VII 
GEQMEDICAL REVIEW OF THE MEDITERRANEAN COUNTRIES. 
Translation prepared by: 
Ut S. Fleet, U. S* Naval Forces, Germany, 
Technical Section (Medical). VII 
There is no other sea in the world around which so many and con- 
tinuous desperate battles have been fought on land, at sea and in the 
air, between the nations living on its shores. This struggle dates 
back as far as to the times of Hannibal and Scipio Africanus, the 
Macedonians, Philip and Alexander, Geiserich and Okba Ben Nafi, to the 
times of the Knights of Malta and the Doges of Venice, the Hohenstau- 
fen Frederick II., to Bonaparte and Nelson, Lyautey and Kitchener, 
Franco and Balbo, Rommel and Eisenhower. The decisions and the deeds 
of each of them put soldiers, ships, and airplanes into action, and 
they were the cause for many invasions, bridgeheads, naval battles, 
and expeditions ashore. A common characteristic of all those actions, 
however, was that the countries on the southern coasts of Europe 
fought against the countries of North Africa opposite them*, Even the 
planning of war, as well as an economic, scientific, and cultural ag-r 
gression or agreement is compelled to take into account the life of 
those two adjacent territories in the broadest sense. On the shores 
of no other sea do the areas of disease and health of Europe and Af- 
rica meet so closely and so powerfully in the positive and in the 
negative sense as in the Mediterranean. Man, animals and vegetation 
of the Mediterranean are living in a special climate, the so-called 
Mediterranean climate, which objectively as well as subjectively is 
so well defined that it appears as a very peculiarly and clearly dis- 
tinguished entity when it is compared with the climate of other mari- 
time areas. No other sea links the continents on its shores together 
so much as does the Mediterranean, inuring the last two decades of 
the 20th century the airplane has served to bring the American con- 
tinent still closer to Africa and Europe and that means to the Medi- 
terranean. Therefore, geomedical "flares" may pass from without and 
frail within through the geopolitical straits, such as che straits of 
Gibraltar, the Suez Canal, and the Dardanelles, to set fire on poten- 
tial foci or to make them smoulder and to spread them, A land-locked 
sea such as the Black Sea may be involved as easily as a free ocean 
such as the Indian ocean. However, the flare may also go the opposite 
way. Only during this war have we become fully aware of the Medi- 
terranean being a European sea, although it has been such a sea even 
from the beginning of historical thinking. The Mediterranean is the 
sea of the Greeks and Romans, of the latin-byzantine-christian civi- 
lization, of fighting Islam, of the safest route to the most valuable 
part of the British Empire, of the Arabian civilization in Spain and 
France which linked anew its southern coastline - North Africa- to 
Europe. Along its shores from Gibraltar to the Bosporus and back to 
the Pillars of Hercules the magic carpet is spread from the occiden- 
tal to the oriental territories which is so colorful and at the same 
time so entangled through Europe's mistakes and which all of us could 
enjoy before this war. It was only the campaign in Southea.starn^Europe VII 
(1941) and the fighting of the German and Italian African Armies which 
made it obvious that the Mediterranean is the continental entity as con- 
ceived by ROSS* This author is anxious to include the coast opposite to 
Europe, that means North Africa, in the Mediterranean territories and in 
its way of thinking again, and he believes that this has priority over 
all other things, and that it would be comparatively easy. Thus, he out- 
lines in the political field an idea of Goethe recommended in his parali- 
pomena to the "West-oestlicher Divan”: "He who knows himself and others, 
knows that the Orient and the Occident are inseparable". 
While Colin ROSS directed our attention to the historical, geograph- 
ical, and intellectual sources for the origin of the "Levant" in the 7th 
volume of the "C&ographie universelle" (Paris 1934) the French geograph- 
ers Max SORRE and Jules SION, and the Bulgarian geologist Dimitri JARANOFF 
give new infor'nation on the Mediterranean and the Mediterranean countries 
(1939/40). JARANOFF who very modestly calls his contribution an "essai 
geographique" was highly regarded by Karl HAUSHOFER. JARANOFF indeed 
completed a well rounded and reliable work which has to be considered as 
the basis of any geomeaical research concerned with the Mediterranean and 
its countries, since as yet there is no planned geomedical research in the 
Mediterranean and its countries, although the tremendous history of this 
sea, which so often has been the center of far reaching political and his- 
torical decisions, invites geomedical researchers for detailed studies. 
Now, the opportunity is given to make a careful analysis of the geomedical 
problems of the Mediterranean. 
Any consideration of the Mediterranean area, the sea, the coasts, and 
of the islands, be it concerned with the conditions at the time of Hippo- 
crates or the conditions at the end of the 19th century must principally 
refer to Gibraltar and Malta which like the Balearic Islands, Sardinia, 
Corsica, Sicily, Candia, and Cyprus, are situated in the midst of the po- 
litical and military sphere of influence of the Italian and British Empires, 
The principal question should be whether they ever were known as areas 
of disease or, preferably, of health, or whether they were outlined as 
such by medical investigation. It is worth knowing whether or not the 
British had followed their line later regarded so strictly during all 
their campaigns in Africa and Asia undertaking no planned military ac- 
tion before the hygienists and technicians had accomplished their work 
of sanitation previous to military action in the prospective area of 
operation. Such preparations usually could have favorable effects only 
if a thorough work was done. "The doctors' and engineers' war" was the 
term applied to these absolutely necessary preparations by Lord Derby, 
before one of Great Britain's Aschanti-campaigns was started. Later on 
Kitchener had very good experiences with them. During the present war VII 
the British returned to the same methods using and evaluating the medical 
topographies to become acquainted with the geomedical conditions of the 
occupied countries or those to be invaded* The basis of all these activ- 
ities is the tradition left to them by one of their most experienced med- 
ical officers, John HENNEN (1779 - 1828), who spent almost his entire 
service in the Mediterranean* HENNEN himself prepared a medical topo- 
graphy of the Mediterranean. This fundamental work is concerned with 
the topography of Gibraltar, Malta, and the Ionian Islands Corfu, 
Kephallenia, Zakynthos, Santa Maura and Ithace. These suggestions and 
medical and topographical details required for the garrisons are given 
in minute entail and set in relation to the fighting strength of the 
troops and the fortress as such. Only in the medical topographies of 
a small number of single garrisons edited by the Prussian Ministry of 
War, the former Austrian Ministry of b«ar,and of the Tiflis Military 
District at the time of the Czars are descriptions of an equivalent 
and permanent value to be found. Similar medical topographies for the 
use of the Armed Forces were prepared on the initiative of Ren§ DES- 
GENETTES, Army surgeon of the French Levant Army during the campaign 
in Egypt and Syria in 1799* 
If one compares the descriptions of the epidemic and endemic 
communicable diseases of the Mediterranean countries with their present 
incidence, one sees clearly that they are always the same, namely plague, 
malaria, abdominal typhus, "yellow fever" (infectious hepatitis?), and 
the "Idiopathic Fever of Malta", sometimes called "Summer Fever". The 
description of the latter is identical with that of Mediterranean or 
Malta fever which we call brucellosis of the Mediterranean. The casual- 
ties caused by this disease within the Maltese garrison which annually 
amounted to many thousands since every newcomer seemed to fall sick with 
them, gave rise to the discovery p>f the bacterium mel.tense by the 
British medical officer David BRUCE in the year of 1887. Not until two 
decades later was definite proof established that the proper source of 
communication is the milk of the Malta goat. This discovery made it 
possible to classify for diagnostic purposes the undulant and remittent 
fevers occurring in the Mediterranean, which were known under various 
terms. The importance of brucellosis throughout the Mediterranean 
was recently emphasized by Horst HABS (cf. map VIl/1) <■ He stresses the 
spread of Malta 'fever to countries north of the Alps and announces the 
invasion of this disease to heretofore healthy areas which are con- 
taminated by the constant progress of Malta brucellosis and the creation 
of new areas of disease. This reminds us of the opinion of Charles 
NICOLLE, who has particular merits as regards the control of Malta 
fever in French North Africa. He asserts that this disease recently 
has been progressively distributed throughout the world: "Elle justifie 
le nom de maladie d‘a7enir" ("one may correctly call it the disease 
of the future'), as he stated in 1920. X am not able to decide whether VII 
Malta fever was "born" in the beginning of the 19th century in Malta 
without ever having been observed there earlier, as NICOLLE stated. 
NICOLLE calls Malta fever the best example of an infectious disease 
coming into existence before our eyes which previously was entirely 
unknown. He compares it with epidemic meningitis as a probable ex- 
ample, since this disease suddenly appeared at about the same time - 
the year 1805 is assumed for Europe. Its North American origin is 
not proven but there is no aoubt about its peculiar migration through- 
out the world since 1805 which made it a typical soldiers' disease. 
The first attempts of epidemic meningitis to gain a foothold in 
Africa were successful after several intervals. It now is firmly 
established in North Africa, principally in the Sudan, the great 
recruiting area for the army of The outbreak 
of epidemic meningitis .'among Sudanese elite regiments and simultaneous- 
ly among the indigenous population revealed an African focus which 
certainly has become endemic and which doubtlessly feeds the foci of 
the North African coast. There is no acute danger of epidemic menin- 
gitis decisively influencing military operations since there is no 
connection between this disease and particular living conditions 
(epidemic equation = "Seucherf‘ormel"). 
Trie efforts of the British Naval surgeons to classify the dif- 
ferent febrile diseases demonstrate the difficulty and uncertainty 
of diagnosis due to the large number of febrile diseases common in 
the Mediterranean. In these efforts 'Mediterranean fever" with and 
without jaundice plays a leciding part. There is no possibility of 
ascertaining whether Malta fever/ as we call it now, at that time 
was accompanied by jaundice having a different appearance than now- 
adays, since no bacteriological and serological methods were known 
in those early times. However, there is no doubt that an epidemic 
jaundice occurred to such an extent among the British Naval Forces 
anu its insular garrisons for many decades - one is tempted to think 
of the epidemic hepatitis of present times - that another expert on 
the Mediterranean diseases, the British Naval Surgeon William BURNETT 
(1779 - 1861) introduced it as "commonly called the bilious remittent". 
To what an extent the syndrome of jaundice struck each physician, is 
revealed by numerous medical histories and epidemioJogical reports. 
Therefore, BURNETT agreed to introduce the more adequate term "Medi- 
terranean fever" instead of the term "bilious remittent". On this 
basis the epidemic jaundice of the Mediterranean, considered identi- 
cal with American yellow fever, was taken to be the same as Medi- 
terranean or Malta fever. 
In this connection it is particularly instructive to know that VII 
Gibraltar was the principal focus of jaundice called fever, 
bilious remittent equal to the yellow fever of the West Indies, 
The British physicians remarked that the years 1799, 1800, 1803, 
1804, 1810, 1813, and 1828 were years of particularly severe Malta 
fever These outbreaks also included Cartagena, Cidiz, Malaga and 
Algeciras to a greater or lesser extent, wnile other towns in the neigh- 
borhood were entirely spared or suffered only very little. Thus, for 
instance, the Spanish troops stationed at a distance of about 2 kilo- 
meters in the glacis of the Rock of Gibraltar were entirely free of 
Gibraltar fever. It is, therefore, clear that the opinion and the sug- 
gestions of the various observers - contagonists or anti-contagonists 
(physicians believing in contact infection or not believing in it) - 
differed considerably. The former asserted that this disease is "sui 
generis" unusually infectious leaving an immunity throughout life. In 
addition they assert that it is of foreign origin and, a fact particu- 
larly important for us, that it is always liable to be imported into 
countries "enjoying a certain degree of heat"# Contrary to them the 
anti-contagonists dismissed their opponents with contrary statements 
and directed the attention to the observation that this febrile dis- 
ease had been inherent along the Spanish coast for a longer or shorter 
period of time and that the outbreaks were only caused by local and 
atmospheric disturbances. 
Both views are supported to a certain degree by our present theory 
of infection. Its distribution depending on a certain temperature sug- 
gests the communicative activity of some insect such as some mosquito 
while the imperceptible occurrence among the population of the Spanish 
Mediterranean coasts permits us to assume a virus reservoir. Further- 
more we must add the fact that the vector of genuine yellow fever, the 
Aedes communicates dengue fever. Therefore, 
the geomedicine of the Mediterranean countries will be completed by 
accurate maps of the distribution of the vectors as well as of the 
endemic or of the epidemic virus reservoirs. Some of the medical his- 
tories of the British reports suggest that pappataci fever at that 
time was among the Mediterranean fevers. This makes these maps, which 
show the cistribution of the mosquitoes all the more valuable, (cf. map 
l/8 and l/3)* One should, therefore, pay particular attention to the 
Bulam is a settlement on the Lesser Antilles on which the yellow 
fever occurred, 
HENNEN died during the outbreak of the year 1828 of the same dis- 
ease in Gibraltar. VII 
recent experience of the British (1941) with yellow fever in the Nuba 
Mountains of the Anglo-Egyptian Sudan (1940) which E. KIRK called "a 
most important outbreak of yellow fever in the Nuba Mountains, the 
most striking rural epidemic of the disease ever recorded from Africa11 
(cf.map VIII/1-3)• Simultaneously G* FINDLAY published important ob- 
servations and therefore the records on this threatening epidemic must 
be examined by experiments and from the geomedical point of view in all 
details. "Although there is no definite account of an epidemic of 
yellow fever in the Sudan in historic times, natives of 
Kordofan were immune to yellow fever when taken to Mexico in 18b3» 
There is aljo evidence that they were far more resistant than Egyptians 
to fevers present in the Upper Nile Province of the Anglo-Egyptian 
Sudan* - There is no evidence to suggest that yellow fever has been 
recently introduced into the Sudan”• 
Comparing the symptoms of all the infectious diseases occurring 
there with each other one is struck as by an "optical signal"(to use 
the words of Gottfried HOLLER) if jaundice is mentioned which is des- 
cribed as an ever recurrent motive as well as an incidental one. As 
a chief symptom it is predominant with yellow fever which is so clear- 
ly described with all its symptoms that there is no doubt whatever as 
to its African or American Origin. Simultaneously the bilious charac- 
ter of other infectious diseases within the same disease area is men- 
tioned. There is no other large territory in the world excluding these 
parts of America and Africa where yellow fever is common, in which such 
an ever recurring symptom is found. One is subject to such an impres- 
sion as is particularly considered by HOLLER in his recently published 
critical and comprehensive study "The epidemic diseases accompanied by 
jaundice" (Vienna 1943)* For this author, however, the jaundice is on- 
ly one symptom which is "explained by the coincidence and the effect of 
several, probably many (sometimes not demonstrable) factors". Applying 
the theory of HOLLER to the Mediterranean complex one will discover that 
the infectious diseases not related to genuine yellow fever or to spiro- 
chetosis ictero-hemorrhagica such as hepatitis epidemica, paratyphus B, 
malaria and recurrent fever, bilious remittent fever and Malta fever be- 
long to the above mentioned group of symptoms. Therefore, the clinical 
and micro-biological differential diagnosis must be made very carefully 
if it is desired to use it for geomedical prognosis; as the geomedical 
distribution of the infectious diseases with some visible chief symptom 
or incidental symptom is almost exclusively restricted to the typical 
Mediterranean climate. According to my personal experience in Asia 
minor and Syria (1916 - 1918) and in Greece (1941) this observation is 
probably correct and agrees with the statements of HOLLER who assumed 
that within this climatic area of the Mediterranean particularly the 
liver in its principal function, which is the preparation and the di- VII 
gestion of the food and the defense against numerous infections, is 
exposed to noxious agents in the altered metabolism. It is the task 
of geomedical research to investigate these problems by means of 
JARANOFF's and our own maps. 
While for recently arriving troops the Mediterranean and its 
territories is a change from a seemingly safe and healthy area to 
an area of disease, it is a healthy region for the indigenous popula- 
tion and those Europeans living in it for a long period. For every- 
body who is transferred to this region the local influences upon the 
macro-organism are and remain relative and subjective. Together with 
a changed disposition of the macro-organism the prognosis is also 
altered. This relation clarifies the geomedical distribution of the 
bilious remittent fever which was given a classical description by the 
German physician Wilhelm GRIESSINGER during his activities in Egypt 
(1850 - 1852). This report led. to the consideration of paratyphoid 
fever C* which was continuously investigated before World War I and 
during the present war has revealed most interesting areas of dis- 
ease in some Mediterranean countries (cf. map l/7)* For military 
geopolitics and geomedicine yellow fever, when considered together 
with the forms of jaundice occurring in the Mediterranean basin at 
earlier times, at the present or in the future, gains importance. 
This is summed up by GRIESSINGER in the following statement: "In 
Europe and among us there are numerous diseases which cannot be dis- 
tinguished with certainty from yellow fever", A map of the occurrence 
of yellow fever in southwest and southeast Spain also showing the test 
methoc, in view of the oynamics of each infectious disease revived by 
war or migration might perhaps reveal a survival of yellow fever in 
the garrison towns described by HEN'NEN as foci of this disease. If 
the testing experiments of Arnold DCHMEN (discussed before the Berlin 
Medical Association on 19 May 1943) with a virus found by him associat- 
ed with hepatitis epidemica brings about similar successful results as 
did the serum tests for yellow fever, GRIESSINGER*s postulate formulat- 
ed a century ago demanding an etiological determination will be linked 
to our present micro-biological research 3), The distribution of hepa- 
titis throughout Europe will soon be delimited in this case. 
3) njt is evident that a precise delimitation of the above mentioned 
diseases from yellow fever as it is revealed by its symptoms, is not 
advisable and that the diagnosis which in some cases is liable to 
cause confusion is based on the etiology for the most part.” VII 
MRUGOWSKY gave his personal ideas on the etiology of yellow fever 
which are still discussed and have not been thoroughly investigated as 
yet, and he gave some evidence for them by means of the following map. 
He relies upon the theory of Alfred WEGENER concerned with the "Origin 
of Continents and Oceans" and asserts that the yellow fever area was 
divided by the detachment of the African Continent from the American 
Continent into an African and an -American part. "In these areas, now 
separated from each other, the yellow fever virus developed two sero- 
logically different varieties. Geological and palaeo-climatic reasons 
are not opposed to this opinion, - In South America the virus, there- 
fore, has always been inherent and was not imported from Africa at a 
later date, - The virus grew in the original area even before the 
cretaceous period". 
The Illustration shows South America and 
Africa during the lower tertiary (Lutetian pe- 
riod.) south America is detached from Africa 
and rotates westward. South America and the 
Antarctic as well as Africa and Madagascar are 
still coherent. The South Pole is situated 
south of the Cape Colony; the equator passes ; 
through present day Central America and the 
Mediterranean countries. The shallow seas 
north of South America and Africa are indi- 
cated by a dotted area. One recognizes that 
in North or South America and in the region 
of Sierra Leone extensive stretches of land 
are waiting which during the lower tertiary 
period begin to detach themselves from each 
other. (According to KOEPPEN, W., and WEGEN- 
ER, A*j the climate of the geological prime- 
val age, Berlin, 1924)• - From MRUGOWSKY, J.: 
Essay of the ontogenesis of yellow fever, 
Arch,Hyg. Vol. Ill, p. 104-112 (1933). 
Plague and tularemia must be considered from another point of view* 
Since ancient times the Mediterranean and its coasts were regarded as 
the principal area of "Levantine Plague", The mysterious countries and 
nations of the Levant, so to speak, were the source of this scourge of 
humanity, which was well known in its symptoms, in the form of bubonic 
and pneumonic plague, as the black death, just as was small-pox. It is 
unknown whether plague was dreaded as a war disease on the Venetian 
battle ships, among the Carthaginian and the Roman legions, or among 
Okba’s cavalry armies, or whether it did not ®ccur at all at that time. 
It is certain that it broke out during the historical controversies VII 
between Great Britain and France, soon after Bonaparte’s invasion in 
Egypt. Here too, the same thing happenod as in the winter camps of 
the Prussian Army during the Years’ War, where the term ’’plague" 
that means the actual diagnosis, was not to be mentioned in public to 
avoid a panic. Such concealing tactics are not desirable nowadays to 
insure an effective control since only an extensive knowledge of the 
epidemics and their details provide the hygienist with effective means 
to extinguish them. A clear diagnosis is required all the more, as it 
frequently happens that within the area of plague tularemia also oc- 
curs which, similar to plague, strikes man as well as animal. The geo- 
medical viius reservoir of both the diseases is identical with the only 
difference that no 1 tularemia foci of the And and 3rd order and ports 
with tularemia incidents are known so far, as is the case with plague 
in the Mediterranean and its coasts. The experience of HENNEN and 
DESGENETTES, however, shows that a certain type of plague occurred 
among soldiers and civilians which apparently was not true plague al- 
though bubos were found. Though DESGENETTES received reports of his 
Army Surgeons from Egypt and Syria on a varying course of the bubonic 
plague, which within a certain time either took a very mild or a very 
severe course, he was correct to maintain his diagnosis since he had 
no other knowledge and since tularemia was not yet known at that time. 
In our time we have available a large number of hygienic and bacterio- 
logical methods of differential diagnosis, if such variations in the 
course of a disease occur. • 
%is increases the value of Bonaparte's intrepid self-experiment 
made in the presence of his Army Surgecn the plague hospital of Yaffa 
(1799). This is recorded in the reports of DESGENETTES and the Erench 
General Staff on the Levant campaign, 
Bonaparte stayed for mure than lj hours in both hospitals without 
considering any special precautions when contacting his soldiers sick 
with plague. During his attempt to prove that plague is not communicable 
the general went so'far as to assist in raising the "horrible" body of a 
soldier who had died from plague and whose tattered uniform was soaked 
with the pus of a draining bubo. There is a very famous picture by Grosz 
showing this visit. 
The distribution of exanthematic typhus shows particular features. 
The entire Mediterranean basin is encircled by foci of exanthem tic 
typhus. Not only does the classical form of the disease occur, but 
also several of its varieties. The progress of the dynamics of exan- 
thema tic typhus since World War I may be recognized from the following 
facts: No earlier than in 1915/16 exanthematic typhus spread as a 
solid focus from its endemic foci in the Caucasus westwards over the 
Anatolic highlands to the rifted Aegean coast, where it was firmly VII 
established. From Anatolia it was carried to Syria and the entire 
Near East by the operations of the German and Turkish Forces. The 
surrender of the British fortress of Kut-el-amara, according to 
British sources, was due to exanthematic typhus within the boun- 
daries of this town. At any rate the besieging army also had to 
bear the same burden of exanthematic typhus, which caused the death 
of the Commanding General, Field Marshal vor der GOLTZ* This ad- 
vance in a westward direction v.'as followed by a second one during 
the civil wnr in Spain (1936-1939). Now and then isolated cases 
of typhus had occurred in southwest and eastern Spain, imported 
from the African coast. The supplies brought in by the Communist 
forces from their base in Odessa imported new infections to Iberia 
which since then have been deeply rooted there, (cf. map Vll/lOa). 
It will be a huge task for the whole of Europe to make the Medi- 
terranean free from exanthematic typhus after the war. Here one 
will have to rely upon the investigations and the research work of 
the outstanding French scientists BURNET, NICOLLE, and the two 
SERGENTTs in Algiers and Tunisia, of the Spaniard PRIMJTIVO DE LA 
QUINTANA which are of equal importance for the etiological and the 
geomedical aspects of this disease. This concept found its reali- 
zation when immediately after the occupation of Abyssinia the Italians 
established an excellent typhus institute in Addis Abbeba. For the 
investigation of murine: exanthematic typhus the German hygienist 
Emil REITHMANN recently published a fundamental monograph based u- 
pon his considerable personal experience in Greece (Endemic Typhus 
throughout the Mediterranean, Leipzig, 1943). 
From its outset in India cholera has frequently used the isthmus 
between Asia and Africa as a springboard to Europe and bo the North 
African coast. It certainly left endemic residual foci in the Nile 
delta from which the disease was spread whenever intrinsic or ex- 
trinsic conditions were given, - Mention must however be made that 
an outbreak of cholera in Egypt does not mean the same in the ad- 
jacent territories or or the Mediterranean islands. The comparison of 
the unpublished maps of Walter HEINE for cholera in Africa in the 
period from 1773 to 1940 according to the data of Georg STICKER and 
Henry-Clermond LOMBARD, substantiates the statement of LOMBARD. HEINE 
sums up that ‘‘heretofore large territories remained safe even during 
the most violent epidemics. This applies to the east coast south of 
the Delagoa Bay, the Cape Colony, and to the western coast as far as 
the Rio Grande, and to the interior of the continent”. 
The close investigation of the almost innumerable small and large 
colonial campaigns of the big European powers in. Africa during the VII 
nineteenth and twentieth century reveals that no mention was unde of 
the cholera although all conditions for its outbreak were present. 
