau with regard to the 
incidence of goiter, the investigations of STICKER with regard to 
plague and some geomedical records on malaria. The "constancy of local 
intensity" (Th. DIETERLE and J. EUGSTER) which has been ascertained in 
the Swiss investigations with the regularity of a natural law, even though 
important movement of the population was involved almost creates an urge 
for the compilation of geomedical maps, the more so, since analogous ob- 
servations were made in Sweden, where the villages with the highest 
goiter rate are preferably located in the neighborhood of meandering 
rivers or dense forests. In the endemic areas there are islands which 
are absolutely free from goiter, such as the villages of the Boezberg 
which appear "as being stamped out of the landscape" (ZEISS). For this 
type of investigation it will be necessary to use plane table sheets 
cr community maps in which the invaded houses will be marked. A con- 
frontation of the maps thus established ever a period of 20 years re- 
veals quite obviously the pronounced local character of goiter. 
One might say that the disease niaifies in the landscape and it is up to the cartographic presentation of this type of disease to 
trace the geographic factors -which to a certain extent determine 
the spread of the disease. This may practically be aone by a pre- 
sentation of ecologic factors, such as the occurrence of a certain 
type of animals which constitute a reservoir for viruses (rodents, 
ticks, etc.) or of disease transmitting insects (anopheles, aedes 
aegypti) or zones of vegetation, formation of soil, climates, etc. 
(see maps of the distribution of citellus and plague in the region 
of the lower Volga iv/la). Geomedical maps so compiled allow for 
a prognosis as to the probable trend of spreading of the epidemics 
as I have first demonstrated for the distribution of tularemia, a 
pestilence-like disease of rodents and men in the maps published in 
PETERMANN1s Geographische Mitteilungen 1940, maps 24/25 in which are 
presented along with the actually invaded areas, the most imminent- 
ly endangered areas of dry climate in Central Europe# 
Geemedical research work with the object of presenting the 
correlation of topographic and medical factors, must under all con- 
ditions be based on feood physical mapsi Medical cartography, as a 
result of the development of this new field of research, finds it- 
self confronted with a host of new tasks, the solution of which is 
by no means simple and depends upon a close cooperation between 
medical experts and cartographers. Geomedical maps require that 
the physical maps be provided with an additional color scheme to 
represent the different vegetations, soil formations or climatic 
conditions which is usually achieved by shades of color# In the 
choice of colors it must be borne in mind on the one hand, that the 
colors used for the medical information do not combine with the un- 
derlying colors of the physical map to form new colors and on the 
other hand, the distribution area of the specific diseases must 
stand out clearly against the zones with indifferent or even anta- 
gonistic geographic factors. Maps of this particular kind do not 
yet come under the scope of this atlas. In the particular case of 
the Mediterranean fever the distribution area is identical with the 
area of the typical etesian climate which on the other hand corre- 
sponds with the distribution of the feoat as the main mild yielding 
domestic animal and this correlation is so obvious that the distri- 
bution map of Mediterranean fever by H# HABS (map VIl/l) may be 
considered as a good example of a geomedical map. 
The distribution maps present, furthermore, the problem of de- 
limitation. As a matter of fact the maps which are based on statistic- 
al data will have the boundaries of the represented distribution cor- 
respond with the administrative boundaries# This will, however, *nly 
in very exceptional cases reflect the real conditions, particularly so if considerable differences exist in the medical supervision and 
methods of socialized medicine and control of epidemics between 
the adjacent territories. In reality, the administrative boundaries 
are no natural barriers for diseases and epidemics. The areas, how- 
ever, where organized control measures are employed and promoted by 
the respective authorities do, to some extent, present a coherent 
complex and may be used as a basis in this type of maps as has been 
attempted for instance in the map by E. MARTINI (map Il/2a) on the 
"Incidence of Malaria in Turkey". In some instances a map represent- 
ing the net of medical outposts ana stations my impart an idea of 
the frequency of the respective epidemic as is the case in the maps 
on Malaria (ll/2a), Plague (IV/la), Leprosy (VIl/6) and Trachoma 
(Vll/I2a.) 
3. Progression Maps. In contrast to the so-called nidifying epi- 
demics which are localized, the cartographic presentation of the 
important wandering epidemics is still presenting difficulties which 
have not been overcome so far. The problem of the presentation of 
the chronologic sequence of diseases in the same space has not yet • 
been solved in a satisfactory manner if abstraction is made of the 
attempt of ROLLER to indicate an increase or decrease in the number 
of disease cases by the position of the hatching. Dynamic maps «n 
the progression of influenza, hoof and mouth disease, the communica- 
ble infantile paralysis etc. The epidemiologic conceptions of in- 
tensity ana extent no longer cover the complexity of the phenomena. 
It is not only of interest that more or fewer people are involved 
but the geographic density of the cases is also of importance. The 
tendency of the epidemic te expand as seen from a geographic angle 
may be great or the epidemic may tend to localize at certain areas. 
It will, therefore, be necessary to induce in a map the factors of 
corigressity and egressity (G. FINGER) which terms define the stag- 
nation of the epidemic at one or several centers of different extent. 
The tendency to expand of an epidemic is described in a very elucida- 
tive manner as the "aggressive" course of the epidemic. The concen- 
tration, that is the converging tendency of the epidemic to encroach 
at certain areas is called the "congressive" course of the epidemic. 
An analogy may thus be established between extent and intensity on the 
one hand ana "egression" ana "congresstion" on the other hand in the 
definition of an epidemic as viewed from a geomedicai aspect (FINGER). 
If the behavior of an epidemic is observed for several years in 
a certain area, as has been done by FINGER for communicable poliomyeli- 
tis in Wurttemberg during the years 1937/42 (see map Vl/2) and if the 
cases are entered into the map by dots of different c®lors for 
each year, this map will allow for comparisons and conclusions. It can be observed for instance that a striking accumulation of polio cases 
was taking place in well defined areas in 1938, such as the valleys 
of the Neckar, Rems and Fils (black dots), whereas in 1939 there was 
no congression whatsoever (blue dots) when the disease was spread all 
over the country in the broadest egression without any recognizable 
centers. In 1942 the epidemic showed again a similar congression as 
in in the same valley areas (red dots). 
The maps of cholera in Russia by R, OLZSCHA may be considered as 
the first successful attempt to represent the dynamics of the course 
of an epidemic in a geographic space by means of a map. These maps 
indicate the begin of the epidemic and the points at which the epi- 
demic began at the same time are joined by lines as was suggested by 
ZEISS (Isodates). The progression of the epidemic is thereby imr- 
pressively illustrated (see PETERMANNfs Geogr. Mitteilungen 1942, 
tables 34 and 35)* The maps reveal that these isodates which con- 
nect areas where the epidemic occurred at approximately the same time 
never have the tendency to intersect as would be the case if the dis- 
ease would not depend on a certain law and if there would be no correla- 
tion between the different cases. 
It is the objective of geomedical research to go into this mat- 
ter and to establish the laws by which the spread of epidemics of the 
past ana of present days is governed and to give prognoses as to the 
presumable progression of the epiaemics, Geomedicine is only in the 
first stage of its possibility in this connection. In the further 
course of research it might be discovered that the epidemics follow 
certain passages as is the case with the weather and meteorologic con- 
ditions. The fact that the major epidemics moved in the same direc- 
tion seems to enhance this idea. With this idea in mind GERLAND 
writes in the description of his disease maps in the third edition 
of the physical Atlas of BERGHAUS: ”The diseases are generally spread- 
ing in an east-west direction opposite to the earth rotation and there 
is often a correlation between the direction of the spreading and the 
prevalent winds”. 
The creation of maps of the health condition of geographic areas 
also belongs within the scope of medical cartography. The production 
of these maps is however opposed by numerous technical difficulties 
of presentation and method, so that no remarkable health maps are so 
far available. It will be a prerequisite in this respect to deter- 
mine the general principles which will have to be adopted in the ap- 
preciation of the health conditions in the respective areas. PITTALUGA 
has suggested resorting the inscription of lines defining the areas of 
similar or comparative hygienic conditions or possibilities of develop- 
ment (isohygienie-lines). 13 
IV. 
No general scheme for the choice of the method of presentation 
can be aeveloped with regard to medical maps. The essence of the 
statement made by GEISLER for the planning maps with that the subject 
is decisive with respect to the method holds true for medical maps too. 
It may even be said that the material to be worked up is still more 
decisive in regard to the method to be used in medical maps. If for 
instance the distribution of a rather rare disease is to be represent- 
ed (such as ankylostomiasis, meningitis, poliomyelitis) on the basis 
of a statistic of the annual cases, it will be the method of choice 
to enter the single cases by the absolute method, that is by marking 
them by dots of different size and color. If a map is, however, to 
be based on the statistical material of certain administrative dis- 
tricts or areas, one will as a rule resort to the relative method - 
relation of the number of cases to the number of the population or 
number of the susceptible members of the population (age groups) - 
anc the presentation will be made by hatching of districts. 
Special attention must be devoted to the choice of sources in 
case of diseases which used not be reported or in countries were no 
well organized health service is functioning. We are here confronted 
with the same problems which geography had to face in the times of 
August PETERMANN who attempted to reduce the white areas in the maps 
of Asia and Africa, Geomedicine must resort to all possible sources 
of information such as reports of explorers and medical everts, pub- 
lications of all kinds, letters of surgeons abroad etc. with the view 
of securing a conclusive presentation of the distribution of diseases. 
It my be expected that the cartographic presentation of dis- 
eases and epidemics will be used in the future as a means of epidemio- 
logic prognosis and research prognosis and research of the primary 
causes of the respective diseases. The importance of geomedicine in 
the future may be outlined by the statement of A. SUPAN : "The carto- 
graphic method is the vital nerve of geomedical research". Their de- 
velopment and furtherance is trustfully laid into the hands of the 
medical doctors and cartographers who in close cooperation will serve 
the common cause. 
H. J. JUSATZ 
Institute for Social and Strategic 
Hygiene of the Medical Military Aca- 
demy and Hygienic Institute of the 
University of Berlin. 1/1 
PLAGUE FOCI OF 1st AND 2nd ORDER IN EUROPE, NEAR EAST, AND 
NORTH AFRICA* 
1921 - 1941, 
Translation prepared by: 
U. S. Fleet, U* S» Naval Forces, Germany, 
Technical Section (Medical), 1/1 • 
All medico-geographic studies of plague must be based upon 
STICKER1s classification of the foci of plague into persistent 
foci with plague nests and endemic plague foci of the 2nd and 3rd 
order. Persistent plague foci were according to STICKER the areas 
of retreat of the shy rodents which in consequence of their living 
together in great numbers in inaccessible alpine plateaus or un- 
civilized steppe areas constitute obliging hosts and carriers and 
prevent the plague bacteria from dying out. 
From these century-old plague foci the epidemic blazes up at 
indefinable intervals and affects rodents as well as humans in the 
neighboring areas from where plague is spread along the trade routes 
all over the world by the rats living in the ports and ships. The 
threat to Europe and the adjacent countries is revealed best by a 
map of the presently known plague foci on the borderline of Europe, 
in Near East, and in North Africa, 
Beside the Central Asiatic focus which is disregarded here, the 
presently most active of STICKERS old plague foci is the African en- 
demic in Uganda on the northwest bank of Lake Victoria. From here 
plague was distributed heretofore to Kenya, to the north of Tanganjica, 
and across Lake Albert to the Congo State, From Uganda as many as 
6000 cases of plague per year were reported to the League of Nations. 
According to STICKER plague had invaded Egypt from this source. 
SUCKER mentions the Asir Highlands as the second persistent focus, 
while the third was in the high mountains around Mt, Ararat. Even 
though no definite data were obtainsd in recont years of greater out- 
breaks of plague from both these sources, a number of smaller inci- 
dents of plague in the vicinity of the above mentioned foci indicate 
that they are not yet extinct. There is no doubt that even for the 
time being they are still of importance for the distribution of the 
plague in the Near East, e.g. for the development of the 2nd order 
plague focus in the Iraq. 
A great importance for the endangerment of the European con- 
tinent by the contamination of the indigenous rodents with plague 
microbes must now be attached to STICKER’S fifth persistent plague 
focus which is located in the Kirghiz Steppe between Ural and Vol- 
ga, and which will be dealt with in a special map. 
The sources of the 2nd order in West and North Africa range 
within the plague foci next to Europe which were not known to 
STICKER and which have developed during the recent decades: These 
are Dakar and the North African coastline area from Morocco to 1/1 
Tunisia. 
Though contrary to the plague incidence in southeast Russia, in 
Egypt, and in Iraq, the number of cases reported here is still within 
moderate limits, their regional and temporal distribution since about 
1920 until the recent times demonstrates that the rodents living on 
the desert border area already seem to be carriers of the plague mi- 
crobe . 
Extensive research work is still necessary to recognize the full 
extent of this source of danger so close to Europe, and to build up 
the most adequate control organization. 
Only for Tunisia aid investigations of the incidence of plague 
with rats reveal that the plague epizootic heretofore was restricted 
to the rats living in towns and had not spread to the desert rats, 
The murine plague wascbserved in Tunisia in the following distribu- 
tion (1937): Epimys decumanus 66 %, epimys rattus and micromys gen- 
tilis 12 % each, the rest epimys alexandrinus and micremys azoricus. 
in s®usse, sfax, near Kair»uan, and in some other places of the coast- 
line area isolated cases of plague were observed. 
In August 1940 some cases of plague, and plague infested rats 
were observed anew in Algiers. Here, too, the epidemic seems to be 
present persistently, even though it was unnoticed for decades, and 
except for a small epidemic in Conde-Smendou, only a few isolated 
cases were observed in Algiers, Oran, Philippeville, and Tangier 
(see table) in 1931* 
In the environment •£ Tripoli from 1930 to 1934 some cases of 
plague were observed in several places (Ajilat Oasis, Gheran near 
Zanzur, amang the Manisir tribe, in Kebasc, among the Guarat tribe, 
in Tarbmina, and in Hiscaria)• 
Morocco displays about the same conditions as the North African 
Mediterranean coast. Alter some smaller local epidemics 1920/21 and 
1929/30 had occurred in the French Protectorate, isolated cases have 
occurred nearly every year without the epidemic attaining a larger 
extent. The last epidemics occurred in 1929 in the valley of Sous 
in southern Morocco, 80 kms. south of Agadir, and in Settat (1929/30), 
63 kms. south of Casablanca, and in addition in Doukkala (1932/33)* 
During the winter of 1940/41 there was a new outbreak of plague in 
Morocco with 237 cases. This wave of disease continued into the 
first half of 1942 with 351 cases. i/l 
, Similar attacks of plague also occurred in Lagos and Nigeria. 
According to the official reports the climax of the plague curves 
was attained in the year 1926 with 1300 cases. After 1931 the 
plague at first segued to have disappeared from Nigeria. In 1938* 
however, 26 new cases of plague were officially reported. 
Contrary to these Dakar and its hinterland, Senegal, consti- 
tute a new and considerable plague focus of the 2nd order. This 
■sown suffered a plague epidemic in 1914 with 2000 cases and 1919 a 
second outbreak with 4300 cases reported. Since this time continuous- 
ly larger or smaller outbreaks of plague occurred in that district of 
Dakar where the indigenous population was housed, and in the environ- 
ments of Dakar, particularly in Thies 65 kms, east of Dakar), Tivaoune, 
Rufisque, Baol, and Louga. Though the number of diseases has decreased 
continuously during the past years one must count on a renewed flare-up 
of this focus at any time. 1/1 
Table 1. 
Occurrence of plague 1921-1940 according to the Reports of 
the International Health Organization and the League of Na- 
tions compiled by H, J. JUSATZ. 
|f ear 
East - Africa| 
"'West* 
f 
-Africa 
North-Africa 
Near 
East 
Europe, 
Southeast 
Uganda 
Kenia 
! 
I 
i 
• 0 
EXO to 
H G 
O O 
m 0 
Lagos 
Nigeria 
Dakar- 
Senegal 
Morocco 
Algiers 
L 
r- 
Tripoli 
-p 
1 
w 
Russia,U- 
ral,Volga 
Don. 
1 ! 
Il921j 5871 ’ 
0 
1799 
«/• 
195 
"34 
356 
137 
646 
1922 ■ 1362i 
•/• 
0 
1343 
34 
19 
8 
487 
685 
160 
1923 
938i1090 
5 
1678 
134 
6 
31 
1519 
787 
489 
11924 
887 
477 
414 
1834 
53 
7 
11 
373 
523 
144 
11925 
947 
1096 
671 
408 
0 
4 
6 
138 
19 
257 
|1926 
1884 
530 
1330 
942 
56 
424 
154 
437 
179 
11927 
2171 
327 
397 
2748 
1 0 
19 
249 
78 
18 
118 
|1928 
1379 
580 
530 
2035 
0 
11 
11 
496 
68 
90 
11929 
5816 
766 
185 
2921 
1283 
4 
171 
178 
135 
81 
11930 
2546 
959 
64 
2227 
356 
46 
123 
4 
3U 
134 
13 
'1931 
2378 
604 
5 
1017 
41 
85 
117 
0 
573 
132 
6 
1932 
1045 
281 
0 
279 
16 
0 
0 
0 
134 
24 
1933 
858 
163 
0 
135 
87 
0 
0 
18 
78 
28 
•A 
1934 
495 
62 
04 
1100 
0 
0 
0 
12 
114 
10 
♦/« 
’1935 
1083 
107 
15 
r 
418 
41 
4 
18 
39 
12 
•A 
1936 
962 
202 
./. 
I •/• 
85 
•A 
8 
7 
77 
1 
•/• 
1937 
493 
145 
6 
*/• 
16 
«/* 
2 
3 
72 
‘/• 
•/* 
1938 
370 
26 
31 
26 
1 
0 
6 
10 
•4 
•A 
11939 
312 
4 
80 
•/• 
1 
1 
100 
(1940 
6 
31 
237 
6 
2 
114 
Legend: •/• - n® data available; 
0 - no case of 
disease; 
empty column 
— no report. 
H. J. JUSATZ. 1/2 
EPIDEMICS OF TULAREMIA IN EUROPE, 
WESTERN ASIA, AND NORTH AFRICA 
1921 - 1941 
Translation prepared by: 
U. S. Fleet, U* S. Naval Ferces, Germany 
Technical Section (Medical) 1/2 
Since the first few serodiagnosticslly certain cases of 
tularemia in man in Russia were recognized in 1926, this epi- 
demic, new for Europe, which infects rodents and man, has migrat- 
ed through vast regions toward North, Central, and South East 
Europe and has settled there. The causes and ways of this west- 
ward movement are still unknown, but it must be expected that 
this epidemic will spread further and finds a new constant home 
among the man-avoiding rodents of the steppe-like regions of 
Europe, from where it occasionally may pass over to the in- 
habitants of the country in individual cases or in small local 
outbreaks. The dependence of the vectors on the bioclimatic 
conditions, however, - most favorable conditions: slight rain- 
fall and steppe-like vegetation - will keep some regions such 
as the coastal districts of Western Europe with rich rainfall 
free from tularemia infections. Also Italy (contrary to a 
former erroneous report from Rovigo) has always remained free 
from tularemia so far. As far as Greater Germany is concerned, 
after the great epidemic of 1936/37 some individual cases have 
been observed even outside the proper epidemic region (Moravian 
basin), such as south of the Danube in Schwechat near Vienna, 
in Graz, and in Burgenland. The most western occurrence of 
tularemia so far was observed in 1939, when a field hare in 
the hunting are of the district Neumarkt (upper Palatinate) 
was proven to be infected with tularemia. The table shows the 
extent of distribution and the various species of the vectors 
of tularemia bacteria. 
H. J. JUSATZ. Nr. 
Year 
Region 
Number of cases 
Species of rodents 
and vector 
I. Eastern Europe 
1. River basin of the Volga. 
1* 
1877 
Astrachan and surroundings 
unknown 
unknown - 
2 
1926 
Volga-delta south west of Astrachan 
(B.,M.,T.,) up to the Caspian Sea 
\ 
200 
water rats 
3* 
1927 
Governmental District Rjasan 
unknown 
?T 
4 
1928 
TT TT Tf * 
12 villages in the district j 
Spask 1 
Total 
water rats 
3 
1928 
Governmental District Rjasan: v j 
15 villages in the district Kosimow 
800 
6 
1928 
Governmental District Rjasan: 
(200) 
310 cases In the district Elatma on 
the Oka 
7 
1928 
Governmental District Wladimir: 
district Melenkoff 
field mice 
8 
1938 
Region of Orel, river basin of the 
5000 
Oka, sometimes whole villages infec- 
ted. Recurrence in spring and fall 
1939 and 1940/41 
/ 
2. River basin of the Ural. 
• 
9 
1928 
Governmental District Orenburg 
8 villages on the shores of the Ural river 
103 
water rats 
10* 
1921 
3. River basin of the Ob. 
Boltscharovo and adjacent villages 
1/4-1/3 of the popu- 
water rats 
on the Ob near the mouth of the Irtysh 
lation water rat 
(Governmental District Uralsk) 
hunters 
11* 
1926 
South of Tobolsk 
water rats 
12 
1927 
Mirinowo on the Irtysh, (district ICfoalsk) 
75 
13 
1928 
Samarovsk on the Ob ( ,f ” 
> 
22 
i 
14 
1928 
Jarowoskie-Jurty near Jalutorcvsk oi 
l UlO 
22 water rats 
Isset (tributary of the Tobol) (district 
Tuemansch) 
15 
1928 
Bolscharow on the Konda (tributary of the 
12 
16 
Irtysh 
or 
1928 
Kushevatt near Obdorsk on the Ob 
27 
water rats 
(district Tobolsk) 
17 
1928 
Muji near Obdorsk on the Ob (district 
75 
water rats 
Tobolsk) 
18 
1930 
Kainsk (near Omsk) in the district 
87 
vectors:flies, 
Barabinsk (West Sibiria) 
gnats,ticks 
19 
1930 
Kurgan on the Tobol (Irtysh-Ob) 
40 
rabbits (hares) 
20 
1931 
Kurgan on the Tobol 
54 
rabbits (hares) 
21 
1935 
Town in West Sibiria on the river S. 