This applies to the two largest campaigns of the past half century, 
the Herero campaign in southwest Africa (1904 - 1906) and the Boer 
War of Great Britain (1899 - 1902). Contrary to that cholera had 
a considerable influence upon the operations during the Krym War 
(1854 - 1856) and the Second Balkan War (1912 - 1913) in south- 
eastern Europe. During the Krym War many thousands of British, 
French, Turkish, and Russian soldiers lost their lives through 
cholera. It occurred not only in the trenches and within the for- 
tress of Sevastopol and throughout the Krym, but also in the em- 
barkation ports of the British and French fleets in the Piraeus. 
The epidemics were restricted to this port, the region about Athens, 
the islands of Paros and Aegine without invading the other parts of 
Greece. During the two Balkan Wars (1912 and 1913) the peculiar 
"immunity" of Greece was also evident. Although the Bulgarian and 
the Greek army on the Kresna Pass suffered heavy losses from cholera 
no case occurred in Greece itself. The Bulgarian army suffered all 
the more, on the Tchotaldja front as much as its enemy, the Turkish 
Army. Cholera, however, decided against the Bulgarians, since they 
lost the struggle when a severercholera seized their 
brave army encircled by its too mighty enemies. It was really chol- 
era which forced Bulgaria back from one of the best parts of the 
country and from the Mediterranean for decades by the Peace Treaty 
of Bucharest (1913)* 
World War I offered no opportunity for this epidemic to take a 
decisive effect in the Mediterranean. Neither in Callipoli, nor in 
Asia Minor, Syria, or Palestine did it appear to a noteworthy extent. 
The outbreaks occurring in the western parts of Asia Minor (1916) and 
in the Near East (1917/18) were easily and rapidly localized and ex- 
tinguished by general sanitary measures and, most of all and in the 
safest way, by the very reliable cholera vaccination. The same ap- 
plied to the parts of the Serbian army assembled in Corfu (1916) 
whose entirely exhausted troops suffered heavy losses through chol- 
era and exant hematic typhus. 
As an introduction to this study I mentioned great princes, 
military leaders, and naval heroes who in their time had altered 
the shape of the world, that means the Mediterranean and its coun- 
tries, and had changed its political boundaries for many centuries* 
All these struggles centered around the civiiization of the Occident 
and "its" Levant. In the wake of the political and the simultaneous VII 
intellectual and religious controversies, medical science followed 
as an auxiliary and also as the valuable substance of philosophical 
and religious ideologies,, Medical scientists with a particular in- 
terest in geography and history, therefore, are not surprised to 
find the studies of Hippocrates born on the Aegean island of Keos 
containing considered ana sharply outlined observations of most 
varied aiseases, the nature and symptoms of which suggest an accu- 
rate geomedical knowledge of the islands of the Mediterranean known 
at that time. Hippocrates therefore may be called with due restric- 
tions the first classical geomedical scientist within the limits of 
his time whose works are revived to a new dynamic interpretation and 
evaluation when considered as a whole and in relation to modern ide- 
as. Only the centuries of medicine and natural science, such as the 
lyth and the 20th century, with their spiritual and material asso- 
ciation with technics, which is one of the most decisive powers in 
the struggle of man with his own kind, carries the medicine of such 
a time away with the exigencies of utility and imperceptibly makes 
it an active fighting force and not only an exclusively charitable 
and succoring component. Geomedicine as a part of war medicine be- 
comes a weapon without knowing it, the handling and use of which may 
be decisive for the outcome in a certain sense, but in any case is of 
importance for war. Tho above mentioned examples speak for them- 
selves. 
There is no doubt whatsoever as to how much the territorial ex- 
pansion of a nation promotes its scientific progress. The outstand- 
ing research work of Spain, France, Italy and Greece curing the mili- 
tary or cultural conquest of their African counter*-coasts is revealed 
by the example of France for Morocco, Algiers, Tunisia, and Egypt, of 
Italy for Tripolitania. of Greece for Egypt and the Eastern Mediter- 
ranean, and of Spain for its part of Morocco. In contrast to that the 
North American University in Beyrouth and all the other North American 
and British colleges and schools create the most disharmonious im- 
pression. They are not "appropriate” for the Mediterranean, as their 
spiritual foundations are contradictory to those reigning throughout 
this area. They disturb the bio-geographical harmony of the psychology 
of the Mediterranean nations which prefer to entrust themselves to the 
mentality of the Germans, the Italians, and the French, the Anglo- 
American point of view being strange to their thinking. 
This statement concerning geopsychology as defined by HELLPACH 
describes "geo-urgia" as a science concerned with the "formation of 
the earth on which we live in order to harmonize better with it, to 
make it our servant, or to adapt ourselves to it", and the attempt 
to achieve this end leads us directly to the geomedical discoveries VII 
in the Mediterranean and its coasts. If we examine a selection of them 
in regard to their value, that means as to their consistency for pre- 
sent and future times, a short and precise survey is sufficient to find 
out that every military, political or scientific enterprise has and will 
become possible only by the discoveries and the research work of hygien- 
ists. Thus, a large number of fundamental discoveries has been made 
throughout the Mediterranean which made possible the surrender of the 
earth to man. In the following a detailed survey of these studies is 
giv en: 
ITALY: 
Hieronymus FRACASTORO: 
Differential diagnosis of the various types 
of typhoid fever. Exanthemtic typhus clas- 
sified as a genuine disease (Verona 1546). 
Bernadino Rj^MAZZINI: 
Author of the first scientific publication 
concerned with the professional diseases 
of man (nDe morbis artificum diatribe.") 
(Modena 1700). 
Angelo DUBINI: 
Discovery of hook-worm (Milano 1838), 
Angelo CELLI and 
Ettore MARCHIAFAVA: 
Discovery of causative organism for 
Malaria tropica (Rome 1889). 
Giuseppe GUARNIERI: 
discovered Guarnieri1s bodies as a diag- 
nostic characteristic of small-pox (Pisa 
1892). 
Angelo CELLI: 
Experimental communication of malaria 
through mosquitoes (Rome 1898). 
Battista GRASSI: 
Discovery of the Anopheles as the exclusive 
vector of malaria (Rome 1898). 
Amico BIGNAMI, 
BASTIANELLI and 
Ba ttis ta GRASS!: 
Ontogenesis of plasmodia malariae within 
the anopheles (Rome 1898). 
• Discovery of Negri's bodies with rabies 
(pavia 1903) • 
Adelchi NEGRI: 
Cialio RAFFAELE: 
Discovery of extra-erythrocytic non-pig- 
merited forms of parasites (EE-forms) in the 
malaria of birds (Rome 1936). VII 
Alberto MISSIROLI: 
Sanitary measures in Sardinia and first 
use of modern chemotherapeutics. Onto- 
genesis of the sporozoites in the malaria 
of birds. Extracellular division of spo- 
rozoites within the lymph spaces. After 
that the sporozoites migrate into the 
endothelial cells (Rome and Sardinia 
1938 - 1942). 
Ihis is only a small selection of the important Italian investi- 
gations but the reference to the great medical tradition of the clas- 
sical medical faculties indicates the practical importance of the a- 
bove mentioned discoveries. The work of RAMAZZINI is mentioned al- 
though at first sight it seems inappropriate to refer to it. Its 
consequences however, demonstrated in other countries, particularly 
in Germany, that the classification of the tropical diseases in 
general and of exanthematic typhus and scurvy in particular as oc- 
cupational diseases liable for indemnity, should be considered as 
equal to service disability in the military sense. During the 19th 
and the 20th century the direct succession is continued from Camillo 
GOLGI, Bartolomeo GOSIO to Aldo CASTELLANI, the successful Chief Sur- 
geon of the Italian Army during the Abyssinian campaign of 1935 to 
1936, The prophylaxis ana treatment of exanthematic typhus in Italian 
East Africa was conducted in an outstanding manner by Giacomo MARIANI, 
Itala ARCHESI and Brenno BABUDIERI, 
Without the classical studies of malaria by Italian scientists 
the development of international malaria research and the rehabilita- 
tion of the marshes of the Campagna would not have been possible. Con- 
trary to that the extermination campaign against ankylostomiasis is an 
example of how a scientific discovery to a certain degree becomes an 
almost invisible political tie and the pioneer of imperialistic ex- 
pansion, The distribution of hookworm throughout the world and the 
exemplary extermination campaign conducted by the Rockefeller Foun- 
dation opened the way for the doliar-imperialism concealed behind 
charitable tendencies as was revealed in some places of the earth 
after the entry of the United States into the war. 
And now let us turn to the African coast opposite France, 
The French Expeditionary Force debarking on 14 June 1830 not far 
from Algiers found a fever scourged country which above all suffered 
from its "climate" ("dans un climat ou 1*element febrile est essen- 
tiellement dominant").(in a climate where febrile diseases are common). VII 
These febrile diseases, among which those accompanied by jaundice 
prevailed reminding one of the yellow fever of the Indies, 
struck the French medical officers as much as they did the British 
30 years ago. By the febrile diseases occurring there the freshly 
conquered country suffered considerable economic and military los- 
ses which were described by the French medical officer Adolphe • 
ARMAND 24 years after the occupation in the extensive work of 
medical topography m6dicale" (Faris 1854). Similar 
to the work of Franz PRUNER on the diseases of the Orient, prin- 
cipally of Egypt, this Frencn publication was a heretofore uncommon 
form of medical topography# ARMAND gives his geographical and 
climatological study under the heading of topography with the motto} 
"La topographie est a la medicine ce que la giographie est h l*his-- 
toire". (Topography means the same to medicine as geography to 
history)* Geomedicine truly cannot be described more briefly, AR- 
MAND recorded the experiences of a whole decade. Turning from that . 
first quarter of the century of French colonization in the Medi- 
terranean to the fundamental discovery of the French medical officer 
Alphonse IAVERAN in Constantine (1880) that malaria organisms are 
living parasites belonging to the protozoa] we remember ARMAND*s 
question in the introduction to his work: "Quelle est la cause des 
fievres d"accks? Residet-elle dans une viciation de l*air, dans un 
poison subtil appelS miasme? Non, assur&aent, ltair de l*Algerie 
n»est pas infectS, et la cause de la fibvre, lk comme ailleurs, ces- 
sera d*§tre hypothetiquement plac6e dans une pr£tendue intoxication 
miasmatique, quand on appreoiera mieux le mode d’action des influ- 
ences climateriques dont une bonne hygiene peut efficacement garantir# 
Cette question pr£alable, pour la resoudre en y ratwacnant ce qu!un 
climat presque semblable nous avait fourni de faits a ?!appui, aut 
faire le sujet d"un traite special sous le titre der. Etudes 6tio- 
logiques des fievres en Algeria et dans d"Italic centrale, avec cette 
epigraphe en indiquant le but: "Le miasme paludeen esc 1»X, l"in- 
connue a liminer du problems etiologique des fievres," ("What is 
the cause of the remittent fevers? Is it contained in a vitiation 
of the air, in a subtle poison called miasma? Certainly not, since 
the air of Algiers is not c >ntaminated and here, as elsewhere, the 
cause of the fever will net be attributed hypothetically to a pre- 
tended miasmatic intoxication as soon as one knows better the mode 
of the effect of the climatic influences which can be appropriately 
modified by effective sanitary measures. The solution of this im- 
portant question by the means available to us, in an almost similar 
climate was tne topic of a special study which appeared under the 
title: "Etiological studies of febrile diseases in Algiers and Cen- 
tral Italy" culminated in the following conclusion:"The paludinal 
miasma is the X, the unknown ligure which most be eliminated from 
the etiological problems of the febrile diseases1!). VII 
This remark of ARMAND was preceded by a similar statement of 
another French medical officer, Auguste HASPEL, urging considera- 
tion of all factors as a whole in his work on the "Maladies de 
ltAlgerie11 (Paris 1850 - 1852) published two years before and high- 
ly appreciated by GRIESSINGER# From CELSUS* words "differunt pro 
natura locorum genera medicinae" HASPEL concludes somewhere in his 
introduction: " Que de choses en effet , \ trouver, & expliquer? 
D’ailleurs la plupart aes observateurs n’ont tenu compte qu‘acci- 
dentellement de l»influence des saisons sur les modifications mor- 
bides et preque tous, pour ainsi dire, se sont absorbes dans lf§tude 
exclusive des fi&vres intermittentes, Nous eussions desire aussi 
que ces habiles medicins eussent franchi la M&diterranee avec un 
esprit plus libre, plus degag£ des id&es syetematiques qui regnent 
en medicine# Cette terre africaine desolSe par tant de maladies 
veut etre vue avec la plus complete independence d*imagination et 
de jugement, Les maladies ae ce pays avaient en outre besoin, comme 
je de le disais dans la Gazette medicale, dfetre etudiees dans 
leur march©, dans leur ensemble, d*un point de vue elev£, dans un 
certain orare qui en fasse sentir llimportance de la liaison," 
("What matters can be can explain this? Elsewhere the 
majority .of the observers took incidental notice of the influence 
of the seasons upon the modifications of disease and almost all 
of them were, so to speak, absorbed by exclusive studies of the 
intermittent fevers# we should have liked that these able phy- 
sicians had crossed the Mediterranean with a more liberal spirit 
and hact been more detached from the systematic ideas prevailing 
in medicine. This African territory, desolated by so many mala- 
dies, should be seen with the greatest independence cf imagina- 
tion and judgement# The maladies of this country furthermore must 
be studied during their progress, as I explained in the Gazette 
Me'aicale, as an entity, from a detached point ofview and in a 
certain order which makes us fedL the importance of their rela- 
tions"# 
The searching of AftMAND and H.JSPEL for the etiology of the 
Algerian fevers was concluded by IJWERAN’s discovery. 
In the following a short survey is given of the big problems 
discussed and studied in the pasteur Institutes of Algiers, Tunisia, 
and Tanger after LAVERAN. 
Alphonse LAVERANDiscovery of a protozoon causative for malaria 
(Constantine 1880)# VII 
Edmond and 
Etienne SERGENT: 
Fundamental investigations of the 
typhus organism and its experimental 
communication to man# Numerous in- 
vestigations of almost all infectious 
diseases occurring throughout the Medi- 
terranean basin (Algiers since 1900), 
Charles NIC0JXE: 
sucessfully injected blood contaminated 
with typhus to monkeys and guinea pigs 
(Tunisia 1909 and 1911). He further suc- 
ceeded in communicating exanthematic typhus 
through the body louse from one monkey to 
another (Tunisia 1909)# 
Etienne BURNET: 
particularly studied the course of the 
brucelloses throughout the Mediterranean 
(Tunisia since 1922). 
Here too, we see the assault on exanthema tic typhus foci through- 
out the Mediterranean basin. I do not exaggerate in saying that typhus 
was the incentive for NIC0LLEfs eminent study "Naissance, Vie et Mort 
des Maladies infeetieuses" (Paris 1930), which is derived from history 
as a spatial and temporal basis for all diseases in the same way as we 
have established it for the epidemiological maps (Seuchenatlas). 
"Lfexistence historique de la malaaie est sa vie a travers les &ges. 
On est en droit de lui supposer, comme a tout ce qui vit, une origins 
(naissance) et une fin (mort). C’est cette existence historique qui 
fait exactement lfobject du present livre. pour l*imaginer, l’ex- 
pliquer il nous sera utile de traiter tout drabord des existences in- 
dividuelle et collective des maladies, de la facon dont elles s'exercent 
ae leur debut et de leur fine” ("The historical existence of disease 
is its life throughout the ages. One is correct to assume for it as 
for every living matter, an origin (birth) and an end (death)# It is 
this historical existence which is the topic of this book# To imagine 
it and to explain it, it will be useful to treat first of all the in- 
dividual and collective properties of the disease in such a way as 
they appear from their origin to their end". These are the words of 
NICOLLS. 
Our reply is that geomedicine is the science to trace these prob- 
lems and to clarify them by its method of medical cartography. Geo- 
medicine will achieve true work all the easier as various countries is- 
sued useful and practicable laws for the control of the malaria, such VII 
as Italy, Greece, Roumania, and Bulgaria. The great clinician Wassil 
MOLLOV and the hygienist Toshko PETROFF of the University of Sofia are 
worthy of the particular gratitude of their country for their prudence 
and their tenacity when the anti-malaria law was prepared the favorable 
effect of which became evident immediately after the restitution of 
Macedonia (1941). Here, again, the consideration of all factors as a 
whole is particularly obvious which for every physician in the Medi- 
terranean countries is so to speak obligatory namely the accurate 
knowledge of the tropical diseases and of general hygiene. MOLLOV 
for instance simultaneously was the Bulgarian specialist for tropic- 
al hygiene ana he was not an "also-tropical hygienist". The Profes- 
sor for physiology in Sofia, Dimitri ORACHOYATZ, is a hygienist of 
high qualities as regards the effect of his medical, scientific and 
organizing virtues. There is no other word of PETTENKOFER’s on the 
purpose and the peculiarity of hygiene which is more appropriate than 
when he calls it the physiology of environment. The leadership of 
the Bulgarian hygienists which is well established even though the 
number of its representatives is small, is proved by the names of 
Stephan K0N3UL0FF, Peter KQSHUCHAROFF, Georgi SHAROFF, Mirtcho SII- 
VENSKY, and Lubimir ZVETKGV. These authors dispose of a most valu- 
able knowledge of the territorial diseases as it is required for the 
geopolitical situation of Bulgaria which has become an emphibious 
country since July 1941. 
Greece, which for many centuries was a part of the Osman Empire 
and successfully fought for its liberty only at the onset of the 19th 
century, had to rebuild its national organization from within in the 
decades to follow and it had to preserve it by new struggles. A basis 
of Greek science had to be formed first. It is true that the Greek 
physicians whose practice was preserved by Greek hospitals in almost all 
large towns or settlements of a Greek colony and religious community 
were much sought for in the Levant. Many Western Europeans who through 
their profession, their research work, or their love for traveling came 
to the Levant, owe their salvation from typhoid fever, exanthematic 
typhus, or malaria to the nursing in a Greek hospital. The formation 
of Greater Greece after the second Balkan War and after World %r I 
promoted the notable development of the national Greek science and a- 
bove all of Groek medicine and natural science. There has been a 
close connection with German medicine since the arrival of the first 
King of Greece, Otto from Bavaria, in Nauplia (1833)• After the Treaty 
of Versailles French more than British influences became effective in 
additionf as the foundation and the first management of the Hellenic 
Pasteur institute in Athens (1920) was entrusted to the very experi- 
enced tropical hygienist Albert CALMETTE, originating from the Medical 
Corps of the French Navy, His co-worker was a disciple of BLANCHARD VII 
and NlCOLLE, the actual director of the Pasteur Institute in Casa- 
blanca, George BLANC, who is one of the most successful research 
workers on exanthematic typhus throughout the Mediterranean* 
Hellenic medicine always preserved and followed the tradition 
of the great Hippocrates from Keos. During the greatest trial of 
the nation, when the Greeks were expelled from Asia Minor tC' their 
country of origin (1922), it showed a great sacrificing spirit, 
Greek science showed its best which it had learned from such hy- 
gienists as Jean CARDAMITIS, Constantin SAVAS, the Consulting Hy- 
gienist of the Greek Forces (l94l) Constantin MOUTOUSSIS, an<* the 
pharmacologist George JOACHIMOGLU. Malaria, black water feve*’, den- 
gue and pappataci fever, Kala-Azar, exanthematic typhus and dysen- 
tery of any etiology and epidemic meningitis are the fields studied 
by these men. Among these scientists we must also mention the emi- 
grated Greek Stephan KARTULIS whose research work on entameba histo- 
lytica in Alexandria (1885 - 1913) provided valuable information on 
which a part of our present knowledge of amebic dysentery is based. 
Even though the history of the discovery of entameba histolytica is 
so complicated that even scientific heroes such as CELLI and. GRASSI, 
KOCH and SCHAUDIN, MARCHOUX, COUNCILMAN and LAFLEUR, MUSGRAVE i*nd 
CLEGG could not find their bearings, as Clifford POBFELI proved, 
KARTULIS paved the way after KOCH had shown him the post-mortem 
evidence of destruction caused by the amebic dysentery. On this 
basis KARTULIS continued his research work. Later on KOCH together 
with George GAFFKY in his report on the Cholera Expedition stated 
that the intestinal amebae curing amebic dysentery were identical 
with those occurring in a tropical liver abscess (1887)* DOBBELL 
(1919), however, asserted that this was well known tr the British 
tropical physicians and he wrote: "that * tropical' hepatic abscess 
is definitely associated with * tropical* dysentery which had, how- 
ever, been recognized long before by the Anglo-Indian clinicians, 
whose observations thus found their true explanation," It hardly 
requires mention that also the Rockefeller Foundation undertook to 
control malaria which in Greece is usually rather severe. Gregory 
LIVADAS and John SPMNGOS made efforts to continue this work in 
cooperation with Germany. The foundation of the German-Greek In- 
stitute for Biology of the Kais er-Wilhelm-S*ciety in Athens (1943) 
demonstrates how much both the German and the Greek science are in- 
terested in the problems of biological research. 
British medicine has a peculiar position throughout the Medi- 
terranean basinv One v*culd expect that British tropical hygiene, ©n VII 
the basis of the strong political position of Britain* would 
have conquered and organized a field of research which from mili- 
tary reasons alone takes a secure position. This is not the case. 
The discovery of the bacterium melitense as the organism causing 
Malta fever (1887) hy David BRUCE, and the cultivation of this germ, 
which was accomplished only two decades later, from the milk of the 
Malta goat by the 11 Mediterranean Fever Commission'* (1904 - 1906) are 
the principal British discoveries. To name just a few of the mem- 
beis of this commission working under BRUCE, such as p, BASSET-SMITH, 
Fo CLAYTON. T. MCCULLOCH, J. EYRE, J. KENNEDY, P. H0RR0CKS, T.ZAMMTT, 
we will find among them the most famous names from British bacteriology 
and tropical hygiene, Otherwise there were just the meaical records 
from the British garrisons, ports, and naval units* One particular 
link in the malaria research shall be mentioned here. That is the 
suggestions provided by the discovery of Ronald ROSS for the work of 
the French and Italian scientists for the elucidation of the etiology 
of the malaria. These suggestions have their source in the synthetic 
reviews of Patrick MANSON* Details of that matter can be found in 
Fritz ECKSTEIN»s historical study on GRASSI and ROSS and in the clas- 
sical article of ROSS himself. By the way, his last scientific ex- 
pedition was devoted to malaria throughout the Mediterranean and par- 
ticularly in Spain, Cyprus, Egypt, and Greece. 
While the countries of the scientists whose discoveries were des- 
cribed here were countries bordering on the Mediterranean, that means 
that they always were "au home", and while they studied the diseases 
occurring there in order to be helpful to their own nations, there was 
no such reason for the German scientists. Germany did not touch the 
Mediterranean even with a small piece of land, nor did it have a man- 
date or a colony on the North African coast. There is only some tra- 
dition originating from the age of the Crusades and the Order of the 
Knights of Malta, and from an engagement of Prussian sailors on the 
coast of "Rif pirates" (1856) and in addition from numerous German 
soldiers who hau fought in foreign services as individuals or in while 
units and thus lost their lives in many cases. Mention is made only 
oocassionally of German physicians as medical officers of German re- 
giments, Not until the campaign of Bonaparte in Egypt was the east- 
ern Mediterranean opened to the influence t>f European medicine which 
then became rather considerable. Since that time it preserved its 
influence throughout the whole Near East and was widely distributed. 
A remarkable feature of this development is the fact that particular- 
ly in Egypt German physicians made fundamental studies the signifi- 
cance of which correctly recognized at that time and which in the 
course of many aecaaes retained their importance as decisive and even 
nowadays are valid facts, and on which other important discoveries VII 
were to be based. 
Franz PRUNER: 
author of the first scientific monograph 
on tropical hygiene and medicine in the 
German as well as in the international 
literature concerned with tropical dis- 
eases: "The Disease of the Orient as seen 
from the point of view of conparable 
Nosology" (Erlangen 1857). 
Theodor BILHARZ: 
Discovery of the Bilharzia Worm (Cairo 
1851). 
1/Vilhelm GRIESSINGER: 
Description of Bilious Remittent Fever in 
Egypt (Cairo 1852). 
Robert KOCH: 
Discovered the Cholera organism 
(Alexandria 1883). 
Artur LOOS: 
Discovery and experimental investigations 
of the invasion of the ankylostoma larvae 
into the human skin (Cairo 1897)* 
Felix GOTSCHLICH: 
Discovery of the El-Tor Cholera vibrio 
(El-Tcr 1905). 