43 
water rats 
(stream water) 
4. River basin of the Dnepr. 
22 
1941 
Bobruisk, river basin of the Berezina 
1 ' 1 
23 
24 
1941 
1941 
Gomel, river basin of the Sozh 
Kursk (river basin of the Desna) 
/ unknown 
l 
t field mice 
25 
1941 
Sumy (river basin of the Psel) 
\ J 
\ 
5. River basin of the Don. 
26 
1938/9 
Rostov on the Don 
unknown 
unknown 
27 
1941 
Region from Stalin to Kharkov 
individual cases 
unknown 
II. North Europe 
28* 
1924 
Dalekarlia 
unknown 
lemmings' 
29 
1929/30 South Norway:Telemark (first case, 
50 
lemmings,hares, 
Valders,Hallingdal,Troendelag,Oslo 
Most in the north:Hattieldal,south 
of the Roes-Vans-lake (66°) 
field mice 
vectors:chrysops 
r 
1931 
Most in the south:Mandal (58°), in 
the western part onlv one case in 
Odde (Hardanger Fjord) 
4 
30 
Central Sweden:villages for'12 km 
31 
hares,squirrels 
round Lindesberg (20 cases),Bollnaes 
(insects) 
(l),N.Edsbyn (1) and 11 cases scat- 
tered in central Sweden 
31 
1934 
Villages in the northern part of 
Uppland and southern part of Gaev- 
leborg: Soederfors'and Gysinge (35 
48 
hares 
cases), Gaevle (6),Haemrange (4); 
Ockelbo (2),Lingbo (1),Falun (1), 
1937 
Filipstad (I) 
32 
Gaevleborg and surroundings of 
115 
hares 
Bollnaes (confluence of Worna and 
vectors:4 species 
Ljusna-Elf) for 50 km round. First 
cases:Moeckelasbo in the district 
Arbra (3) on 21s‘t of July, ' 
Ki la for s, So eder hamm, L j usdal, 0 sla ett - 
fors,Gaevle 
of aedes and 1 
Theoba ldia 
33 
1938 
Gaevleborg and surroundings 
200 
hares,vectors: 
gnats (aedesci- 
34 
1938 
nereus) 
Lappmark: Arjeplog on the Stor-Afvan 
60 
lemmings 
(Skelefte-Elf),most northern occur- 
rence in Scandinavia until now (66°) 
III. Central Europe 
35 
1935/7 
Moravian Basin: North East corner of 
about 600 
hares,bisam rats, 
the district Lower Danube (district 
200 of them 
field mice, 
Mistelbach and Gaenserdorf), even 1935 
in Lower Da- 
Vectors: cats, 
cases in Bernhardstal,Leopoldsdorf i 
M., Fuchsenbichl, 1936:first case: 
• 
nube dis- 
ferrets 
' 
trict 
Reintal. Main seat:Bernhardstal (44) 
9 
391 
Reintal (10),Rabensburg (5),Poysdorf 
in Moravia 
(4) ,Poysbrunn (4), and 15 other villa- 
ges. Cf land Moravia; the'district Ho- 
donin,Mikulov,Vyskov,Brno, first case 
in Nova Charvatska Ves (20),Main seat: 
Postorna (47)#'Of Slovacia the districts 
and Slovacia 
Skalica,Senica ,Malacky,Pressburg 
Individual cases:Zwettl,Znaim,Schwe- 
chat near Vienna,Graz,Koh-Fidisch 
! T)nr. nanlonrl \ 
\ ID CtJ- 'w ll-LU HU J 
IV. South East Europe and Asia Minor 
36 
1935 
Thracia: Valley of Kaynardsha 
26 
rabbits 
37 
1936 
Thracia: Surroundings of the town 
153 
rabbits (hares) 
Lueleburgaz in the valley of Eaynard 
- 
(133 of them 
vectors:horse- 
sha. Principal seat: Turgutbey 
soldier s) 
ticks,flies,gnats 
38 
1937 
Thracia: 33 villages in the surroun- 
178 
(stream water) 
• 
dings of Lueleburgaz (110 villages 
(85 of them 
examined) 
soldiers) 
39 
1937 
Asia Minor: Konya (Dep. Konya) 
4 
unknown 
butchers 
40 
1937/8 
Asia Minor: Anatolian Highlands 
Ankara 
6 
unknown 
41 
1937 
Wansee 
6 
unknown 
V. North Africa 
42 
1933 
Tunis 
unknown 
rabbits 
43 
1933 
French West Africa 
3 
palm-rats 
Note: 
The occurrences marked * are not confirmed 
by bacteriological or 
serological diagnosis. 
- T . .Tl-.P ,t7 
CT a b -Z e l/3 
PANDEMIC DISTRIBUTION OF THE INDIAN CHOLERA 
1934-1943. 
Translation prepared by: 
U. ,S. Fleet, U« Naval Forces, Germany, 
Technical section (Medical)« 1/3 
Cholera, which in the beginning of World War I occurred among 
the furces of the Central European powers in the Eastern Theater 
of Operations, appeared so abruptly that it resulted in a catastrophe 
of the greatest bearing due to the failure of the measures taken a- 
gainst it. This cholera epidemic was discussed immediately before 
World War JI in a historical review by J. KAUP in the Muenchener 
Medizinische Wochenschrift 1936, page 1227. The comparison of the 
great losses of the Austro - Hungarian Army on the one hand, which 
was not vaccinated even after the occurrence of the first cases, 
and of the small morbidity and death rate of the German forces on 
the other hind, which were vaccinated immediately after the out- 
break of cholera, revealed the efficiency of the cholera immuniza- 
tion. 
After the experience gained during World War I it is now pos- 
sible to avoid such a catastrophe by the repeated immunization of 
every soldier in due time. The problem is still to be solved whether 
or not it is possible to predict dangerous situations such as de- 
veloped with the occurrence of cholera during the war between *.ustria 
and Prussia in 1866 in Central Europe and in the beginning and after 
the end of World War I in the eastern European countries for a cer- 
tain period so that the necessary defense measures can be taken in 
time • 
Concerning the outbreaks of Indian cholera, which for the first 
time wss carried from Asia to £urope 110 years ago, it has been known 
for a long time that cholera is spread with certain periodical fluc- 
tuations from its original source in Bengal on the Ganges river to 
the.adjacent countries where it may completely disappear, while in 
India itself it increases and decreases within the regular interval 
of several years* The close study of the various outbreaks through- 
out large areas, which for the first time was accomplished by STICKER, 
reveals the following 6 pandemicsi 1. 1817 to 1823, 2. 1826 to 
1837, 3. 1646 to 1862, 4* 1664 to 1875, 5. 1683 to 1893, and 
6. 1902 to 1923# In a first study at the onset of World War II (Die 
Medizinische welt, 14th edition, No. 39, page 994, 1940), I made 
reference to the fact that recently cholera has set out from India 
to a new, the 7th pandemic, which, however, has not reached the same 
violent character as the past outbreaks since the mass immunization 
was employed as a measure of defense in the non-Indian countries. 
The character of cholera as a wandering epidemic,however, can also 
be demonstrated for this recent cholera wave when its incidence is 
studied on geographical maps, subsequent to a decrease of the number 
of cholera cases in India after the last years of the severe cholera 
epidemic from 1927 to 1930 to one fifth of the annual average, a new 
steady increase of the number of cholera cases became obvious during 1/3 
the years immediately before the outbreak of World War II, During 
19 a considerable increase of the deaths from cholera occurred 
resulting in a new maximum of the annual morbidity curve (370,000 
cases were reported with more than 180,000 deaths;, I do not know 
whether or not these figures were exceeded by those of the famine 
year 1943, as no statistical material is available. It is however, 
established, that the recent outbreak of cholera was not confined 
to its proper origin on the Ganges river in Bengal and in Asam, but 
that during the recent years cholera has spread to an ever increas- 
ing extent beyond the boundaries of India all over Greater Asia and 
even throughout northwestern Asia, 
The countries of Far India and the East Indian Islands are in- 
volved to a certain degree in all transitory advances of the Indian 
cholera epidemics. Throughout these territories cholera is also 
found in intervals of several years. The years of maximal lethality 
are always followed by years which are almost completely free from 
cholera. The greater the distance of the various territories from 
the actual epidemic focus, the less marked is the periodical return 
of cholera to these countries. In Siam from December 1936 on the 
number of cholera cases was continuously increased in connection with 
the increase of cholera in India, so that the monthly number of new 
cholera cases exceeded one thousand in February 1937* 
prom juiy 1937 on the cholera morbidity in the ports of the 
south Chinese coast and on the island of Hainan began io rise. The 
French colony of Kwang-chou-wang was involved in August, As a mat- 
ter of fact at that time the entire Kwantung coast of China had to 
be considered as contaminated. In Portuguese Macao more than 350 
and in Hongkong almost 1,000 victims were recorded in 1937* 
In Shanghai, where the first cholera cases were recorded on 
30 August 1937, cholera was spread around affecting 3,414 persons ac- 
cording to the official statistics. In the French concession in Shang- 
hai, where the epidemic attained the climax on September 11th with a 
daily sick rate of 146 cases 300,000 immunizations were carried through. 
In the next year there was a new outbreak of cholera in Shanghai with 
7,436 cases before November 193B and with a death rate of 2,238. 
The temporal coincidence of the years with the greatest lethality 
from cholera in India and French Indochina is very conspicuous. Here 
too, the most disastrous cholera epidemic of the last 30 years occurred 
in 1926/27 with more than 40,000 deaths (within 2 years). The number 
of deaths dropped at the same point of time at which cholera attained 
its maximum throughout the area of Assam, Simultaneously with the 
flaring up of cholera in India in 1934 a new severe epidemic broke eut 1/3 
in 1937/38 after an interval of about ten years. This new epidemic 
lasted from September 1937 (first case on September 7th in northern 
Indochina (Tonkin) near Haiphong; cholera was imported from the 
Chinese coast to the Thai-Vinh province) and a focus developed be- 
fore October 1938 the morbidity rate being 20,000 with almost 15,000 
deaths. 
For a special reason this epidemic is of interest to us. In 
Indochina the greatest attempt of a biological prophylaxis ever ac- 
complished during a cholera epidemic was carried through since al- 
most the entire population of Indochina was vaccinated against 
cholera * with a population ef 15 million persons 12,474,000 immuni- 
zations were effected. But in spite of this measure there is al- 
ways the danger of a new outbreak of cholera, if the Indian focus 
runs over. In November and December 1943, 322cases of cholera with 
227 deaths were observed when it broke out in Haiphong. 
In 1938 cholera flared up again along the entire south Chinese 
coast involving the south of China, namely the provinces of Kwantung, 
Kwangsi, and Honan to a particularly high degree. The first inci- 
dence of cholera was observed here in the month of May 1938. The 
also invaded Central China. In the eastern part of Kwan- 
tung almost 20,000 cases and 5,000 deaths occurred. In the north 
of china this cholera epidemic was spread as far as Tientsin, Taku, 
Korea, and the Manchurian towns of Dairen and Mukden. 
To control the great cholera epidemic in northern China more 
than 8 million vaccine bottles were provided for the Chinese Govern- 
ment by the Board of Hygiene of the League of Nations. However, even 
in the year to follow, 1939, the epidemic did not completely subside. 
In the ports of the south China coast, in Siam, Hongkong, and in 
several other places new cases of cholera were observed in 1939, the 
number of which was not fully known when World War II broke out.- 
In several Japanese ports isolated cases of cholera imported 
from other countries were recorded (1937 in Hircshima, Tokuyama, 
Kobe, Oku (district of Okayama), totaling 57 cases and 20 deaths). 
In 1938 cholera was observed in addition in Fukuyama, Okayama, and 
Wakamatsu. 
After an interval of only 2 years following its spread to 
the southeast, cholera also invaded the northeast of the Asiatic 
continent. In northwest India where cholera is not endemic, an 
outbreak occurred in 1938. According to the reports of an epi- 
demic in Hasset in the state of Swat, pilgrims from the United 1/3 
Provinces and from Calcutta are said to have imported cholera in the 
month of June 1938* About 30,000 vaccinations ware carried through* 
In May 1938 cholera had even advanced to Peshawar, the well 
known fortress of the Khyber Pass. The Afghan authorities took 
adequate prophylactic measures in time to prevent cholera from in- 
vading the Afghan territory. But although physicians and vaccine 
were sent to the frontier cholera broke out in Afghanistan. Nomadic 
tribes crossing the border were contaminated with cholera and brought 
it to the Afghan territory and to Kabul, the capitals Subsequentr- 
ly a general vaccination was carried through in Kabul, where 204,442 
persons were vaccinated within one month with the result that the 
number of new cholera cases was considerably diminished and cholera 
disappeared from those districts in which the vaccination was made 
carefully. Before the end of November 1938 isolated cases occurred 
in Kabul. In the meantime, however, cholera was spread to Kandahar. 
From the beginning of the choleia epidemic (June) until November 23rd 
the number of the recorded cases of cholera was 3,291 with 1,710 deaths. 
In 1938 almost half a million persons were vaccinated, and on January 
12th the Afghan authorities were in the position to announce that the 
cholera epidemic on the Afghan territoriy was extinct. According to 
recent reports there was a new outbreak of cholera in Afghanistan in 
the summer of 1939j 809 deaths were recorded during the period bet- 
ween July and November 4th 1939. In January 1940 a new outbreak of 
cholera was reported from Afghanistan. 
In spite of all prophylactic measures cholera occurred through- 
out Iran in 1939 causing the death of more than 300 persons. The 
strict measures taken here at first prevented cholera from being 
spread a second time to the Iranian territory. However, a new out- 
break of cholera seems to have occurred towards the end of 1943 which 
this time most likely was imported along the sea route through the 
Persian Gulf. In 1943 quarantine was imposed on the towns of Abadan, 
Bandar Shahpur, and Kermanshah. Simultaneously cholera seems to have 
occurred in Iraq, as quarantine measures were imposed on Basra. 
In the course of the past century the Iranian Highlands were 
repeatedly the bridge upon which the cholera, being a migrating epi- 
demic, regularly advanced from India to the European part of Russia. 
Starting from the coast of the Caspian Sea, which forms the northern 
border of Iran, cholera invaded Russia via Astrakhan,on the mouth of 
the river during its first great progress in the years 1830 and 
1847. The recent reports suggest that during the present seventh 
pandemic outbreak cholera seems to be taking this route for the in- 
vasion of Europe, in August 1942 several cholera cases were observed 1/3 
in Makhachkala and in Stalingrad. In September and October 1942 
cholera occurred in Rostov on the Don river and in several small 
places of the D0nez basin. 
The second route for the great cholera invasions of the past 
century is that from the Persion Gulf and the Two-river-country 
Iraq through Syria to the Mediterranean basin and its European 
shores. In the course of the years 1884, 1891, 1903, and 1912, 
cholera regularly was spread from Baghdad to Syria. Recently this 
danger again became imminent during the summer of 1931, when there 
was an outbreak of cholera in Basra and seveial other places in 
Iraq, and when strict prophylactic measures had to be taken, such 
as the medical examination of all travellers coming from Iraq with 
special regard to vibrio carriers. During the last migration 
cholera arrived again at the critical point at which its invasion 
must be feared in the Mediterranean basin and its European coasts. 
H. J. JUSATZ 
(Institute for General and Military 
Hygiene of the Academy for Medical 
Officers and Institute of Hygiene 
of the University of Berlin)• 1/6 
PARATYPHOID A IN EUROPE 
(1902 - 1939) 
Translation by: 
U# S. Fleet, U. S. Naval Farces, Germany, 
Technical Section (Medical). 1/6 
Paratyphoid a occurs in tropical and subtropical countries. 
Its area of distribution includes the entire Indo-Pacific area 
with India, Far India, the Islands of the East Indies (Insulinde), 
the southern parts of china and Japan, In these countries the in- 
fections with bacillus paratyphosus A (BPJON and KAYSER 1902) con- 
stitute a rather considerable portion of the typhoid infections. 
In the Central American countries and in the southern and eastern 
states of the United States paratyphoid A also occurs rather reg- 
ularly without appearing with the same regularity as f.i. in the 
above mentioned Indo-Pacific area. Only few data are available 
on the distribution of paratyphoid A throughout all the other non- 
European areas, as neither clinically nor bacteriologically has 
a sufficient and satisfactory distinction been made between para- 
typhoid A and the related organisms of the bacillus typhosus and 
bacillus paratyphosus B Schottmueller, 
In the European territories paratyphoid A heretofore was reg- 
ularly observed only in the Mediterranean countries. It is very 
likely that world war I, from 1914 to 1918, with the temporary trans- 
fer of a lirge number of non-European troops to the European terri- 
tories promoted the spread of paratyphoid A throughout Europe, The 
literature reports a few isolated cases only for the period before 
World War I the geographical distribution of which is recognizable 
from the attached map, The increased paratyphoid A incidence after 
that war probably is not only to be traced back to the increased 
attention but to the improvement of the bacteriological and sero- 
logical methods of diagnosis as well. 
During World War I from 1914 to 1918 a large number of isolated 
cases of paratyphoid A occurred in Europe and small epidemics were 
observed in regions, where diseases due to bacillus paratyphosus A 
had not been observed previously (cf.map). This particularly ap- 
plied to the German ana French battle front from Metz to Reims,* 
where paratyphoid A occurred on both sides and, in addition, to the 
Austrian-Italian battle front, the Saloniki front, and Roumania, 
In the Eastern Theater only isolated cases occurred. In all the 
above mentioned battle areas the highest paratyphoid A incidence 
was attained in 1916 although the same conditions favorable to the 
outbreak of paratyphoid A were offered by the events in 1917 and 
191B. Altogether 4135 paratyphoid A cases were found throughout 
the German Army, The comparable figures of the different theaters 
of war are given in Table 1, 1/6 
Table 1. 
Diagnosis through bacteriological examination 
Area: 
Year 
Paratyphoid 
A 
Paratyphoid 
B 
Typhoid 
Fever* 
I. Balkan: 
1* Bacteriological 
1915 
4 
52 
83 
diagnosis of the 
1916 
* 422 
. 327 
125 
field lab.Ueskueb 
1917 
37 2 
343 
49 
2* French Levant Army 
Beceohaj) 
to September 
1915 
1916 
226 
26 
82 
June to December 
1917 
100 
36 
59 
II* Western Theater: 
1* German Forces 
1914 
26 
156 
107 • 
1915 
100 
689 
2163 
\ 
1916 
570 
3149 
43 3 
1917 
362 
5485 
212 
Percentage of Paratyphoid A in relation to all typhoid 
diseases: 
Western Theater: 
2. French Forces 
1914 
- 
- 
- 
1915 
10 % 
- 
- 
June 
1916 
92 % 
- 
- 
December 
1916 
20.2 % 
- 
- 
1917 
40-55 % 
10-33 % 
25-30 % 
1918 
7-15 % 
15-25 % 
60-75 % 
III* Italian Theater: 
Austrian Forces 
End Nov. 
1915 
first cases 
of paraty-A 
beg.Dec. 
1915 
20-25 % 
20 % 
50-55 % 
End Dec. 
1915 
50 * 
15 % 
35 % 
Feb. to June 
1915 
75 % 
15- 20 % 
5-10 % 
July to Nov. 
1916 
20—45 % 
50- 60 % 
5-10 % 
There was no spread of paratyphoid A after World War I. Only a 
very small number of scientific publications supply information on 
the occurrence of paratyphoid A throughout Europe during the period 
after w°rld War I* X/6 
North of the Alps paratyphoid a is and always was rare and oc- 
curred with a certain regularity only in those places which have to 
be considered as the centers of traffic with the Mediterranean coun- 
tries or with the oversea areas of distribution, such as f*i, Amster- 
dam Rotterdam, Hamburg, Munich, Breslau, Paris, Inmost of the cases 
the infection with paratyphoid A was due to a stay in the tropics or 
the subtropics. 
North of the 56° latitude no case of paratyphoid A was observed 
except for one case in Petersburg (Leningrad). 
Within the territory uf Greater Germany only 2 rather great 
paratyphoid a epidemics have been observed so far. During the epi- 
demic in Koenigsberg (1922), involving 244 cases, 124 cases gave a 
positive serological reaction for paratyphoid A and bacillus para- 
typhosus A was isolated in 24 cases* The origin of this epidemic 
was not recognized. The last epidemic of paratyphoid A happened 
in Vienna in March 1939* in the barracks where 121 cases fell sick 
with it, one of which was fatal. Bacteriological proof was estab- 
lished in two third of the cases only, usually through a blood-agar 
culture medium. Here, most likely the infection of the soldiers par- 
taking of the food with paratyphoid A was effected by lettuce imported 
from Sicily by a Vienna vegetable dealer. This latter occurrence shows 
the exposure of Germany to the danger of an occasional spread of para- 
typhoid A from the Mediterranean countries. For Italy, Croatia, Al- 
bania, Greece, French North Africa, and Syria paratyphoid A occurs as 
an endemic which, however, does net attain the extent of the para- 
typhoid A incidence throughout eastern Asia, With the available 
statistical material and estimations the proportion of paratyphoid 
A to the total number of the typhoid diseases of the intestine after 
the years following upon World War I is given in Table 2 attached 
to this article. 1/6 
Table 2» 
Proportion between Paratyphoid A and All Para- 
typhoid Diseases after World War I* 
Area 
Year 
Paratyphoid 
• A 
Paratyphoid 
B 
Typhoid 
Fever 
Black sea Area: 
Rostov (Don) 
1926 
5 -10 % 
5 - a % 
34 % 
Mediterranean Basin: 
French Mediterranean coast 
(estimation) 2 % 
13 % 
30 % 
Southern Italy 
(province of Bari) 
1933133 
19.9 % 
12.1 % 
68 % 
French North Africa 
(Colonial Army) 
1929-37 
16 % 
40 % 
44 % 
Croatia: 
Area of Osijek and Susek 
1931-35 
23 different 
strains were 
cultivated 
15 strains 
cultivated 
Remaining parts of 
Croatia 
1931-35 
9 strains 
cultivated 
46 strains 
cultivated 
W. DOMLE. 1/7 
PARATYPHOID C THROUGHOUT EUROPE nND THE MEDITERRANEAN 
BASIN 
Translation prepared by: 
U* S. Fleet, U* S* Naval Forces, Germany, 
Technical Section (Medical). 1/7 
Paratyphoid C is the term for the typhoid diseases of man 
caused by organisms of the group Bacterium suipestifer# 
It progresses under the symptoms of a mild typhoid fever, 
the fever lasting usually less than ten days. As a rule para- 
typhoid C does not seem to be accompanied by intestinal ulcers. 
The post-mortem inspection reveals typhoid granulomata in the 
spleen, the liver, and in the mesenteric glands. The symptoms 
of paratyphoid C are rarely observed in the pure form, as it 
usually is an infection associated with other infectious dis- 
eases (such as malaria, relapsing fever, infectious hepatitis, 
dysentery, etc,). In such a case the paratyphoid C infection 
shows suppurative complications as the only symptom. 
Paratyphoid C must not be confused with the acute gastro- 
enteritis caused by Bact. suipestifer, which usually occurs as 
a group infection after eating contaminated pork and sausages 
made from pork. The term paratyphoid C should not be applied 
for such diseases nor for the enteritis due to other bacilli of 
the Salmonella group. 
Two types of bacilli of the suipestifer group may be con- 
sidered as the causative organism of paratyphoid C5 these are 
the type Erdzindjan or Orient (Salmonella paratyphi C) and the 
type Kunzenaorf (Salmonella cholerae suis varckunzendorf), 
I. Paratyphoid C of the type Erdzindjan was found during World 
War I in the Balkans and in the Near East. During the pe- 
riod immediately after that war sporadic cases were found in 
the border areas of the eastern Mediterranean basin. Dur- 
ing World WTar II it was not observed throughout this area. 
Some observations made in Volhynia suggest that during World 
War I paratyphoid C also occurred in the Eastern Theater of 
Operations. It was of a certain importance during the years 
of famine and epidemics in Russia from 1919 to 1923, where 
it occurred under the term paratyphoid N, which was observed 
particularly as a complication of relapsing fever. However, 
the diseases discussed under the term paratyphoid N are not 
identical as to their bacteriological cause, part of them 
being aue to the Bact. enteritidis Gaertner. Only a small 
fraction of the cultivated organisms was so thoroughly ex- 
amined that they were recognized with certainty as belonging 
to the type Erdzindjan. In one case (in Rostov) the type 
Kundenzorf was found. 1/7 
The center of the paratyphoid C incidence was the 
southeast of Russia. The cases found in Leningrad prin- 
cipally seemed to affect those persons who had arrived 
from the southern territories. In the course of World 
War II Erdzindjan strains originating from pw*s were 
sometimes cultivated (HORN) without detailed epidemio- 
logical data being available. 
No certainty is established as to the epidemiology 
of the paratyphoid C caused by the type Erdzindjan. 
As this organism has not been found in animals so far, 
it is permissible to assume that it is communicated di- 
rectly from man to man. The contamination through cer- 
tain insects was also discussed, but no proof is here- 
tofore established as to the way of the infection. 
II. The type Kunzendorf was not recognized as the causative 
organism for paratyphoid C during world War I. It prin- 
cipally was found during the period between World War I 
and World war II in the Balkans, where it was observed 
again during World War II« 
With the heretofore available methods this organism 
cannot be distinguished from the organism of hog-cholera 
and of the acute gastro-enteritis of nan due to eating 
contaminated pork. It is not proven as yet whether or 
not paratyphoid C of the Kunzendorf type is connected with 
swine as the source of infection. 
It is still aj matter of doubt whether or not the occurrence of 
paratyphoid C throughout the Near East and throughout Russia should 
be considered as a geomedical entity. In addition two more such 
areas exist, one of them being situated in the East Indies, the other 
one along the northeastern coast of South America. 
For the evaluation of the chartographical design one must bear 
in mind that the diagnosis paratyphoid C is only possible if the 
clinicians and the hygienists cooperate sufficiently. The places 
given in the chart, therefore, are the places, where paratyphoid C 
has been found incidentally and they should be considered as the 
first data of the actual distribution of this disease. However, it 
is worth noting that the diagnosis was established during World War I 
on both sides of the front in several places independently in the 
Balkans and in the Near East on the one hand, and that on the other 
hand paratyphoid C was not observed in Germany and in the Scandinavian 1/7 
countries, where the research in paratyphoid and enteritis was par- 
ticularly intensive (except for 1 case in Mecklenburg)a 
Therefore, the answer must be found for two geomedical questions: 
1. What is the reason for the absence of paratyphoid C cases in 
northern, central, and western Europe? 
2o Why has the type Erdzindjan which previously prevailed in 
the southeast, given way to the type Kunzendorf? 
These two problems cannot be solved before the following two 
epidemiological questions have been answered: 
I* Through which way is the paratyphoid C of the type Erdzind- 
jan communicated? 
2. What is the proportion between the paratyphoid cases of the 
type Kunzendorf and the corresponding infections of the swine 
and of the gastroenteritis of man? 
K* HABS 
(institute of Hygiene of the University 
of Berlin)• I/s 
DISTRIBUTION OF THE SANDFLIES 
(GENUS PHLEBOTOMUS) 
IN EUROPE 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical). 1/8 
The cartographical description of the distribution of 
the genus Phlebotomus in Europe is intended to afford a syn- 
opsis of the hazard of those regions in which the occurrence 
of diseases of which the Phlebotomus is a vector, must be 
reckoned with. Furthermore, the map is intended to make 
possible a judgment of the probable situation of the north- 
ern boundary of the distribution area of the Phlebotomi. 
It must be considered that the present principal distri- 
bution area of the genus Phlebotomus in Europe - the Medi- 
terranean region - for this genus which was distributed 
throughout Europe in the tertiary age, is only an area 
of retreat whose northern boundary is determined above all 
by climatic factors. To illustrate these conditions the 
course of the 10° C. annual isotherm is indicated on the 
map. On the other hand the various species of the genus 
can probably’ spread farther than the limited flying range 
of the single flies suggests. This is proven by the wide 
distribution of almost all species of the European Medi- 
terranean area which have spread from the western Medi- 
terranean coasts to northern India, even to the eastern 
Chinese coast. This is also indicated by the fact that 
some species (e.g. ph. perniciosus and Ph. sergcnti) are 
distributed in French North Africa southward only to the 
edge of the desert (do not reach Biskra for instance), 
but then possess again island-like distribution areas 
at some elevated places in the middle of the Sahara. 
Even if it must not be regarded as impossible on 
the strength of such reflections that a few species of 
the genus may occur also in the north of the present known 
northern boundary of the distribution area, it is on the 
other hand practically impossible that these species have 
any epidemiological importance far outside the distribution 
area known today. Today the genus Phlebotomus is too 
well-known, so any of its species can occur but only 
rarely and isolated, in European regions from which they 
have not yet boon reported. 
On the map the distribution areas known for those 
species which are known to attack man have been entered. 
The species of Phlebotomus occurring in the European 
Mediterranean region may be divided into two groups of 
species. One of these, the minutus-group (called also 
scrgentomyia or prophlebotomus) finds its blood-donors 1/8 
almost exclusively amongst the reptiles and thus is of no 
importance for man. It has not been considered on the 
map. By the way, its distribution area nowhere in Europe 
reaches the distribution area of the other group of species 
indicated on the map. The other group of species (sub- 
genus Phlebotomus in a stricter sense) comprises only 
species which attack man in addition to other mammals 
(and sometimes birds). In this group of species, a series 
of species has been distinguished which vary only in very 
slight characteristics and obviously replace each other in 
various geographical areas. It is suitable to separate 
them in a few form-groups (it is not yet certain whether 
the forms of those groups to which the special names have 
been given, must be regarded as races or as different 
species). These arc: 
Ph. papatasii Scopoli (distributed in the whole Medi- 
terranean region and \from there up to North India). 
Ph. sergenti Parrot (with the forms sergenti Parr, and 
alexandri Sint, in the whole Mediterranean region, 
caucasicus Marz. in Transcaucasia, Iran, Russian 
Central Asia, and mongolensis Mewst. in China and 
perhaps in Russian Central Asia as well). 
Ph. perniciosus Newstead (with the form perniciosus 
in the districts west of the Adriatic, the form 
tobbi Adler, Theodor & Lourie in the Mediterranean 
countries adjoining in the east,and the forms 
kandelakii Schtschur in Transcaucasia, Iran, and 
Russian Central Asia). 
Ph. perfiliewi Parrot (in the eastern European Medi- 
terranean countries Italy and Algeria, and the 
form transcaucasicus Perf. in Transcaucasia). 
Ph. major Annandale (with several less important 
forms distributed from North India and Russian 
Central Asia to Italy, in Southern Franco and 
Spain represented by ariasi Tonn.). 
Ph. chinensis Newstead (with several less important 
forms distributed from China and North India to 
the eastern Mediterranean region, in Italy and 
France represented by larroussei Lang. & Nitz.). 1/8 
These forms have a varied spidemiological importance. 
Ph. papatasii is generally regarded as the vector of 
pappataci fever. It must be considered, however, that 
the positive recognition, particularly of the females, 
has been made possible only recently. For this reason 
and for others mentioned below, it is no longer possible 
to affirm that the species with which the first experi- 
ments of transfer were made, was actually ph. papatasii. 
Ph. perniciosus, Ph. sergenti, and Ph. major (in the plain 
of the Dalmatian coast) are suspected to be the other 
vectors. It is perhaps not accidental that pappataci 
fever is'more important in the eastern Mediterranean region 
than in the western section in which Ph. papatasii seems 
to be of less importance (also Ph. major in the typical 
form evidently does not occur there), and in which Ph. 
perniciosus is said to bo much more frequent than Ph. 
papatasii at some places and at certain times. 
Ph. papatasii and Ph. sergenti (both or one of the 
two species at other places) are called the vectors of 
the oriental boil, Ph. perniciosus (in the western Medi- 
terranean region) and Ph. major and chinensis (in the 
eastern Mediterranean region) of Kala-Azar. 
Just as in their medical importance the single species 
considerably differ in their way of living as well. Ph. 
papatasii, for instance, remains in the interior of living- 
and bedrooms even in daytime and bites only in them. The 
other species, however, visit the living- and bedrooms 
only in search of food and bite in the open as well, as 
far as known until now. In contrast to Ph. papatasii, 
they are attracted by artificial light and differ' from 
each other also by the time of their flight into the 
buildings. If thus there is shown a denser hatching 
of some regions on the map (as expression of greater 
density of the species) one must not be lead to expect 
in these regions a greater individual frequency of the 
sandflies at any rate; it may bo supposed on the other 
hand that the importance of the Phlebotomi is particularly 
great in these regions, since the single species present 
there are, as it were, both temporally and locally re- 
presented in their attacks on man. This is also of 
importance for measures of protection and control. I/S 
The density of hatching in the single regions, however, 
is partly based on the degree of their exploration. Today, 
the best explored countries are Spain, France, Italy (par- 
ticularly the environments of Naples, Sicily, and Malta), 
French North Africa (Algeria), Serbia, Greece, Crete, 
Palestine, Syria, and Russia. Turkey, Italian North Africa, 
and Egypt are explored to an absolutely insufficient degree. 
It is certainly no accident that near the probable northern 
boundary only one or a few species at a time have been 
observed, and the elsewhere most frequent species Ph. papa- 
tasii is not one of them: in the very thoroughly explored 
France, Ph. papatasii is known only at a few places on the 
southern coast. The findings reported from Switzerland 
(Vaud, Ticino) probably refer to Ph. perniciosus. Even 
the findings in the Po-plain (Torino, Milano etc.) have 
been made a long tine ago. On the Balkan peninsula, the 
northern boundary of the species is near Ristovac accor- 
ding to recent data (it has been recently reported also 
from southern Bulgaria). Older data report the species 
from Roumania as well (Mehadia, Walachia, Iasi). It is 
urgently necessary to examine tho Phlebotomi occurring 
in Roumania once more as regards the species to which 
they belong. Recent reports from Roumania (Bucharest) 
speak only of the Ph. chinensiSo Also from the Dalmatian 
coast (it was proven there the first time that pappataci 
fever is transferred by phlebotomus!), only Ph. major 
has been recently reported. Ph. papatasii has not been 
found in the north of the Erym; in the Caucasus, Georgievsk 
is the most northern reported location. 
The species occurring most toward the north are in 
France Ph. perniciosus and Ph. larroussei, on the Balkan 
peninsula Ph. perfiliewi (Szeged, Hungary), in Odessa 
and on the lower Dnepr Ph. chinensis and Ph. sergenti, 
and in the Caucasian region Ph. major (Armavir, most 
northern reported location of the genus Phlebotomus in the 
Soviet Union according to SERGIEV). Among the mentioned 
northern forms, Ph. perniciosus is a pronouncedly western 
species, which has not been frequently found (in the form 
tobbi) in the eastern Mediterranean region. It is perhaps 
not accidental, however, that ph. perfiliewi, the species 
reported most northward on the Balkan peninsula, is 
closely related with Ph. perniciosus. Ph. larroussei 
is closely related with Ph. chinensis which has been found 
in Roumania, in Odessa, and on the lower Dnepr. In addition 1/8 
to ph. sergenti, also found in these regions, Ph. chinensis 
is the only one of the species occurring in the European 
Mediterranean region, which is spread up to China, though 
it never passes the 45th degree north latitude. 
In summary, it can be affirmed that an occurrence 
of the genus Phlebotomus far to the north of the previously 
known distribution area (apart from possible insignificant 
islands of distribution) is extremely improbable. If a 
few species should occur farther northward, these are 
probably Ph. chinensis, Ph. major, or Ph. sergenti (less 
probably Ph. perfiliewi), which are active at night, do 
not visit living- and bedrooms in daytime, and of whose 
epidemiological importance (as far as pappataci fever 
or, more generally, the "slight summer fevers" are con- 
cerned) nothing positive is known. Thus, it is prac- 
tically impossible that Ph. papatasii, whose epidemiolo- 
gical importance is most certain, as generally believed, 
should occur outside the distribution area of the total 
genus indicated on the map. 
W. HENNIG 
(Institute for Trojjical Medicine 
and Hygiene of the Military 
Medical Academy) Il/l 
OCCURRENCE OF PLAGUE IN THE NEAR EAST 
1917 - 1941. 
Translation prepared by: 
U. S* Fleet, U# S* Naval Forces, Germany, 
Technical Section y( Medical) • II/l 
For many centuries the Near Orient, the area situated between 
the two oldest origins of the plague, that is between the Central 
African and the Central Asiatic mountains was always the preferen- 
tial location of plague epidemics. From the most extensive per- 
sistent plague focus in Higher Asia with its western plague nests 
in the spurs of the Hindu Kush massif the plague within several cen- 
turies has repeatedly invaded the adjacent countries of the Near 
Orient, Afghanistan (derat 1877/78, Kandahar 1883/84), Chorassan 
(Mashhad and environments 1881, 1887, 1890), and the Iranian pro- 
vinces Gilan (Resht 1877: 2000 deaths), Kurdistan (1878, 1881, 
1883) and seistan with the town Turbeti-Scheich-Djama and Avaz 
(1905/06). These areas must be regarded as exposed to plague even 
today, even if no reports of plague in Afghanistan and Iran were 
available during the last decades. 
The very old persistent plague focus on the Northwest shore 
of Lake Victoria (cf.map) according to STICKER constitutes the 
source of the former occasional occurrence of plague in Egypt and 
in the North African colonial countries from Tripoli to Morocco, 
In recent times the Nile valley must be considered as a new plague 
focus of the 2nd order on account of the regular annual occurrence 
of plague in this area, 
In the Near East two persistent plague foci exist according 
to STICKER: 1* One of theia is situated in the Highland of Asir 
between Nejd, Hejaz and Yemen, southwest of Mecca, the district 
of the Beni Scheir, of which there are no reports since those made 
by STICKER. 2, The other one is located in the mountains around 
MS. Ararat with the highlands of Armenia, Azerbeidzhan and Kur- 
distan, which according to STICKER were a persistent focus of plague 
before 1902. While in these two areas only very isolated cases of 
plague occurred during the past years (as e.g, in Karabach 1931), 
and only few epidemics in the adjacent regions such as the epi- 
demics in Jidda 1897/98, 1906/07, Aden 1900, 1905, 1913, 1917 and 
1928), in present times a new plague source of the 2nd order has 
been formed in the Near East5 namely in Iraq, which originated from 
this focus, and where even nowadays cases of plague occur annual- 
ly. Recently (1940/41) cases of plague were reported in El Keweit# 
Of the most important plague foci of the 2nd order which be- 
came famous during the past century, namely the ports of the Levant, 
only Beyrouth was left with a few isolated cases of plague, without 
the epidemic spreading from here to Syria and Lebanon, Except for 
a few isolated cases which were imported to the ports Antalya, Izmit, II/I 
Istanbul, Trabzon (Trabezond) Turkey has also been free of plague 
epidemics during the past decades (since 1871)* 
Egypt, which according to SUCKER was invaded again by plague 
in April 1899 from Alexandria after plague had been extinct in that 
country since 1846, in recent times is the most important plague 
focus of the Near East as regards the area of spread and the number 
of cases, plague has its foci in the Nile valley and claims a 
great number of victims among the rural population of many pro- 
vinces. Almost every year small or more extended epidemics break 
out which on four occasions amounted to more than 1500 cases with- 
in one year (1908, 1911, 1916, and 1923). Usually only sporadic 
cases of plague occur and small epidemics against wnich energetic 
measures are taken immediately. It is primarily due to these 
watchful measures that plague has not spread further in the Nile 
valley. During the past 15 years (1926 - 1940) the greatest number 
of plague cases occurred in the provinces Asyut, Minia, and Girga. 
Several times cases were also observed in Garbia, Bani Suef, Man- 
falut, Menufia, and Giza. Only two to three times within 15 years 
was it observed in the provinces Aswan, Beheira, Fayum and Qena, 
Cairo has remained free of plague from 1899 unto this day, 
despite the fact that isolated cases of plague were imported al- 
together 16 times during the past years. 
The Anglo-Egyptian Sudan has also always been free from plague 
since 1899 although the plague focus of Uganda is not far from it. 
H. J. JUSATZ* II/2 
DISTRIBUTION OF THE FEVER-MOSQUITOES 
IN WESTERN AND CENTRAL ASIA 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
' Technical Section (Medical). II/2 
The map is intended to show the occurrence of the 
most important vectors of malaria in Western and Central 
Asia. The possible distribution in the loss known regions 
is considered as well. 
Anopheles elutus (6) *) is the most frequent species 
in the Near East and in the Balkan peninsula. It breeds 
in warm, and even in salty water and thus is frequently 
observed at the coast. Very important vector! 
A. maculipennis (1) has a vast area of distribution 
through the whole of Europe, from the north (Arkhangelsk) 
to the Caucasus, from Turkey through Syria, Palestine, 
northern Mesopotamia to Persia. The larvae live in a 
similar way as those of A. elutus (swamp-breeders), and 
also stand water containing slight amounts of salt, but 
decrease in the southern region in favor of A. elutus. 