Robert DOERR: 
communicates the Pappataci Fever, through 
the blood arid phlebotoma mosquitcss (Her- 
cegovina 1908). 
In the following we shall give a review of the German research 
work done in the Mediterranean. 
A solid basis was given by PRUNER’s work which in its disposition 
and views cn the disease of man, animals, and plants constitutes a 
genuine geomedicine of the Orient. The etiology of the syndromes given 
by PRUNER was demonstrated by outstanding and very accurate investi*- 
gations of GRIESS1NGER and his assistant BILHARZ soon afterwards. In 
spite of their general significance for the parasitic diseases of nan, 
the observations of the two scientists at that time had no other ef- 
fect than to cause curiosity because the German scientists showed little 
interest in diseases not occurring within the boundaries of their coun- 
try. At the utmost such diseases were imported by Germans returning to VII 
their country and usually were not diagnosed as of an infectious 
nature. Sudaeniy the situation changed, as Gorman 
trade extended beyond the boundaries of the Levant and took its 
place in the extra-European territories and increased in importance 
twelve years after the constitution of the new German Empire and one 
year before the acquisition of its «wn colonies in Africa. The trop- 
ical diseases were carried closer tJ the Occident. Bacterielogy, the 
classical representatives of which were PASTEUR and KOCH, gradually 
attracted more attention, since instinctively one became aware of its 
significance for diagnosis and recognition of the great plagues ji 
the world. Therefore the discovery of the cholera organism was to 
cause a tremendous sensation. Hygiene revealed a rapidly migrating 
Asiatic epidemic, which heretofore had been considered as dreadful, 
before it was able to invade the Mediterranean and it is likely that 
it prevented this plague from advancing further towards the Occident. 
In former times the discovery of organisms causing diseases was 
published first in tne secluded scientific archives and periodicals, 
gradually spreading from there into the more or less interested pub- 
lic, while nowadays wire and radio broadcast the outbreak of every 
epidemic from the most remote parts of the world* But it was cholera 
which very soon presented a great number of unexpected problems to 
the hygienists, when PETTENKOFER established his principal theses on 
cholera, the unknown problems of which have became a particular field 
of concern for geomedicine. The present-day generation of hygienists 
is hwpeful regarding the solution of these unsettled questions by 
geomeaical methods* An encouraging preliminary work has already been 
done. 
After the discovery of the El-Tor-vibrios by GOTSCHLICH, not to 
speak of many other types occurring in Soviet Russia and East Asia it 
became obvious how little had been done hitherto in systematically 
classifying the genuine cholera organisms and other organisms similar 
to cholera and related to them. 
An important intermediate research work in the field of parasitolo- 
gy concerned with the worms contaminating man was done with the clas- 
sical studies of BILHARZ ana LOOS in the period from 1851 to 1897* They 
completed the studies taken up by DUBINI and finished by BILHARZ, GRIES~ 
SINGER, and PRUNER. 
In addition mention must be made of pappataci fever occurring with 
man in the Mediterranean basin which in its etiology and spreading was 
recognized first by German scientists* The preliminary work of Airis 
PICK in Hercegovina (1386) concerned with the differential diagnosis of VII 
the various transitory fevers gave a solid basis on which Robert DOERR 
continued his decisive final experiments with blood containing viruses 
withdrawn from man and injected to man and with a mosquito which com- 
municated the disease from patients to healthy persons. In this way 
GRAHAM had demonstrated the virus causing dengue five years earlier in 
Syria by passing blooa through mosquitoes (1903). This disease is the 
same acute affection of the knee joint or the "acute rheumatism" which 
was correctly outlined by PRUNER in his accurate clinical study con- 
tained in his above mentioned work. It is all the more worthy of at- 
tention, as its vector Aedes aegypti simultaneously is the vector vf 
genuine yellow fever. One of the greatest and most violent outbreaks 
of dengue in Greece and particularly in Athens was reported by MOU- 
TOUSSIS (1928). All experiments concerned with the communication of 
febrile diseases are based upon the classical experiments with malaria 
as a model disease. 
There is a large number of funaamental discoveries which were ac- 
complished by German scientists in a remote part of the Eastern Medi- 
terranean basin and the effects of which reach into the present day. 
Egypt itself lies before us as a geopolitical and simultaneously geo- 
medical bridge linking Asia and Africa on which many lives are lest, 
if the warnings and suggestions of the hygienists are noo sufficiently 
considered. Because the enormous Nile River reigns over the country 
no general and no hygienist will be successful against it unless they 
make it their ally by accurate observations and definitions of its en- 
vironmental conditions by means of geomedica.i maps c The French in- 
fluence upon Egyptian medical science in spite c£ the short stay of 
the Erench Expeditionary Force in Egypt remained important enough to 
provide a dominating influence on the training of the Egyptian medic- 
al officers and civilian physicians (1823 - 1848) for a man like An- 
toine CLOT-Bey, who was much discussed and opposed because of his views 
on plague. In this sphere of influence and in the decline of the in- 
stitutions brought up to a high standard by CLOT but declining after 
his return to France, GRIESS1NGER and BlLHARZ were involved. The 
personal and material difficulties in the educational activities of 
both scientists must be traced back to this fact which would have 
been rendered ineffective by a man like PRUNER, who, however, at the 
time of GR1ESSINGER was living in Germany to restitute his health* 
After his return in the latter part “.f March 1852 he seems to have 
been in-contact with GRIESSINGER only very superficially as the time 
of the arrival of this scientist was in august 1850. The literature 
states about GRIESSINGER: "without being able to contact PRUNER"• 
The suggestions for GRIESSINGER, however, were unusually numerous 
and valuable. Ten years later he compiled the famous volume on the VII 
infectious diseases in the "Manual of Specific Pathology and Therapy" 
(Handbuch der spezieilen pathologie und Therapie) edited by Rudolf 
VIRCHOW (Erlangen 1857), As a preliminary publication he had pre- 
pared "Clinical and Anatomical Observations tx the Diseases in Egypt" 
in three volumes of the -“-rchive for physiological Medicine (Archiv 
fuer physiologische Heilkunde ) (1853-1855), 
CIOT returned to the Nile valley in I856 and he succeeded once 
mere in developing his foundations to a high standard but he was not 
able to remain there because of sickness, and he finally returned t# 
his country in 1858# PRUNER* under the supervision ef CLOT, was in 
charge of military ana civilian hospitals for several years. To- 
gether with CLOT he acted with the same authority and importance and 
in spite of his German education he was considerably influenced by 
the French, This is revealed by his work on the "Topographie medicale 
du Caire avec de plan de la ville et ses environs" ("Medical topo- 
graphy of Cairo with a plan of the city and its environments") edited 
by him in Munich in French "at his own expense", (1847) the total of 
which has to be considered as a model of any such scientific enter- 
prise* He explains the reason for this study and here too, he puts 
yellow fever and racial pathoifgy to the forei"Les maladies de tautes 
les parties du globe, sans meme en excepter la fievre jaune, s’offrent 
l’une apres 1*autre A l’oeil scrutateur; et l’idee que la boite de 
Panaore sfest videe dans cet ancien Emporium des richesses n’est ni 
neuve ni exageree. - Le but exclusif de ce petit travail est de pres- 
enter a nos confreres l’aper9u des maladies qui regnent comme perman- 
entes ou passageres dans la capitals de l’Egypte, en ayant egard a 
l’etiologie et aux modifications que les maladies offront dans les 
differentes races ..." ("The diseases of all parts of the earth 
including yellow fever are shown to us one after the other; and the 
idea that Pandora’s box was opened in this old emporium of riches 
is neither new nor exaggerated. The exclusive desire of this little 
work is t.- present to our colleagues the description of the maladies 
occurring permanently or transitorily in the Egyptian capital with 
regard to their etiology and to the modifications shown by them a- 
mong different races.") With this topography PRUNER had completed a 
small but noteworthy early study of his compatriot and friend Jacob 
Ritter van ROESER, personal physician of some minor German prince. 
The title of that study was "Some Diseases of the Orient, Observa- 
tions Gathered during a Journey to Greece, Turkey, Egypt, and Syria", 
(Augsburg 1837)• Here ROSSER, like PRUNER 15 years later, was most 
impressed by the significance of the Mediterranean basin for the dis- 
covery ana the history of diseases, principally of the infectious 
diseases and he (ROESSR) writes in his introduction: " I want to di- 
rect attention to the fact that these are the diseases of those c#un- VII 
tries in which physical sufferance was perceived first, considered 
and subjected for the weal of humanity to scientific research and 
that the old heroes of medical science described them and that 
similar to the human races living in this area they certainly still 
possess many of their former peculiarities c j that the works of the 
ancients cannot be fully understood and evaluated without their be- 
ing studied." 
Both POESER and FRUFER have antecedents who wrote critical 
summaries ni medical geography ana topography and in most cases 
stood isolated. One of these, Moritz RASPER, Professor of the 
University of Leipzig, was correct-/ in criticising the great ig- 
norance of the etiology and the epidemiology of diseases, partic- 
ularly of the infectious diseases, among German physicians. His 
work: "Nature and Treatment of the Tropic?.1 Diseases elucidated 
by Medical Topography of the Tropical Countries and Completed by 
the Special Diet to be Considered in the Tropical Countries for 
their Prevention " (2 vol., Leipzig 1638), certainly is the first 
German manual of tropical aiseases which, nowever, is not based 
tn personal experience but on the~knowledgs of the literature 
which is very critically evaluated. Topography is a solid basis 
for this author and he writes: "The earlier medical topography of 
those countries is a necessity not satisfied yet and known to every 
physician who has studied this topic with some thoroughness since 
FINKE*s medical geography is so full of errors that it is of no use 
for the practice of medicine,, as one easily discovers when glancing 
through it". The incentive for his studies was the occurrence of 
yellow fever in Barcelana (1821) and he extended his studies to East 
India and particularly to Egypt# It almoi t happened that we, his 
descendants, inherited a map "for the explanation of diseases" but 
"to avoid an increase in price" he had "fqr the present omitted it 
up n advice of the publisher". 
The geomedicine of the Mediterranean basin would not be complete 
without considering the highlands north aid south of it. Such high- 
lands according to HAUSKCFEE!s opinion hai e their proper geopolitical 
dynamics. The same applies to their geomt dical situation. This re- 
quires, however, special studies which would have to elaborate on the 
“boundaries of their geographic and political significance" according 
to HAUSHOFER with a view to areas ef disease and health. The hereto- 
fore commenced and available investigations of the geomeaicine of 
cholera in Switzerland (Use TEUBER) ana in the Alps of the , 
former Austro-Hungarian monarchy (Gertraud KREB3) are the first at- 
tempts in this direction, "Tha alpine pass-Countries” according to VII 
Albrecht HaUSHOFER (1928), as a model test, may be of great value 
f»r the geomedicine of the highlands. V'lhen considering Germany as 
the former battle-field of the Occident, that is of the world, the 
military politics, as conceived and outlined by Oscar von NIEDER- 
MAYER (1939 and 1943) will have to be taken into account. And fin- 
ally a worldwide study of geomedicine, not writteh and investigated 
as yet as a complex, will have to be available one day, particular- 
ly of the North American tropical sea with the Gulf of Mexico and the 
Caribbean, the sea between Australia and Asia, and the Japanese sea, 
the geopolitical power fields of which were discussed by Hermann LAU- 
TENSACH 15 years ago (1928). In addition the Mediterranean of the 
North, the Baltic must be mentioned, the geomedicine of which has 
been increased for the past 30 years in its importance for the mili- 
tary power of the Germanic nations living around it as it is the area 
where poliomyelitis occurs. 
One more word on the visible shrinking of the continents through 
the airplane. The problem is whether or not its technical dynamics 
produces a dynamics of the epidemics. The big powers are well aware 
•f this danger which they dreaded when they signed the"International 
Medical Agreement on Aviation" in 1933i it was joined by Germany in 
1935* It is directed principally against the great world epidemics, 
namely plague, cholera, yellow fever, exanthematic typhus, and small- 
pox. 
In this agreement the airways are checked with particular care, 
and one must bear in mind that its demands and observations are ce- 
pied from those of naval traffic and were changed accordingly. But 
how little aid one think of the land routes* Thus relatively little 
attention was paid, to the first crossing of the Sahara desert in 
motorcars by the French from Tuggurt t* Timbucteo (17 December 1922 
to 7 January 1923). At any rate this crossing was equivalent to a 
flight over the same distance. Politically as well as medically ac- 
cess was gained to a new area, or better still, two parts of Africa 
were linked together over a desert. 
finally I should like to outline that our adversaries always 
made successful attempts to acquire colonies through their physicians. 
Our own colonial history, too, is relatively rich in important phy- 
sicians acting as political coloniai. pioneers. It was the unrelent- 
ing conqueror of French Morocco, Field Marshal LYAUTEY, who confessed 
that the hygienists and hospital units commissioned by him frequent- 
ly advanced into unoccupied and empty territeries and "were 
more attractive than rifle-balls" ("jauaient un rfrle d!attraction VII 
autrement efficace que le coup de fusil”. 
H. ZEISS 
Institute of Hygiene of the University of 
Berlin and Institute of General and Mili- 
tary Hygiene of the Military Academy of 
Medical Officers. Berlin. VIl/ 1 
MEDITERRANEAN FEVER 
(melitensis-brucellosis) 
IN THE MEDITERRANEAN REGION, 
Translation prepared by: 
U. S* Fleet, U* S* Naval Forces, Germany 
Technical Section (Medical)« VIl/1 
The Mediteffanean fever (Malta fever), caused by bacterium 
militense (brucella melitensis), is primarily an epidemic of ani- 
particularly goats and sheep. Together with the infective 
abortions of cattle, caused by br. abortus Bang* and the infec- 
tious epidemic of pigs, caused by br. suis, it forms the circle of 
brucellosis. The agents are closely related to each other; they 
cannot always be definitely separated from each other in labora- 
tories, particularly since there are intermediate forms and secon- 
dary types with a certain geographical distribution. Brucellae 
may infect the various domestic animals (such as horses, dogs, 
cats, chicken), wild animals and laboratory animals5 epidemic 
distribution, however, is limited to the infection, principally 
of the named animals. According to the respective predominant 
breeds of animals, the epidemics distribution - area of abortus 
brucellosis is spread over north and central Europe, that of me- 
litensis-biucellosis over the Mediterranean basin. Suis brucel- 
losis bae occurred only in a few small groups in Europe so far, 
without having any constant foci. 
All three brucellae may pass over to man and produce in him 
the clinical picture known as ”undulant fever”. But a separate 
representation of melitensis-brucellosis is justified, since br. 
melitensis has a considerably greater pathogenity to man than br. 
abortus and the European br.suis, so that it causes not only in- 
dividual cases, but may also cause epidemic-like numbers of cases. 
On Malta, the clinical picture was determined first. In 1887, 
the a6ent was found there by BRUCE; in 1904/05, the way of transfer 
was explained. Without offering remarkable symptoms itself, the 
hornless Maltese goat formed the source of infection for man. With 
the Maltese goat, which is a favorite breeding-animal and conse- 
quently often exported, melitensis brucellosis has been widely 
spread. It can be assumed for certain, however, that the indigen- 
ous goat-races of other countries were primarily infected as well. 
As an epidemic of the goat, melitensis infection produces re- 
latively slight symptoms of disease though it may lead to abortions 
and loss of lambs, particularly on its first introduction into a 
stock. Owing to the insignificant economic damage, no careful 
examinations as regards the distribution of this epidemic of ani- 
mals are available. - Also the data on the melitensis cases of man 
are not exact in most countries as regards the absolute figures, 
since, above all, classes of the population are infected with 
whom a positive medical diagnosis is not always made.. The data 
are sufficient, however, to fix the limits of the epidemic area 
of melitensis-brucellosis in the Mediterranean region and to draw VIl/l 
up a medico-geographical map, even if the representation of in- 
tensity in the various districts mist be based on estimates to 
a large degree. 
If the cartographical representation is to be enlarged to a 
geomedical one, we may start from the following reflectioni 
Potential distribution area of Mediterranean fever is pri- 
marily the total region where goat-breeding is predominant* This 
region coincides to a large degree with that zone of the Mediter- 
ranean climatej which is arid in summer. Only a flora whose proper 
vegetation period falls in late winter but which is capable of 
persisting through the whole year, may grow during the hot, arid 
summers on the one hand, in the moist but mild winters on the other 
hand. In the agricultural landscape, we find no dense groves of 
olive-trees or evergreen oaks, and the moisture in the soil does 
not allow the cultivation of cereals and tropical fruit. In wide 
tracts, however, we only find the macchie, that community of plants 
consisting of evergreen shrubbery with small hard leaves, and hard- 
leave-pasture composed of single trees and a ground flora of shrubs 
and vegetation, which explains the predominance of the goat as milk 
supplying domestic animal. The keeping of goats makes the growth 
* of a compact higher vegetation impossible by their constant grazing 
and maintains and festers the formation of chalk, which excludes 
the breeding of cattle, in its turn. 
The mentioned region is characterized as the vegetative area 
of the hard leaf plants, It approximately coincides with that 
zone which has been climatologically named the zone of etesian winds by 
HETTNER, It forms the zone of transition between the tropical ana 
non-tropical climates. In summer, it is under the influence of 
tropical air-currents, there are trade-like winds ("etesiane") which 
carry hot and dry air. In winter, the region is included in non- 
tropical air movements, which involves predominant west-winds, as- 
sociated with frequent atmospheric disturbances. The gradations 
which consist from lower to higher latitudes, in the fact that in 
the former the rainfall is limited to a still shorter period than 
in the latter, which are also recognizable from the sea-coast 
toward the interior in a decrease of the total rainfall, and which 
finally 6xist in different altitudes, can be neglected for the 
present purpose. For this reason, the etesian--zone has been 
entered in the map as a regional unity. 
The representation shows that the etesian-zone and the prin- 
cipal distribution area of melitensis infection largely coincide. VII/1 
The endemic area of the epidemic is better marked by this climatic 
zone than by the 55° F (r 12,8°C) isotherm as its northern boundary, 
which was indicated by HUGHES in 1899 but is often mentioned even 
today, with addition of the endemic foci up to the 68°F (= 20°C) 
isotherm approximately, which runs along the North African c^ast. 
Even if the epidemic area in the Mediterranean basin is natural- 
ly limited by the etesian zone; the following must be considered: goat- 
breeding in Europe plays a part also outside this area. If melitensis 
infection is not endemic there after all, this can be explained by the 
fact that the way of breeding the goat - i.e. the factors starting from 
the fact that the goat is no longer the exclusively or predominantly 
milk-supplying domestic animal- has become decisive for the limits 
of the epidemic. It cannot be refused from the first, however, that 
still other geomedical laws inherent to the epidemic itself cause its 
limits within a certain region. Since the map shows, in addition, 
that there are centers of activity at the northern edge of the epi- 
demic area, it is necessary to enter into a further analysis of the 
dynamics of Mediterranean fever. 
Now as ever, the center of the epidemic is Malta (12-17 % of the 
goats infected, sick rate around 7>5 permille of the population annual- 
ly). In the endemic area of the adjoining coasts and islands, the epi- 
demic is in a certain condition of equilibrium, characterized by the 
fact that 5 - 15 $ of the goats on an average are infected. The human 
sick rate, with constant infection of the goats, depends on the possi- 
bilities of infection. It is, for instance, much lower in the eastern 
Mediterranean basin, where milk is partaken of chiefly in a boiled state 
(or as yoghurt), than in the western part. 
If the epidemic center were in a condition of complete stability, 
it could be implied that there was a maximum of infection in the cen- 
ter of the area, which constantly decreases in intensity towards the 
periphery. This conception corresponds to former representations of 
Malta fever and probably to the geomedical conditions of former de- 
cades as well. Today, such a decrease still exists towards the south 
and the east of the epidemic area. 
In Africa, the etesian zone is joined towards the south by the 
circle of arid steppes and deserts, which, with its scanty population 
and accordingly smaller number of domestic animals, causes a decrease 
of intensity of the epidemic, even if the goat is the most important 
domestic animal. In the east, Cyprus, Palestine, Syria, were formerly 
regarded as infected, while during partly careful recent examinations, 
only individual infections were detected. The same seems to be true VIl/1 
for ail Asia Minor as well. It is possible, that this zone is an 
area of retreat of brucellosis. In southeast Europe, only Greece 
is infected,apart from the Adriatic coast. Even if the data there 
are scarce, it may be said that the epidemic is slowing down even _ 
in Macedonia* Towards the north, a zone free from brucellosis fol- 
lows, since in the other Balkan countries even the abortus infection 
of cattle is insignificant. No activity of melitensis brucellosis 
can be recognized in this region. 
If the situation on the northwestern edge of the Mediterranean 
epidemic area is different, this is caused by the fact that the epi- 
demic has found a new form there by the transition to the sheep. Even 
in the center of the endemic area, the sheep is infected in addition 
to the goat. In the northern border-districts with predominant sheep- 
breeding, the sheep has not only become an independant carrier of the 
epidemic, but its melitensis brucellosis, which, by the way, is cha- 
racterized clinically by the frequent occurrence of abortions, is 
recently no longer limited to the epidemic area of melitensis brucel- 
losis of the goat. 
Thy conditions in southern France have been carefully examined. 
While, in 1900, only two departments had been infected, the figure 
rose to 17 in 1929* ho 97 departments in 1935 (Taylor, Lisbonne and 
Vidal) The main focus remained at the Rhone delta (the departments 
Bouche du Rhone, Gard and Herault); the whole Provence and Languedonc 
had to be regarded as infected. Furthermore, in 1929.» the department 
Meurthe et Moselle, in 1932, even Meuse had been reached through mi- 
grating flocks of sheep, with the advance up to beyond Vobdun* even 
the 49th degree of latitude has been passed, at the same time, the 
epidemic has turned eastward and arrived at the upper Rhine Lowland 
Flain, 
A similar development appears to have been started in northern 
Italy. Ihe seriously infected southern Italy (animal chiefly in- 
fected: goat), is followed by a less infected zone (Latium, Abruzzi, 
Marks, Umbria). In Tuscany, the intensity of the epidemic in- 
creases once more: now the sheep is the chiefly infected animal. 
Vvith migrating flocks of sheep, militensis brucellosis is taken over 
the Apormine into the po-plain. Since this focus of activity simul- 
taneously forms a zone, where abortus-brucellosis is frequent not 
only in cattle but seems to have a remarkable tendency to pass over 
to man, a secondary epidemic center forms there, whose dynamics can- 
not yet be forecast. Gn the Iberian peninsula, too, a condensed 
focus of sheep-brucellosis seems to form at the northern boundary of 
the etesian zone. VIl/1 
If thus brucellosis cculd get a new impetus by its transfer to the 
sheep, this means that it has separated from its old geomedical 
laws and that a certain prognosis can no longer be established 
for the zone of European continental climate which adjoins the ete- 
*one in.the north. One more possibility of development of 
melitensis brucellosis renders any prognosis for any length of 
time vague: In the experiment, br. melitensis is pathogenic al- 
so for cattle, causes abortions in them and is secreted with the 
milk, thus shows the same behavior as br. abortus Bang. Under 
natural conditions,too, it has been repeatedly proven that in 
mixed stocks, into which goat- or sheep burcellosis is penetrated, 
cattle have been infected and that this infection was transferred 
to man. Such occurrences have remained isolated in the Mediter- 
ranean area of the epidemic so far; the infection of cattle oc- 
curred only as a consequence of sheep brucellosis. But whenever 
melitensis infection with its greater pathogenicity to man would 
replace abortus infection in cattle, we should have to face an 
absolutely new, serious brucellosis situation in Central Europe. 
The brucellosis area in the Crimea and on the northeast coast 
of the Black Sea holds a special position. A few human cases have 
been reported even in former decades, and since the zone 
extends to this region it might be regarded as an extension of the 
Mediterranean epidemic area. According to Soviet Russian examina- 
tions, however, it must be-assumed that a melitensis brucellosis 
of the sheep is concerned, which has advanced from the interior of 
the country. Thus, a large independent epidemic zone extends from 
the south Ural through the Kirghiz steppes, the Caucasus, Georgia, 
Azerbeidshan to the Iranian Highland^,and the occurrence at the 
Black se& may be regarded as its western border zone. The epi- 
demic formula of this region, in which melitensis infection of cattle 
seems to be of importance as well,cannot yet be evaluated. 
H. HABS 
(Hygienic Institue of the Berlin University)* Vll/2 
MALARIA IN SPAIN AMD PORTUGAL. 