In Turkey, A. maculipennis is limited to the highlands, 
but also haunts brooks and thus becomes a brook-breeder. 
This work pays no special attention to the single species 
of A. maculipennis, since examinations in this line are 
still incomplete in Western Asia. 
A. superpictus (2) spreads from the Mediterranean 
region through Iran and Turkestan to India (rare in Egypt). 
Shallow mountain-streams are preferred breeding-places. 
The mosquitoes greedily bite during dusk and night and 
are considered as very important vectors of malaria. 
For A. superpictus and A. elutus, Turkey forms a 
central area, from which the two species extend into the 
adjoining regions. The fauna of Macedonia is closely 
related to that of Anatolia; both regions form a 
biological unity. Also with regard to these regions 
it can be said that years with large rainfall favor 
swamp malaria by fostering the breeding-places of elutus 
and maculipennis, that dry summers, on the other hand, 
reduce these and favor mountain malaria, because of the 
fact that the rivers dry up but small rivulets are more 
easily conserved in the mountains and thus give rise to 
typical breeding-places of superpictus. 
*) The figures in brackets indicate on the map the 
respective species of Anopheles. Rare species have 
been inserted in brackets on the map. II/2 
A. bifurcatus (3) occurs frequently in wells even in 
southern Turkey; in Palestine it is a typical cistern- 
breeder . 
A. hyrcanus (5) has an extensive area of distribution 
in south Europe, western Asia, Caucasia, Persia, Turkestan, 
India to China and Japan. The larvae prefer shallow 
stagnant water with rich vegetation and even slightly 
salty water. They avoid muddy water. The mosquito is a- 
free land insect (wild mosquito). In the Caucasus it may 
be regarded as a vector. 
i 
A. plumbeus (A) is chiefly distributed in the Caucasian 
region and is at most of local importance. 
Map 1. Spleen indices in Palestine 
Territories infected with malaria are 
hatched II/2 
From the west two species extend to the area shown 
on the map: 
A. algeriensis (7) through all western Asia. It is 
absent in Arabia and south Russia. We point out here its 
occurrence in Germany (in the north up to Mecklenburg). 
A typical free land mosquito without any practical 
importance. 
More toward the east is found: 
A. pulcherrimus. It has its area of distribution 
from northwest India through Tadzhikistan, Uzbekistan, 
Turkestan, Turkmenia (Transcaspia), Caucasian region to 
Mesopotamia (particularly frequent). It breeds in shallow 
ponds covered with vegetation, occasionally in rain-pools 
as well as in rice-fields. It is active at dusk. The 
mosquitoes are attracted by light. As an inhabitant of 
the steppe, it has a particularly great flying capacity 
and a great power of resistance against dryness. A. pul- 
cherrimus hibernates as a larva and is probably an impor- 
tant vector. 
From north Africa the following species extend: 
A. sergenti (13) has its principal area of distri- 
bution in the southern Mediterranean area, extends to 
Palestine and is no longer observed in Turkey. The larvae 
live in vegetation covered banks of ponds and lakes in 
sunshine. They avoid water containing salt. It easily 
penetrates into houses and is probably a serious vector 
in Palestine and Egypt. 
A. multicolor (14) extends from north Africa through 
Egypt, Syria, and Iran to northwest India. The larvae 
live, in small pools, wheel tracks, and hoofprints, even 
waste waters and they like salt particularly. They stand 
a salt percentage up to 6The flying capacity of the 
mosquitoes is considerable (up to 13 Km.!). •*»■. multicolor 
is regarded as a vector of malaria in Egypt. 
A. pharoensis (15) does not reach so far: Toward 
the north to Syria, towards the east to Mesopotamia. 
It chiefly breeds in swamps, rice-fields, and papyrus- II/2 
swamps. Completely stagnant water with rich vegetation 
is characteristic for it. It has been recognized as an 
important vector in the Nile region. 
Map 2. Spleen indices in Iran 
Regions infected with malaria are hatched 11/2 
In southern Arabia, numerous Central African species 
occur, whose northern and eastern boundaries of distribution 
are not yet sufficiently known. As important vectors we 
mention A. funestus and A. gambiae. On the map, the 
species occurring in the southern section have been entered. 
From India, some species spread to north and west, 
their area of distribution in eastern Iran and Afghanistan 
is not yet sufficiently known. 
A. Stephensi (10) extends to the Persian Gulf and 
thus roaches Mesopotamia. A. Stephens! is considered a 
very important vector of malaria. 
A. turkhudi (9) extends through southern Arabia to 
the Anglo--Egyptian Sudan. Nothing positive is known about 
the practical importance of A. turkhudi. 
In Afghanistan, the occurrence of Indian species is 
to be expected. In addition, various eastern and northern 
malaria-mosquitoes penetrate from the other adjoining 
regions. The following species must be reckoned with: 
A. superpictus, A. pulcherrimus, A. stephensi, A. hyrcanus, 
A. sergenti, A. multicolor, and A. turkhudi. In the north- 
western corner, serious tropical fevers occur, even in the 
area of Mashhad which extends to Afghanistan through the 
north Iranian border mountains. In the southwestern part, 
serious tropical fevers occur again. 
As regards Palestine, exact work is available (see 
special map with indications of spleen indices and areas 
of distribution). In the coastal region and in the valley 
of Esdrelon tertiana is predominant, around the lake of 
Nazareth quartana. The whole valley of the Iordan river, 
the town of Tiberias excepted, is largely infected with 
malaria. The Naamin River (Nahr Na’airen) which flows into 
the Bay of Acre, is very dangerous! Affule and Haifa are 
usually rather free from malaria, but are seriously 
infected with pappataci fever. 
A special map informs about Iran. The regions on 
the Caspian Sea have a large rainfall and are partially 
swampy. The coast has numerous lagoons. In the provinces 
Ghilan and Mazenderan there are many rice-fields, and II/2 
there is a malignant malaria, also along the rivers Kura 
and Araxes and along the further coastal region, there 
are great endemic malaria-areas, as well as on the southern 
coast and in the Persian Gulf .(Shat-el-Arab » delta of the 
Euphrates and Tigris Rivers). The port of Bander Abu Shehr 
(Bushire) is regarded as particularly intensely infected. 
From May to September *tertiana, from August to October 
tropica is said to be predominant. Malaria then spreads 
along the coast and passes over into the region of Balu- 
chistan. In the interior of the country there are numerous 
endemic foci, fostered by widely spread subterranean canals 
and salt swamps. Despite its altitutde (1,?00 m.) , Shir;-m 
is intensely infected with malaria. Malaria usually does 
not reach altitudes higher than 2,000 m. Also all Meso- 
potamia is considered largely infected with malaria, 
particularly in the place of pilgrimage Karbala, there is 
a high mortality of malaria. Only the oil regions are 
relatively healthy, since the waters there are covered 
by a thin layer of oil and thus the malaria mosquitoes 
cannot live. 
E. M.JRTINI and J. HLISNIKOWSKI Il/2a 
OCCURRENCE OF MaLARIA AND DISTRIBUTION OF .JTOPHELES 
IN TURKEY 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical) Il/2a 
1. The drawn out boundary lines indicate the boundaries 
of Vilajets (Administration Districts) which are only finely 
dotted in the mao. They are specially marked only with 
those Vilajets which form the center of an area of malaria 
control. Such a center often reaches farther than the 
Vilajet boundaries, then it is marked with interrupted 
lines in its approximate outlines. In other cases, part 
of those Vilajets does not belong to the control area, 
because it is not much infected with malaria, then it is 
also marked with interrupted lines. Furthermore, the 
control stations are indicated by dots, the centers by 
spot with a little flag. The Roman numbers I-IX are 
explained on the left side, X-XVIII on the right side. 
Sinco in the course of time the control areas are 
extended, reorganized, or subdivided, an exact 
representation of the present condition without 
consulting the government files is impossible. 
The data are based, above all on the lectures 
of Asim Arar and Serafettin Atananoglu at the 
3rd Congress of Tropical Medicine and Malaria 
in Amsterdam, and on the lecture of Hussameddin 
on the 2nd International Malaria Congress 
in Algiers. The representation is a summary one. 
Districts only slightly infected with malaria 
and thus not included in the control zones have 
not been particularly marked. 
The first letters of the towns with malaria-stations 
have been entered. These are: 
Trakya. Edirne: Lueleburgaz, Uzunkoeprue, Hayrabolu, 
Corlu, Kesan, Galebolu, Istanbul. Kocoeli: Karasu, 
Adapasari, Hendek, Duezce, Sapanca, Soeguet. Bursa: 
Yalova, Karacabay, .Jenisehir, Inegoel, M.Kemalpasa. 
Balikesir: Bandirma, Manyas, Ezine, Edrenit. Eski- 
sehir: Mihaliccik, Sivrihisar. Manisa: Akhisar, 
Menemen, Karsiyaka, Turgutlu, Salihli, Alasehir. 
Aydin: Torbali, Civril, Nazilli, Denizli, Karahayit, 
Bagarasi, Milas, Koizegiz, Fethiye. Samsun: Bafra, 
Carcamba, Terme. Kars: Igdir. Ankara: Tosya, Ilgaz, 
Cerkes, Cankiri, Etimesut, Keskin, Polatli, Haymana. 
Kayseri: Yerkoey, Finarbasi, Doveli. Diyarbakir. 
Konya: Afionkarahisar, Cihanboyli, Aksaray, Akcehir, II/2a 
Ilgin, Beysehir, Eregli, Karaman. Maras: G-oeksun, 
Pasarcik, Islahio. Adana (Seyhan): Kozan, Kadirli, 
Osmaniye, Ceyhan, Doertyol. Icel (Mersin): Tarsus, 
Si 1 ifke, Ananur. 
2. The hatching indicates the general degree of 
malaria infection: large interrupted hatching: "nalaria 
present, in part to a considerable extent", uninterrupted 
hatching "serious nalaria", cross-hatching "very serious 
nalaria". Particulars see 5- Some smaller regions which 
are completely free from malaria, e.g. those with alti- 
tudes higher than 2,000 M. , are included in the hatching, 
as well as some smaller, healthier districts .are in the 
cross-hatched areas. 
3. The numbers in italics entered on the nap refer 
to the species of Anopheles, as explained in the list 
beside the nap. As on other naps, the data express the 
places examined rather than affording a real notion of 
the distribution of the species. Apart from some parti- 
cularly hot districts and some salt desertlike regions 
as well as very high altitudes, A. maculipennis occurs 
practically everywhere in the country. 
A. The legends loft and right of the nap indicate 
in their headings number and name of the control-districts. 
Below them, on the right side, there is, in large-faced 
type, the parasite index of the control area according 
to the work of As in Arar. The index is found by drawing 
blood-drops from large numbers of persons and by examining 
them for malaria parasites. The figure of the positive 
findings, divided by the total number of the persons 
examined and expressed in %, is the parasite index. 
Here, it has been obtained from many thousands of 
examinations through several years in every Vilajet. 
The malaria-rose beside it corresponds in the numbers of 
mm. of its diameter to this index. It is subdivided 
in sectors which correspond to' the proportion of the 
three principal kinds of malaria and to the nixed 
infections (chiefly tertiana * tropica parasites). 
The figures on the left side express another index: 
the average annual figure of the persons found infected 
with malaria in the respective control area, divided by 
the total number of inhabitants of the central Vila jet 
in 1935 (census of the people), again expressed in %. II/2a 
5- These very indefinite indices also form the basis 
of the hatching, and that as "malaria present" everything 
up to 12 % included, as "serious malaria" index between 
12 and 25 and "very serious malaria" more than 25 %• 
The first step will have to be subdivided in a future 
work. The difference of the Vilajets appears much more 
distinctly in the figures on the left than in those on 
the right. 
This is due to the following fact: The figure 
of persons infected with malaria (No.4) comprises 
in addition to those recognized as germ carriers 
during the blood-examination also those whose 
infection with malaria is only observed on the 
spleen, and partly probably cases which have 
become, manifest purely clinically. Thus, it 
is more complete and thereby larger. But it 
refers not only to the persons examined but to 
all the population among which these cases have 
been found (if control area and Vilajet approxi- 
mately coincide). If small portions of a Vilajet 
have not been included in the control, they are 
usually mountainous or half-desertlike and thus 
thinly inhabited regions, whose much better health 
hardly affects the Vilajet average because of the 
small numbers of inhabitants (Adana, Aydin among 
others). On the whole, the sentence is true for 
the countries with hot climates; "Where there is 
plain and water, there is luxurious fertility, 
dense population, economic prosperity and con- 
siderable malaria". Even if during the establish- 
ment of the control centers chiefly the economic 
importance has been decisive beside malaria con- 
ditions, both are frequently in the same line. 
If the not included and thus healthier regions 
are large and more densely inhabited, they not 
only decrease considerably the index on the left 
as contrasted to the index on the right during 
the computation of the figures, but even more 
than is actual since the cases of malaria 
occurring in these regions have not been included 
in the computation. In spite of that, the ex- 
aggerated differentiation of these figures is 
advantageous, on the whole. Istanbul shows how Il/2a 
differently the two indices indicate: The 44,000 
inhabitants of the 18 villages under malaria control 
have a parasite index amounting to 6.2 but they 
represent only one twentieth of the inhabitants 
of the Vila jet. Thus, the infection referred to 
the total district of Istanbul, lies far below 
1 fo, and this figure- is of more practical import. 
Only with the new centers in Kars and Diyarbakir, 
the figures on the left are deceptive, since the 
greater part of the Vilajets is not yet under 
control there. For this reason, this index is 
much lower today than it will be in a few years 
(in 1939, more than 70 % were infected among 
21,000 persons examined of the Vilajet Kars, 
more than 40 $ among 23,000 persons of the 
Vilajet Diyarbakir. Also in Konya and Kayseri 
the infection with malaria in the proper malaria 
control area is in part considerable). 
* 
However unstatistical this index is, it gives the 
more practical clues. On the whole, the majority of 
the regions endangered by malaria and economically 
important in the west are under control, and the control 
are?s, which run along the linos of communication, adjoin 
approximately. Today the portions seriously infected 
with malaria of 31 of the 62 Turkish Vilajets are under 
control. Only the mountainous and thus healthier parts 
of the country, particularly the east are not under 
control. The most serious malaria is observed in the 
lowlands of the hot southern coast. In the north it 
is not quite so serious even on the sea coast, and in 
the highlands, it is on an average not so frequent as 
in the lowlands. The proportion of the tropica in total 
malaria and thus the danger of life by malaria usually 
follows the same rule. Despite that one finds some very 
seriously infected towns and villages in the highlands 
even in altitudes higher than 1,000 M. 
In addition to the local average summer temperatures 
malaria is determined by geomorphology and the fre- 
quency of vectors is chiefly based on it. For this 
reason, plains are usually more infected with malaria 
mountains are healthier, high altitudes even comple- 
tely healthy. Malaria which occurs in altitudes of Il/2a 
1,700 M., is often not autochthonous but is obtained 
during seasonal work in lower altitudes. The local 
differences, which may be of considerable practical 
importance might have been entered only according 
to official Turkish data in maps on a scale of 
1 : 1 million or less. Even some smaller districts 
e.g. near the coast which are doubtlessly seriously 
infected with malaria and might have been marked in 
the map, have not been marked since there are no 
exact data available concerning them at present. 
Furthermore, the interior of largo towns is usually 
healthy (Istanbul, Eskisohir, Afyankarahisar, Konya). 
Ankara even in 1926 was so well restored to health that 
no attention need bo paid to malaria within the city. 
In Izmir, the center of the town is healthy, but the 
suburbs in the north and south extend into regions very 
seriously infected with malaria. In the course of time, 
the indefatigable hygienic work of the Turks has improved 
much. Disturbances of normal life, however, may restore 
the old unfavorable conditions. 
The most dangerous si:ecies of Anopheles are: A. 
elutus, superpictus, maculipennis. The first is the 
principal vector in the hot lowlands, chiefly also in 
the elevated plain, the last in the north and in the 
elevated plain up to the mountains. A. superpictus 
chiefly occurs in the mountains and hills. 
It is fostered by dry summers with early termination 
of the spring-rains. On the other hand, such years 
dry up the breeding places of A* elutus in the plains 
early and extensively. Thus, they are unhealthy in 
mountains and hills, but healthy in the plains, 
Years with late and great rainfall in spring, however, 
effect the reverse. For this reason, the distribution 
of malaria intensity often fluctuates with the years 
in the single regions in different ways. 
The present species correspond to the Macedonian 
species, like the Anatolian fauna on the whole. Only in 
the extreme south (Iskenderon(Alexandrette)), A. sergenti 
joins them. In the southern plains, the flying time of Il/2a 
the Anopheles begins more than one month earlier than on 
the elevated plain and lasts longer as well. 
On the whole, only a very summary representation not 
considering the most recent facts could be given in the 
present state of affairs. 
E. MARTINI II/ 3 
ARTHROPODA AS VECTORS OF DISEASES 
(EXCEPT ANOPHELES) 
IN THE NEAR EAST 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Gernany, 
Technical Section (Medical) II/3 
Yellow Fever Mosquito - Sandflies - Ticks 
If the exploration of the distribution of diseases 
or of species of animals is still in its beginnings, the 
reported locations by no means give a picture of the 
actual distribution but often only of the presence of 
explorers who worked in the respective region. If, for 
instance, Phlebotomus squanipleuris has been found in 
India and on the Caspian Sea, nobody doubts that it will 
occur between these places as well and beyond these. The 
sane applies to Ph. tiberiadis (Tiberias and Abyssinia). 
Only the future work of decades may give approximately 
truthful concepts of such distribution and of its laws. 
On the nap, the places are indicated by figures. 
If no positive data are available, the figures are absent. 
The occurrence of Aedes aegypti is in part only concluded 
from the report of dengue-epidemics, since according to 
the present opinion, this disease is transferred only 
by this mosquito in the Mediterranean region and in western 
Asia. 
The Russian territories and Egypt, Palestine, and 
the Sudan are explored most. Only rare reports are 
available on Anatolia, Syria, Iraq, and Arabia. 
I. Yellow Fever Mosquito: Aedes Aegypti 
Aedes aegypti: yellow fever mosquito. Cosmopolitan. 
Transfers dengue in the Mediterranean region and western 
Asia. Occurs in the Mediterranean coastal districts, in 
Asia Minor in altitudes up to 600 M., Black Sea coast 
of the Caucasus and Asia Minor, Syria, Palestine, Egypt, 
Sudan, Red Sea, Arabia, Iranian coastal region. On the 
Iranian highlands its occurrence must not be expected 
on account of the too severe climate. 
II. Sandflies: Phlebotominae 
The medically most important species of Phlebotomi, 
Ph. papatasii sergenti, major, and chinensis occur 
throughout the Near East, as far as the ecological 
conditions are present. According to KAMALOV (1934) II/3 
all species of Phlebotomi are absent in western Georgia 
(except the Black Sea coast). Ph. perniciosus, which is 
important in the western Mediterranean region, evidently 
has its distribution boundary in the Near East and is of 
no great importance there. As regards the other species, 
it is hard to say to what degree the scarce data are to 
be explained by actually dispersed distribution, by the 
way of living, or by confusion with other species. 
Synopsis of the reported locations in the 
Near East known until now 
(in brackets: Smaller reported locations 
which are not indicated on the map) 
1st group: Phlebotomus papatasii 
Ph. papatasii Scopoli: the transfer of pappataci 
fever and (at least in some regions) Oriental boil has 
been proven. Distributed throughout the Mediterranean 
region up to the Oriental (India, Java) and in part of 
Ethiopia. 
Synonym: duboscqui Nev. Lem. 
Transcaucasia: Tiflis, Erivan, Nakhichevan, Baku, 
Dzhulfa, Poti, Batum, Gonio, Gori, Bortchalo, 
Karaiasi, Kakhetia, coast of the Black Sea as far 
as Trabzon; Iran: Resht, Tehran, Kaswin, Manjil, 
Hamadan, Kermanshah (Abu Gherm, Kerind, Aabanshah, 
Rutbah); Iraq: Mosul, Baghdad, Basra; Palestine: 
Jerusalem, Jericho, Haifa, Amman, Djerash, Maan, 
Mozah, Rosh Pinah, Tiberias; Syria: Alep, Hellaweh, 
Tripoli, Batrun, Enfeh, Beyrouth, Zachle, Adde, 
Beherreh, Bet Mori, Bar Elias, Kubba; Egypt: Cairo, 
Zagazig, Sudan (El Fasher, Singu, Abu Haraz, Ghoz 
Khadra, Tokar, Hombori); Turkey: Dardanelles, Izmir, 
Ankara, Jachshehan, Istanbul. 
2nd group: Phlebotomus sergenti 
Ph. sergenti Parrot: the transfer of Oriental boil 
is regarded as proven. Distributed from the western Medi- 
terranean region to northern China. II/3 
One distinguishes the varieties mongolensis Sinton 
(synonym: borovskii Chodukin Sofjeff) and alexandri 
Sinton . 
Transcaucasia: Erivan, Baku, Tiflis, Gori, (Mukhran, 
Muranie); Iran: Kazvin, Tehran; Iraq: Mosul, Baghdad, 
Amara; Syria: Bcherreh. 
Ph. caucasicus Marzinovsky: Known only in Trans- 
caucasia, Transcaspia, Iran, and Afghanistan so far. 
Synonyms; li Popov, selectus Khodukin. The older 
data of reported locations must be used with great 
reserve, since the species was usually mistaken for 
sergenti formerly, from which it is difficult to 
differentiate. 
Transcaucasia: Erivan, Baku, Tiflis, Gori, Karaiasi, 
Kakhetia, Nakhichevan; Iran: Tehran, Kazvin, Hamadan, 
Assadabad, Kermanshah, Mashhad, (Abu Germ, Kerind, 
Aabanshah, Rutbah). 
3rd group: Phlebotomus major 
All species of this group are susp.ected to be vectors 
of Kala-Azar, the participation in the transfer has been 
confirmed so far with more or less probability only with 
chinensis, major, and perniciosus. 
Ph. major Annandale: distributed from the eastern 
Mediterranean countries (Italy, Greece) and the Crimea to 
the Oriental region. Regarded as a vector of Kala-Azar 
in the eastern Mediterranean region. 
The aninals in Syria and Palestine belong to the 
var. syriacus Adler and Theodor. 
Transcaucasia: Tiflis, Erivan, Borjom, Gori, Bortchalo, 
Gomi, Gandzha (Kirovabad), Barda; in the north Cau- 
casus region as far as Armavir; Palestine: Jerusalem, 
Haifa, Mczah, Hosh Pinah; Syria: Alep, Batrun, Enfeh, 
Zachle, Adde, Bcherreh, Bet Meri, Bar Elias (Kubbah), 
Cedar Grove; Turkey: Dardanelles. II/3 
Ph. perniciosus Newstead: regarded as an important 
vector of Kala-Azar in the western Mediterranean region. 
Distributed throughout the Mediterranean region. Eastern 
boundary of distribution 'area seems to be in Palestine 
and Iraq. Former reports from Transcaucasia and Trans- 
caspia are said to be based on false determination of 
species. Since, however, the species is positively known 
to occur in Iran (Resht), it is possible that recent 
reports from Transcaucasia (POPOV 1935: Gandzha (Kirovabad) 
and Barda in Azerbaidzhan) are true after all. 
Variety: var. tobbi Alexander, Theodor, and Lourie 1929- 
Palestine: Rosh Pinah; Syria ? (without specified 
location of occurrence); Iran (Resht). 
Ph. chinensis Newstead: On the strength of success- 
ful experiments of infection, suspected of Kala-Azar trans- 
fer particularly in northern China. Distributed from 
northern China to the eastern Mediterranean countries 
(Crete, Roumania, Dalmatia, Malta). 
Apparently split up into a series of geographical 
races. According to Adler, Theodor, and Lourie 
1929, the animals occurring in Iran, Transcaucasia, 
and Transcaspia belong to a special race ("longi- 
ductus Parrot") , the animals in Syria to a second, 
those in northern Palestine to a third. 
Transcaucasia: Erivan, Tiflis, Kakhetia, Bortchalo, 
Gori, Gonio, Borjom; Iran: Tehran; Palestine: 
Rosh Pinah; Syria: Alep, Bcherreh. 
4th group: Phlebotomus minutus 
As far as known until now, without any medical impor- 
tance. Despite that, human blood has been found also in 
Ph. minutus, and this species of Phlebotomus is the only 
one reported from Aden (pappataci fever!) so far. It is 
known of the African species Ph. schwetzi and some others 
of the minutus group that they attack man. 
Ph. minutus Rondani and some 13 other species: The 
older data of reported locations must be treated with the 
utmost reserve, sincekother species of the same race have XI/3 
been often reported as minutus. In Europe "minutus" is 
positively known only in Greece. It is probable that also 
part of the reported locations from the Near East actually 
refer to other species of this race. 
III. Ticks: Ixodidae 
1. Argas persicus Oken: Poultry tick. Western Asia, 
Cyprus, Egypt, Sudan, southern Russia. Is suspected of 
transferring Asiatic relapsing fever occasionally in 
addition to poultry spirochaetosis. Observed in poultry 
pens and surroundings. 
2. Ornithodorus papillipes Birula ( = tholozani 
Laboulbene and Megnin]: Iran, Afghanistan, Caucasus, 
Transcaucasia, Arabia, Palestine, Syria. Most important 
vector of the Asiatic relapsing fever (Miana)'. Occurs 
in houses, caravanseries. 
3. Ornithodorus lahorensis Neumann: is suspected 
like the preceding species of being a vector of the 
Asiatic relapsing fever. Occurrence equal to that of 
the preceding species, only it alone is reported from 
Asia Minor. Transfers tularemia in Asia Minor, same 
locations as the preceding species. 
h. Ornithodorus moubata Murray: transfers African 
relapsing fever. Whole of Africa (referred to the map): 
Egypt, Nile valley, Sudan, Erithrea. House vermin. 
5. Rhipicephalus sanguineus Latreille: Dog tick, 
transfers the exanthematic tick fever. The reported 
occurrence certainly does not correspond to the actual 
distribution. North Africa, southern Spain, southern 
Italy, Greece, Asia Minor, Iraq, Palestine, Arax valley, 
Georgia, Sudan, Erithrea, Arabia (Sana). Imported into 
rooms with central heating, even in Germany, parasite 
in hotels. 
6. Amblycmma hebraeurn Koch: Africa. In the Sudan 
it transfers African tick-typhus. Free land tick, on 
pastureland, in stables. 
R. von BLUMENTHAL and W. HENNIG Il/4 
AMEBIC DYSENTERY THROUGHOUT THE NEAR EAST. 
Translation prepared by: 
U« S# Fleets U* S* Naval Forces, Germany, 
Technical Section (Meedcal)« II/4 
Amebic dysentery (entameba histolytica) is found throughout 
all territories of the Near East* However, frequently n* clear 
distinction is made from bacillary dysentery, so that one must 
think of bacillary and amebic dysentery when the dysentery inci- 
dence is discussed* The above mentioned fact also explains the 
frequently contradictory statements concerning the frequency of 
amebic dysentery* For the search for dysentery ameba the fresh 
stools of the patients, which possibly should still be at body 
temperature, must be examined for motile vegetative forms ®f the 
entameba histolytica, or a preparation according to Heidenhain 
mast be made. The diagnosis of an amebic dysentery should be 
considered as established only if there is no doubt of the pres- 
ence of tissue invading forms containing erythrocytes. In Turkey 
amebic dysentery was observed along the frontier between Turkey 
and Persia and throughout the Gallipoli peninsula (Dardanelles) 
as well as throughout its Mediterranean Coast territories. No 
further data are available# 
In Iraq amebic dysentery is widely spread, Baghdad, Amara, 
Kur, and Basra are the territories with the highest incidence. 
Particularly the territory between the Euphrates and the Tigris 
rivers and first of all upper Mesopotamia (july-October) must be 
considered as contaminated with amebic dysentery. 
In Iran some cases were observed in Teheran, but one should 
consider the entire area and particularly southern Persia as ex- 
posed to the oanger of infection with amebic dysentery# 
Southern Russia and Transcaucasia are areas of endemic dysen- 
tery# It is particularly the region of Baku (Balachany), Tiflis, 
Erivan, and Gandzha (Kirovabad) which are repeatedly mentioned as 
contaminated with amebic dysentery* In the period between the 
months of June and September there is a considerable increase of 
the number of cases# 
Syria passes for an area where amebic dysentery is endemic. 
It is particularly frequent throughout the Lebanon and Beyrouth, 
Several cases of amebic dysentery have also occurred in Damascus# 
In Palestine amebic dysentery is considered as one of the 
Mmost frequent diseases", 35 % of all dysenteric diseases are due 
to infection with amebae, which attains its highest frequency dur- 
ing the summer months# The entameba histolytica was very frequent- 
ly found in Jerusalem, Tiberias, Haifa, Damascus, and Nazareth, Ac- Xl/4 
cording to recent reports (1940) 30.5 % of the Arab population have 
the be regarded as contaminated with entameba histolytica; one third 
of the contaminated persons do not suffer from intestinal discomfort. 
The reaction for occult blood in the stools is negative in 5*26 % of 
the cases. 
In Transjordania no accurate data on the occurrence of amebic 
dysentery are available, but it is almost sure that here too, a 
widespread incidence of amebic dysentery must be taken into account. 
For Arabia only very general data for dysentery are known* As 
exposed areas the following territories were mentioned: The coasts 
of the Red Sea and the Persian Gulf> and the Yemen territory* 
In Egypt amebic dysentery is found throughout the entire terri- 
tory# The coast areas of the Mediterranean and the Red Sea, the Nile 
delta, and the Nile valley and the Suez Canal Zone (Alexandria, Cairo, 
Port Said) are regarded as contaminated to a particularly high de- 
gree, In addition the Sudan (Khartoum) and Nubia must be considered 
as areas exposed to amebic dysentery. 
G. PIEKARSKI. II/5 
IEISm/LuNI,SFS 
IN THE NEhJt SiiST 
(with 5 Charts) 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical) II/5 
The Leishmaniases, namely Kala-Azar (Loishmania 
donovani) and the Oriental Sore (Loishmania tropica) 
apparently occur throughout the entire Near East. It 
obviously soens that a closer investigation is sufficient 
to reveal that they are frequent in number even in terri- 
tories whore they seen to occur as sporadical cases only. 
Even though it was denied that Kala-Azar occurs in certain 
countries, such as f.i. in Palestine, one recently found 
cases of Kala-Azar in that country in addition to the 
dermal Leishmaniasis. The Kala-Azar of the Mediterranean 
littoral usually occurs as a Leishmaniasis of the children 
(L. infantum), while it is very rare that adults are 
afflicted with it. In the Near East one frequently finds 
the Leishmaniasis of the dogs in addition to the human 
forms. Attention must be paid to it, as the dog must 
be considered as a virus reservoir and therefore as a 
source of infection. 
The transmission of Leishmaniasis is attributed to 
the sand flies of the species phlobotomus (Ih. maior, 
papatasii, perniciosus, sergonti et al.), but the relations 
between the Loishmaniae and the phlobotomi cannot yet 
be regarded as clear. (Compare the distribution of the 
Thlebotomi, Map II/3, with that of the Leishmaniasis, 
Mai II/5). 
For Turkey only very few data are available. The 
dermal Leishmaniasis has been observed in Istanbul, 
Trabzon, Inebolu, Mytilone, Smyrna (Izmir), Nicosia 
(Cyprus), Heredore on the Gulf of Alcxandrette (Iskenderon), 
Adana, in the district of Balikesir and Tchanakale and 
around the sources of the Euphrates and Tigris rivers. 
In 1940 the first case of of an adult was 
observed in Inebolu. 
In Iraq the Oriental sore occurs as the principal 
form of Leishmaniasis. It is frequent throughout the 
territory between the Euphrates and Tigris rivers (Meso- 
potamia) , among other placos in .Juntas, Amaru, Basra, 
Diasekir, Kirkuk, Kut, Mosul, Nasaria, Suloimani, Baghdad, 
with the air-port Hunaidi south of the town (occurrence 
of Oriental sore principally during the months September 
to March). Kala-Azar was observed only very rarely. The 
first case was found in 1916 in Baghdad. Later on some 
more cases were discovered there as well as in Mesopo- 
tamia (Kut 1919). II/5 
In Iran too, Kala- 
allegedly occurs, 
but no accurate data 
arc available. Contrary 
to thpt WENYON (1922) 
stated that Kala-Azar 
is unknown in that 
country. Oriental 
sore is widespread, 
and it is found in 
Tehran, on the Persian 
Gulf (Bushire), 
Shi ra z, I sf ahan, Quin, 
pendeh, Yezd, and in 
the provinces along 
the Caspian Sea. 
In southern Russia 
it also occurs fre- 
quently, and it is 
particularly the Cau- 
casus area (Transcau- 
casia, Azerbaidzhan) 
Chart 1. Azerbaidzhan 
0 Canine Leishmaniasis 
6 Visceral Leishmaniasis 
& Dermal Leishmaniasis 
(Reported by J.MRUGOWSKY) 
with Baku,. Eriyan, _ ... . 
Gandzha, Lenkoran,-t 
Tiflis, and the Kura 
area (district of 
Ka sakh) which are 
contaminated (cf. 
Chart 1 and 2). 
In eastern Georgia 
Kala-Azar and dermal 
Leishmaniasis occur. 
Their area of dis- 
tribution is con- 
gruent with the oc- 
currence of the 
phlebotomi. 
Chart 2. Kala-Azar in the Kasakh distr. 
Villages afflicted, after BOGOJxtVLENSKI 
1 Firli 6 Gusein 11 Tatly 
2 K.Chalfaly 7 D.Koinan 12 Geodzholy 
3 Khilehyna o Kyrly 13 K.Tcheily 
4 Tchily 9 Ag Kcinak 14 Urk Mazly 
3 Kosalar 10 Kasakh 15 Damirchilar 
(Reported by I.MRUGOWSKY) II/5 
In Syria the Loish- 
mania donovani (L. in- 
fantum) and the Loish- 
mania tropica also are 
frequent and they are 
distributed throughout 
the entire territory. 
Oriental sore princi- 
pally is found in 
Aleppo, in the littoral 
plain of Lebanon, in 
Bar Eliaz, and in 
tab. Kalu-Azar was 
also observed in Le- 
banon (Beyrouth) and 
in the Djebel district. 
In Palestine and 
Transjordania accor- 
ding to recent in- 
vestigations the two 
Leishmaniases wore 
frequent. They occur 
principally in Jeru- 
salem and in the vi- 
cinity of this town. 
But one finds them 
moreover irregularly 
distributed through- 
out the entire terri- 
tory of Palestine 
(see Chart 3)* Places 
where Leishmaniases is particularly frequent are Amman, 
Artuf, Haifa, Hebron, Jericho, Cantara, Mozza, Tel Aviv, 
and many small villages in tho vicinity of the large places. 
Only some general data are available for Arabia. One 
assumes that Kala-Azar occurs in the Aden protectorate, in 
Oman, and on several islands of the Persian Gulf. Hodjaz 
and Yemen also are considered as infected with Kala-Azar. 
The Oriental sore occurs in addition to Kala-Azar in 
Egypt. The principal areas of endemics are situated in 
the Egyptian Sudan, in the river basin of the Blue Nile 
(cf. Chart A), in Darfur (western Sudan), and in Kordofan; 
Chart 3* Palestine 
9 Oriental sore 
£3 Kala-Azar 11/5 
Chart 4. Eastern Sudan 
Oriental sore q and hatching: Kala-Azar 
those of the Oriental sore are situated in the Nile delta 
(cf. Chart 5)* A sporadic incidence of Kala-Azar was ob- 
served in the southern Sudan (1939)• Kala-Azar principally 
occurs during the months from August to Eebruary. II/5 
Chart 5- Nile delta 
9 and hatching: Oriental sore q Kala-Azar 
Recently dermal Leishmaniasis has teen obser¥ed in the 
Sudan not far from the Abyssinian frontier and Kala-Azar 
(Leishmania infantum) near the Mediterranean coast, in 
Alexandria, and in Cairo. It is worth mentioning that 
4 cases of oral Leishmaniasis were found in the x*nglo- 
Egyptian Sudan (1935)* 
G. PXEKjiBSKI II/6 
LEPROSY IN IRAN. 
Translation prepared by; 
U. S. Fleet, U, S. Naval Forces, Germany, 
Technical Section (Medical)* ii/6 
The cartographic presentation of leprosy still offers consider- 
able difficulties, although the disease lends itself particularly well 
for geomedical research because of its positive symptomatology and 
the existence of definite foci in the invaded areas, 
OBERDOERFER has outlined in his book ''Fighting Leprosy" (Leipzig, 
1941), the general principles for the cartographic registration of 
this epidemic. Countries which are free from leprosy and where oc- 
casional cases are caused by immigration and countries which are prac- 
tically free from leprosy (less than 1 in 10,000) will have to be se- 
parate from countries with a moderate infection rate (not considerab- 
ly more than 1 in 10,000) and countries where leprosy is common (a- 
bout 1 in 100)* 
The list of countries where leprosy is moderately frequent in- 
cludes Asia Minor and Egypt, OBERDOERFFER has initiated the carto- 
graphic registration on the occasion of his last journey in those 
countries. It was intended to create a map of the distribution of 
leprosy setting forth at the same time the factors facilitating the 
spread of the mycobacterium leprae such as the presence of the sapo- 
toxin containing aroideen (colocassia and certain species of alocasia) 
and agrostemma githago, the seeds of which are sometimes contained in 
the breadstuffs if the cleansing methods are not satisfactory. OBER- 
DOERFFER in his last investigations in Iran was able to prove the cor- 
relation between the distribution of these plants and leprosy and the 
absence of leprosy in areas whei’e these plants did not grow, OBER- 
DOERFFER has fohnd out that the impurities of the bread due to agro- 
stemma reach only up to the north-south parting line of the waters of 
the Elburs as far as Kuh~i~Baba in Hindukusch, South of this line 
there is no agrostemma githago. The distribution of colocasia begins 
again only at the Indian frontier and at the coast of the Persian, Gulf. 
The distribution of leprosy is exactly the same. South of this water- 
shed not a single case of leprosy has become known. We have thus found 
the great no mans land without leprosy and without sapotoxins that 
served as a barrier to the spread of leprosy from India to Europe un- 
til the time of Alexander the Great. These facts are based on per- 
sonal observations and on the reports of European grain experts and 
medical everts who had stayed for many years in that area. (Extract 
from OBERDOERFFER’s last journey report of 6 June 1941)• 
Tne result of these investigations was entered into the enclosed 
map of the distribution of leprosy in Iran. A draft of a map by OBER- 
DOERFFER which was placed at our disposal by Professor Dr. BUTENANDT 
was used in the compilation of our .map. The result of OBERDOERFFER’s ii/6 
investigations is in good accord with earlier reports which state 
that leprosy is cony lately unknown in the greater part of the coun- 
try and the main area of distribution stretches from the northwest 
frontier near TJibris, passing by Sendschan and Kaswin, north of 
Teheran through Gilan (with Rescht and pahlewi as invaded places) 
and Masenderan to the northeast of Chorassan including Mesched. 
Near Mesched there was in 1928 a village with 125 cases of leprosy, 
A leprosy colony with 32 Kurdish leprosy patients was to be trans- 
ferred in 1939 from senandaj, the capital of Kurdistan, to Hamadan 
where a new leprosarium had been completed. Outside tnis distri- 
bution area leprosy is found only 3n some places along the south 
coast, especially at Bushir among the pearl fishers. The total 
number of leprosy cases in all of Iran is estimated at 1000 to 2000, 
that is an incidence of 1 to 2 in 10,000. 
OBERDOERFFERis opinion is confirmed by the latest publications 
of American missionaries in 1939 on 520 leprosy cases in Iran. Ac- 
cording to this report 50.6 % of the Gasc;s were people of the Turkish 
race from Azerbaidzhan and the north of Chorassan. 33 % were Mongols 
who had immigrated from Afghanistan, 11.6 % were Kurds from the west- 
ern frontier, 3*1 % were Gilanis and only 1.7 % had to be considered 
as genuine Iranians. The most intense incidence of leprosy with the 
Kurds in the west is also confirmed by these reports. Leprosy was, 
however, not found in a single case among members of the Iranic 
Lures ana Bactiares who lived among them. 
M. CBERDOERFFER t AND H.J. JUSATZ. II/7 
.Li\f&YLQSIOMIi■ SI6 BILHaRZIaSIS IN THE NEAR EAST, 
(With 1 map in the text) 
Translation prepared byj 
U. S* Fleet, U. S» Naval Forces, Germany, 
Technical Section (Medical). Xl/7 
I, Ankylostomiasis, 
Hookworm disease is caused by the hematoda Ancylostoma duo- 
denale and Necator americanus by penetration through the skin of 
the larvae hatching out in the humid soil. The disease is able to 
spread at an average temperature of 20 to 35°C* if the soil has a 
certain humidity provided either by irrigation or by rainfall of 
at least 400 mm. The infection is contracted by walking with bare 
feet or bathing in fresh water containing feces of the indigenous 
population and sometimes by drinking infested water. 
In Turkey only the highly infested province of Rise (Lasistan), 
a shore district of the Black sea southwest of the Caucaais, has been 
the subject of close investigation. The infections were caused by 
Nacatar Americanus which was found in most of the villages of that 
area in 20 to 67 % of the population. The number of hookworms in the 
infected individuals amounts on an average to 45* 
Arabia, Afghanistan and Belutehistan are apparently not invaded 
by Ankylostomiasis, which fact must be explained by the small amount 
of rainfall in these countries. In Iraq, by contrast, several foci 
have been discovered which are, however, less severe due to the rites 
(washing after defecation ana urination), in this country. 