(with 2 Illustrations), 
Translation prepared by: •_ 
U. S. Fleet, U. S. Forces, Germany, 
Technical Section (Medical). vti/2 
I. Malaria in Spain. 
Malaria occurs in all of Spain, though the cases in high alti- 
tudes in the mountains are probably imported. The province of Ca- 
ceres stands out considerably as being particularly infected (see 
table 1). Tne provinces Badajoz, Cadiz, Murcia, Alicante, Jaen 
and Huelva follow; then, at a distance, Sevilla , Ciudad 
Rear, Cordoba, Salamanca, and Avila. 
Thus, the serious malaria areas of Spain largely form a con- 
tinuation of the Portuguese malaria area into the upper courses of 
the large rivers flowing into the Atlantic, which decreases to the 
same degree as the region is more remote from the coast and more 
elevated. 
On the eastern side of the peninsula, Murcia and Alicante are 
rather marked malaria districts. The whole mountainous north of Spain 
is not infected with malaria, the same is true for the cen- 
ter of the country, (e.g. Cuenca). In the province of Madrid and 
even more, of course, in Madrid City, malaria has only slight imr- 
portance. The pronounced difference in altitude probably accounts 
for the fact that the province of Granada stands apart as one of 
the healthiest areas of the Mediterranean coast. It is a remark- 
able fact that both the Ebro-delta and the Llobregat-delta are only 
occasionally more intensely infected with malaria. 
Ihe rule that areas less infected with malaria have predominant- 
ly non-malignant tertiana, is true for Spain as well; in addition, 
that spring, malaria until the middle of June causes almost always on- 
ly a slight second-day fever. Only then do the serious (tropica) 
cases begin and are temporarily predominant at some places in mid- 
summer and early fall. Considering the whole year, however, tropica 
infection attains only 20 - 25 % of the malaria cases, even in the 
most seriously infected districts. The broad valleys and the level 
regions with their more dense rural population are the foci of seri- 
ous malaria, as contrasted to the higher altitudes. 
The plain between Sierra de Credos and Sierra de Guadalupe (see 
map) is the largest malaria district. There, the anopheles find ex- 
tensive possibilities of development through the numerous artificial 
water-reservoirs for the irrigation-systern (alberca), particularly 
in the valley of La Vera (Tietar). In addition, the water-places, 
which are left behind by the banks of the rivers drving up in summer 
(remanso) and ditches with stagnant water (quebrada; form favorable VI1/2 
breeding-places for the anopheles. In the south of the Sierra de 
Guadalupe, the very slowly flowing Guadiana-river traverses the 
province Badajoz for a distance of almost 300 kms. After intense 
rains, it may flood an area of 400 km2 and thus leave behind in- 
numerable pools in the dry season. 
As in northern Italy, malaria in Spain on the whole seems to 
have a retrograde tendency (see tables 2 and 3)> and thus, tropica 
seems to decrease in its proportion to tertiana. 
In the province Valencia, the cultivation of rice did not cause 
any serious outbreak of malaria, on the other hand, there exists 
much malaria in the Ebro-delta near Tortosa in the rice-fields. 
Thou6h the provinces Barcelona, Gerona, Lerida, and Tarragona were, 
on the whole, but slightly infected with malaria in lyl5j there 
were infected districts, in which in one case, for instance, 46 % 
among a total of 26,000 inhabitants had been infected with malaria, 
though it was tertiana in most cases. Even afterwards, the malaria 
index has remained rather high there. These malaria foci limited to 
small areas allow favorable total averages for the provinces despite 
their rice-field malaria. Since there are no exact data in the of- 
ficial statistics of 1934* these districts have been indicated in the 
map as "endangered by malaria". The focus in the province Tarragona 
(Ebro-delta) shows, as a peculiarity, a high percentage of quartana 
forms (30 % of all cases). 
In the Llobregat-delta, too, the attempts at rice-cultivation 
have led to the outbreak of a circumscribed malaria in an otherwise 
healthy region. 
The variety of the regional picture renders difficult a carto- 
graphical representation of the distribution of malaria in Spain. 
Since a moderately exact statistic of the endemic cases is available 
only for those provinces which have joined the Malaria Control Serv- 
ice - at present, only an attempt can be made to represent on the map 
the varied malaria infection of the population in 16 provinces for 
one year of report (1933) by various marking of those districts in 
which advisory places (dispensories) of the Malaria Control Service 
have been established. VIl/2 
Table 1. 
Malaria Control Service in Spain 1). 
(Comision Central Antipaludica)♦ 
Results of the year 1933. 
Province 
Centers of treatment 
Number of 
Number of Calculated 
positive 
positive 
per 1000 
cases ob~ 
cases 
inhabitants 
served 
in the province 
1.Alicante 
San Fulgenico 
2271 
3435 
6,16 
Orihueia 
1164 
2.Avila 
Total: 
1294 
'5,75 
3«Badajoz 
Total: 
12367 
17,20 
City Control Service 
10249 
La Bazagona 
654 
Jarandilla 
392 
' 
Jaraiz 
1163 
Majadas 
276 
* 18232 
4.Caceres 
Mirabel 
951 
39,57 
Navalmoral 
1961 
Peraleda 
246 
plasencia 
784 
El Robledo 
508 
Trujillo 
733 
Valle del Jerte 
310 , 
Arcos de la Frontera 
2691 
5.Cadiz 
Jerez 
1372 ] 
5275 
10,63 
Villamartin 
1212 J 
Daimiel 
2) ) 
6.Ciudad 
Gualdalmes 
2) appr« 75© 
appr. 1,50 
Real 
Puertollano 
366 J 
7*C°rduba 
Fuenteovejuna 
La Carlota 
397 j 
218 i 
615 
0,90 
Galanas 
984 ) 
8.Huelva 
Gibraleon 
1074 
2793 
7.70 
El Repilado 
735 J 
Campo Redondo 
2561 1 
9. Jaen 
Guarroman 
470 
> 3418 
5.00 
Linares 
387 J 
Murcia y Huerta 
3468 
10.Murcia 
S.Pedro d.Pinatar 
785 
5436 
8.40 
San Javier 
1183 j 
XLoOrense 
Castrelo de Mino 
*) 
*> 
12.Sevilla 
Lebrija 
Lora del Rio 
1027 1 -j Ron 
800 ) 1827 
2.18 ~ 
13 •Valladolid 
Total: 
*) 
*) 
14 .Zamora 
Total: 
*) 
*) 
15.Salamanca 
Matilla de los Canos 
194 
0.56 
16.Toledo 
Talavera de la Reina 
494 
0.98 
Total number of 
positive cases observed 
55746 
7.35 
in 16 provinces 
in 1933: 
taken from: Anuario Estadistico de Espana ano XIX - 1934, 
Madrid 1935, page 814. 
2Vor both places, only data on the total number of the persons ex- 
amined have been submitted (498 and 633, respectively) • 
* N 
' s no data available# VIl/2 
Table 2, 
Mortality of Malaria in Spain, 
Year 
Total 
Per 100,000 
inhabitants 
1910 
4707 
according to 
1922 
1527 
7.1 
data of the 
1923 
1291 
5.9 
Hygiene Section 
1924 
1195 
5.5 
of the League of 
Nations. 
1931 
1932 
364 
308 
1.54 
1.30 
According to 
data of the 
1933 
289 
1.27 
official sta- 
tistical annual 
registers. 
Note: Comision central antipaludica since 1920, 
Prof, G. PITTALUGA estimated the number 
of malaria-cases in Spain in the early 
twenties to be 300,000 cases annually. 
Table 3* 
Mortality of Malaria 1931 ~ 1938. 
in Italy: 
in Spain: 
in Portugal: 
1931 
364 
149 
1932 
3171 
308 
137 
1933 
1956 
289 
148 
1934 
2238 
286 
196 
1935 
1693 
220 
214 
1936 
1291 
168 
236 
1937 
1032 
217 
280 
1938 
738 
289 
217 
The absolute figures of positive malaria findings observed in 
these districts, which are listed in table 1, have been added up for 
the whole respective province and then reduced to 1000 inhabitants 
of the respective province, even if the control area does not extend VIl/2 
to the whole province. But since the rate of the reported endemic 
malaria cases in the provinces outside the control districts is 
probably not considerable, the figures observed are sufficient for 
a scale of comparison of the provinces and for a basis for the draw- 
ing up of a synoptical map. The various hatchings on the map thus 
indicate only approximately the actual conditions in the respective 
infected districts. To increase the clearness of the single malaria 
areas, the respective mountainous regions have been excepted from the 
more marked hatching because of the slighter density of population and 
of anopheles which is to be expected there. In contrast to Portugal, 
no values of the spleen index and the parasite index could be given 
for Spain. 
II. Malaria in Portugal. 
in the Portuguese section, as on the whole Iberian peninsula, 
the varieties of A. maculipennis (l) are the principal vectors of 
malaria. A* bifurcatus (3) is distributed over the whole country, 
though usually rare and widely spread. In addition, no other spe- 
cies of anopheles have been mentioned previously, though A. algeri- 
ensis (7) and A# plumbeus (4) should be expected as well. 
With A. maculipennis, only the variety atroparvus is mentioned 
in addition to the typical form. The pictures of the eggs of the lat- 
ter are not quite convincing, A. maculipennis atroparvus lives in 
the proper malaria areas. Where the variety typicus is more frequent, 
malaria occurs more rarely. But even in the distribution area of atro- 
parvus, malaria is serious only where the gnat occurs in great multi*- 
tudes. This is the case particularly in the rice-districts. 
In 1935, around 50,000 acres had been cultivated with rice. This 
form of cultivation, however, extended further. Outside the rice cul- 
tivation area, there is a considerable malaria zone on the river Dcuro 
and its affluents. There, the majority of the rivers dry up in sum- 
mer and dissolve in large water-pools, which produce masses of A. mac. 
atroparvus. The Guadiana river, too, almost completely ceases to flow 
in summer and is accompanied by malaria areas at some places. In ad- 
dition, there is a moderate amount of malaria in the south and east, 
where lazy watercourses produce plenty of atroparvus. 
Thus, the highest sick-rates of malaria occur in the rice-districts 
on the Sado (district Setubal, parts of Beja and Evora) on the Tejo (dis- VXl/2 
Explanation of Signs: 
national boundary 
bound.of the his to 
regions in Spain 
and Portugal 
bound.o.t.prov.ieSp. 
" o.t.dislr.i.Port* 
Illustration 1* 
Mortality of Malaria in 1924 per 100,000 inhabitants, 
(According to data of the Hygiene section of the League 
of Nations) 
more than 40 more than 20 more than 10 more than 5 
mere than 2,5 VIl/2 
trict Santarem), on the Guadiana (district Evora), on the Mondego (dis- 
trict Coimbra) and on the Douro (district graganca) (see table 4 and £). 
Table 4. 
Malaria in Portugal, 
Province 
Number of new 
calculated 
spleen in- 
parasite- 
cases of ma- 
per 1000 
dex 
index 
laria in civ# 
inhabitants 
1933 2> 
1933 2' 
and mil.hosp. 
in 1934 1) 
Aveiro 
10 
• 
13.0 
o,67 
Beja 
287 
1.20 
35.7 
14.3 
Braga 
5 
• 
0 
0 
Braganca 
25 
0.10 
30.0 
15.0 
Castelo Branco 
77 
0,20 
10.1 
2.9 
Goimbra 
456 
1.10 
54.5 
$.3 
Evora 
130 
0.70 
65.2 
5.2 
Faro 
39 
0.10 
39.1 
1.8 
Guarda 
14 
» 
23.5 
5.9 
Leiria 
32 
0.10 
0 
0 
Lisboa 
306 
0.33 
18.1 
6.0 
Portaiegre 
170 
1.06 
55.0 
15 c0 
Porto 
15 
» 
0 
0 
Santarem 
292 
0.80 
41.6 
20.8 
Setubal 
654 
2.80 
95.4 
34.0 
Viana do Castelo 
4 
% 
1.2 
1.2 
Villa Real 
17 
• 
10.8 
4.0 
Viseu 
15 
• 
2,0 
0 
Portugal total: 
2548 
0.40 
Notes: From: Anuario Estatistico de Portugal, Ano de 1934* Lissabon 
1935* page 87. 
2) 
From: F. Landeiro and F. Cambournac: 0 Sezonismo em Portugal, 
Lissabon (Table VII). 
• a no data available VIl/2 
Table 5. 
Malaria Control in Portugal.'*'^ 
Control centers 
Province 
number of 
consulta- 
tions in 
1934 
number of po- 
sitive findings 
in 1940 
Aguas de Moura 
Setubal 
• 
512 
(Palmela) 
Idanha a Nova 
Castelo 
Branco 
• 
1491 
Montemor o Velho 
Coimbra 
• 
11190 
Soure 
Coimbra 
7891 
8972 
Azambuja 
Lissabon 
• 
2302 
ponto de Sor 
Portalegre 
• 
1907 
Benavente 
Santarem 
4877 
13056 
Alcacer do Sal 
Setubal 
10443 
8541 
Pocinho (Tras os 
Braganca 
374 
1771 
Montes ) 
Total: 
23585 
36090 
1) 
Notes: From: Anuario Estatistico de Portugal* Ano de 1934* Lissabon 
1935* Page B9* Monthly Synopsis of Consultations in 1934* 
• = no data available. 
in Portugal, there are all forms of malaria, even tropica (often 
in the majority, which suggests a hyperendemic situation for tertiana 
(see table 6))* The seasonal distribution is the usual one (see 111. 
2), with spnng-tertiana and tropica occurring first in June, later 
predominant, in the most serious malaria area on the Sado, spleen in- 
dices up to 95 % have been observed, (Alcacer do Sal) but at other 
places, too, spleen indices of 34 % and parasite indices of 42 % have 
been found. In Agnas de Monra (Pamela), the children not yet one year 
old were infected without exception in 1936 up to the end of September, 
viz. almost nobody there escaped malaria infection in that year. Ma- 
laria infection up to around SO % of the population has been observed 
for instance in Landeira. vii/2 
Illustration 2. Monthly total of new cases of treatment 
in Portugal in 1934. 
From: Anuario Estatistico de Portugal 
1934 (Lissabon 1935) page 89. 
Table 6. 
Proportion of the various Malaria-forms in Fortugal in 1934- 
Number of patients in 1934 
thereof: 
Total:■ 7966 
tertiana: 3885 s 48*1 % 
tropica: 2559 = 32,1 % 
quartana: 541 — 6,8 % 
mixed forms:359 s 4,5 % 
indefinite: 672 a 8,5 % 
Through the wandering toward the interior of the agricultural 
seasonal workers (ranchos), malaria is continuously distributed in 
the country despite all control measures* In 1940, the various sta- 
tions of the Control Service (see map) registered more than 36,000 
new cases and issued around 80 kg quinine preparations* The most 
important means of control against malaria is an adaptation of rice- 
cultivation: no sowing but planting and to let the field dry about 
5 days after every 10 days of irrigation. This will not decrease 
the crop* It is better to increase the crop by more careful culti- 
vation than by further extension of the rice-fields* If necessary, 
the cultivation of rice must be terminated completely in the direct 
neighborhood of important places. To control the anopheles, the 
usual methods should be used, though petroleum and Schweinfurt green 
should not be used in rice-fields. VIl/2 
The cartographic representation of malaria occurrence in Por- 
tugal is first intended to indicate the districts with intense in- 
fection, furthermore, in adaptation to the representation of the 
malaria conditions in Spain, to afford a synopsis of the varied 
hazards in the single districts of the country in the same year 
(1933)* The basis of this chart has been the registrations of the 
General Directory for Public Health and of the Rockefeller Foun- 
dation (R, HILL, F. LANDEIR9., F. CAMBOURNAC) for the year 1933 on 
the distribution of spleen index and parasite index in Portugal, 
In addition to that, the data of the figures of patients treated 
at the dispensaries in 1934 and 1940 according to the statistical 
annual registers have been consulted and evaluated by calculating 
them for the number of inhabitants of the respective district in 
the same way as the Spanish data. Thus, the degree of the probable 
malaria hazard of single regions can be easily determined on the 
map. A more exact representation must be reserved for a future 
work on the basis of larger material of examination. 
III* Distribution of Anopheles on the Iberian Feninsula. 
On the Iberian peninsula, there are, apart from very high al- 
titudes, practically no districts without any anopheles# 
A. maculipennis(l): The sign for the everywhere present A# 
maculipennis on the map is not limited to certain places but is 
entered for whole regions, though it would have been more correct 
to indicate those places at which it is not found. This irust be 
reserved for a future, more detailed work. On the other hand, the 
signs for the four "strains" of a, mac. refer to certain places, 
for which the differential diagnosis of the strains of A. mac, has 
been made on the eggs. 
On the Iberian peninsula, A. mac. is the principal vector of 
malaria. As a gnat of the warm sunny waters, which exist above all 
in the valleys and lowlands with agriculture, and as the chief vec- 
tor of malaria, A. maculipennis is observed without fail within the 
areas of the malaria control stations. As it is particularly close- 
ly associated with man and animals, it is easily observed everywhere 
and tinus has been reported from almost all regions and thoroughly ex- 
amined. On the other hand, much too little attention has been paid 
previously to the other species of anopheles. VXl/2 
A. bifurcatus (3), for instance, has been mentioned from quite 
different parts of the peninsula with quite different climates; in 
Spain, chiefly at places of which particularly exact examinations 
of the occurrence of anopheles are available (e.g. Navalmoral, pro- 
vince Granada), The conclusion is justified that A. bifurcatus is 
absent in hardly any province. 
The accidental findings of A. plumbeus (4) and a* algeriensis 
(7) permit no conclusion as regards the actual distribution of these 
species on uhe peninsula, though they probably are of no practical 
importance anywhere, 
A. hyrcanus (12) has been observed only in the east of the pen- 
insula, chiefly in the rice-districts, though it is probably more 
widely spread than the previous locations indicate, 
A* hispaniola (9) and A, superpictus (2) are limited to the 
southern section of the peninsula. They chiefly occur at the foot 
of the mountains and in the mountains. Onxy in the neighborhood of 
Navalmoral, where particularly industrious examinations have been 
made, A* hispaniola has been found even in the center of the coun- 
try. Tne boundaries of both qpecies are probably more northward 
than the previous data indicate, though it is not certain whether 
they are of considerable importance for the distribution of ma- 
laria in Spain. 
Of the "strains" °T A, maculipennis (l), atroparvus is most 
widely spread and is predominant in Fortugal almost exclusively. 
There, only the nominate form A. ma. maculipennis occurs in ad-' 
dition to atroparvus. The few places where it has been observed 
suggest that it is still widely distributed in the highlands and 
mountains of the north and in the west of the peninsula. 
On the other hand, A. mac. melanoon and A. mac. labranchiae are 
limited to the east and represent the predominant forms there. 
In the rice-districts of Portugal, A. mac. atroparvus occurs, 
sometimes in great multitudes. On the Mediterranean coast, it in- 
habits the new rice - areas in the north, in the deltas of the Ebro 
and of the Llobregat, while it is replaced by A. mac. melanoon in 
the old rice areas. In the southern adjoining area, A. mac. la- 
branchiae inhabits the richly irrigated gardens, particularly of 
Murcia. 
Of the strains of a, mac., chiefly the two forms of the la- 
branchiae-group, labranchiae and atroparvus, are associated with VIl/2 
serious malaria. It cannot yet be determined today, whether this 
is accidental or whether their way of living makes them more dan- 
gerous vectors than A* mac. typicus or melanoon. GIL COLLADO points 
out that in the province of Caceres the numbers of atroparvus are by 
no means particularly large and the breeding-places by no means ex- 
tensive. It is possible that the previous history of the gnats plays 
some role, perhaps even more the conditions of temperature. 
Thus, the anopheles fauna of the west of the country approaches 
that of western France and Germany, the fauna of the east that of 
Italy. 
E. MARTINI and H. J. JUSATZ 
(Institute for Tropical Medicine and Hygiene 
and Institute for General and Military Hy- 
giene of the Military Medical Academy) • VIl/3 
OCCURRENCE OF MALARIA AND DISTRIBUTION OF ANOPHELES IN ITALY. 
( with 1 text-map). 
Translation prepared by: 
U. S. Fleet, U, s* Naval Forces, Germany, 
Technical Section (Medical). VIl/3 
I, Occurrence of Malaria in Italy* 
Map VIl/3 indicates on a large scale the extent and situation 
of malaria foci with regard to the intensity of malaria occurrence 
in 1940* The altitudes, particularly the Apennine, with their 
scarcity of malaria form an effective contrast to these foci. Par- 
ticularly in the north the altitudes are practically free from ma- 
laria. On the Italian continent and on Sicily, one assumes the 
vertical boundary of malaria to be at around 400 m. On Sardinia, 
some altitudes higher than 800 m. are still considerably infected 
with malaria. Since the majority of the population who are ma- 
laria-free is crowded in the cities, malaria in the lowland in- 
fects a much greater proportion of the country than of the people. 
The intensity and danger of malaria varies a great deal in 
the single foci. Due to the wanderings of the population, no 
district is absolutely free from malaria, though the hazard of 
infection is slight in the district declared not infected with 
malaria. In some sections still marked as endangered with ma- 
laria, on the map - particularly Lombardy - the hazard of malaria 
has practically disappeared recently. For outward reasons, how- 
ever, these districts have not yet been separated from the malaria 
areas. There malaria may recover much of its former importance, if 
the present situation is basically altered by serious changes of the 
composition of the population, such as wars of occupation by foreign 
troops. 
The average malaria moroiaity of she districts p -;r 10-000 in- 
habitants appears relatively low not only by the mixture of propor- 
t:Ur.c quit©, differently infected with malaria,but also by the factthatin 
a country used to its fevers* there are many case*; oaf-treated and 
thus not known to the surgeon nor statistically registered, par- 
ticularly the cases of slight tertiana and the recurrehces of tropica. 
In addition, in the districts seriously infected with malaria, there 
is such a quantity of acouired immunity among the adult population 
that numerous persons nc longer fall ill by the infection but are, 
at the most, carriers of parasites and thus dangerous to their en- 
vironments, They are not even known to the surgeon as infected. In 
central and southern Italy* the relatively moderate morbidity rates 
thus by no means adequately indicate the degree of hazard to non- 
iramune strangers. Nor his malaria, i.e. the danger of infection de- 
creased so much in the course of this century as the decrease of ma- 
laria morbidity seems to show. 
Lethality (- number of cases with fatal termination per 100 
malaria cases) has rather decreased to a fifth of that of the be- vil/3 
Table 1. 
Reports of Malaria. 
Year 
cases 
fatal cases 
lethality 
in % 
1902 
177945 
9908 
5,6 
1906 
230798 
4671 
2.1 
1910 
201247 
3621 
1.8 
1914 
129428 
2045 
1.6 
1922 
234656 
4085 
1.7 
1926 
220602 
2683 
1.2 
1930 
203590 
2781 
1.4 
1934 
222171 
2238 
1.0 
1933 
74276 
736 
1.0 
ginning of the century aue to improved medical work and increased 
administering of quinine. 
The figure of malaria cases per 10 000 of the population for 1940 
and for the 94 districts of Italy is indicated on the text-map (see 
111. 1). 
The figures show the average morbidity as a medium value of in 
part quite different malaria conditions of the single sections oft 
the whole district, which may contain communities free from malaria 
as well as those infected. In table 2, the figure of the communities 
declared as infected with malaria is indicated for every district. 
Of course, the malaria rates of the communities would show a consider- 
ably more exact picture of the distribution of malaria in the country 
and bridge over, at the same time, tha abrupt contrasts at some dis- 
trict boundaries. But even within one community, part may be hardly, 
the other seriously infected with malaria. This applies, above all> 
to the extensive precincts of the cities, in the interior of which, 
malaria, as rural epidemic, can rarely settle, while the outskirts may 
show various conditions and contain several malaria foci beside each 
other. Around 37 % of the inhabitants of Italy live in towns with 
more than 20 000 inhabitants. Above all, Rome itself is absolutely 
free from the danger of infection in the interior. Thus, more than 1 
million men enjoy this protected situation. Thus, the average in- 
fection within the district of Rome is kept far below the statistical 
extent which would correspond to the rural proportion of the outskirts 
and their surroundings. These would hardly show the contrast to the VIl/3 
northern and southern adjoining districts as indicated on the map. 
The fact that the malaria foci, i. e. the places of endemic 
malaria, occupy only part of some communities endangered by ma- 
laria explains that in such communities, there lived, in the twen- 
ties* around 41 % of the inhabitants of Italy, in the malaria foci 
themselves, however, only 12 % of the inhabitants. It is true, how- 
ever) that imported malaria may occur everywhere in Italy, partic- 
ularly at the hospitals of the large cities,, 
AH these figures, however, show only a very conservative pic- 
ture of the extent of the actual infection. A satisfactory result 
cculd be obtained only on the basis of systematic observation of 
spleen- and parasite index of the children. Such examinations, 
however, have been previously unde in Italy only to such a slight 
extent that their cartographic representation is not yet possible. 
Table 2. 
Numbers of communities declared infected with malaria in 
the single districts. Condition in the fall of 1943* 
Piemonte: 
Aosta 0 
Novara 0 
Vercelli 0 
Alessandria 0 
Torino 0 
Asti 0 
Suneo 0 
Lombardia; 
Milano 97 
Pavia 65 
Como 0 
Varese 0 
Cremona 29 
Brescia 0 
Sondrio Q 
ergamo 1 
Venezia Tridentina: 
Trento 0 
Bolzano 0 
Venezia: 
Venezia 25 
Belluno 0 
Verona 30 
Vicenza 0 
Udine 25 
Padova 12 
Rovigo 16 
Mantova 3 
Treviso 1 
Venezia Giulia: 
Trieste 7 
Gorizia 0 
P ola 18 
Flume 0 
Emilia: 
Piacenza 0 
Parma 0 
Regio Emilia 0 VI1/3 
Table 2 (contd.) 
Emilia: 
Modena 0 
Forli 0 
Ferrara 17 
Ravenna 3 
Bologna 0 
Liguria: 
Genova 0 
Imperia 0 
Savona 0 
Spezia 0 
Apuania: 
Massa Carrara 0 
Toscana: 
Firenze 0 
Lucca 0 
Pistoia 0 
Arezzo . 0 
Siena 0 
Livorno 3 
Grosseto 16 
Marche: 
Pesaro 0 
Ancona 0 
Macerata 0 
Ascoli Ficeno 0 
Umbria: 
Perugia 0 
Terni 0 
Rie ti 0 
Abruzzi: 
Aquila 0 
Chieti 32 
Pescara 6 
Teramo 0 
Lazio; 
Viterbo 16 
Roma 44 
Frosinone 22 
Littoria 19 
Campania: 
Campobasso 84 
Napoli 30 
Avellino 60 
Benevento 54 
Salerno 60 
puglie: 
Foggia 52 
Bari 17 
Brindisi 19 
Taranto 26 
Lecce 79 
Matera 30 
Lucania: 
Potenza 69 
Cosenza 65 
Calabria: 
Catanzaro 90 
Reggio Calabria 65 
Sicilia: 
Palermo 73 
Messina 35 
Enn.a *} 
Catania 30 
Agrigento 40 
Trapani 17 
Siracusa 15 
Ragusa 12 
Caltanissetta *) 
Sardinia: 
Sassari 70 
Nuoro 88 
Cagliari 117 
Zara: 
Zara 9 
*) no aata available. VXl/3 
districts with eoracunit ieo * I 
Infected with malaria 
cistricts with less th-n l,o 
districts with X to 5 
districts with 5 to 10 
aiatricts with 10 to 25 
districts with 25 to 50 
districts with 50 to 100 
aistricts with more than 100 
cases of malaria per 
10O00 inhabitants. 
Illustr* 1* The districts of Italy declared infected with malaria in 1940* 
(With indication of the number of communities declared infec- 
ted with malaria within a district infected with malaria). VIl/3 
Unfortunately, there are no differential reports of the kinds 
of malaria for large synopsis of Italy available so far. Plasmodium 
ovale has not been found in Italy. Plasmodium malariae is nowhere 
found frequently in Italy. It is completely absent in the sections 
of northern Italy with only slight fever and near Maccarese (dis- 
trict Rome). As regards tropica/*the rule is true also for Italy 
that the proportion of tropica increases with the intensity of ma- 
laria infection. Thus, Piedmont, Liguria, Friaul, Lombardy, and 
Emilia are practically free from tropica and show the spring peak 
or the double peak of the epidemic curve due to tertiana. With the 
decrease of malaria on the- whole also tropica, has almost coi>- 
pletely disappeared from Maccarese. 
Also in Italy, the period of malaria infection lies in sum- 
mer in the north, it begins somewhat later than in the south and 
is shorter, particularly with tropica. Generally, malaria in Italy 
culminated in August and September, especially in the south. Even 
there, the maximal proportion of tertiana occurs in May and June, 
since the spring-fevers are tertiana almost exclusively. The sumr- 
mer peak is the peak of relative frequency of tropica as well. 
As of July, tropica rapidly increases in southern Italy, while it 
occurs epidemically in northern Italy only in August and September. 
A certain decrease of malaria morbidity is aue not only to im- 
proved medical activity and better supply of remedies to the popula- 
tion, but probably also must be regarded as a partial phenomenon of 
the great decrease of malaria in Central Europe since the middle of 
the past century. In the coastal plains, the decrease of morbidity 
is chiefly caused by the systematic sanitation of the soil within 
the plan of agricultural ameliorations (e.g. Maremma of Tuscany, 
Maccarese and Tiber-delta, pontinian Swamps, Venetian Coast and 
po-delta). Not only the creation of draining-systems were important, 
but also the freshening of the soil and waters by skilful irrigation 
replaced the dangerous salt-liking anopheles by less dangerous fresh- 
water species. 
Distribution of Anopheles in Italy, 
The following species of anopheles have been observed in Italy: VII/3 
!• A* maculipennis in the varieties: 
A - A* mac 4 maculipennis (typicus) 
B — A* mac. atroparvus 
C - A. mac. melanoon 
D - A. mac. labranchiae 
E-- A. mac. messeae 
2. A»superpictus 
3. A*bifurcatus 
4. A*nigripes (plu&beus) 
5* A»hyrcanus varpseu- 
dopictus 
60 A^elutus 
7. Aoalgeriensis 
8. A.italicus 
17 • A.marteri 
The signs for the various species of anopheles (figures) and for 
the maculipennis "strains” (capital letters) have been entered on the 
map according to the places where they have been found. The represen- 
ted locations have been selected in a way that the respective places 
are characteristic for a whole region and the respective names could be 
accordingly entered on the respective region. Marks without simultaneous 
entry of a location refer to larger geographical areas in which no 
characteristic locality could be determined. 
Of these, a. maculipennis (l) and A. bifurcatus (3) are certain- 
ly distributed at appropriate places all over Italy, the islands in- 
cluded. Of course, some high altitudes are free from them. If A. bi- 
fur catus (3) is not so frequently observed, though reported at widely 
separated places this 3e caused by the fact that it is not so conspicuous 
to the observation of the malariologist, for it avoids the houses and 
is seldom observed in stablest The larvae are found in particular, 
cool waters. 
A. pseudopictus (3) lives under similar conditions. In Sicily 
and Sardinia, it has not yet been observed, in southern Italy, only 
at one place. It is marked as frequent only in the province of Bo- 
logna, A* algeriensis (7), too, has been found almost everywhere in 
Italy, even if only dispersed and isolated. 
The principal distribution of A, superpictus (2) is the southern 
part of the Ap ermine peninsula ana begins only about 60 kms. south of 
Rome, It has not been observed on Sardinia and Corsica, but has been 
occasionally found in the northern provinces. It formed 4 % of the 
anopheles of Novarra (FRONGIA 1931)• VIl/3 
A. nigripes (4) has been previously observed at some places in 
Central Italy and on Corsica. It is probably widely distributed in 
Italy as well, for it occurs even in more northern latitudes, e. g. 
on the Baltic Sea, but it occurs in Italy, as everywhere else, only 
in small numbers and then limited to forests, old parks, etc* 
A* elutus (6) is a species fond of salt and probably occurs every- 
where in the coastal lowlands, particularly on the northern Adriatic 
coast* It is frequent on Corsica, for Sardinia it was reported only 
once (HACKETT 1924) and has not yet been found on Sicily. It is rare 
in the provinces of the Continent. 
A. italicus (8) has been certainly found only onco in Calabria. 
A. marteri (17) has been recently observed on Sicily, formerly, 
a larva had been found once on Corsica (1925). 
Of the five varieties of A. maculipennis (l), A. mac.labranchiae 
(D) has been found in Upper Italy and Emilia, only in limited numbers. 
It is rather a western form (is absent on the Balkan peninsula) and is 
predominant on Sicily and Sardinia. 
The other four varieties occur now and then in all Italy, par- 
ticularly the typical form, but their frequency is varied. The ©rti 
di Schito near Naples and the ground of the former Lago Funcino in 
the Abruzzi have turned out to be the areas with the purest occurrence 
of a, mac. maculipenni (a). a. mac. atroparvus (b) is the predominant 
anopheles in some districts of Lombardy and many places of Emilia, 
particularly in the po-delta. A. mac. melanoon (C) occurs especially 
in Central Italy, A. mac. messeae (E) in upper Italy. 
Serious malaria in Italy is associated with the three southern 
forms of anopheles; with A* elutus (6), A. mac. labranchiae (D) and 
A. superpictus (2). 
E. MARTINI 
(Institute for Tropical Medicine and Hy- 
giene of the Military Medical Academy, 
Berlin)• VIl/4 
OCCURRENCE OF MALARIA AND DISTRIBUTION OF ANOPHELES IN 
SOUTH EAST EUROPE 
(With k maps.) 
Translation prepared by: 
U. S« Fleets U. Sc Naval Forces, Germany, 
Technical Section (Medical). VIl/4 
I. General Climatic Data. 
The area of the map comprises the whole South East European 
peninsula, if one takes - as usual - the Save-Danube line as its 
northern boundary. Geomorphologically and climatically, it is di- 
vided into two large areas: the continental northern area and the 
peninsular Mediterranean southern area. On the map, the geomorpho- 
lo&ical boundary described by 0. MAULL has been entered. The cli- 
matic and vegetation-boundary, which can be marked by the olive-tree 
boundary, lies somewhat more toward the sea than the geomorphological 
one, but runs parallel on the whole (see also the region of the etesies- 
climate on Aap VIl/l). 
On the map, the climatic difference between the two large areas 
has been indicated by entering the 22°~July and the 0°-January iso- 
therms • In the Mediterranean South East Europe, both run parallel, 
so a mild winter corresponds to a hot summer. On the other hand, in 
the continental southeast Europe, only the 22°-July isotherm turns 
far toward the interior of the country from the Danube delta, while 
the 0°-January isotherm runs along the coast; thus summer has high 
temperatures also in this area, and on the other hand winter frost. 
Not only the continental but also the Mediterranean climate of 
Southeast Europe has a marked seasonal rhythm. With the former, this 
rhythm is characterized above all by the contrast of temperature with 
the latter, by the distribution of rainfall (see the climograms for 
Agram ana Bucharest on the one hand, for Scutari, Athens and Istanbul 
on the other on map VIl/14)• 
II. General Data about the Distribution of Malaria. 
In the whole region, summer-temperatures are high enough for a 
sufficiently long time so that not only an increase of anopheles to 
great density but also the development of the tertiana-plasmodia in 
the anopheles is guaranteed* In the northwestern area, malaria tro- 
pica occurs only to a slight degree. Malaria quartana occurs in the 
whole region (except the Sava-Danube district), but is statistically 
so insignificant that it may be neglected in the representation* 
Dynamically regarded, the region of the map evidently lies with- 
in the area of the great change which becomes manifest in all Europe 
by a retreat of malaria toward the south* Particularly malaria tro- 
pica has lost much ground in the northern section of the region of the 
map. Wars and times of distress, however, again and again increase 
the infection and cause a new settling of malaria tropica in the terri- vii A 
tories of retreat* The entries on the map correspond to the be- 
havior of malaria between the two World Wars. 
Malaria morbidity may undergo considerable fluctuation from 
one year to the next, on the one hand in dependence on the factors 
influencing the development of anopheles (chiefly the quantity of 
rainfall), on the other hind in consequence of events effecting the 
social structure and the general health conditions of the population. 
Table 1. 
Of ©very 1200 cases, the share of the single months is: 
Malaria 
wrtianu 
Malaria 
tropica 
Jan 
Feb~ 
Mar J 
Apr 
May _ 
June 
July 
AUg~ 
Sept 
Oct 
Nov 
Dec* 
Seasonal distribution of malaria cases in South 
Macedonia (German troops 1942). 
The seasonal rhythm causes an interruption of the infections which 
sets in approximately in November. Malaria accordingly obtains a 
distinct seasonal character* It begins with spring-tertiana (composed 
of recurrences andjlafce cases) with ifcte peaip if^Ma^ch*-April. Since vii A 
the termination of June, the first new tertiana-infections appear, 
which are soon followed by the first tropica cases in the tropica 
areas. The tertiana peak usually occurs in August - September, the 
tropica-pesak in September - October (see table 1.), 
A synoptical representation of malaria in Southeastern Europe 
must desist from the plan of giving uniform figures of the degree 
of infection. In the politically split area, the data are absolutely 
of different value; they have been obtained at various times, by va- 
rious methods (e.g. spleen index, frequency of disease, mortality) 
and with very different exactitude; for many regions, there are no 
useful values whatsoever. 
Thus, it was only possible to try to start from one*s own ex- 
perience and to unite the data of literature and statistics to a 
temporary whole. 
Data about spleen index figures for Greece are indicated on map 
VIl/4a, for Albania on map VIl/4b. The most important places in Bul- 
garia infected with malaria are shown on Illustration 1 (according to 
DRENSKY 1940)• Malaria morbidity in the single administrative dis- 
tricts is represented for Serbia on Illustration 2 (according to da- 
ta of the Chief Medical Officer), for Croatia on Illustration 3 (ac- 
cording to a map of the Central Hygienic Institute in Agram), for 
Roumania on Illustration 4 (according to ZOTTA 1938), 
The representation of the principal map is based on the follow- 
ing principle: The endangering of two areas by malaria may be dif- 
ferent quantitatively and qualitatively, A quantitative difference 
consists in the frequency of malaria cases in general, a qualitative 
difference in the proportion of malaria tropica in total malaria. 
Both differences are usually so closely correlated that in the less 
infected districts, the relative figure of tropica cases decreases as 
well. This correlation is present above all, if the differences are 
caused by the climate. On the other hand, there may be geomorphologic- 
al differences within climatically uniform regions, which cause dif- 
ferent densities of anopheles and a thus different danger of infection, 
so that both in a pure tertiana area and in a mixed area, there are 
distinct zones of serious and less serious intensity. VIl/4 
► Motariadurchseuchfe Orte 
5 assjnierk Orte 
8 Untersuchungsstotiofiffi 
Illustration 10 Map of the most important 
Malaria districts of Bulgaria. 
places infected with malaria 
anti-malaria controlled areas 
examination-stations• 
Accordingly, three principal marks have been chosen which are 
intended to indicate the proportion of malaria tropica in total ma- 
laria; then these have been divided into 2 degrees of intensity. But 
since the principal marks indicate quantitative differences as well, VIl/4 
overlappings are inevitable. Thus, it is possible that in one zone 
the mark 1 b had to be chosen for places with approximately the same 
danger of malaria as those which are indicated by the mark 3 a in an- 
other section of the map. 
HI* Distribution of Anopheles. 
Ihe following species of anopheles have been observed on the 
southeast European peninsula; 
A* algeriensis 
bifurcatus 
elutus (sacharovi) 
byrcanus 
italicus 
A. maculipennis 
marteri 
plumbeus 
superpictus 
Of these species the following can be eliminated at once as 
vectors; A» italicus which is reported only in uncertain individual 
findings, the tree cavity breeder A* plumbeus, which is distributed 
almost all over the region but never occurs in a great density, and 
A* marteri, which has been found only in limited districts of the 
southern section of the map and breeds in cool, shadowy mountain- 
brooks. Also the other free land gnats are insignificant: A* al- 
geriensis and A* hyrcanus (pseudopictus), though the latter occurs 
in considerable density in rice-districts and in the Danube delta 
and has been occasionally suspected to be a vector# The localities 
where these species have been found ai*e not entered on the map. 
A. bifurcatus occurs in the whole area, apparently with in- 
creasing density toward the south. It may be regarded as chiefly 
a free land gnat, though it occasionally finds its preferred shadowy 
cool breeding-places among human settlements as well (in wells and 
cisterns). On 1#ie continent, it is improbable that A# bifurcatus 
is a vector. On Crete, it is regarded as a vector, though its im- 
portance is certainly less than that of the other species. On the 
map, it accordingly has not been entered on the continent and is in- 
serted in brackets on Crete, Thus, there remain, as principal vec- 
tors, A» elutus, A. superpictus and A. maculipennis. 
A*elutus is known as a brackish-water-breeder but is found in 
fresh water with little shadow near the coast as well. In the in- 
terior of the country, it is practically completely absent, and al- 
so in salt-districts. A elutus practically dominates the malaria VIl/4 
situation of the lagoon - and delta - districts, of the whole southern 
coastal zone generally. It occurs in great density on the Adriatic 
coast up to Montenegro, furthermore at the mouth of the Narenta (Neret- 
va), further northward, it probably occurs in a few places. Its dis- 
tribution area there adjoins that of A maculipennis labranchiae. On the 
BL&dcsea coast, A. elutus extends nortnward to Burgas, not so dense to 
the north of Constanza, where it is replaced by A. maculipennis atro- 
parvus, 
bis 1 % 
1% - 2% 
2% - 3% 
3% - <*% 
uber 4% 
Illustration 2. Annual malaria cases in Serbia in % of the 
population 1942/43* vii/4 
Thus, the northern boundary of its chief distribution lies near 
42° (see secondary map 1) that of its distribution on the whole near 
44° northern latitude* 
A. superpictus prefers, as breeding places, stony, sunny brook- 
beds with a moderate stream. It occurs up to altitudes of 800 m. in 
the mountain valleys and within its distribution area, participates in 
deciding the malaria situation in the mountain-valleys and in the hills, 
but it occurs in the middle and lower courses of the rivers as well. 
Its compact distribution area from the south on the Adriatic to the bay 
of Cattaro, in the interior to the north of Kumanovo a It has been 
found even near Mostar, in the interior up to Vranjae In the eastern 
section, it is the principal vector as far as the Rhodope-massive; 
though it has been found even on the northern slopes of the Balkan 
mountains, it apparently is of no considerable importance for the 
malaria situation (see secondary map 1.) 
A, maculipennis is distributed over the whole region. The follow- 
ing strains have been observed (se secondary map 2): 
A* maculipennis maculipennis (typicus) on the whole peninsula, 
chiefly in the hills of the interior, even in altitudes of more than 
1200 m* in the river valleys often near the forests, usually mixed 
with other strains, 
maculipennis labranchiae as braakish-water breeder in the 
area of the Adriatic coast up to the level of Sebenico toward the 
south, about 80 kms. toward the interior, 
A* maculipennis atroparvus, a brackish water breeder too, on the 
Black Sea coast north of the Balkan mountains, it occurs to a limited 
degree also in the interior of continental South Eastern Europe, par- 
ticularly on salty soil. Most western locality is near Ossijek in Cro- 
atia, most southern near Skolpje, 
A* maculipennis messeae as principal form in the valleys of the 
large rivers in the north, mixed with typicus in the whole interior 
up to Upper Macedorra (more frequent in the Macedonian lake-districts), 
A. maculipennis subalpinus in the southern section of the pen- 
insula under similar eccological conditions as A, mac,messeae. Since 
it had not been differentiated from the latter formerly, its boundary 
of distribution toward the north is not certain. 
Regarded over large areas, elutus, labranchiae and atroparvus on 
the one hand, messeae and subalpinus on the other may be considered VIIA 
Illustration 3» Frequency of Malaria in Croatia. 
up to 10 % 
more than 10^ 
of the population infected Vll/4 
geographically vicarious forms with sufficient approximation, while 
typicus is distributed over the whole region. Secondary map 2 is 
based on this concept. Single localities have not been marked on 
the principal map since it cannot do justice to the actual condi- 
tions of occurrence, and since the findings recorded in the liter- 
ature are still too inadequate and regionally too different. It is 
not yet certain how great the importance of the single strains as 
vectors is, it may also vary for every geomorphologic situation. 
Only large-scale serial examinations of the sporozoite-index, which 
are not yet available, can be decisive. 
IV. The malariological Structure of the Region. 
The geomorphologic-climatic division of southeastern Europe into 
a continental and a peninsular section is also expressed by the; malaria 
situation, as shown by the principal map. In the latter section, the 
22°-July isotherm is as it were the guiding line of malaria which pas- 
ses right through the most seriously infected areas (see e.g. Southern 
Macedonia)• In the former section, however, the isotherm is approxi- 
mately the boundary - line of malaria distribution, the infected re- 
gions lie on the warmer side of the line. 
On the whole, continental southeastern Europe is characterized by 
the fact that on the one hand, only the maculipennis strains act as 
vectors and that, on the other hand, the hazard of tropica, infection is 
less than in the peninsular section. 
The malariological boundary does not quite coincide with the geo- 
morphological one on the Black Sea since a coastal region extends there 
to about the level of Constanza, which must be accounted epidemiological- 
ly to the peninsular section. This is easily explained by the fact that 
the West Pontine Climatic Zone with Mediterranean character extends north- 
ward over the spurs of the Balkan mountains as well. 
On the Adriatic coast,the northern zone of the peninsular section 
is in a special position. According to the entries on the map, the ma- 
laria situation is similar to that of the continental section (exclusive 
occurrence of A* maculipennis, predominance of malaria tertiana). It 
must be considered, however, that malaria tropica has there decreased in 
frequency only recently and that, in contrast to the continental section, 
A»mac. labranchiae occurs as a vector. If the geomorphological boundary 
is thus simultaneously a primary malariologic boundary, a secondary ma- 
lariologic boundary can be drawn on the Adriatic coast approximately at Vll/4 
''a sea of mslaria 
r*r 100000 inhabitants! 
dp to 25C 
up to 500 
up to 750 
up to 1000 
up to 2000 
up to 1000 
Illustration 4a Frequency of Malaria in Roumania. 
(Average of the years 1925-36) 
according to ZOTTA 193&» 
the level of the Bay of Cattaro. In the following further subdivision 
into single malari0logic zones, it must be considered that only the most 
important joints coula be schematically emphasized. The figures of ma- 
laria intensity must be regarded as roughly approximated values. Effects 
of sanitation could not be considered. The especial position of the 
towns must be pointed out, whose centers are usually free from malaria. Vll/4 
A. Continental section of South Eastern Europe. 
1* The Croatian-Serbian Sava-Danube Area* 
(Country between the rivers). 
The malaria situation is chiefly determined by the spring 
tions in the Danube and Sava lowlands, particularly within the mouths of 
their affluents* The mc6t important anopheles is A* mac* messeae, usual- 
ly mixed with A. mac* typicus; the latter is predominant in the hills* 
Occasional occurrence of A* mac. atroparvus on salty soil must be reckoned 
with. Within the mark 3 a, the rate of the reported cases lies between 
2 and 5 % of the population annually0 In the endemic area, however, al- 
most all children are infected. Mai* tropica is far less frequent than 
mal* tertiana* 
2. The serbian-Bosnian Mountainous Country. 
The entomologic situation in the river-valleys and basins is similar 
to that of zone a 1* but A. mac. typicus is more important as a vector of 
malaria in the hills. In general, the morbidity is less than in zone A 1. 
- Mal* tropica is rare. 
i 
3* The Lower Danube-Basin (Moesian Basin) 
a) Wallachia: 
The Danube, which is accompanied by a broad area of marshes and 
inundations, and the deeply incised lower courses of the northern af- 
fluents cause extensive breeding-places for A. mac. messeae. The plains 
between the wqter-courses, particularly the Baragan-steppe, have fre- 
quently salty soils and accordingly predominance of A. mac. atroparvus, 
while A. mac. typicus is usually less frequent. The rate of the re- 
ported malaria cases within the mark 2a amounts to 5 % of the population 
on an average, ihe spleen index usually amounts to 25 %, at some places 
up to 70 %* Mal. tropica accounts for about a fourth of the cases. 
b) D^nube-delta: 
Despite heavy distribution-of anopheles(chiefly A. pseudopictus, 
then A. mac. messeae, and rarely atroparvus), slight frequency of ma- 
laria. Spleen-index around 5 Proportion of tropica around a third 
of the cases. VIl/4 
c) North Bulgarian Plateau: 
Due to the steep Danube banks and the better drainage condi- 
tions of the affluents, there are fewer possibilities of breeding- 
places than north of the Danube, Chiefly A. mac. messeae and typi- 
cus are found. Spleen-index within the mark 3 a usually 5 - 10 %• 
Proportion of mal, tropica less than 10 % of total cases. 
d) Dobruzha: 
On the side toward the Danube, chiefly messeae. in the center, 
according to the salty ground, chiefly Af. mac atroparvus, on the 
coast, a. elutus as well. Malaria-cases occur in Lke whole zone, 
particularly on the coast where there is a transition to the situation 
on zone B 5* 
B. Peninsular-Mediterranean Section of South Eastern Europe. 
1, The Dinarian Coastal streak. 