A more intense distribution was reported in Iran in the last 
years, although the climatic conditions are not in favor of -a spread 
(little rainfall, cold winters). Peculiar habits in the life of the 
indigenous population are probably responsible for this fact (HEINE 
1938). 
The hookworm disease occurred in several areas of Transcaucasia. 
Especially in the west of Georgia, in Abchasia, a strip of shoreland of 
the Black Sea with a humid and hot climate, several foci were 0bserved. 
About 59 to 80 % of the population is infected with hookworms. An ex- 
amination in a school at suehum revealed that 72 % of the pupils were 
infected. According to PODIAPOLSKA (1936) the following numbers of 
hookworms could be ascertained in 708 Georgians: 
in 426 - 60.2 % 1 to 10 hookworms 
in 176 - 24*8 % 11 to 50 hookworms 
in 54 - 7.6 % 51 to 100 hookworms 
in 52 - 7#4 % 101 to 500 hookworms. 
The disease has also been observed in the eastern part of Trans- 
caucasia. The areas of Zakatal and Lenkoran in Azerbaidzhan are said 11/7 
to be particularly invaded. The average incidence is stated to be 
6 to 7 %. 
Foci of the disease have recently been observed in Syria and 
in the area of the Lebanon. The parasites were probably brought in- 
to these areas by workers on the banana plantations. 
In Palestine the disease is rather frequent in 'the Arabian 
orange plantations in the shore district of Jaffa, The incidence 
amounts, in some of the villages, up to 50 to 80 %% In the cities 
by contrast, such as for instance in Jerusalem, there was only 1 % 
out of 1344 inhabitants suffering from the infection. 
In Egypt, Ankylostomiasis is strongly distributed in the delta 
of the Nile as well as in some other, artificially irrigated, areas, 
in the delta of the Nile more than 25 % of the population are hook- 
worm carriers. Certain villages have incidences up to 72 %* We have 
to deal here in most cases with ancylostoma duodenale. The number 
of worms is low in most of the cases but severe clinical cases have 
also been reported. 
II. Bilharziasis. 
We have to deal -with two types of Bilharziasis, namely B. haema- 
tobia (Bilharziasis of the bladder) and B, mansoni (B. of the intestins). 
A distribution of the disease is only possible in areas where fresh- 
water snails permit a subsequent stage of development of the parasites. 
The most important intermediary hosts are: Bullinus (Isodora) truncatus 
for Bilharziasis haematobia and Planorbis (Planorbula) boissyi for B# 
mansoni. Bullinus truncatus includes the species of B, contortus, 
dybowskii and innesi. 
The infection is caused by the free-swimming cercariae and may, 
therefore, be contracted from certain bathing places or by drinking in- 
fested water. 
Bilharzia haematobium is endemic throughout various parts of 
Iraq. According to older reports about 20 % of the population of Meso- 
potamia are said to be infected. Many cases were reported more recent- 
ly from Bagdad, Basra and the villages on the Tigris. 47 % out of 711 
school children were infected at-Basra 1921/22. Similar reports were 
received from the lower valley of the Euphrates and the adjacent areas 11/7 
of Iran, especially from Khorramschar• 
Certain localities especially the water places with carrier 
snails along the shore of Palestine are notorious for the prevalence 
of Bilharzioses. 4*3 % out of 1256 school children of the district 
of Jaffa excreted eggs and 6*7 more percent were suspected in 19254 
In the first 6 months of 1937 the Municipal Hospital of the City of 
Tel Aviv had to treat 142 new cases of Bilharziasis, 
In Arabia, Mecca is notorious for its prevalence and from there 
the Bilharziasis haematoma spreads over all the countries of Islam# 
Besides in this particular locality, the dry deserts offer little or 
no possibilities for the development of the snails. Nevertheless in 
1925 two possibly endemic cases were reported of Aden, It was also 
reported thatabout 9#5 % of the inhabitants of the shore district 
of Yemen are infected with B. haematobia. Cases of B, duodenale 
have also occurred in this area, 
Bilharziasis is of special importance in Egypt where the arti- 
ficial irrigation offers the ideal living conditions for snails. 
According to recent and careful examinations 6 millions out of 16,5 
millions of the Egyptian population are infected with B, haematobia 
and 3 more millions with B. mansoni. About 1.5 millions of these are 
infected with both types, so that about 7 million people are infected 
with either type of B, In the northern and eastern part of the delta 
of the Nile (District I) about 60 % of the population are infected 
with B0 haematobia and about just as many with B, mansoni. In the 
southern central part of the delta (District II) B* haematobia occurs 
in about 60 % of the inhabitants, B, mansoni, however, only in 6 %, 
In the lower valley of the Nile between Cairo and Assiut (District 
III) B. haematobia occurs also in about 60 b of the population, B, 
mansoni, however, is less distributed because of the absence of the 
intermediate host. In the upper valley of the between Assiut 
and Komombo (District IV) the incidence of the disease is much lower. 
Only about 5 % of the population are infected with B# haematobia. As 
is set forth in the following table, the severity of the infection is 
indicated by the number of eggs excreted ana the percentage of fatali- 
ties. 
Bilharziosis was also observed in the Oasis of Dachel in the 
Lybian desert westward of the Nile. At Rashada, one of the settle- 
ments of the Oasis, about 68 % of the inhabitants were reported to 
be infested with B, haematobia. 60 %B. haem 
u 60%B mans. 
60 XB hoem 
u 6%B mans 
60% B haem 
u OX B mans 
SXB.haem 
u OX B mans 
Bilharziosis in Egypt. 
(According to J, A. SCOTT, 1937). IX/7 
Bilharziasis in Egypt. 
District 
— 
rural 
population 
Infei 
Haemat.; 
;tions % 
.Mansoni 
Ratio of 
fatalit. 
due to B; 
other dis- 
eases (1) 
Excreti 
eggs (2 
Haemat. 
on of 
Mans. 
li 
4,200,000 
60 
60 
1:22 
24 
400 
II 
2,000,000 
60 
6 
1:40 
23 
300 
III 
3,400,000 
60 
0 
1:40 
27 
IV 
2,100,000 
5 
0 
1:1000 
11 
(1) between the ages of 5-65 
(2) in 50 ec of urine or 
1 cc of feces (according to «J,A» SCOTT, 1937) 
The carrier snail Bullinus truncatus is distributed in all parts 
of the wile, it can easily be collected on the water weed (Potamoge- 
ton crispus) in the little bays of the river. Bullinus is especial- 
ly frequent in the numerous canals, irrigation systems and pools. 
Curing the periodical draining many of the snails dig in the ground 
or draw back on little pools ana so survive the dry period. Locali- 
ties where Bullinus truncatus was found and which were mentioned in 
the literature are: The pools of the Zoological Gardens of Giza, 
Marg, Ismalia, Alexandria and environs, Roaa Island, Korn Oba, Oasis 
of Dachel, etc. - Planorbis boissyi the transmitter of B, mansoni 
is missing in upper Egypt (south of Cairo). Nor is it found in the 
larger canals but it is distributed in the irrigation canals of the 
delta. Planorbis boissyi is even more resistant against drought 
than Bullinus truncatus. It is found above all in the following 
localities: Marg, Belbeis. Ismalia, Alexandria, Samanoud, Cairo 
(but not irt the Nile river). 
Bilharziasis has been endemic for quite a long time in the 
northern Anglo-Egyptian In the middle Sudan the disease 
occurs here and there but a prevalence could not be noticed at any 
time. The infections are, however, widely spread in the southwest 
of the country, especially in the villages of the Darfur province. 
In certain areas of this district about 90 % of the school children 
were reported to be iiifected. 
C. SCHLIEPER. Xl/9 
DEMSITY OF POPULATION IN THE NEAR AND MIDDLE EAST. 
Translation prepared by: 
U. S# Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical)* ii h 
Statements concerning the density of population refer mainly 
to the country population as regards their actual space of living, 
because, in addition to cultivated areas, the respective adminis- 
tration districts also include steppe- and desert, areas. The part 
of the population living in towns with more than 3000 inhabitants 
was not considered in the calculation of the average density, in 
the map only cities with 10,000 and more inhabitants are marked 
by special signs. 
TURKEY: After the incorporation of the Sandshak Aloxandretta 
(Hatay), the area of Turkey encompassed 768,736 square kilometers 
without lakes (8,434 square kilometers) and swamps (11,70 square 
kilometers). At the census held on the 20th October 1940 the 
total number of the population amounted to 17*869,901 people. 
The portion of the country population was 76,5 % (1935). We 
find a density of country population of 50 - 100 inhabitants per 
square kilometer in the fertile gardening uistricts of the south4- 
ern coast of the Black Sea, in the north Anatolian mountain for- 
ests as well as in the east Pontic highland and in the agricul- 
tural well developed plains of western Anatolia. The steppe ar- 
eas of interior Anatolia have a density of scarcely 10, most 
sparsely colonized is eastern Anatolia, The reason for this is 
the extermination of about 2,000,000 Armenians and Kurds after 
the First W#rld War. 
TRANSCAUCASIA; The area of Transcaucasia, since 1920 again under 
Russian control, encompasses within the three Soviet Republics on- 
ly part of the ethnographic nations which extend into the Turkish, 
respecitvely Iranian state. 
T ~ 
Soviet Republic: 
Area 
sq.Km. 
1 
Inhabitants 
1939 
City - 
* 
Country 
Inhabitants 
per sq.Km. 
Georgia 
69,600 
3,542,289 
28.5 
71.5 
50.9 
i Azerbaidzhan 
86,000 
3,209,727 
37.7 
62.5 
37.12 
Armenia 
30,000 
1,281,599 
30.7 
69.3 
42.72 
IRAN: Iran, with an extent of 1,645*000 sq. Km. has 15*055*115 in- 
habitants according to the census of 1933* The distribution of the ii/9 
population is disproportionate, 9,140,000 inhabitants live in 
the northern and north-western part of the country, including 
the area of Kermanshah and Hamaden. This amounts to 65 % of the 
total population with an average density of the country popula- 
tion of 10-15 inhabitants per sq.Km., tohile the extensive areas 
of tha south and east are sparsely populated and the s&lt deserts 
are deserted. The province of Kerman has hafdly more than 2 in- 
habitants per sq.Km. 
In Iran, a marked migration to the cities can be observed, 
which is expressed particularly in the marked increase of the po- 
pulation of Teheran, Tabriz, Isfahan and Meshed, 
AFGHANISTAN: The estimated population of Afghanistan, with an 
area of 731*000 sq. Km,, varies between 6 and 12 million inhabitants. 
About 500,000 people live in 11 cities with more than 20,000 inhabit- 
ants each, While the desert areas of the south are deserted, the ir- 
rigated valleys of the mountains have a density of country population 
of 10 - 20 inhabitants per sq.Km, 
BALUCHISTAN: is for its larger part infertile mountainous country. 
In 1931 inhabitants were counted in its area of 348,698 
sqfKm, There are only a few areas which have more than 1 inhabit- 
ant per sq.Km. 
The most densely populated part of Baluchistan is the area of 
British Baluchistan Quetta-Piohn with 24,000 sq.Km. and Siarat. The 
area of Chagi, through which a strategically important railroad 
leads to the border of Iran, is almost deserted. 
IRAQ: According to their own reports, Iraq encompasses an area of 
453,500 sq.Km. (Almanac de Gotha 1942: 291,980 sq.Km.) with about 
4,000,000 inhabitants (the official estimate made by the Iraq govern- 
ment amounting to 6,000,000 is probably too high). The portion of 
the city population amounts to 25 %* The bulk of the domiciled po- 
pulation conglomerates in the irrigated cultivation areas of the 
Euphrates and Tigris as well as the large affluents of the Tigris 
in Lower Mesopotamia, The highlands in the northeast, especially 
the mountain edges, bordering on irrigated plains and the oil-area 
around Mosul are relatively densely populated by Kurds# Domiciled 
Jazids live in the Jebel-Sinjar. Nomadic Arabs inhabit the inter- 
mediate river-basin of Upper Mesopotamia* II/9 
SYRIA; In 1939 Syria had 3>778,500 inhabitants and a total area 
of 203,000 sq.Km. The most densely populated area is the Republic 
Lebanon with 9,200 sqcKm. and 855,000 inhabitants, 25 % of which 
live in cities# This results in an average density of population 
of the country population of nearly 70 inhabitants per sq0Km, 
The autonomous coastal areas of Latakia, adjoining in the north, 
have a density of country population of 48 inhabitants per sq.Km* 
with inhabitants and an extent of 6,500 sq.Km* The in- 
terior Syrian area, adjoining in the east, registers a low colo- 
nization in certain areas, which becomes more dense only in the 
surroundings of Damascus, Alep and Hama. The autonomous area of 
Druse has a density of country population of about 6-7 inhabit- 
ants per sq.Km. In contrast to the fragmentary permanent coloni- 
zation of the northeastern steppe, which is cultivated mainly by 
Armenian, Kurdish and Assyrian refugees, only about 150,000 nomads 
live in the southeastern deserts. 
Palestine with an extent of 26,305 sq.Km. has about 1,6 mil- 
lion inhabitants (1941)* While the southern part, which changes 
into the desert, has only a density of 4 inhabitants per sq.Km., 
and the Jordan ditch is deserted, the surroundings of the large 
cities and the areas of the western mountain edges, bordering on 
plains, has, on the other hand, a density of population of about 
50 - 140 inhabitants per sq. Km. While the increase of the Arabs 
is attributable to a strong natural fertility, the increase of the 
Jews on the other hand is a consequence of immigration. Today al- 
ready about 4/5 of the Jews live in cities. The most impressive 
example of an unhealthy absorption by the cities is the city of 
Tel Aviv, which was developed by international Jewish capital. 
This city had 45>000 inhabitants in 1931* and in 1940 the po- 
pulation there had increased to 180 000 people. 
TRANSJORDAN: (including the quarreled about area of Maan and Aqa- 
ba) with an extent of 90,000 sq.Km. has about 332,000 inhabitants* 
6000 of these live in cities and about 200,000 in the fertile area 
of the western tabular edge (Tafelrand) approximately 5,000 sq.Km. 
cultivated area). This results in a density of population less 
than 2 inhabitants per sq.Km. for the remaining parts. 
ARABIA: Estimates for the entire area of the peninsula vary bet- 
ween 4»5 and 12,3 million inhabitants. According to official state- ll/9 
ments, Saudi Arabia is supposed to have 5*750,000 inhabitants and 
an extent of 1,579,000 square kilometers. The density of pop- 
ulation in the sultanate Nejd and the kingdom Hejaz could be bet- 
ween 1-3 inhabitants per sq.Km. The emirate Asir on the other 
hand shows a density of population of 10 - 20 inhabitants per sq.Km. 
Yemen claims to have an area of 62,000 sq.Km. with 750,000 inhabit- 
ants, v. WlSSMaNN estimates its total population to be 3,5 millions; 
he furthermore estimated that the population of Rathjen was even more 
than 5 millions. Here too, the average density of population is ap- 
proximately 10 - 20 inhabitants per sq.Km. 
EGYPT: Only l/30 (35,170 sq.Km.) of the total area (994,300 sq.Km.) 
of Egypt are cultivable soils; the valley of the Nile, the Fayum- 
basin and the delta of the Nile belong to the most densely populated 
areas of the world. In the cultivated areas there is an average 
density of population of 364 inhabitants per sq.Km., even if cities 
of more than 10,000 inhabitants are eliminated. The peninsula of 
Sinai, which is connected with Egypt does, aside from the capital 
El Arish (10,000 inhabitants) not have any colonies worth mention- 
ing. The Bedouins are distributed over 61,000 sq. Km., of which 
only 88 sq. Km. are cultivated areas. This results in an average 
density of population of only 0,3 inhabitants per square kilometer. 
Tne village Cantara East (500 inhabitants) located at the Suez Canal 
and at the farthest point of the Palestine railway, sheltered, on 
20f8 sq.Km., the largest military town the world has ever seen dur- 
ing the First World War, 
H. HARMSEN. Ill/l 
OCCURRENCE OF MALARIA AND DISTRIBUTION OF ANOPHELES IN THE 
TRANSCASPIAN REGION. 
(With 1 text-map). 
Translation prepared by: 
U. S* Fleets U, S« Naval Forces, Germany, 
Technical Section (Medical)* Ill/l 
I, Landscape and Climate, 
Turkestan is a lowland desert surrounded by mountains and must 
be regaraed as part of Central Asia because of the appearance of its 
landscape, which is caused by the extremely arid climate. 
Immense sand-deserts, half-deserts, arid steppes, gallery-forests, 
forest and high mountains with the largest glaciers in the world de- 
termine the varied landscape-picture (see map IIl/3)> whose great cli- 
matic, regional and biological contrasts hardly permit a general con- 
sideration. B°th the climatic ana the oecologic and other conditions 
preaestiiS this region particularly as a first-rate reservoir of epi- 
demics ana not only as regards malaria. 
Text map 1 shows a synopsis of the climatic conditions according 
to A. SCHULTZ and distinctly demonstrates the enormous contrasts of 
this region, we know that the development of malaria plasmoaia pro- 
gresses only with temperatures higher than 16°C« and progresses to 
completion practically only with 17UC. ana more, and that the more 
certainly ana quickly, the higher the temperatures are. The optimal 
values for tertiana lie between 23° and 26°C., for tropica between 
2B° and 30°C« We assume 10 days approximately as the shortest period 
of development for both forms. During the observation of the iso- 
therms, not the annual, but the summer-isotherm, above all the average 
temperature of the hottest summery-month is decisive: For this reason, 
continental places, as particularly exist in our region, have more 
possibilities of development for malaria than places with sea-climate 
with equal annual average temperature. 
The climate is markedly continental with great daily and season- 
al fluctuations. In summer, there are central Asiatic cyclones, in 
winter north Asiatic anticyclones. According to A* SCHULTZ, the follow- 
ing climate-districts can be distinguished: 
9 
I, Desert-climate with rainfall below 200 mm. almost completely 
rainless summer, average temperature of the hottest month higher than 
27°, of the coldest month around 0U, Chiefly spring-rain, 
II. The temperate aesert-and steppe- climate in northern Turke- 
stan with rainfall up to 250 mm, , which is fairly uniformly distri- 
buted over the whole year, with the hottest month of 25°C and the 
coldest of below 0°C, III/l 
III. The steppe ana promontory climate with rainfall from 
250 to 500 mm,, which falls chiefly in winter; the hottest month 
having more than 25° ana the coluest being below 0°. 
IV. The steppe ana promontory climate of northeastern Turke- 
stan with rainfall from 250 to 500 mm,, which is uniformly dis- 
tributee over the whole year, with the hottest month of more than 
22° ana the coldest of below 0°C. 
V. The mountain climate with more than 500 mm, rainfall, which 
is uniform over the whole year, the hottest month having more than 
22° and at least 4 months with a temperature of more than 10° (local- 
ly aevelopea especially in Tienschan)• 
VI. The highlana aesert climate. 
We fina the slightest rainfall in the Amur-delta (only 80 mm.) 
The duration of the snow fluctuates intensely. In the mountains* 
it lasts more than 4 months. 
lines of e-iual temperature 
line* of erual precipitation in cm 
Climate-map of Turkestan. 
(Accoraing to Arwea SCHULTZ, Manual of Geographic Science, Pub- 
lishers Athenaion, Potsaam). IIl/l 
IIo Occurrence of Malaria in the Transcaspian Region. 
Before World war I) about 3s million malaria cases were annually 
counted in Russia, i« e* 215 - 230 per 10 000 inhabitants. Of course, 
this rate changed in intensely infected areas* Thus, there were 8C<3 
cases in the Caucasian region, 400 in the Volga region, and 250 in 
Turkestan per 10 000 inhabitants. These sick-rates are not only sub- 
ject to the usual seasonal fluctuations (seasonal malaria), but with- 
in certain periods the cases of malaria increase in such a way that 
one may speak of epidemics. In Russia, such epidemics occurred in 
the following years: 
1894, 1899 > 1903, 1908 and probably the greatest in 1923, which 
gradually subsided in the subsequent years. RASHINA reports the fol- 
lowing figures for 1923 - 1926: 
Year 
reported malaria cases 
per 10,000 inhabitants 
1923 
6,239,000 
474,0 
1924 
5,983,477 
449,7 
1925 
5,428,429 
388,8 
1926 
4,523,696 
310,1 
But these figures comprise only part of the actual malaria cases, 
since a great proportion of the population shunned voluntary treatment 
ana thus coula not be listed ana since only a slight proportion of the 
population were properly examined owing to the vast distances ana other 
obstacles given by the nature of the country. Thus, DOBREITZER estimates 
the actual figure,of malaria cases in 1923 at more than 12g millions, 
that is more than aouble the reported cases. The causes which led to the 
last almost catastrophic epidemic, are manifold. One of them was the 
starvation and the constitution of the inhabitants weakened by epidemics 
(spotted fever, relapsing fever, cholera), Then, there was the decline 
of agriculture and the associated marked decrease of the numbers of 
aomestic animals* Many bew breeding places of anopheles arose owing 
to the deficient cultivation of the soil, ana the climatic conditions 
for further aevelopment of the plasmouia were present as well, thus 
malaria could seize the population weakened by hunger and privation as 
swift as lightning to an extent previously unknown* 
After the war, numerous malaria stations were established, par- 
ticularly in the endemic areas. Through the Kirghiz steppe, a ring of 
stations for observation of the plague was laid, and these stations 
were simultaneously charged with research and treatment of malaria. Ill/l 
The most serious malaria foci there uo not always lie directly on 
the rivers but also in the steppe, such as in the district of 
Saratov - in the region of Novousensk and Dergatskhi. One may 
even speak of a steppe-malaria, for these regions have a very arid, 
desert-like cLimate, ana all the same, almost every inhabitant had 
on an average two kinds of malaria (tertiana ana tropica) per an- 
num* 
In Turkestan, malaria is limited to the river-oasis settlements, 
furthermore to the canalization-systems, rice-fielas, reservoir-ponds, 
then to the natural accumulations of water and to the swamp-territories 
caused by deficient canalization. There are everywhere possibilities 
of breeding for the anopheles, which are even present along the moun- 
tain-rivers high up the mountains. 
The the Atrek region, malaria is of great importance and holds 
the first rank among the infectious diseases. In West Bukhara, tro- 
pica is predominant; also Samarkand is infected with tropica. In 
1932, an almost 100 % infection of the population with malaria was 
observed, in Pamir ana farther in the Altaic district, there exist serious 
endemic tropica-foci. The sick-rate there rose in 1925 to 711 per 
10 000 inhabitants. The hunger-steppe, too, which has been extensive- 
ly irrigated in connection with the cotton five year plan, shows an 
increasing tendency of tropica. 
In other places of the country, the rate of malaria cases has 
increased again and again since 1924, so that Russian authorities 
have even pointed out the possibilities of a new imminent epidemic. 
Since in the Afghanian and Iranian territories adjoining in the south, 
in which there is no malaria control whatsoever, extensive tropical 
foci are known, ana since through the constant military movements in 
Iran, there exists an increased hazard of infection and many possi- 
bilities of importing the disease,the occurrence of extensive epi- 
demics must be always reckoned with, if the respective climatic con- 
ditions are present. 
At present, large parts of Turkestan must be regarded as endemic 
malaria-areas, with the children forming the principal reservoir for 
this epidemic. By a change of immunity conditions (caused by dis- 
eases, starvation, etc.), new cases also of aaults ana thus new epi- 
demics, may occur any time, In addition to tropica, tertiana and 
quartana occur in the whole region. The endangering of the single 
regions by malaria is marked on the map by more or less dense hat- 
ching of the respective regions. Only regions to the west of the Ill/l 
74th decree of east longitude have been considered. 
Ill, Distribution of Anopheles. 
A. maculipennis (1) is aistributed over the whole of Turkestan, 
It is a principal vector of malaria. The larvae prefer sunny waters 
covered with low dense grass or horizontal vegetation (sea-weea, 
movicphylum, etc.), but they stana even slightly salty water (atro- 
parvus). Important breeaing-places are furthermore the areas of in- 
undation of the rivers, canalization-systems, steppe-ponos, and 
swamp aistricts. The fdbernation is supposed to be finished even in 
the middle of February (about the middle of March at the latest). 
The first eggs occur in the beginning of April, the first gnats in 
the beginning of May. One occasionally finds the larvae also in 
tubs. The principal flying time of the gnats is from the end of 
July to the beginning of August. The occurrence of numerous new 
malaria cases is probably associated with it. Thus, for instance, 
the garrison of Samarkand haa the peak of the malaria curve in 
August (spleen index 20,4 % in 1933)» The gnats hibernate in stables 
cellars, ana barns. As regarus the distribution of the single races, 
it is obscure so far, Messeae seems to be predominant, atroparvus 
arouna the Caspian Sea. The number of generations fluctuates between 
2 (in the Altai-mountains) ana 9 (in the sana-desert). Maculipennis 
occurs in altituaes up to 1200 m. 
A. superpictus (2) is aoubtless the principal vector. The larvae 
are fauna from May to November in shallow brooks or river-beds (brook- 
breeaers), but also in all other waters, in overflooded meaaows and 
rice-fielase On the whole, sunny places are preferred. Deep river- 
beas may only temporarily lie in the shauow, otherwise the larvae 
cannot uevelop. Superpictus occurs in altituaes up to 2000 m. and 
likes to breed with bifurcatus. Its importance as a vector of 
malaria is positively proven. The gnats are very greedy for blood 
ana bite frequently, especially uuring dusk ana night. They like 
to fly into houses ana stables ana bite both man and animals. Prin- 
cipal flying time of the gnats: August - September. 
A. bifurcatus (3) occurs, not very frequently, throughout the 
whole region, in the mountains up to 1500 m,,where it usually breeds 
with superpictus. The larvae often live throughout the whole year at 
the foot of the mountains. It may be neglected as a vector* Ill/l 
A* plumbeus (4), a typical tree-cavity breeder, may hardly be 
considered as a vector oue to its rarity in the Transcaspian-Tur- 
kestanian region. 
A. hyrcanus (5): The original species is one of the most wide- 
ly distributed species of the globe and shows a marked variability. 
In the Transcaspian area, one finds most frequently the var. pseu- 
dopictus (light fourth hind leg section) besides the typical form 
as well. The larvae appear particularly in the inundated areas of 
the rivers (reed) from April to the beginning of‘November. In the 
Transcaspian region, its part as a vector is not positively settled, 
though the importance of this species increases toward the east. 
An. hyrc. sinensis plays an important role in Eastern Asia, as well 
as hyrc. nigerrimus in Southern Asia and in the Malayan region. The 
principal flying time of the gnats falls in the months of June-Au- 
gust. 
A. elutus (6) extends from the south into the region and prefers 
approximately the same breeding-places as maculipennis, but also 
stands a more intense sunshine on the water and a greater salt con- 
tent, It teis its main importance in the east, but also in southern 
Turkestan, it is an important vector of malaria# 
( 
A. algeriensis (7) was found only once in 1930 and has no im- 
portance at all in Turkestan, 
A. pulcherrimus (8) must be regarded as a principal vector par- 
ticularly in many districts of the desert territories# Toward the 
north, it extends to the hunger-steppe. The larvae prefer ponds 
covered with marshy places, stagnant water, rice-fields, 
and even salty water# The gnats are chiefly active at dusk and also 
fly into houses, in search of the light# As steppe-insects, they 
dispose of a good'flying capacity and are capable of a great re- 
sistance against dryness. They hibernate as larvae# 
The regional distribution of the Various species of anopheles 
shows, as a summary, the following picture: 
The mountains and promontories of Southwest Turkestan are par- 
ticularly rich in anopheles, and the gnats appear in vast numbers from 
August to September. During the last few years, malaria there decreased 
considerably owing to sanitation-work. Toward the north, the variety 
of species decreases considerably and only maculipennis (1) remains 
finally. Ill/l 
The Syr-Darja-region can be subdivided into three areas accord- 
ing to BALKASHXNAj 1* foot of the mountains, 2. southern subtropic- 
al area of Mediterranean type, 3* northern district (character of 
Central Asia)% The anopheles in this area show a special type of 
distribution. Bifurcatus (3) occurs frequently at the foot of the 
mountains, more rarely in the desert districts. Hyrcanus (5) is 
more rare at the foot of the mountains, but more frequent in the 
northern and southern part. The larvae appear there, from the 
middle of May to October. Pulcherrimus (8) is absent in the north. 
Superpictus (2) is frequent in the south and at the foot of the 
mountains. Maculipennis (1) is predominant in the northern dis- 
trict, but is frequent elsewhere as well. 
Some additional species probably reach from Afghanistan into 
the Transcaspian region. We also know that the border-districts 
are seriously infected with malaria. On the whole, Turkestan still 
holds many problems awaiting a solution. 
E. MARTINI AND J. HLISNIKOWSKI 
(Institute for tropical medicine and hy- 
giene of the Military Medical Academy). IIX/2 
SANDFLIES AND TICKS AS VECTORS OF DISEASES 
IN THE TRANSCASPIAN REGION 
(WITH 3 ILLUSTRATIONS) 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Meaical) III/2 
I. Sandflies: Phlebotominae 
The phlebotominae of Russian Central Asia belong 
to the same species as those occurring in the Mediterrarean 
region or in the Near East or are closely related with them. 
Only one form (Ph. kandelakii, which I should like to ackl 
to the European perniciosus-group) has the eastern boundary 
of its distribution area there, the others extend further 
to the east (chinensis, sergenti group) or to the south- 
east (papatasii, major). Though nothing positive is 
known about the medical importance of the phlebotominae 
in Russian Central Asia itself, the experience obtained 
in the Mediterranean region, in the Near East, in China, 
and in India can thus be transferred to this region 
(even if only with reserve). For the same reason, it can 
be assumed that the species reported from Russian Central 
Asia are distributed through the whole region and occur 
even where they have not yet been found so far. The map 
shows that (with one exception) the northern boundary of 
the distribution area of the phlebotominae lies along 
the Transcaspian railroad. Of course this can be ex- 
plained by the fact that the collecting expeditions on 
whose results alone our present knowledge of the distri- 
bution of the phlebotominae in the Transcaspian area is 
basod, moved chiefly along this line until now. There 
is no reason to assume that the phlebotominae might not 
occur further north of this line as well, particularly 
if they can also live far from human settlements in the 
burrows of mammals (especially rodents) and of birds, 
as recent examinations have shown more and more distinctly. 
Some facts are known about the way of living of 
the phlebotominae in Turkmenistan: Most species have 
been found in large numbers in the burrows of the various 
mammals. In porcupine nests in which the temperature 
does not drop below 15° C., they develop throughout the 
winter. The graphical representation below (Illustration 
1) shows the principal flying times of some species in 
such rodent burrows. Where man lives, Ph. papatasii, 
sergenti, caucasicus, and minutus join him closely. 
The same species (in addition chinensis) have been 
found particularly in the "Suijms" in the district 
of Kaary Kala. m/2 
Ph. papatasii 
Ph. sergenti 
Ph. caucasicus 
Ph. minutus 
Ph. major 
Illustration 1. Principal flying times of the 
sandflies in Turkmenia 
These "Suijms?t are caves in the mountains dug out 
by the Turkmenians in order to store grass (clover) for 
winter use. As regards the vertical distribution of 
the species, data are available as well. According to III/2 
them, almost all species occur up to altitudes of 1,000 M. 
Only Ph. sergenti (perhaps the form mongolensis) and two 
species of the major-group occur up to 2,300 M. in the 
Pamir mountains. Ph. wenyoni has been previously found 
only in altitudes higher than 700 M. The vertical dis- 
tribution varies in the single districts of Turkestan. 
Illustration 2. Distribution of Phlobotomus 
in Kirghiz!stan (according 
to data of PETRISHCHEVA) 
The indicated places have been entered according to their 
geographical latitude (abscissa) and according to their 
altitude (ordinata). The oblique lines indicate the average 
summer temperature. In the area marked A, all species ob- 
served in Kirghizistan have been found, in the area marked 
B only the species Ph. chinensis and Ph. caucasicus (ser- 
genti-group). Ill/2 
Illustration 2 shows, for instance, that in southern 
Kirghizistan, only Ph. caucasicus and Ph. chinensis 
pass a certain altitude (around 1,800 M.) and that, 
at the same time, only these species occur in northern 
Kirghizistan and then in lower altitudes only. This 
makes it clear that one approaches the northern boundary 
of the total distribution area of Phlebotomus where only 
these two species (or one of the two, for instance Ph. 
chinensis) are found (such as in northern Kirghizistan). 
As in the greater part of the distribution area, the 
phlebotominae generally have two principal flying times 
in the Transcaspian Region as well, though these coincide 
in districts with unfavorable climates. This is known 
only of Frunze so far. Illustration 3 shows in what way 
this depends on the average monthly temperature of the 
summer months. 
Mean monthly temperature in Ashkhabad 
Mean monthly temperature in Frunze 
Flying time of Phlebotomus in Ashkhabad 
Flying time of phlebotomus in Frunze 
Illustration 3° Dependence of the flying times of Phlebo- 
tonus on the nean monthly temperature 
(according to PETRISHCHEVA) III/2 
Synopsis of the Reported Locations known 
until now in the Transcaspian Region 
1st group: Phlebotomus papatasii 
Phlebotomus papatasii Scopoli: is in addition to 
Ph. pcrniciosus, Ph. sergenti, and perhaps Ph. major, 
the principal vector of pappataci fever in the Medi- 
terranean region. In the same area, it is regarded as 
the most important vector of Oriental boil (alone or 
in association with Ph. sergenti). Distributed from 
the western Mediterranean region to northern British 
India. 
Turkmenistan: Numerous individual reported locations 
in the area of Khcrki and Khelif, in the area of 
Chardjui, Deinau, and Farab, in the basin of the 
Tedjen and Murgab rivers (among others: Merv, Takhta, 
Serakhs, and Kushkaj, and in the area of the Kopetdag 
river from Kizil-Arvat to Kaary-Kala, Geok-tepe, 
Firuze, and Ashkhabad. 
Tadzhikistan: Duzhambe (Stalinabad), Yanghy-Bazar, 
Kiafirnigan, Kulab. 
Usbekistan: Tashkent, Termez. 
Southern Kirghizistan: Osh, Dzhalyal Abad, Bazar 
Kurgan and other locations. 
2nd group: Phlebotomus sergenti 
Phlebotomus sergenti Parrot (including caucasicus 
Marz., alexandri Sinton, and mongolensis Newst.): In 
the sergenti-group several forms are distinguished, 
about whose positions as "varieties", races or inde- 
pendent species nothing positive can be said. It appears 
to be certain that the only form occurring in China, 
mongolensis, occurs only in high altitudes in the moun- 
tains of Tadzhikistan, while another form (probably 
alexandri) is more widely spread. The form caucasicus 
is limited to Transcaucasia, Iran, and Central Asia, 
while Ph. sergenti seems to be the typical form of 
the European - north African countries, and alexandri 
the form of Iraq and northern India, though all these 
forms have been reported from the Central Asiatic III/2 
republics as well. Their relations with one another must 
be carefully reexamined in order to obtain useful data 
on their importance as vectors of diseases. 
In the principal distribution area of the form 
mongolensis, the Oriental boil apparently does not 
occur. In Tashkent, the transfer of the canine leish- 
maniasis on hamsters is said to be possible through 
the form caucasicus. In Iran, however, the distribution 
of the form caucasicus does not coincide with that of 
the Oriental boil. This is reported, on the other hand, 
of the typical form sergonti, but has been recently re- 
ported also of caucasicus from Transcaucasia (Georgia). 
In the Mediterranean region, Fh. scrgenti is regarded 
as an important vector of Oriental boil and pappataci 
fever in addition to Fh. papatasii. For this reason, 
one must suspect temporarily all forms of the group 
sergenti. 
Tadzhikistan: Kulyab, Duzhambe (Stalinabad), 
Yanghy-Bazar, Kiafirnigan. 
Turkmenistan: Area of Kherkhi and Khelif, area 
of Chardjui, Farab, and Deinau, basin of the 
Tedjen and Murgab rivers (Merv, Tedjen, Serakhs, 
Takhta, Kushka and other locations), and the 
area of the Kopet-dag river (from Kizil-Arvat 
to Kaary-Kala, Geok-tepe, and Firuze, and Ash- 
khabad), Pamir: Khorog, Fish, Darmorak, Andercb, 
Sizd, Varmar, Barushan. 
Uzbekistan: Tashkent, Bukhara, Andishan, 
Shakrisyabs, Samarkand, Termez, Kitab, Gusar. 
Kirghizistan: (in the south Osh, Dzhalal Abad, 
Bazar Kurgan, Gultcha and other locations; in 
the north only Frunze, Alarchi, and Belovodsk). 
The map shows which forms of the sergenti group 
have been reported from the single finding places. 
3rd group: Phlebotomus major 
All species and forms of this group are regarded 
as vectors of Kala-Azar infections. 
Phlebotomus kandelakii Shchurenkova: I regard 
Fh. kandelakii as the most eastern representative of 
the important form group perniciosus which is widely III/2 
spread in the Mediterranean region. Nothing is known 
about the way of living and medical importance of the 
form kandelakii itself. In Turkmenistan it is said to 
be limited to altitudes lower than 300 M. , in Iran, 
however, to mountainous regions higher than 1,500 M. 
This needs checking. 
Turkmenistan: District Kaary-Kala, Firuze, Dzhuli, 
Ashkhabad, Murgab and Todjen valleys: e.g. Tedjen, 
Me rv, Ta kht a, Ku shka. 
Uzbekistan: Shakrisyabs. 
Phlebotomus major Annandale: This species is regarded 
as the most important vector of Kala-Azar in the eastern 
Mediterranean region. It is distributed from India to the 
central (probably even western) Mediterranean region. Ph. 
wenyoni Adler, Theodor & Lourie, a species treated as 
independent, is probably only a race of limited distri- 
bution (only reported location known in Iran and 
western Turkmenistan). 
Turkmenistan: District Kaary-Kala, Ashkhabad, 
Geok-tepe, Kushka, Kizil-Arvat, Khelif. 
Uzbekistan: Tashkent, Samarkand. 
Phlebotomus chincnsis Nowstead: The importance as 
a vector of Kala-Azar in northern China is regarded as 
proven. It is distributed from northern China to the 
central (and with one race perhaps to the western) 
Mediterranean region. In Transcaspia, it is among the 
important species in addition to caucasicus, the species 
advancing most to the north and to the highest altitudes 
in the mountains (see Illustration 2). The insects oc- 
curring in Russian central Asia belong to the strain 
f?longiductus Parrot’M 
Turkmenistan: In the district of Kherkhi and Khelif, 
in the area of Chardjui, Farab, and Deinau, in the 
basin of the Tedjon and Murgab rivers (among others 
Tedjen, Serakhs, Merv, Takhta, Kushka), and in the 
area of the Kopet-dag river (from Kizil-Arvat to 
Kaary-Kal, Geok-tepe, Firuze, Ashkhabad). 
Tadzhikistan: Stalinabad, Kulyab. 
Uzbekistan: Bukhara, Tashkent, Kitab, Shakrisyabs, 
Samarkand, Andishan. Ill/ 2 
Kirghizistan: Osh, Dzhalal Abad, Gultcha and other 
snail locations in the south, Frunze, Tokmak, and 
other smaller locations in the north, see 111. 2. 
Kazakstan: Alma Ata. 
4th group: phlebotonus ninutus 
Phlebotonus ninutus and numerous other "species". 
As far as known until now, most species suck blood from 
reptiles and thus are of no considerable medical impor- 
tance. It is somewhat doubtful, however, whether this 
most common opinion is actually true. 
II. Ticks; Ixodidae 
In Russian Central Asia, two species of the genus 
ornithodorus nay be regarded as vectors of Asiatic 
relapsing fever: 0. papillipes Birula ( = tholozani 
Laboulbene and Megnin) and 0. lahorensis Neumann; only 
for 0. papillipes has the transfer been proven, while 
the data on the importance of 0. lahorensis for the 
transfer are contradictory. Similar to bugs, the ticks 
live in stables, inns, caravanseries, and bite in the 
dark. They chiefly live on cattle, but also on rodents. 
The spirochaetes of relapsing fever are transferred to 
the following generation in the eggs. They increase 
within the egg, and stand the castings of the skin. 
Virus reservoir are chiefly rodents, particularly 
those living in the neighborhood of human houses and 
of stables, such as nice and rats. Even the pig 
possibly plays some role, since ticks have been found 
in pigsties. The question is not yet definitively 
answered for the western and central usiatic relapsing 
fevers. 
The cases of relapsing fever reported from Russian 
central40ia correspond in character to the course of 
Persian relapsing fever (Miana). The numbers of the 
annually reported cases remain slight, usually below 30. 
The majority of the cases occurred with soldiers who 
had cone from other regions and had been bitten by 
ticks in the billets. Ill/2 
The disease usually has a non-malignant course, no 
fatal cases have been reported for this region. A more 
serious course of disease may be expected among a popu- 
lation weakened by starvation and epidemics. 
No data are available from this region as regards 
tick-typhus. The vector, Phipicephalus sanguineus Latreille, 
exists in this region but no reported locations are indicated. 
Synopsis of the reported locations known until now 
in the Transcaspian Region (according to Russian 
data, the figures are the same as on the map) 
4 Dzhalyal Abad 
6 Osh 
7 Andishan 
8 Kokand 
9 Harm 
10 Khorog 
11 Sari Khasna 
12 Kulyab 
14 Syr Darya valley 
15 Tashkent 
15 Gusar 
17 Stalinabad (Duzhanbe) 
18 Shakrisyaba 
23 Samarkand 
24 Nur Ata 
25 Bukhara 
28 Merv 
30 Murgab valley 
37 Ashkhabad 
41 Firizkuh 
With the locations mentioned the ticks reach the 
northern boundary of their distribution area and, at 
the same time, the ICatu-tau mountains, 44 - 45° n.l. 
and 78 - 80° e.l., is the most eastern reported location 
in the Soviet Union known until now (not on the map). 