In the Karst zones of Dalmatia, breeding places of anopheles are 
found chiefly in the poljes (tub-valleys) -with irregulated drainage 
and at the small water-places (Lokvas). Principal vectors: A. mac, 
typicus and messeae, in northern Dalmatia, chiefly A* mac. labranchiae 
as well. Since the turn of the century, there has been a considerable 
decrease of malaria, particularly of the once frequent mal, tropica. 
Spleen index within mark 3 a is still around 50 
In the Hercegovina and in western Montenegro, the situation is sim- 
ilar. The principal vector is A. mac. messeae. Spleen index, 10 - 20 
The tropica proportion has fallen below 10 
On the mouth of the Narenta (Neretva), the malaria situation is 
similar to that of the coastal districts of zone B 4« 
2. High and Central Macedonia, Rhodope-region. 
Mountains and river-valleys abound with extensive breeding pos- 
sibilities for A. maculipennis (chiefly typicus, in addition to messeae 
and subalpinus) and for A. superpictus. Valleys and mountains up to VIl/4 
1200 m. are seriously infected. Spleen index in most settlements 
within mark 1 a is between 50 and 100 %f within mark 1 b, 15 “ 30 %• 
There is a high proportion of tropica. 
3. Central Bulgaria (Eastern Roume.lia) 
On the upper course of the Marica . and on the Tundza, extensive oc- 
currence of A. maculipennis, besides A. superpictus (?). Within 
mark 1 a, the spleen index is higher than 30 % as f£r as no measures 
of sanitation were carried out. There is a great proportion of tropica 
4. Albania, Greece, Thracia. 
Very serious coastal malaria is found in the lagoon- and delta 
districts. A* elutus predominates. A. maculipennis is found(chief- 
ly typicus, in addition to subalpinus). In the interior of the coun- 
try, particularly in valleys and there are numerous 
breeding places of superpictus and maculipennise Within mark 1 a, 
the spleen index usually is between 30 and 300 %. There is a very 
great proportion of malaria tropica (details see map VIl/4a and VIl/4b). 
On Crete and the Aegean islands there is much the same situation, 
though usually more circumscribed occurrence. On Crete, perhaps also 
A. bifurcatus is important as a vector. 
5. Western pontine Coastal Region* 
6n the whole, the same entomologic conditions as on the Mediter- 
ranean coast with predominant importance of A. elutus. In the district 
Burgas-Aitos, the spleen index is 25 - 50 %, There is a very great 
proportion of malaria tropica. 
H. HABS 
(Hygienic Institute of the Hansa 
City Hamburg). VIl/4a 
OCCURRENCE OF Mai.ARIA DISTRIBUTION OF 1N0PHELES IN GREECE, 
(With 2 text-maos). 
Translation prepared by; 
U* S. Fleet, U» S. Naval Forces, Germany, 
Technical Section (Medical)* VIlAa 
Except for the high mountains, the whole of Greece is more or 
less intensely infected with malaria. The map shows those districts 
in which malaria must be considered a frequent national disease and 
in which there is consequently an increased hazard of infection. The 
map of the region which has been examined by German experts, is based 
on around 25 000 spleen palpations and as many blood examinations of 
school-children at 350 places. The data for Peloponnesus and Epirus 
have been taken from LIVADaS and SPHaNGOS, Malaria in Greece, Athens 
1942. In addition, for the rest of the region, some Greek examina- 
tion-results, partly from the same source, partly according to local 
health authorities, have been used as well, for the adjoining Albani- 
an and Macedonian territories, the examination- results of the mis- 
sion of the "Instituto. di Malariologia E, MARCHIAFAVA" from June 
1939 to November 1940 have been consulted (Rivista di Malariologia 
XX (1941), section X, Nr. i/3, pafce 69 - 228). 
Groups of Age. 
March 
April 
May 
June 
July 
August 
September 
October 
November 
December 
January 
February 
P la smod • falciparum 
Plasmodivivax 
plasmod•malariae 
Illustration 1. Seasonal Distribution of the kinds of 
plasmodia to the groups of age. YIl/4a 
According to the Italian examinations of the years 1939 - 1941 
(G. LEGA), malaria is very intensely distributed in Albania, partic- 
ularly along the coast and along the rivers and mountain-brooks, at 
some places even up to altitudes of 1GC0 - 1200 m, All three kinds 
of parasites occur, chiefly pi. vivax and pi, falciparum* The prinr- 
cipal period of malaria in Albania lasts from June to October, As 
most important vectors, A. elutus (6) is predominant along the coast 
and A» superpictus (2) in the river valleys in the interior of the 
country, A* maculipennis, typicus holds the second place. 
The spleen and parasite -indices refer to school-chilaren and 
are higher than those of the rest of the population, as experience 
has shown. By the way, these figures are subject to considerable 
fluctuations, their constancy may be expected neither in different 
years nor in different seasons. They can "only indicate the extent 
of malaria infection, not its absolute height at any time you 
choose and it may occur that very seriously infected places are quite 
close to places which are remarkably slightly infected. Only par- 
ticularly characteristic indices have been indicated. Spleen-and 
parasite index oo not always run parallel. The spleen index is u- 
sually higher than the parasite index, particularly if there is no 
recent epidemic in addition to the enaemic. If there has been such 
a recent epidemic, the parasite-inoex will sometimes rise higher 
than the splenic-inaex, A high parasite index, associated with a 
marked density of anopheles, always involves an increased hazard of 
malaria infection for foreigners. 
All three kinds of plasmoaium occur throughout Greece. Their 
distribution is apparently pot very closely dependent on the regions, 
but chiefly a function of the group of age and of the season. This 
is demonstrated by Illustration 1, which is based on 15 7&7 Greek 
examinations from 1931 to 1939* 
Good work has been aone on the malaria-entomology for Greece. 
In addition to the detailed data of HADJINICOLAU in LIVADAS and 
SPHANGOS, a series of American works (BARBER, RICE’and others) deal 
with it. As regards the geographical distribution of the species 
of anopheles to the single regions, the published knowledge is 
scarce, however, the gaps concern chiefly the species rare in Greece 
ano not pathogenic: A, algeriensis (7), A. hyrcanus (12), A* plum- 
beus (nigripes) (4), ana A. marteri (17)« The most important vectors 
A, maculipennis (1), A. elutus (6) and A# superpictus (2) occur al- 
most everywhere, and A. superpictus may settle also in typical breed- 
ing places of maculipennis, particularly in the late summer, A. bi- Wll/Ua 
furcatus (3) seems to be a vector of malaria only in Crete. Since 
A. elutus (6) has a high natural infection index (N,l) ana, in ad- 
dition to that, is more likely to bite man, the question of its 
distribution is of practical importance. 
The most important breeding-places of anopheles are small and 
large marshes, brackish-water swamps in the coastal districts, 
banks of slowly flowing rivers with a rich vegetation, sunny moun- 
tain-brooks ana rivers with gravelly beas, irrigation- and drain- 
age systems in bad state of repair, loam-pits, and badly set Ar- 
tesian wells. The banks of sunny mountain-brooks with poor vege- 
tation are typical breeaing-places for A. superpictus (2), which 
may often be associated with A. maculipennis (l) and A<» elutus (6), 
in the late summer and fall. A# elutus (6) requires sunny breed- 
ing places, with some horizontal vegetation. It prefers brackish 
water, but is also found in fresh water far from the coast. A ma- 
culipennis (1) is the typical marsh-breeaer in fresh water. 
I 
(N. I. 
Precipitine test with anopheles caught in 
Species 1 
(Salivary- 
homes 
stables 
i 
glanas) 
positive for 
positive for 
human 
animal 
human 1 
animal 
blood 
blood 
blood | 
blood 
A« elutus 
2,37 
61,3 
38,7 
7,5 
92,5 
A* maculi- 
pennis 
0,27 
21,2 
7 8,8 
c 
99,5 
A. super- 
pic tus 
' i 
! 
1,87 
j 
29,7 
70,3 
,,6 
98,4 
Geologically seen, Greece is the result of various foldings with 
elevations ana depressions. The manifold formation of mountains ia 
partially opposite direction was extremely favorable to the formation 
of basin-regions ana deeply cut-in river—valleys. The disintegration 
is fostered by the violent force of the sun on the deforested moun- 
tains. The decomposition of the stones which often contain a great 
percentage of felspar provides the rivers - particularly in Macedonia - 
with a considerable content of colloid clay, In its turn, this leads VIl/4a 
to the formation of typically elevatea river-beas with spring 
inunaations ana to the gathering of perioaically floodea, im- 
permeable alluvial lana, marshes, ana river-aeltas. Thus , the 
marsh-breeaers A0 maculipennis (!) ana A* elutus (6), find ex- 
tensive breeding-places. In the mountain-brooks, A. superpictus 
settles, which likes the sun ana breeds somewhat later in the 
year. Thus, the mountains ana hills are by no means free from 
malaria, only from 1000 m altituae on can the absence of endemic 
malaria be expectea0 In adaition to swamp malaria and mountain 
malaria, malaria by man’s hand plays an important role in Greece. 
The earth for railroaa dams ana protective aams against water has 
often been removed without respect for the new formation of breed- 
ing places of anopheles. Particularly in Maceaonia, the often 
unclosea Artesian wells cause the same aamage. 
UVADAS estimates the total number c£ the annual malaria 
cases in Greece (old bounaaries) to be arouna 1 000 000. Malaria morbidity 
in the Army ana police, per 1000 men, amounted to: 
Year 
Army 
Police 
Year 
Army 
Police 
1930 
125 
77 
1934 
91 
51 
1931 
121 
120 
1935 
117 
73 
1932 
145 
21 
1936 
142 
72 
1933 
128 
B3 
1937 
119 
61 
The monthly distribution in percent, calculated from 7476 cases 
of various malaria stations, is shown by Illustration 2. 
J F M A M * J J A 5 C N 0 
Illustration 2* Annual course of malaria* VIlAa 
The Greek organization for malaria control is well equipped 
in personnel. Even after the outbreak of the war, their area of 
work has been continuously extended. 
F. RONNEFELDT 
(institute for Tropical Medicine and 
Hygiene of the Military Medical Aca- 
demy). VIl/4b 
OCCURRENCE OF M/ILARIA IN ALBANIA. 
Translation prepared by: 
U» S. Fleet, S. Naval Forces, Germany, 
Technical Section (lledical). VIIA b 
OCCURRENCE OF MALARIA IN ALBANIA. 
The malaria situation of Albania corresponds to the geomorpho- 
logic and climatic conditions which have been described for the pen- 
insular-Mediterranean section of southeastern European peninsula 
(see text to map VllA) * On the lower courses of the rivers and in 
the whole coastal region, the southern section excepted, there are 
in the regions of inundation, marshes and lagoon-zones extensive 
breeding possibilities for A* elutus, which is mixed vdth A.maculi- 
pennis typicus. In the region of the middle and upper courses of 
the rivers and in the mountain-valleys, A# superpictus is the pre- 
dominant vector, in addition to which A. imculipennis typicus oc- 
curs as well. The latter is of great importance in the area of the 
Scutari-lake, - The other anopheles observed in Albania (A, pseu- 
dopictus, bifurcatus, algeriensis, marteri, plumbeus) are epidemio- 
logically insignificant. 
The first adult flies of elutus appear at the end of Mayj the 
principal flying time lies in June and July. A, maculipennis be- 
haves in a similar way. In the respective zones, the first cases 
occur in the second half of June and persist till the end of Oc- 
tober, The flying time of A, superpictus begins in the middle of 
July, malaria in the interior zone of the country accordingly sets 
in in the first half of August and persists until November, 
The proportion of tropica cases is very great (more than h alf 
of the total cases), with children, quartana infections are fre- 
quent, During the determination of the parasite index in children 
at the places entered on the map* the following distribution was 
found in 1939: 28 % tertiana, & % tropica, 16 % quartana. 
The zones' of various degrees of hazard by malaria have been 
represented according to a still unpublished map of A, COLUZZI, 
This representation shows, on the whole, the shape of the surface 
of the country. All lowlands have been indicated as seriously in- 
fected, furthermore, part of the elevated valleys, finally the basin- 
plain of Korea. There is probably no considerable difference of the 
hazard from malaria between the plain and the "Zone of medium mam 
laria-endemlc". 
The data of the dpleen index show that there are, in part, con- 
siderable differences of malaria intensity (examinations in 1939 and 
1940 according to G# CASINI), VIl/4b 
Since 1929> measures of sanitation have been carried out by 
the Albanian Government with the help of the Rockefeller-founda- 
tion only in the towns, and these have been continued from 1939 
to 1942, by the Italian Instituto di Malariologia "E. MARCHIAFAVA". 
Tn the course of these measures, the spleen index decreased 
in Tirana frcm U2 % (1929) to 11 % (1938) 
in Durazzo from 45 % (1929) to 18 % (1938) 
in Scutari from 49 % (1939) to 18 % (1938) 
in Berat from 70 % (1933) to 31 % (1938) 
in Valona from 85 % (1931) to 48 % (1938). 
In Elbasan, no important results have been obtained (spleen in- 
dex around 50 %). 
There are malaria stations in Tirana, Valona, and Durazzo. 
H. HABS, 
(Hygienic Institute of the Hansa 
Gity Hamburg). VII/5 
LEISHMANIASIS 
IN THE MEDITERRANEAN BASIN. 
(With 8 Drafts attached to the text.) 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical). VIl/5 
Visceral Leishmaniasis (Kala-Azar, L. donovani) and dermal 
Leishmaniasis (Oriental Sore, L. tropica) are characteristic dis- 
eases of the Mediterranean basin. Almost throughout the entire 
Mediterranean littoral and the islands one must expect both these 
diseases. As a rule they occur only as sporadic cases. Even 
though they are observed at all times and in all places they do 
not assume the form of epidemics. The most suitable term to be 
applied to them would be "endemo-sporadic diseases". 
In this connection I want to stress that the marks in the 
principal maps and in the drafts indicating the incidence of 
Leishmaniasis refer to all places in which autochthonic cases of 
Leishmaniasis ever have been recorded and that no special conside- 
ration was given to the actual number of cases in these places. 
Such a procedure is justified by the fact that the places in which 
Kala-Azar or Oriental Sore have occurred once, are regularly af- 
fected again by such diseases although there may be nc such cases 
for several years. The hiding place of the organism during the in- 
terval is so far an unsolved problem of the epidemiology of Leish- 
maniasis, The phlebotomi (see HENNIG, map l/8) as the probable 
vectors are a reservoir of the agent only under certain conditions. 
The question of to what extent higher animals particularly the 
mammals, harbor the parasites and thus may become the source of 
a new infection for man is still more important. For Kala-Azar of 
the Mediterranean it seems to be established that the dog should 
be considered as a possible source of infection. For this reason 
areas with an occurrence of canine Leishmaniasis which are worthy 
of mention, have been given consideration on the maps. In all cases 
in which no special note was made the observations made throughout 
the entire Mediterranean basin are valid, that Leishmaniasis of dogs 
occurs in addition to the intestinal Leishmaniasis of man. This 
fact does not apply to the Indian Kala-Azar. It frequently happens 
that dogs suffer from a general Leishmaniasis without showing any 
symptoms. In their skin, however, Leishmaniae may be found. Dermal 
lesions which my have the appearance of the Oriental Sore of man 
according to CAMINOPETROS are only secondary manifestations of a 
visceral canine Leishmaniasis. 
It may be true that while studying the epidemiology of Leish- 
maniasis previously insufficient consideration has been given to 
the fact that the Leishmaniases do not occur in the form of epidemics, 
but in general are found as isolated cases. This suggests that the 
Leishmaniae are not primary parasites of man. During the recent years VIl/5 
a few data for such an assumption were established by some Russian 
scientists. They found that in the sand desert the wild rodents 
may be the carriers of the Leishmania tropica. In the Murgab val- 
ley in Turkmenistan the phlebotomi of the sand desert deliver their 
eggs in the burrows of the wild rodents (gerbils, ground squirrels). 
The detailed investigation of the various rodents revealed the most 
remarkable fact that on the average 30 % of 1087 rodents examined 
were contaminated with Leishmaniae (LATYSHEW and KR0NK0VA 1941)* 
In the course of that year the number of infected animals was in- 
creased from 2-3 % in the month of May to 56*3 % in the months of 
November and December. Through experiments proof was established 
that the organism of Oriental Sore is identical with the Leish- 
maniae found with the rodents. Similar findings were irade with 
two other representants of the family of the rodents, namely the 
Meriones erythrourus and Spermophillopsis leptodactylus which are 
the typical representatives of the sand desert fauna. Hence it 
results that originally the dermal Leishmania apparently was a 
disease of animals ana that the rodents have to be considered as 
the carriers of the agent and the source of the infection. This, 
for its part, would result in entirely new viewpoints for the 
fight against that disease. As the same relations are assumed 
for the Leishmaniasis in Tunisia, this observation is of some im- 
portance. 
The frequency of Leishmaniasis differs widely in the various 
countries of the Mediterranean basin. In this connection I want 
to make reference to the fact that one does not always know with 
certainty whether ur nut all cases of Kala-Azar and Oriental Sore 
have been recognized as suchr The increase of the morbidity rate 
therefore not always mean that the frequency of the 
maniae has increased. In the malaria areas for instance cases of 
an enlarged spleen in which no malaria plasmodiae were found very 
often were diagnosed as a chronic malaria without parasites. If 
once the erroneous diagnosis had been recognized, frequently even 
foci of visceral Leishmaniasis were revealed. Relevant references 
can be found in a large number uf studies on the occurrence of 
Leishmaniasis. In many cases this may be the reason for the wide- 
spread opinion that in the Mediterranean basin adults do not fall 
sick with visceral Leishmaniasis. It is established with certain- 
ty that the visceral Leishmaniasis of the Mediterranean basin is 
chiefly a disease of the children (usually between the first and 
the third year uf age). However, even adults are not protected 
against the infectiun.. 
The majority of the cases occurs in the months of March to 
June. There are local variations which will be discussed below. vil/5 
In some parts of Spain Kala-Azar is very frequent. Chart 1 
attached to the text shows the number of cases which had occurred 
before 1935 in the afflicted provinces since the discovery of vis- 
ceral Leishmaniasis in 1912. 
Illustration 1. 
Visceral Leishmaniasis in Spain and Portugal. 
(after NAJERA ANGULO 1935). 
Kala-Azar: h or oblique hatching from the left upwards to the right; 
Canine Leishmaniasis: o ; Oriental Sore; e , or hatching downwards toward 
the right side, (siiailar for all other charts). VIl/5 
Even though these figures do not represent all the cases of 
visceral Leishmaniasis which to our knowledge have been under 
treatment up to the present date, they indicate clearly the re- 
latively high frequency of that disease in the various provinces 
of Spain* 
Before 1925 the total amount of Kala-Azar in was 343* 
During the following years it was raised to 892 cases. As a rule 
it affects children in the age between 1 and 4 years (6 months up 
to 10 years). However, adults are also afflicted with visceral 
Leishmaniasis in an ever increasing number. This was recently re- 
vealed during the civil war in Spain, when 5 members of the "Legion 
Condor" (German troops in Spain) fell sick with Kala-Azar. 
The infection usually occurred during the late summer or in 
the fall. Daring the winter the first symptoms will appear. The 
canine Leishmaniasis apparently is of special importance. . It is 
Jdund with certainty in the big cities and it seems to be distributed 
to a greater or lesser degree throughout all the provinces of Spain, 
in this connection the reference of KOWALZIG is worthy of note, that 
the troops of the "Legion Condor" amongst which 5 cases of Kala-Azar 
had occurred liked to play with stray dogs. An extensive examina- 
tion of the dogs in Madrid made in 1935 revealed that 178 out of 
2,000 dogs examined were infected with Leishmaniae, and in Sevilla 
in 1933, 5 out of 78. Cats may also be carriers of leishmaniasis, 
although the likelihood is very small. Only 1 cat out of 495 cats 
examined in Sevilla was contaminated with Leishmaniae 
In spain the phlebotomi are considered as the principal vec- 
tors of visceral Leishmaniasis; in many cases ticks are also re- 
garded as transmitters between the dogs and man. 
Oriental Sore is not very frequent in Spain. It occurs under 
the term L-lunari and it is more frequently found among children. 
During the period from 1913 to 1934 27 cases were recorded. How- 
ever, as with visceral Leishmaniasis one must take into account 
that more cases are revealed, if a thorough search for them is 
made * 
The east coast of the province of Tarragona (Arboli, Alforja), 
and Valencia should be regarded as endemic areas of Oriental Sore. 
Isolated cases were recorded in Abaran (Province of Murcia, 1935) 
Perello (Province of Tortosa), Castellar de Santesteban (Province 
of Jaen) and on the coast of Granada. VXl/5 
Portugal geographically does not belong directly to the 
Mediterranean basin. However, it can be regarded as "the con- 
tinuation of the Mediterranean coast to the Atlantic1', as the 
Mediterranean diseases are spread as far as its territory* In 
1910 visceral Leishmaniasis was observed in Portugal for the 
first time and here too it~occurs predominantly as a disease 
of infants. About 86 % of the children sick with Leishmaniasis 
were 2-5 years old. The greatest hazard occurs at the age 
of 2 years. 
The geographic distribution of Kala-Azar in children is very 
irregular. Centers of endemics are Lisbon and the northern terri- 
tory around Porto, and the valley of the Douro (Illustration 1). 
The coast areas are above all involved, but isolated cases occur 
in the area between Lisbon and the Douro in the north, and the 
coast of the province of Algarve in the south. In the northern 
area of endemics, where the first case was observed in 1927, 16 
cases were recorded before 1934* All of them were children under 
4 years of age. Recently the first case of an adult contaminated 
with Leishmania was observed in the valley of the Douro river. 
Within 5 months 11 cases of Leishmaniasis were found among child- 
ren of the age from 7 months to 8 years in Alcazar do Sal. As a 
rule, Leishmaniasis is not frequent. However, it has been re- 
peatedly stressed by the scientists that it is very likely that a 
more widespread distribution of this disease will be revealed with 
the increase of its knowledge. Nevertheless an epidemic occurrence 
of Leishmaniasis need never be taken into account. 
Dermal Leishmaniasis as an autochthonic disease does not seem 
to have occurred in Portugal as yet. 
It is certain that canine Leishmaniasis occurs in the big towns. 
In Lisbon 2 % of all dogs were found to be contaminated in It 
is not clear whether the dogs must be considered as a source of in- 
fection or not, but it is regarded as probable by reason of general 
observations and experiences in the Mediterranean area. Extensive 
systematic investigations of Spain and Portugal are not available. 
In France the most extensive focus of Kala-Azar extends direct- 
ly along the Mediterranean coast from the Franco-Italian frontier 
to Marseille, and it is continued deep into the country for 100 kms* 
The first case of infantile Kala-Azar in France was found in 
1918 in Nice. Since then a relatively large number of cases have 
occurred in the French Mediterranean coastal area between Menton and VII/5 
and Marseille. The two principal foci are Nice and Marseilles, 
During the period before November 1934 about 150 autochthonous 
cases of infantile Kala-Azar were observed; CASTILLON (1937)> 
however, holds that it is very likely that the real number of 
the recognized cases is three times as high. GIROD (1936) re- 
ports 146 cases for the region of Marseille since 1922; it is 
certain that 135 cases of these were truly endemic. In addition 
to 137 children, 5 adults and 4 youths were contaminated. As is 
shown by the figures Kala-Azar here too is principally an infants 
disease. During the recent years, however, several cases have 
occurred in adults. The first autochthonous case in an adult was 
observed in 1923* it was a 32 year old woman keeping 3 bogs, one 
of which suffered from visceral Leishmaniasis, Since then numer- 
ous cases of Kala-azar in adults have been recorded. Before 1938 
4 more cases of adults sick with Kala-Azar were reported from 
Marseille and Arles. It is very likely that the dogs must be 
considered as carriers and it appears that the organisms are 
communicated to man through an intermediate carrier. The definite 
proof of these connections is not established so far. It is cer- 
tain that just in the area of the southern French Mediterranean 
coast, in which human Leishmaniasis is to be found, many infected 
dogs occur and that the dogs apparently play an important role 
in spreading the disease. During the last years several cases of 
Kala-Azar were observed in the interior of France which, as far 
as it could be established, could be traced back to dogs who had 
been living on the Mediterranean coast. PEHU and BERTOYE (1937) 
observed 3 cases of an autochthonic infantile Kala-Azar: one of 
them was found in Remiremont in the Vosges mountains where it was 
established for certain that a five year old child had played very 
frequently with a dog which came from Italy. The second case oc- 
curred in the vicinity of Aubenas and the third in Aubenas itself 
(province of Ardeche). Contaminated dogs were also found in Tou- 
louse, Biarritz, and Bordeaux. In consequence of this observation 
CASTILLON believes that for the future in France Kala-Azar may oc- 
cur more frequently. In all coastal towns of southern France there 
are many contaminated dogs, An investigation of the dogs in Nice 
during the year 1932 revealed that 19,b% of the dogs were carriers 
of Leishmaniae. A certain number of these dogs showed no symptoms 
of disease. This high percentage is not found in all towns; how- 
ever, it ranges between 2 and 10 %m 
An autochthonous Oriental Sore has not been observed in France 
so far. VIl/5 
No reports are available on the occurrence of Leishmaniasis 
between Marseille and the Spanish frontier. However, there are 
considerable doubts as to whether tnis part of the Mediterranean 
coast is really free from Leishmaniasis, since the adjacent Spanish 
littoral shows a considerable incidence of Kala-Azar. 
In Corsica visceral Leishmaniasis was observed in the north, 
in Bastia and Calvi and in Ghisonaccia (central part of the east- 
ern coast). Among the cases observed in these places was a 23 
year old patient who beyond all doubt had acquired the infection 
in Corsica. - One out of 16 dogs which were examined in Bastia 
and its environments was infected with leiahmaniae. FIERI and 
LENA (1933) assume that in this case too, the dogs have to be 
considered as the carriers of the agent. - There has been no 
Sriental Sore so far. 
In Italy the frequency of Leishmaniasis is greatest in the 
south of the country# The highest number of infections was found 
in Calabria and on the island of Sicily. Since 1925 Leishmaniasis 
has been a notifiable disease in Italy* The annual number of 
Kala-Azar cases varies from 200 to 300. The geographical distribu- 
tion of the 202 cases reported in 1932 was as follows: Liguria 8, 
Emilia 2, Toscana 1, Latium 1, Campagna 10, Apulia 5, Calabria 5> 
Sicily 166, Sardinia 4. Most of the cases occurred during the 
month of March, but Leishmaniasis was also found during the period 
between April and August. 
Illustration 2. 
Leishmaniasis in Sicily# vii/5 
In Sicily more than SO % cf all cases occurring in Italian 
territory are to be found. The principal endemic areas are lo- 
cated in the provinces of Catania, Palermo, and Messina (ill,2). 
Kala-Azar is prevailingly distributed along the coast while in 
the interior only a small number of isolated cases can be ob- 
served, The occurrence of visceral Leishmaniasis apparently de- 
pends on a certain altitude. None of the 1424 cases found dur- 
ing the years 1916 to 1926 was found at an altitude higher than 
733 M, Usually visceral Leishmaniasis occurs at an altitude 
between sea-level and 214 M. In Catania alone the annual number 
of infections frequently amounts to 150 to 200* 
Kala Azar is principally found with children. In Sicily 
60 '/o of all cases are children under 2 years of age. However, 
recently several cases of visceral Leishmaniasis of adults were 
observed. In Catania 3 to 6 adult cases used to occur every 
year. According to IZAR the actual number of adults sick with 
visceral Leishmaniasis is always larger than that of the sta- 
tistics, as the symptoms of the disease are different with a- 
dults and with infants, and as only the symptoms of the latter 
are remembered when the aiagnosis is established. Most of the 
cases are found during the months of March and Aprils In Pa- 
lermo, the number of cases is particularly high during winter 
and in spring. The incidence is highest with the poor popula- 
tion of the suburbs. 
The incubation period is reported to be 6 months and less. 
In the territories with visceral Leishmaniasis a considerable 
infection of the dogs with Leishmaniae is regularly found. In 1912 
1.09 % of the dogs in Catania, according to another author 2.42 % 
(of I65 dogs) were infected. An examination of the dogs in 1933 
revealed that 6 % of the aogs examined were contaminated. This 
fact is of an epidemiological interest as under certain circumstances 
the dogs are of some importance as a source of infection of man. 
The disease is transmitted above all by phlebotomi, possibly 
by Ph. perniciosus and ph. major. 
During recent years Oriental Sore has become familiar to an in- 
creased degree. It was observed for the first time in 1910, prevail- 
ingly in Calabria, Reggio, and in the vicinity of Messina (Bordonaro). 
According to recent investigations made by M0NACELLI (1934) the casual 
occurrence of Oriental Sore must be taken into account for all Sicily 
and the southern parts of the Italian peninsula, while in central Italy, VIl/5 
namely in the province of Teramo (111.3)* There is an endemic 
focus with numerous cases (VANNI 1938)# During the months of May 
to July 1938 about 300 cases were observed. The highest number 
of cases occurred among the rural population, particularly among 
children of the age group between 7 and 13 years NUTRARIO (1934) 
assumed that there is an endemic zone along the Adriatic coast 
between the Romagna and Apulia. 
The highest number of cases 
of Oriental Sore is found dur- 
ing the months of February to 
April. The phlebotomi (F&# pa- 
patasii and sergenti), which are 
considered as the vectors of der- 
mal Leishmaniasis swarm until 
October. Hence it results that 
the average incubation period is 
six months. However, this can 
be considerably longer. 
Illustration 3» 
Dermal Leishmaniasis (Oriental 
Sere) in the province of Teramo 
(Acc. to VANNI 1938). 
In Sardinia the number of cases 
of Leishmaniases was relatively 
small. According to FRANCO 31 
cases were observed before 1931> 
which were recognized as .Leish- 
maniasis by microscopic examina- 
tion. 24 of them were visceral, 
6 of them eternal Leishmaniasis. 
One oase was considered as a 
mucosal Leishmaniasis. Pronounced 
foci of Leishmaniasis do not ex- 
ist in Sardinia. The places of 
occurrence are distributed through- 
out the entire island (111.4)• 
Illustration 4. 
Leishmaniases in Sardinia. Vll/5 
Some of them are located in the mountains where they are found 
at an altitude of even 1,000 M* (Fonni)* 
The 24 cases of visceral Leishmaniasis were found within a 
period of 11 years, during which only one case per year occurred 
on the average. In 5 single years no case occurred, while 13 
cases were observed in the course of the year 1930. I want to 
mention as a peculiar fact that 20 of the patients belonged to 
the male eex, while only 4 females were affected. The age of the 
patients varied between 8 months and 33 years. Even though a 
large number of these patients - as in most cases of the Mediter- 
ranean Kala-Azar are infants and children in the age group bet- 
ween 8 months and 10 years, a relatively high number of patients 
in the second decade of life was found in Sardinia, One case was 
that of a 33 year old adult. Both FRANCO and lZAR assumed that the 
small number of visceral Leishmaniasis of youth and adults is to 
be traced back to the fact that the possibility of Kala-Azar is 
not always taken into account when the diagnosis is considered, - 
22 of the 24 cases have to be considered as autochthonous. Between 
1931 ana 1938 only 3 or 4 cases of Kala-Azar were found. 
Before 1931 only 6 cases of Oriental Sore were found, one of 
them in 1910, one in 1920, and 1924, and 3 cases in 1931* All 
patients were males in the age group up to 24 years. One of them 
was living in a mountain village at an altitude of 1,000 M, Before 
1938, 3 more cases of Oriental Sore were observed (Sedini, Cossione, 
Ittiri). 
Canine Leishmaniasis has been known since 1917* hut it was 
found in only a very few places. In Sassari 12 cases of canine Leish- 
maniasis were examined. They could be proved as Leishmaniasis by the 
demonstration of the organism* 
On the island of Malta many cases of Kala-Azar occur annually. 
According to a report given in 1934* 121 cases were notified in 1933* 
This figure allegedly represents the annual average. According to 
another author the number of infections is considerably smaller. ZAHRA 
(1931) reported the number of cases treated from March 1923 to 1932 
as 313» Kala-Azar occurred chiefly in the rural districts. The number 
of cases found in adults was small. Some autochthonous cases occurred 
among the troops# 
In Malta dermal Leishmaniasis was recognized only once in 1934. 
For this case the source of infection was not known and it is question- 
able whether this single case should be considered as endemic. vii/5 
Illustration 5* 
Leishmaniasis on the Adriatic coast, 
(According to TARTAGLIA 1938) 
Of the northern part of the Balkan peninsula the eastern Adri- 
atic coast shows a high incidence of Kala-Azaro In the coastal 
towns and villages of this area inserted in the chart altogether 
89 cases occurred during the period from 1931 to 1934* 59 of them 
were observed in the province of Ceta, and 30 In the littoral of 
the Herzegovina. The number of cases in each village varied con- 
siderably. In the vicinity of Spalato 13 cases occurred, 8 of which 
were found in Klis, 3 in zrnovica, 1 in Cuecine, and 1 in Yesenica, 
In the mountains the disease is observed at altitudes of up to 300 
to 400 m* 82 of the 89 cases found before 1934 were observed with 
children in the age group of 1 to 12 years, usually with those of 
2 to 4 years of age. There were only 7 cases of adults between 20 
and 47 years suffering from Kala-Azar, 6 of them females, 1 of them 
a male. TARTAGLIA (1934) however, assumed that the number of adult VIl/5 
cases of Leishmaniasis is considerably higher, as most likely the 
disease is not recognized in all cases and very often is con- 
sidered as a chronic malaria without findings of parasites. This 
assumption was confirmed by a report of SIMITCH (after ABRAMOV) in 
1938* During the years of 1933 to 1936 this author examined 42 
Kala-Azar patients among which there were 25 adults. In 1937* 
25 out of 50 patients were auults suffering from Kala-Azar which 
at first was not recognized, but was considered as malaria. Kala- 
Alzar is more frequent in the villages than in the towns. The af- 
fected persons, particularly the children as a rule are poor and 
belong to the rural population. 
Canine Leishmaniasis occurs in addition to human Leishmanias- 
is, al'though the two are not always concurrent. An examination of 
dogs in Split revealed that in 1935, 4 out of 50 and in 1936 2 out 
of 28 dogs were contaminated with Leishmania. In these cases too, 
the dogs are considered as the source of the infection and for the 
prevention of the disease the extermination of the dogs was recom- 
mended. 
Oriental s°re has not been found in this area so far. 
Roumania also is not free from Leishmaniasis. Even as early 
as in 19l2 infantile Kala-Azar was observed in Bucharest and 1934 
MIHAILESCU and NIKOLOFF had found 2 cases of canine Kala-Azar in 
Bucharest. A frequent occurrence of this disease, however, seems 
not to be observed. There are no recent cases, so that the sus- 
picion is aroused that the earlier cases were imported. 
In Hungary the first autochthonous case of Kala-Azar was found 
a short while ago (GELDR1CH 1941)* The infection apparently had oc- 
curred in Szeged. 
The presence of phlebotomLin this country, particularly of Ph* 
macedonicus which allegedly transmits Kala-Azar in Greece, has been 
known for a long time. 
In Bulgaria at first only isolated cases had occurred. An auto- 
chthonous case of Kala-Azar in a 26 year old soldier was reported in 
193S. It appears that this soldier had acquired the infection in the 
vicinity of the Greek frontier. MOLLOV, however, who made reference to it as- 
aumaa that more cases occur along the coast of the Black Sea. SLIVENS- 
KE (Sofia) had the same opinion when there was a discussion of Kala- 
Azar in 1940. He holds that a large number of cases would be found 
if a thorough search for visceral Leishmaniasis would be made in the VII/5 
villages of Thrace and Macedonia, Even without a special search 
in the villages single cases were found as in the village of Petro- 
vo-sve ti-Wratch, 
Oriental Sore was observed once in Aitos, 
There are large areas with Kala-Azar in Greece, Even more than 
100 years ago this disease was known in that country as a clinical 
syndrome (Hydra, Spezia)« In our days visceral Leishmaniasis is en- 
demic in the provinces of Messenia and Argolis, on the Peloponnesus, 
in the town of patras, in Thessaly, and on the islands of poros, 
Spezia, Hydra, Crete, Kephalonia, Kerkyra, and in the vicinity of 
Athens, In the eastern part of the Peloponnesus, in Argolis, 200 
cases of infantile Kala-Azar were found within 3 years (KIRIMILIDES 
1938)» While in the villages of the plain of Argolis Kala-Azar oc- 
curs sporadically only, one may even speak of an epidemic incidence 
of the disease in the area northwest of the town of Athos, Here too, 
the disease principally affects children of 2 to 3 years. The 
province of Messenia was investigated with regard to Kala-Azar by 
PAPANTONAKIS (1936), Most of the villages located at an altitude 
of 100 to 500 M, on the hills and mountains were involved, while 
the plains apparently were free from Kala-Azar, Accordingly many 
cases occur in the northeast of the province, while the number of 
Kala-Azar cases is small in the southwest. In 20 smaller villages 
about 135 Kala-Azar patients could be found, most of them child- 
ren of 2 to 3 years. The principal focus of Kala-Azar in the Medi- 
terranean has been considered to be the island of Hydra, A pub- 
lication in the year 1911 made reference to the fact that 39 of 
the deaths of children below 6 years of age had to be attributed 
to Kala-Azar on this island. In athens 46 cases of human Leish- 
maniasis came under medical treatment in the periods between 1933 
and April 1934* 18 of the patients originated from Athens, 14 of them 
from the island of porus, the rest from the remaining parts of Greece, 
It was frequently remarKed that the patients had kept dogs in 
their houses many of which were infected with Leishmaniae, During 
the same period between 1933 and April 1934 in Athens and in the vil- 
lages of Attica 31 sick dogs were observed. Similar cases occurred 
in the Peloponnesus, CAMINOPETROS found that canine Leishmaniasis 
always precedes the human Leishmaniasis, In 1936, 498 stray dogs 
were examined 55 of which were infected. 
Most of the cases appear auring spring and curing the first 
months of summer while the occurrence of Kala-Azar is rare in autumn 
and winter. VIl/5 
In Greece Oriental sore is a relatively rare disease of the skin. 
In Athens 93 cases came under treatment in 1916 to 1928, 17 of 
them were found in Athens, 60 patients in Crete and 16 cases on 
the other Greek islands and in various places of the mainlandB 
A center of an endemic infection exists on the Peloponnesus (Ne- 
apolis, Kampos, Kodronas, and Laya)• There, dermal Leishmaniasis 
apparently has occurred for many years. 
Illustration 6. 
Leishmaniasis in C r e t e • 
Oh Crete Kala-Azar and Oriental Sore are to be found. 
The first case of visceral Leishmaniasis was observed in 1907. An- 
nually an average of 50 Kala-Azar cases is recorded in the district 
of Kanea. In Kanea itself with its 30,000 inhabitants both types 
of Leishmaniasis occur. The periphery of the town, the borough 
Hagios Ioannis is the principal place where Kala-Azar occurs. In 
the quarters of Halepa and Koum-Kapi small foci exist. No such foci 
were found in the old Turkish city. From 1930 until 1935 about 172 
cases were treated at the sanitary station. A recent observation of 
MUEHLENS (1943) reveals that 18 Kala-Azar cases were subject to treat- 
ment in the period from 1 July 1941 to 1 August 1942. Kala-Azar was 
found curing all seasons. The frequency was slightly increased during 
the winter months. 50 % of the patients were infants under 2 years 
of age. Annually one or two adults with Kala-Azar are found. 
Canine Leishmaniasis allegedly occurs in the neighborhood of 
the sick persons. A considerable reduction of the number of dogs 
on the island which was accomplished for other reasons resulted in 
a decrease of the morbidity rate among children. VIl/5 
There is a huge number of cases of Oriental Sore in Kanea. 
They are chiefly found in the old Turkish part of the city* All 
age groups are liable to infection* From 1932 to 1934 614 cases 
were observed. This number, however, represents only a small 
fraction of the real number of infections. A certain seasonal 
increase of frequency could not be remarked. 
phlebotomus major and phlebotomus perniciosus were considered 
as the vectors of Kala-Azar•(MUELHENS 1943)• 
On the island of Cyprus only isolated cases of visceral Leish- 
maniasis were observed (in Nicosia); likewise dermal Leishmaniasis 
was rare. In 1934* 2 cases of dermal Leishmaniasis were treated in 
the hospital of Nicosia, canine Leishmaniasis did not occur on 
Cyprus. 
From Turkey reports are available (MARCHIONINI 1940) which in- 
dicate that there were numerous cases of Oriental Sore in central 
and eastern Anatolia. Preferential areas are those with a dry con- 
tinental climate (a long hot summer, a short cold winter). In Axt- 
kara about 200 cases of Oriental Sore were treated in the period 
between March 1936 and June 1939. No accurate data on the places 
where it occurs are given in the literature. 
The adjacent countries of the Near East, Syria, Palestine, and 
Egypt, have been discussed in connection with map Il/5: Leishmaniasis 
in the Near East. For Egypt the occurrence of Oriental Sore in the 
vicinity of Rosette in the Nile delta and of Assyut in the Nile valley 
must be mentioned in addition. 
The frequency of Leishmaniasis in the countries of the North African 
littoral varies considerably. 
In Tripolitania Leishmaniasis was found in Tripoli and Homs on- 
ly. The total number of the Kala-Azar cases is about 16, that of 
Oriental Sere about 4 to 3* Canine Leishmaniasis was also found in 
these places and according to one of the authors allegedly had af- 
fected 13 % of the dogs examined. 
In the girenaica single cases of Kala-Azar were observed in 
Benghasi, Tolmetta, and Derna, - Canine Leishmaniasis war found in 
Benghasi, but apparently it was not frequent in this area. 
In Tunisia accurate observations of the development of Leish- 
maniasis were made for many years, At intervals of 4 years accurate vii/5 
reports (NICOLLE, ANDERSON) were published during recent years. 
These reports show that in the places given in Illustration 7 
the morbidity with visceral Leishmaniasis has increased slowly 
but continuously. 
Illustration 7* 
Leishmaniasis in northern Tunisia (before 
1938). 
The new cases usually are always found in the same villages. 
The total of 131 cases observed in the period from 1906 to 1937 
reveals that the hazard of the infection is very small. Since the 
report of the year 1934j 8 more cases occurred before 1937o Until 
1925 visceral Leishmaniasis was found exclusively among children. 
Duping the following period ending in 1938 it was also observed with VII/5 
6 adults. The fact that adults also can fall sick with visceral 
Leishmaniasis was of some importance because one had assumed that 
the organism of infantile Leishmaniasis is a special type of or- 
ganism which is not pathogenic for adults* The major part of the 
infantile patients (87) was of Italian origin, the remainder came 
from Italian-French (5)> French-Maltese, and indigenous parents. 
Except for 1 case in Tozeur in the south, Kala-Azar ex- 
clusively occurs in the northern part of Tunisia, 
In the south the Oriental Sore is widespread. The cases of 
dermal Leishmaniasis are particularly concentrated in the mountain- 
ous oases, chiefly in Medlaoui and Gafsa, The entire region north 
of the Chott-el-Djerid is an endemic center for 0riental Sore, In 
the north only sidi Yussef on the frontier between Algeria and Tun- 
isia is known as a place where Oriental Sore occurs. Yussef on the 
one and Tozeur on the other hand give proof that one cannot speak 
of the two types of Leishmaniasis being vicarious for each other. 
Both of them are liable to occur simultaneously in the same region. 
Oriental Sore seems to be tied to mountainous, rocky areas. It 
apparently depends on an intermediate carrier which has.to be con- 
sidered as the reservoir of the agent. One suspects that this in- 
termediate carrier is a certain olass of rodents in Tunisia, the 
Ctenodactylus Gondi (see the general remarks in the introduction). 
Canine Leishmaniasis also was repeatedly found in Tunisia. 
Its frequency in the towns is given as 1 to 2 %• - Accurate in- 
vestigations on the relations between human and canine Leishmaniasis 
had been maae but they supplied no definite information. 
In Algeria the area of Oriental Sore extends deep into the 
area of the sand deserts of the Sahara as far as the general border- 
line located at 30° latitude. The southernmost place of occurrence 
is I&Ii on the wadi Gir. In the vicinity of Colomb-Bechar and in 
the oasis of Figuig numerous cases of Oriental Sore were observed. 
This borderline area between Algeria and Morocco has to be con- 
sidered as an area of endemics. The remaining south Algerian ter- 
ritory south of the Great Atlas mountains shows only isolated cases, 
which, however, are found in almost all oases of this area (Laghouat, 
Gharuaja, Vargla). An endemic area which has been well known for a 
long time is situated in the Oasis of Biskra and south of it in the 
vicinity of Touggourt and in the \5asis of SoUf, A second zone with 
Oriental Sore is located in the foothills of the Little Atlas Moun- 
taina Oriental sore was found in many places in the oases and the 
valleys of these mountains. In the region of Algiers, and Constan- Vll/5 
tine the number of places where Oriental S°re occurs> is par- 
ticularly frequent. The number of single observations, however, 
is very small, and it does not exceed 1 to 5 cases<> 
Illustration 8, 
Leishmaniasis in northeastern Algeria* 
Visceral Leishmaniasis is not very frequent in Algeria. It is 
exclusively found in the Algerian littoral. Since 1911 when Kala- 
Azar was observed for the first time in Algeria, until 1931 only 21 
cases were aiagnosed, 4 of them in adults. 8 of these cases were 
observed in the province of Constantine, while 1 case was found in 
Mostaganem. The geographical origin of 3 more oases is uncertain. 
From the Sahara cases of visceral Leishmaniasis of man have not been 
reportea. 
Canine Leishmaniasis was repeatedly found in Algeria and it was 
sometimes observed in various other places of the littoral, above 
all in the province of Algiers, The oases of the Sahara seem to be 
free from canine Leishmaniasis. 
In Morocco K&la-Azar was found for the first time in Meknes in 
1921. since then a few cases have been observed in the vicinity of 
Tetuan, in Fez, and around Marrakech and not far from Ighan in the 
southwestern part of the Atlas Mountain# Three out of the total VIl/5 
of 6 certain cases occurred in adults, 3 in children. Even though 
an accurate search certainly will reveal more infections of man, 
there are no large areas of endemics in Morocco, The same applies 
to canine Leishmaniasis. In Casablanca, Tangier, and Fez some 
dogs contaminated with Leishmaniae were caught, but there is no 
widespread distribution of canine Leishmaniasis. 
In southern Morocco a large endemic area of Oriental Sore 
takes its origin. From the southern Moroccan territory of the 
oases of Buanane, Boudenib along the northern border of the Sa- 
hara it extends through southern Algeria to southern Tunisia, 
In southern Morocco itself dermal Leishmaniasis occurs in Fez and 
east of this town. The oases located in the south along the foot- 
hills of the Atlas mountains together with the south Algerian oases 
Figuig, Qolomb-Bechar, and Beni Ounif form an endemic focus with- 
in which numerous cases were observed. 
The comparison of the areas of distribution of visceral and 
dermal Leishmaniasis reveals that Mediterranean Kala-Azar is spread 
farther to the north than Oriental Sore, This fact is of some 
interest because of the fact that the phlebotomi which principally 
occur in the northern parts of the Mediterranean basin (ph* chin- 
ensis, perniciosus, ana the species of the "major"-group) are the 
species which are considered as the probable transmitters of vis- 
ceral Leishmaniasis, On the other hand Phlebotomus papatasii is 
predominantly found throughout the area of Oriental Sore (cf, 
HENNIG, map 1/8), 
G. FIEKAESKI 
(Institute for Tropical Medicine and 
Hygiene of the Military Medical A~ 
cademy)• VII/6 
LEPROSY 
IN THE MEDITERRANEAN BASIN 
(with 4 Chart3) 
Translation prepared by: 
U. S. Fleet, U. S. Naval Forces, Germany, 
Technical Section (Medical) VXI/6 
One of the strangest epidemiological phenomena is the 
relatively rapid disappearance of leprosy in the course of 
the 16th century in spite of its widespread and general 
occurrence in Europe and in the Mediterranean countries 
during the medieval ages. The reason for this rapid ex- 
tinction of leprosy is completely in the dark. On the other 
hand, however, the reasons which were responsible for the 
continuation of leprosy for many centuries up to the present 
day in single confined areas of the most varied European 
and Mediterranean countries are not clear either. In the 
countries of the European continent small endemic foci of 
leprosv exist which at first seem to be distributed rather 
arbitrarily and the comparable investigation of which, 
according to systematical viewpoints, is an urgent task 
for European scientific cooperation in the future, after 
the attention of the leprosy research recently was directed 
by the thesis of OBERDOERFFER to the importance of the 
alimentary factors, namely to the foodstuffs containing 
sapotoxin, and to the corn-campion as an admixture to the 
grain. A substantial preliminary work, however, would 
be the cartographical registration of all places where 
leprosy occurs. The map given below is intended to be a 
contribution to this task which, after the end of the war, 
needs to be completed by inquiries made in the countries 
themselves, as was initiated by Emmo and Elisabeth GEHR. 