The distribution boundary according to PAVLOVSKY is 
indicated on the map. Of course, it is not impossible 
that a few foci will be found some day beyond it. 
R, von BLUMENTHAL and W. HENNIG 
(Institute for Tropical Medicine 
and Hygione of the Military 
Medical Academy) III/3 
IEISHMaNIiiSES 
IN THE TRiINS CASPIAN TERRITORY 
(with 2 Charts) 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical) III/3 
Throughout Turkmenistan, in the territories south of 
the line Frunze - Chimkent - Bukhara - Kizil Arvat, Leish- 
maniasis (Kala-Azar, visceral Leishmaniasis, Leishmania 
donovani, and Oriental sore, dermal Leishmaniasis, L. tro- 
pica) is relatively frequent. 
This kind of distribution is duo to the distribution 
of the various forms of vegetation dependent on the climate 
and to the density of population of that country. Some 
of those areas in Turkmenistan in which Leishmaniasis does 
not occur are areas of a very thin or of no population 
(cf. map III/4). In a report by MARZINOWSKY (1934) the 
statement was made that dermal Leishmaniasis is to be ob- 
served in dry areas without a grass cover of the earth 
and with a deep level of the subsoil-water, while Kala- 
Azar is found near the mountains and with a level of the 
subsoil-water close to the surface. This observation 
requires a more accurate examination. The territorial 
distribution of the principal forms of vegetation, there- 
fore, is simultaneously exhibited in the map. 
Dermal Leishmani- 
asis shows a certain 
increase of its fre- 
quency in the south- 
western parts of the 
territory, namely 
in the valleys of 
the rivers Murghab, 
Tedzhen, and Atrek, 
as well as around 
the towns of Ash-* 
khabad and Merv. 
The medical inspec- 
tion of 1,216 per- 
sons in the facto- 
ries and in the 
schools of Merv 
revealed that 761 
of them were or had boon suffering from Oriental sore. 
Further places of incidence of dermal Leishmaniasis are 
Termez, Tashkent, Kokand, Ashkhabad, and Bukhara. Accord- 
ing to PETERSEN in Turkmenistan the disease principally 
occurs during the months of December and January. 
Chart 1. Samarkand and environs 
G Kala-Azar A Oriental sore III/3 
Kala-Azar usually occurs as a Leishmaniasis of infants 
(L. infantum) (as f.i. in Samarkand). Throughout the terri- 
tory of Turkmenistan, however, it also involves the adults. 
Various Russian scientists emphasize the fact that in Turk- 
menistan visceral Leishmaniasis is found with the adults as 
well, ”a matter to be made known to the general public” 
(1925). 
In Bukhara and in the southern part of the Aim-Darya 
several cases of Oriental sore and of visceral Leishmaniasis 
were observed. Snail foci and isolated cases, however, 
occur throughout the entire area of southeast Turkmenistan, 
and they were particularly observed along the track of the 
Central Asiatic Railroad (see Chart II). 
Chart II. Kokand - Andishan 
£j Kala-Azar £ Oriental sore 
The frequency of Leishmaniasis apparently varies 
extraordinarily, and throughout the Transcaspian terri- 
tory the number of cases is much smaller than in India. 
While in 1925 180,000 cases were recorded in Bengal, 
only few hundred cases were found in Central Asia during 
the same year. As it was emphasized elsewhere in the 
Atlas of Epidemiology (see comment to map II/5), in the 
regions where so far only isolated cases of Leishmaniasis 
were observed, more accurate and close investigations 
were sufficient to reveal a frequent occurrence of these 
diseases. The average number of Kala-Azar in the new 
city of Tashkent f.i. amounted to 25 oases of Leishmaniasis 
per year (1923). The observation could, however, be made III/3 
that this group of diseases was slowly spread, and in 1928 
to 1930 two new foci appeared in the center of the city. 
Samarkand with 4 % of all children in the age between 
2 and 3 years suffering from Leishmaniasis has the highest 
incidence. It is followed by Kokand and Tashkent. 95 % 
of the sick persons range within the age groups between 0 
and 16 years. 
The canine Leishmaniasis is worth particular conside- 
ration, as it has not yet been possible to exclude it as 
a source of infection which at least applies to the Kala- 
Azar of the children. Some of the Russian scientists hold 
that the dogs n most likely are the real virus carriers 
of the human Leishmaniasis ??. There were reports partic- 
ularly from Tashkent and Ashkhabad that a great number of 
dogs in these towns were contaminated with Leishmania. 
There are even statements of some scientists which indi- 
cate that the entire oountry of Turkmenistan is populated 
with infected dogs. As a result of these conditions the 
complete extermination of the dogs was recommended as an 
efficient measure for the elimination of Leishmaniasis. 
In 1913 Leishmaniae were found in about 25 $ of the dogs. 
In 1926, however, only 2.2 % of the dogs were contaminated. 
A similar frequency of disease was observed in the dogs 
in Ashkhabad. The examination of the entire dog population 
numbering 3,385 dogs revealed that 97 of them, equal to 
2.86 were contaminated with Leishmaniasis (1935)* 
The largest number of patients is found during the 
spring and summer months, while the minimum is observed 
in November. Contrary to that, Kala-rAzar of children 
attains its maximum during the fall and winter months 
which corresponds to the summertime maximum of the 
Leishmaniasis of the dogs, if one considers that the 
incubation period of the children is l| to 3 months. 
One regards the sand flies of the species phlebotomus 
as the vectors of Leishmaniasis. The phlebotomi of the 
sergenti-group are considered as the transmitters of the 
Oriental sore, those of the major-group as the vectors of 
the visceral Leishmaniasis. 
Complete information on the distribution of Leish- 
maniasis throughout the Transcaspian territory for the time 
being is very difficult to compile so that it is likely 
that this study requires a number of complementary data. 
G. PIEKARSKI in/4 
DENSITY OF POPBLVTION IN THE TRANSCASPIC aREA. 
(with 1 map in the text). 
Translation prepared by: 
U. S* Fleet. U, S( Naval Forces, Germany, 
Technical Section (Medical)« hi A 
In addition to the presentation of the "density of the popu- 
lation in the Near and Middle East", the map of the density of 
population of the Transcaspian area, which was elaborated accord- 
ing to the same points of view gives an idea of the concentrations 
of the population of this area of the Middle-East-, which is under- 
going intensive transformations. The considerably enlarged scale 
as well as extensive sources facilitated a more precise presenta- 
tion and a correction of the corresponding part of the map Il/9. 
The 8 smaller Federal Republics of the USSR are, as the south- 
ern frontier of the Russian Empire, formations of special dynamics* 
Georgia, Azerbaidzhan and Armenia are within the Transcaucasian area 
while the Republic Daghestan and the autonomous republic of the Kal- 
myk north of the Caucasus are in a certain special position. The 
Transcaspian area from the lower Volga to the Chinese border is the 
area of the Republic Kazak, whose southern and eastern parts to- 
gether with Turkmen, Uzbek, Tadzhik, and Kirghiz fill the Turkestan 
area. Today (1945),the influence of the Soviet Union extends farther 
eastwards to the area of east Turkestan (former Chinese province 
Sinkiang) and outer Mongolia. 
The Transcaucasian, as well as the Turkestan area distinguished 
themselves by a considerably larger increase of bheir population, as 
can be seen by comparing the results of the Russian Census of 1926 and 
1939, which showed an increase of the population of the Soviet Union 
of 15.9 %. 
i 
Federal Republic 
Total population 
Increase of population 
, 
1926 
1939 
in per cent 
Georgia 
2,677,000 
3,542,000 
32.3 
Azerbaidzhan 
2,314,000 
3,210,000 
38.7 
Armenia 
881,000 
1,282,000 
45.4 
Turkmen 
998,000 
1,254,000 
25.6 
Uzbek 
4,566,000 
6,282,000 
37.6 
Tadzhik 
1,032,000 
1,485,000 
43.9 
Kirghiz 
1,002,000 
1,459,000 
45.7 
The distribution of the population in Russia is very dispro- 
portionate. s°uth of the 55° northern latitude in Siberia, 92.6 % 
of her population are living on only 2?.4 % of her surfaee. The 
distribution of the population of middle Asia is similarly dis- iiiA 
proportionate. In the area of the fertile black-earth of the 
northern part of Kazak, the population is equally dense as in 
the southern area of Siberia. Its desert-zones and plains are 
sparsely populated, while the ancient cradle of mankind, Tur- 
kestan, in its areas of fertile loess along the foot of the 
mountains has oasis-like, densely populated cultured areas. 
"South of Orenburg the plains begin - there is Asia". E- 
ven in the 19th century the Empire of the Tsars safeguarded it- 
self against an invasion of the steppe Kirghizes by a protecting 
rampart of Cossacks consisting of peasant-soldiers. The villages 
of the Cossacks on the western bank of the 8rai ag well as on the 
eastern bank of the Irtysh formed far a long time, together with 
the c°ssacks-line (Orenburg - Orsky Troitsky PetropavlovskyOmsk) 
the border of the Russian Empire* Today the Russian farmer has 
spread over the steppe. 
Kazak (Kasakstan) with its extent of 2,958*800 sq.Km. is the 
second largest federal republic of Russia. Its average density 
of population is low because of the extensive desert-and plain- 
areas $ the ratio is 2.2 inhabitants for every square kilometer. 
As regards Siberian conditions, however, the country with its 
inhabitants is still well populated. The number of 
Casac-Kirghizes, a nomadic tribe, predominantly engaged in rais- 
ing cattle, is registering a remarkable declination m number be- 
cause of their removal from the steppe. 1897: 4*235.-6985 1926: 
3,968,2895 1939: 3*098,764# in the last twelve years alone their 
number decreased by 21.9 % and now they represent only 57*1 % of the 
total population. The Russians (19*7 %) and Ukrainians (13*2 %) are 
mostly farmers in the fertile northern border-areas, 44*283 Germans 
in 128 settlements have been counted amongst them* The Uzbeks (3*3$) 
live in the southern part, the Kara Kalpak (1-8 /o) in the delta of 
the Amu-Darya and south of the desert Kyzyl Kum (1926: 146,317* 1939: 
185,775)5 there they have an autonomous area which belongs to Kazak. 
The remaining 4.9 % are divided in several smaller tribes, like the 
Tarantshs, 6,000 families of which the Russians transferred as wel- 
come settlers in 1730 from Chines e-Turkestan to the Ili-valley5 in 1882 
they amounted to 36,000 families in Semirentshensk alone and were 
said to be 53*010 families in 1926; furthermore the Dunganes in the 
extreme northeast of Turkestan and others. 
Kazak is a country rich in raw-materials and natural resources 
(treasures of the soil), inspite bf the extensive, dry Kirghiz-step- 
pe, the salty Kaspi-lowlands, the dreary Ust-Urtplateau of the desert 
Kyzyl-Kum and the famine-steppe• In the north it shares the fertile m/4 
black-earth zone, attached to which are chestnut-brown,soils suit- 
able for farming; irrigation is the decisive factor everywhere. 
The mining-districts are numerous too, located in the northeast, 
like the rich mineral coal areas of Karagandinsk and Spask;; as 
well as the gold, iron, and manganese - deposits in the seven- 
river-land of Semipalatinsk, which were made accessible by the 
construction of new railroads, Karaganda, still unknown in 1926, 
reported 165,900 inhabitants in 1939. Alma Ata, which was es- 
tablished as a fort by the Russians in 1859> and which iri 1863 had 
only one brick- and 766 wooden buildings, grew from 1926 with 
45>400 inhabitants to 230,000 inhabitants in 1939* i.e, 507 
proportion of City - Country- 
population 
1926 
8,5 % 91.5 % 
1939 
27.5 % 72.5 % 
The mining and industrial development is expressed in the con- 
siderable increase of the city-population* 
Turkmen (Turkmenistan; with an extent of 443.-600 sq>Kma was 
formed out of the former province Turkestan, parts of Bukhara and 
Chiva. The average density of the population is low (2,8 inhabit- 
ants) on account of the extensive Kara Kum - Black Desert - • 
The Turkmens, who offered the last brave opposition against Rus- 
sian conquest - the Russians conquered it only in 1881 - form with 
70r.2 % (1926) the major part of the population* They too increas- 
ingly change over to agriculture from the nomadic life,, The Uzbeks 
represent 11*7 %} the Russians 9*1 %, the Armenians 1*5 %y Kirg- 
hizes 0,7 % of the population. The remainder with 6,8 % are Per- 
sians, Jews of Bukhara and others. 
Considerable parts of the Turkmenish population fled to Iran 
and Afghanistan during the sanguinary suppression of the rebellions 
which occurred in Middle Asia jn 1916; the strong natural growth 
as a result of modern hygiene and the declination of the mortality 
rate is therefore noteworthy.. 
The capital Ashkhabad with its more than 100,000 inhabitants 
has almost reached the number of inhabitants of the old Persian 
Meshed* The increase of the city-population is strikingly high 
compared to the small number of cities. ii i A 
Density of population in Kasakia and Turkestan. IXl/4 
proportion of city - 
country- 
population# 
1926 
13*7 % 
86*3 % 
1939 
33*2 % 
66*8 - % 
This might depend on counting a large part of the population, 
living densely in the oasis - Merv has over 400,000 - as city-pop- 
ulation. 
Uzbek (UsbekistanJ with an extent of 378,300 square kilometers 
was formed in 1922 from the province Syr-Darya and the nuclear-area 
of Bukhara; it has the largest density of population with 16,6 in- 
habitants for each sq.km. The Uzbeks (sarts) not only represent 
65 % of the population, but are on the other hand a most capable 
race of men and are leading in their native state as well as in the 
whole area of Turkestan, as regards culturing of oasis, trade and 
commerce. In 1926, the Tadzhiks represented 19 %$ Casac-Kirghizes 
3 % and others 8 % of the total population. The Ferghana-basin with 
considerable mining industry and cotton plantations is part of Uzbek. 
It has a density of population of 100 - 150 inhabitants. Another part 
of Uzbek are the extensive oasis areas in the river valleys of the 
Zaravshan and Tshirtshnik with 50 - 100 inhabitants per sq.km. There 
are "villages" with 10,000 to 15,000 inhabitants * The densely pop- 
ulated oasis Chiva-Chovesma with an extent of 7*cO0 sq„km. represents 
an exclave which belongs to Uzbek too. The capital Tashkent, which 
in 1897 had 155*673 inhabitants, in 1912, 272,000inhabitants and now 
600,000 inhabitants, is now larger than Teheran. Because of its 
coal ana naphtha this oldest center of trade is nowadays the center 
of the iron consuming industry with large tractor factories. 
proportion of city - country 
population 
1926 
22.2 % 77.8 % 
1939 
23.0 % 77.9 % 
In spite of an increase of 37.6 % of the total population at 
this time, the proportion city - country in Uzbek has scarcely changed 
contrary to nearly all the other areas of Russia. This is a conse- 
quence of gaining new areas for settlement, to which we will refer 
later. ii i A 
Tadzhik (Tadshikistan). The up to then "autonomous" republic 
was changed into a federal republic in 1929, and was enlarged by 
the district of Khodshent,which was taken from the province Uzbek. 
This was preceded by a transfer of the Tadzhiks from the area of Kokand 
and Ferghana to the southern border, the upper course of the Amy. 
Darya and its by-valleys, which were especially suitable for cotton 
cultivation; in 1928 the areas for cotton cultivation could be in- 
creased here from 70,000 to 200,000 hectare, The Tadzhiks are the 
descendants of an old Aryan population of Middle Asia, they are farm- 
ers, in the hills also cattle-raisers, which had been supplanted in- 
to the mountain-valleys by the Uzbeks. As regards religion, they 
were Schiiten (shiits). Politically this created a counter-weight 
to the Uzbek (oes-beg - autocracy) who are leading not only in the 
central Asiatic trade, but also in the conservative Mohammedanism 
(Sunnits), and at the same time this secured the southern border a- 
gainst the Afghans. The area of this state, which had an extent of 
143*900 sq. km, includes the "Roof of the Earth", the Pamir-plateau 
with the autonomous area of (35*700 inhabitants to 
0.3 sq.km.). Inspite of this the average density of the population 
is 10,3 inhabitants per square kilometer. 
Proportion of x 
±0 city- country- 
population 
1926 
3.0*3 % 89.7 # 
1939 
17.0 $ 83.0 % 
In addition toKhcdshent the center of industry, which was founded 
by Alexander the Great at the entrance to the Ferghana-basin, Stalin- 
abad as the capital plays the most important part. The little vil- 
lage Djushambe with 5*600 inhabitants in 1926, developed into a town 
of 82,500 inhabitants in 1939, this means an increase of 1472 %• With 
more than 90,000 inhabitants it now reaches the number of inhabitants 
of the Afghan town Herat and is not far bulow Kabul, The formerly 
great danger of malaria in this area was eliminated by a systematic 
sanitation. 
Kirghiz (Kirghisistan). This last federal republic with an ex- 
tent of 196,700 sq.km, has an average density of population of 7*4 in- 
habitants per square kilometer. The country is poor. The mountains 
in the direction east-west have Alpine climate, farming is possible 
only in the lowest valleys, while in the remaining parts pasturage 
is predominant. III/4 
The Kara-Kirghizes represent 67 % of the population, Russians 
12 Uzbeks 11 %} Ukrainians 6 % and the remaining 4 % are others. 
The Uzbeks live predominantly in cities, the Russians as settlers 
in the fertile spurs of the mountains around the capital Frunze. 
With Osh, the state participates in the mining area of Ferghana. 
Proportion of 
city - 
country 
population 
1926 
12.2 % 
87.8 % 
1939 
18.5 % 
81.5 % 
The recruiting of a larger number of people to build earth- 
works along the western front of Russia - until in 1917* 180,000 
are said to have been recruited- and the sanguinary rebellions in- 
duced the Rirghizes to change over to china into the area of Cash- 
gar and Culdsha. During this time the cattle-raising was reduced 
by 75-80 %, and the area under cultivation decreased by 60 %. 
Presently Kirghiz has the strongest increase of population - 45*7 % 
in 12 yearsi 
Development of population: While, with few exceptions, the 
country population declined in the Russian, especially the Ukrain- 
ian territories and also in Siberia, in Turkestan a strong, natural 
increase of population can be observed* The increase of population 
in the Turkestan area amounted from about 9 millions in 1926 to a- 
bout 13 millions in 1939 (10,5 millions in the four federal republics 
and 2*5 millions in the southern part of Kazak) that is about 4 mil- 
lions* These additional 4 millions could not all find employment with 
the industry, therefore an extension of settlements with the utiliza- 
tion of all water supplies and technical possibilities was necessary. 
A manifesto, issued on 22 December 1939 by the government of the So- 
viet Union demanded that the new formation of irrigation territories 
be the community task of Turkestan. It was planned from 1940 to the 
end of 1945: 
New formation of 
new collective 
irrigation areas 
farming estab- 
hectars 
lishments: 
UzbeK 
430,000 
58,600 
TurKmen 
104,000 
15,000 
Tadzhik 
113,700 
13,000 
Kazak 
425.000 
42,000 
1,073,200 
128,600 in A 
•*ith an average of 5 heads per establishment this means a 
new employment of about 640,000 people which is about 7 - 8 % 
of the total population. The major principle was to resettle 
the nomads and carry out a resettlement from the hills into the 
steppe. Within the years of 1938 - 1939 the cultivation of Uz- 
bek was enlarged by 160,000 hectare, A comparison of the ex- 
isting cultivated areas with the areas to be cultivated shows 
in 1000 hectars: 
Cultivated 
areas 
1937 Areas cultivated 
1940 
- 1945 
Total 
cotten 
total 
cotton 
Uzbek 
2653 
906 
430 
100 
Turkmen 
394 
133 
104 
25 
Tadzhik 
737 
111 
114 
39 
Kazak 
3331 
111 
423 
63 
These data of the Gosplanizdat are interesting in that they 
show that they have learned from the famine in 1930-1932, which 
was mainly caused by the planting of cotton, and as a result of 
this now strive for an economic as well as a nutritional self- 
sufficiency of the various territories based on traffic- and mili- 
tary-geographical interests. With these areas to be cultivated, 
the plantation areas for grain will be extended by 30 - 40 
During the summer of 1939 the construction of the large Ferghana- 
irrigation-channel (more than 350 kilometers long, width of the 
water-level 20 meters, raising 100 cbm/sec.) was started and finished 
as a community task of 160,000 Uzbek men and women. Only resettlers 
of the local population will get the territory thus gained. Thus, 
the healthy growth of this group of people merging now inwardly 
with the Russian Empire is secured. 
Under the influence of the centrally directed development of 
the southern border-republics of the USSR, a far-reaching change 
of the middle-Asiatic territory is developing. A considerable in- 
crease of the space for living and earning ones livelihood was the 
result of an improved status of communications and economics; with 
a simultaneously strong, natural pressure of population. This con- 
glomeration of people will not be without influence on the neigh- 
boring countries. 
H. HARMSEN, 
(Hygienic Institute of the University 
of Berlin and Institute for General- 
and Military Hygiene of the Medical 
Military Academy).