For the countries of the Iberian peninsula Emmo and 
Elisabeth GEHR carried through a new cartographic investi- 
gation shortly before the beginning of the war which supplied 
accurate information on the present distribution of leprosy 
throughout Spain and Portugal by means of two cartographic 
designs (see Illustration 1 and 2). The predisposing factor, 
which with regard to leprosy seems to be confined to certain 
areas of the earth and which is changed only over very large 
time intervals, seems to implicate a certain diet on the 
basis of obsolete agricultural methods and economical con- 
ditions in these areas as well. This causes such a high 
admixture of corn-campion seed to the grain that as a result 
of the high consumption of grain, particularly by the poor 
among the rural population, a considerable amount of sapo- 
toxin may be taken in which, according to OBERDOERFFERTs 
hypothesis, creates a disposition for leprosy. VII/6 
0,2 %» atf/wV 
47-419%. 
ax-ear* 
\o.of-oo*%. 
\urrter QC7%c 
Illustration 1. Distribution of leprosy in Spain 
. • . (after M0NTAHES and ARMAS) 
' In Spain leprosy oases seen to increase rather than 
to decrease in number. While in 1851 HIRSCH gave the 
official number of lepers as 284 p'atients, E. and E. GEHR 
quote the official figure according to GIMENO (1928) as 
732, and according to'M0NTAKES (1934) as 928 cases. The 
principal foci are situated in southern Spain, on the Medi- 
terranean coast, and in the extreme northwest. Some of 
them are connected with the Portuguese foci. 
In Portugal conditions are very'similar• The number 
of 800 lepers given by HIRSCH for 1821 did not decrease 
in the-.course of. the last century as in other European’ 
countries, and it rather was increased. According to the 
statistics for 1938, it amounts to 1124 cases. .. The total 
number of the lepeps in Portugal itself is estimated at 
3-4,000 throughout'the Portuguese mainland. - * VII/6 
According to the Portuguese 
data Portugal, not considering 
Russia, where the number of leprous 
patients is not known, has the 
highest number of lepers of all 
European countries in proportion 
to its population. 
In the two countries of the 
Iberian peninsula the immigration 
and the remigration of leprous 
nationals from overseas is con- 
sidered as an important factor 
for the increase of leprosy. 
This problem also exists in France 
and Italy. 
Contrary to Spain and Portugal, 
almost no autochthonic leprosy 
occurs in France. The last cases 
of a definitely inherent leprosy 
in France were observed in some 
valleys of the Maritime Alps 
(Faillon valley: Contes, La Tri- 
nite, Paillon; in Eze, Castagniers, 
St. Maurice (1929)). The number 
of such cases is continuously de- 
creasing* /ifter i860 about 100 
lepers were found in the rural 
district of Nice, which had been 
reduced to 40 in 1914, and to 15 
in 1929. Some of the old foci 
are said to have completely died 
out, such as the foci in the Yar 
valley and in the Rhone delta. 
There, the last case was found 
in La Crau in 1925. In addition 
to the above mentioned cases in 
the area of the Maritime Alps, 
3 more autochthonic cases were 
observed in the vicinity of Tulle. 
Several cases wore spread to the 
province of Cental (District of 
Mauriac). It is likely that 
here too, there was an old leprosy 
I 05 and me fa 
j 02 -0# 
j 0.7 * 079 
' 0,05 -0.09 
0,07 -004 
: an fee 907 %o 
Illustration 2. 
Distribution of leprosy 
in Portugal 
(after SILVA CORREIA) VII/6 
area in which similar to Brittany and the Provence, leprosy 
was observed rather frequently before the end of the 18th 
century. They were, however, restricted to single villages 
and to certain families (in the Provence: Martigues, Bi- 
trolles, the vicinity of Marseille, and Toulon). 
In these areas a very small number of lepers is found 
in some remote villages where it affected only the members 
of a few of the indigenous families. 
Contrary to this atitochthonic form of leprosy, the 
other form of leprosy increases in importance. This is 
the continuously increasing number of leprosy cases imported 
from the French colonies and from other overseas countries 
by the returning emigrants (tradesmen, missionaries, soldiers 
etc.). Their number was continuously increased before the 
outbreak of the war. Even though no accurate figures are 
available the leprosy cases treated in the clinic or in the 
policlinic of St. Louis Hospital in Paris clearly show the 
increase of the number of such cases: 
1887 to 1895: 80 cases, 
1910 to 1925: 104 cases (Report of the French 
Academy). 
During the period after World War I about 160 to 200 
lepers lived in Paris, who had been infected with leprosy 
in the overseas countries. To these one must add the 30 
cases observed in Bordeaux during the last 20 years before 
the last war, and further 39 cases in the hospitals of Mar- 
seille. 
In the fall of 1929 a leprosy sanatorium was established 
in France with the aid of an American society, the -Society 
for the Victims of Tropical Diseases. According to the 
report of December 1936, 59 lepers were admitted to this 
sanatorium during the first 7 years of its existence. It 
is called the Sanatorium of Valbonne and it is situated 
at a distance of 10 km. from the Pont St. Esprit in the 
province of Gard. 
There is a retreat area of leprosy in the Canton of 
Wallis in Switzerland. Here, a 20 year old girl suffering 
from nodular leprosy (P0METTA 1906) was discovered during 
the construction of the Simplon tunnel. Two lepers out VII/6 
of the 5 cases discovered in 1907 were living in Guttal in 
1921, and 1 in Getwing, while 2 of them had succumbed. 
In Italy leprosy has recently played a more important 
part than in the adjacent central European countries. Two 
problems particularly were subject to discussion in a broader 
public during the last years: 
1. The significance of the leprous remigrants from 
overseas, particularly from Brazil, for the increased number 
of leprosy cases in Italy, and 
2. The registration and the isolation of the really 
autochthonic leprosy. 
The epidemiological explanation of the autochthonic 
leprosy would be a very important basis for the solution 
of the problems of leprosy of our days. So far no one has 
been successful in finding an adequate explanation for the 
obstinacy with which leprosy persists in certain areas 
even though it appears there only with very few isolated 
cases throughout the lifetime of several generations. In 
its present appearance leprosy seems to be the most inactive 
of all epidemics, but also the most resistant and it even may 
be impossible to extinguish it. 
During the leprosy conference in Berlin in 1904 M;LfTE- 
GAZZA gave a report on 246 cases in Italy. The official 
estimation revealed 212 cases in 1913 and 196 cases in 1923* 
Even in 1926 274 cases were observed, which means that the 
number was not as reduced compared to 1904• Even though 
the figures for the various areas varied considerably in 
the statistics of the various years, the total result re- 
veals no substantial decrease of leprosy in Italy. 
From time to time lepers are detected who never had 
left their villages and who had never been in contact 
with leprous persons and who had lived with their families 
for many years without being detected. During the period 
from 1925 to 1937 as many as 66 such autochthonic cases 
were discovered in Italy. These freshly discovered leprosy 
cases frequently directed the attention to those leprosy 
foci which were well known during the past century and 
which in our time were considered extinct. Such cases 
were reported from Liguria, Ferrara (Comaechio), Piedmont VII/6 
(Yercelli, Monferrato), Parma, Romagna, Lombardia aiid 
Campania, and they represent a great problem for leprosy 
research. To make close investigations of these retreat 
areas of leprosy in Europe accurate geomedical records 
are required of all the areas which during the past century 
were considered as contaminated with leprosy. This also 
applies to the Riviera valleys, namely the Val di Var, Val 
di Nervia, Val d’Oneglia, which towards the end of the past 
century were the last remnants of an originally large area 
extending from Chiavari (Riviera di Levante) along the 
Italian and French Riviera as far as to the mouth of the 
Rhone river. In 1843 about 100 lepers lived in this area, 
40 of whom were admitted to the leprosy asylum in San Remo 
which was established in 1858. West of this area the 
French leprosy territory of the Provence was situated 
(see above). 
Further impressive examples for the course of leprosy 
in recent times are the old leprous areas of Italy, namely 
Sardinia, Sicily, Calabria, and Apulia. 
The leprosy incidence in Sardinia is the greatest of 
all the Italian provinces and it was very thoroughly in- 
vestigated. The autochthonic cases of leprosy in Sardinia 
were closely watched for many decades by SERRA. Their 
geographical distribution reveals several larger leprous 
foci which can be traced back for a very long period of 
time. Since the end of the past century the number of the 
autochthonic cases in Sardinia has neither increased nor 
diminished to a marked degree. In 1902 MANTEGAZZA recorded 
more than 43 lepers, in 1912 more than 47 were observed 
by SERRA, and in 1918 RADAELI found 67 cases in Sardinia. 
The villages where leprosy occurred were situated to the 
west of the central parts of that island around Oristano 
and along the road to Cagliari (see map VIl/6a). In all, 
131 cases of leprosy were recorded during the period from 
1891 to 1932 which were distributed throughout 32 villages. 
In 1932, 29 lepers were found in 11 different places (see 
Table I). There is a distinct focus in the district of 
Oristano in the village of Terralba which is inhabited 
by 4,000 persons and in which 17 lepers were found in 1918. VII/6 
Table X 
Leprosy in Sardinia 1932 
(According to P.PIKETTI) 
Place 
Number of 
cases 
Place 
Number of 
cases 
Cabras 
3 
Oristano 
4 
Cagliari 
1 
Santa Giusta 
1 
Cagliari 1 
Seneghe 
2 
Carloforte 
1 
Siamaggiore 
1 
Nurachi 
3 
Solanas 
2 
Ollasta Sinaxis 
• 3 
Terralba 
7 
In the second place in the. official statistics of the 
Italian provinces in 1926 one finds Sicily with y6 cases 
of leprosy, which are spread throughout the entire island 
although they are particularly frequent-in the provinces 
of Messina, Cqtania, and Syracuse. The route of the lep- 
rosy infection from the middle of the past century on can 
be traced accurately. From 1867 to 1911 the various scien- 
tists found 315 cases altogether which were distributed 
throughout the villages recorded in Table II. According 
to TRUFFI the geographical distribution reveals several 
real endemic foci: Lipari, M. S. Giuliano, Trapani, Flo- 
ridia, Pachino, and particularly Avola, which were mentioned 
by HIRSGH in 1881. The villages with lepers found by 
TRUFFIfs inquiries in 1924 are given in the map VIl/6b. 
On the continent the southernmost provinces of Apulia 
and Calabria for the time being are the largest Italian 
areas of endemic leprosy. In the old focus in the province 
of Bari, which in the official statistics of 1926 takes the 
third place with 29 leprous persons, 127 autochthonous 
leprosy cases were observed during the period from 1886 
to 1930. One of the most important foci is situated in 
Cariati (4,000 inhabitants) where about 20 cases occurred 
between 1890 and 1923. In addition a small endemic focus 
exists in the province of Reggio di Calabria not far from 
Gerace Marina where 27 cases occurred, 20 of which were 
still alive in 1933* The village of Portigliola (2,500 
inhabitants) had 1 case of leprosy 70 years ago, while VII/6 
Table II 
Leprosy in Sicily 1875 to*l7ll 
- * 
(According to la MENS A) 
Province of 
Provinoe. of 
Province of 
Province of 
Syraouse 
Messina 
Palermo 
Trapani 
Buccheri 
Messina A 
. Palermo 
Trapani 
Avola 
Mirto • * 7' 
* Oarini 
M.S.Giuliano 
Floridia 
Li pari 
Petralia 
Favignana 
Solarino 
Portorici 
Polizziv , 
Castellanare 
Chiaromonte 
Montagna' Re ale 
Cefalu 
Partanna 
Spaccaforno 
Mondanici 
Monte lap re- 
Salapar,uta 
Modiea 
S.Stefano 
Ustica 
Marsala 
pachino 
Camastra ' ••• 
Pormini 
Pantellaria 
Noto 
Graniti 
Valledolmo 
Augusta 
Nizza Sicula: 
•■-Chiusa 
Iozallo 
Falcone l 
• • Sclasani 
Monte Rosso 
Caste1-Umb er t o 
' 
total 12 
• * 
vi- :U : 
10 
8 communities 
Province of 
Province of 
') \ 
Province -of 
Catania 
Girgenti . 
Caltanis-setta 
Catania 
Girgenti 
Vallelunga ' r. 
■ '• • 
Motta S. 
Sciacca ■> 
Anastasia 
Naro •" ;T• 
Randazzo 
Sanbucazabut 
Calatabiano 
Vizzini 
•» 'r* - 
y.cireale 
Catena Nova 
total 7 
4 
1 communities VIl/6 
Table III 
Data on the Distribution of Leprosy 
throughout the Mediterranean Countries 
Country 
New cases 
(R.E.League 
1935 1936 
reported 
of Nations) 
1937 1938 
Total number 
of lepers 
Estimated number 
of lepers 
Year 
Data according to 
Spain 
68 
• 
928 
2,500 - 3,000 
1934 
Montanos (quoted after Gohr) 
Portugal 
. 
• 
0 
. 
1124 
3,000 - 4,000 
1938 
Silva Correia (qu.after Gohr) 
France 
• 
• 
. 
. 
40 
200 
1925 
Academy report 
Italy 
54 
54 
21 
• 
2?4 
1926 
Official statistics 
Malta 
2 
14 
6 
9 
63 
1924 
Cochrane 
Rounania 
10 
9 
10 
13 
140 
500 - 600 
1939 
Anghelescu (quoted after Gohr) 
Yugoslavia 
2 
8 
5 
9 
42 
1926 
Gohr 
Montenegro 
. 
. 
e 
.100 
1 
1904 
Gehr 
Bulgaria 
0 
0 
1 
0 
7 
1930-40 
Gohr 
Greece 
21 
41 
31 
23 
758 
1,000 - 3,000 
1939 
Gohr 
Turkey 
43 
62 
57 
57 
593 
2,000 - 3,000 
1927-40 
Gelir 
Cyprus 
12 
7 
15 
12 
74 
1928 
Sulzberger 
Syria 
r*. 
o 
15 
12 
21 
unknown 
Palestine 
6 
7 
10 
7 
120-150 
1937 
Canaan 
Iraq 
164 
121 
208 
105 
300 
1928 
Cochrane 
Egypt 
Tripolitania 
139 
• 
156 
312 
533 
0 
6,513 
unknown 
18,000 
1929 
Dalganouni 
Tunisia 
2 
5 
3 
4 
unknown 
Algeria 
I 
2 
2 
5 
150 
1385-1923 
Montpellier 
Morocco (French) 
429 
544 
481 
458 
1,330 
1921-32 
Flye St. Marie VII/6 
nine lepers were living there in 1931. While by the 
official estimation of 1912 only one case was recorded 
in the three southern provinces and while only 6 cases 
were revealed by the inquiries of 1929, in recent times 
Apulia and Calabria stand in the third place after Sar- 
dinia and Sicily as far as the absolute number of lepers 
is concerned. 
In Malta obligatory measures against leprosy were 
ordered in 1919 and a leprosy asylum with 150 beds was 
attached to the charity hospital in the vicinity of Valetta. 
From 1900 to 1926, 255 lepers died in Malta, while 43 were 
discharged as cured and 63 retained in the asylum. 
For the Balkan countries E. GEHR published his accurate 
investigations of the distribution of leprosy in our time 
(1939) in 1941 and evaluated his results as a support for 
0BERD0ERFFERfs hypothesis. These investigations again show 
the almost complete absence of leprosy in the modern agri- 
cultural countries, such as Bulgaria, and the greatest in- 
cidence throughout the poor and outmoded agricultural terri- 
tories of the Balkan. The greatest number of lepers was 
observed in Greece with 756 patients, and here it is par- 
ticularly Crete where more than one third of qll the Greek 
lepers live. The total is estimated at 1,000 to 3,000 
cases. According to GEHR, here too, the areas with ad- 
vanced agricultural methods, such as the large lowlands 
where the grain is cultivated, and the tobacco areas of 
Agrinion, Boeotia, the Drama basin, Thessaly, Thrace, and 
Macedonia, are free from leprosy. Although one third of 
the Greek people live in the big cities, leprosy is a dis- 
ease of the open country '’which is rather unusual behavior 
for an infectious disease and which always attracts the 
attention in all countries where leprosy occurred.” (GEHR). 
Approximately five sevenths of the Greek lepers originated 
from the islands, particularly from Thasos and Aegina, Samos 
and Zante, Chios, Leukas, Corfu, and Euboea (see 111. 3). 
On the mainland the number of leprosy cases is continuously 
diminishing, since the registration of leprosy as well as 
the isolation of the patients and the medical examination 
of the members of the families was enforced by the law of 
duly 1920. VII/6 
fHe and netr 
0,5%,- 
0,2%,- 0,6%, 
0.1%,-0,19%, 
uaffr 6.1 S, 
♦ Leproserkr 
(+) Leprashrfion der k/Zn/k 
ftnfektionskra/iktwten SaJornk/ 
Illustration 3. Distribution of leprosy in Greece 
(after Enmo GEHR) 
In Greece the lepers are admitted to two big leprosy 
asylums, namely in the leprosy asylum which was set up in 
1904 on the island of Spinalonga eastward of Crete with 
390 patients, and in the Nosokomion Linodhon Noson in the VII/6 
vicinity of Athens on the road to Dhaphni, with 230 patients 
In addition 60 patients were confined in Samos, 20 in Chios, 
and 10 in Thessalonika. 
In Rounania leprosy is much more infrequent than in 
Greece. According to GEHR 140 lepers are living in Rou- 
mania most of which are detained in the only Roumanian 
leprosy asylum in Tichilesti which is situated in the 
northern part of the Dobrogea (District of Tulcea). About 
10 fresh cases are recorded every year. The majority of the 
cases are found in the districts of Tulcea, in the Danube 
delta, and in Ramnicul-Valcea and the adjacent districts. 
The incidence of leprosy is still more inconsiderable 
in the former Yugoslav territory. GEHR mentions only the 
figure of 42 cases which was published first in 1926. These 
patients originate from the mountainous countries of Bosnia 
and Herzegovina. No recent data are available on Albania 
and Montenegro. 
Bulgaria is almost free from leprosy. Only 7 cases 
were observed during the period from 1930 to 1940 some of 
which were attributable to a family epidemic. 
The distribution of leprosy throughout Turkey needs 
detailed inquiries before definite data can be given. For 
the recent period the only material available, records of 
the Turkish Ministry of Health, gives the number of regis- 
tered leprosy cases between 1927 and the end of August 1940 
as 593 cases. The total, however, is estimated at 2,000 to 
3,000 lepers. According to various reports an increased 
frequency of leprosy must be assumed for the eastern and 
southeastern provinces, and for the coast of the Black Sea. 
Here, special mention is made of the mountainous and coastal 
areas of Kastamou (with Devrekani), Sinop, and Samsun. 
For Cyprus only the data of 1928 are available accord*- 
ing to which 74 lepers were living in Nicosia. In 1867 the 
leprosy asylun of this town harbored 35 patients. HIRSCH 
made reference to the fact that in Cyprus leprosy is prin- 
cipally found in the districts of Morfu, Lapethus, and 
Kythraea, which are situated in the wet climate of the 
lowlands. VII/6 
In Syria leprosy occurs particularly south of Beyrouth 
'"and along the Palestine frontier, and according to older 
observations also in the valleys of the Lebanon and the 
Antilebanon. Almost every town has its leprosy houses, 
but no exact data are given in the literature. 
In Iraq the number of lepers is estimated at 500 patients 
(COCHRANE 1928), one half of whom are Persians. In general 
leprosy seems to be rare throughout the entire Arabian 
territory, as due to the religious ideas and rules the 
lepers are banished and secluded from the others. A fre- 
quent incidence of leprosy was observed throughout the 
coast territory of the Persian Gulf, such as f.i. in Oman 
and along the coast from Kuwait to Ras el Rheina. For the 
lepers of the Pirates coast an isolation station was es- 
tablished in the vicinity of Dubai. 
A report on leprosy occurring in Palestine was given 
by T. CANAAN as late as in 1937* The total number of lep- 
rous persons amounted to 120 to 150 cases. According to 
this author the older and higher figures are definitely 
wrong. The geographical distribution of the cases was 
given by CANAAN who prepared a roll indicating the origin 
of the lepers on the basis of the data contained in the 
records of the leprosy qsylum in Jerusalem. These records 
reveal that leprosy occurred in the course of this century 
in 142 different villages which were situated particularly 
In the vicinity of Jerusalem, while the coast was relatively 
free from this disease. The same investigations also showed 
that leprosy is observed with Jewish nationals as well as 
with the Bedouins, both of which, however, fell sich vd th 
leprosy much less frequently than the inhabitants of the 
towns and the Fellahs (see map VIl/6c). 
Egypt which, according to the conformable opinion of 
all medical historians, must bo considered as the principal 
old focus or even as the homo country of leprosy in the 
medieval ages, in our days should also be regarded as that 
Mediterranean country in which for the time being the dis- 
ease has the highest rate of incidence. The German medical 
scientist Dr. Franz ENGEL-Bey who for 30 years before World 
War I was the director of the statistical department of the 
Office for Public Health estimated the number of lepers in 
Egypt at 4,000. The real number, however, was said to be 
18,000. At the International Congress for Tropical Medicine 
in Cairo in 1929 DALGAM0UMI gave the actual number of lepers VII/6 
in E~ypt as 6,513- Before tho end of 1937, 5,000 lepers 
wore detected and subjected to treatment as a result of 
tho campaign against leprosy which was intensified from 
1929 on. No material on tho geographical distribution 
throughout tho country is available. However, one must 
assume that about one half of tho populated territory 
should be considered as contaminated with leprosy. In 
the month of February 1929, in addition to the lepra 
hospital of Cairo (150 patients in 1936), policlinics 
for lepers were organized in Cairo, Zaqaziq, and Suhag, 
1931 in Tanta and Minia, and 1936 in Alexandria and in 
two other places. A leper colony for 250 male lepers 
was established in Abou Zaabal north of Cairo. 
A conspicuously small number of reports on leprosy 
is available in Tripolitania and in Tunisia so that 
HIRSCETs cautious statement could not bo checked. He 
asserted that Tripolitania and Tunisia ’bare exempt from 
leprosy”. In the Cyronaica only a very few cases of a 
genuine autochthonic leprosy wore observed among tho 
indigenous population. While there are no data in the 
literature on leprosy in Tunisia, reliable records on 
leprosy are given in .JLgeria and Morocco. 
In Algeria 150 cases were observed within the 40 years 
from 1865 to 1923* This figure, of course, only displays 
an approximate estimate of the real conditions. MONTPELLIER 
stated that in Algeria the leprosy focus did not enlarge, 
but was not extinct either. Particularly the Kabyles 
are the victims of the disease, among them a certain tribe 
with an old racial disposition and very primitive habits 
of life. Of the European immigrants the Spaniards provided 
the major part of the Eurojoean lepers in Algeria, in addi- 
tion to the Maltese and the Italians. Some of the Spaniards 
imported the infection from their home country. The smallest 
number of lepers occurred among the French, and only 4 
definite cases of infection were published heretofore in 
Algeria. 
Even towards the end of the past century there was 
a largo leper colony with 200 patients in Morocco in the 
vicinity of the town of Morocco. The lepers always used 
to be accommodated there in special settlements (’’Harat” 
and ’’Zariba”). Two leprous foci are distinguishable in 
the French protectorate of Morocco, a large focus in the VIl/6 
northern part with about 1,000 lepers, and a second 
important focus in the south among the Doukkala tribe 
where the ratio between leprous and healthy people amounts 
to 1 : 1,000. In 1933 F. E. If LYE SUBTLE MARIE gave a 
report on 330 cases in the district of Fes which occurred 
within 11 years. Some of the tribes in that region are 
real foci of leprosy such as f.i. the Jebala along the 
frontier of Spanish Morocco and the tribe of Beni Sadden 
with 34 eases for the total of 8,000 individuals. The 
number of leprosy cases throughout the entire territory 
of Northern Morocco is estimated at about 600 lepers. 
This survey on the occurrence of leprosy throughout 
the Mediterranean basin reveals that here leprosy does 
not belong to the extinct diseases and that its further ' 
course in the various areas of retreat must be watched 
carefully. 
H. J. JUS.xTZ 
Illustration 4. 
Tho florae give the approxlaat© aua&©r of cases ear 
1.00 Inhabitants of oach tribe, Uccqtilng to rLTO SA1KTE StBIE).