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Medical geography: has J.M. May borrowed M. Sorre's 1933 concept of pathogenic complexes?

La géographie médicale : J.M. May a-t-il emprunté le concept de complexe pathogène à Sorre ?
Rais Akhtar


Le cadre conceptuel et méthodologique de la géographie médicale moderne s'est forgé dans les années 50 avec la publication d'un article de J.M. May : «  La géographie médicale : ses méthodes et ses objectifs ». On tente ici de discuter les apports de J.M. May, et de M. Sorre qui a proposé le concept de « complexe pathogène » en 1933, 17 ans donc avant que J.M. May ne publie son article. Le « complexe pathogène » de Sorre comprend des facteurs physiques, biologiques et anthropiques. Sorre a été le premier géographe académique du XXe siècle (après Ratzel en Allemagne), qui a importé des données de la biologie en géographie, géographie générale et plus particulièrement en géographie médicale. Il a également développé les relations entre géographie et sociologie. Cet article se propose d'examiner la contribution de M. Sorre à la géographie médicale en insistant tout particulièrement sur le complexe pathogène ainsi que sur les liens entre J.M. May et l'American Geographical Society. Les informations données ici tendent à prouver que J.M. May a emprunté les concepts fondamentaux de M. Sorre.

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I am grateful to the Maison des Sciences de l'Homme, Paris for providing a grant that enabled me to carry out work on French Geography in general and the contribution of Maximilien Sorre in the development of conceptual and methodological dimensions of Medical Geography in particular. I am also grateful to Dr. Jean Luc Racine for his encouragement. I am grateful to colleagues in Paris with whom I initiated discussion on the subject particularly Dr. Marie-Claire Robic, Prof. Paul Claval, and Dr. Jean- Marie Amat Roze for their fruitful comments. On my recent visit to Paris, I met Prof. Jean-Louis Tissier and I am grateful for his observations on Max Sorre. I am also thankful to Dr. Beatrice Collignon for English translation of selected portions of M. Sorre's 1933 paper. I am also grateful to the reviewers of the paper for their constructive comments.

  • 1 J.M. May was born in Paris on January 27,1896, and took his preliminary degrees at the Sorbonne (19 (...)
  • 2 Maximilien Sorre had served in a number of universities including the University of Lille,and famou (...)
  • 3 « [Ces complexes manifestent] une dépendance plus ou moins marquée à l’égard des conditions de mili (...)
  • 4 « [la notion de complexe pathogène est] une sotion susceptible de servir de fondement à l’une des p (...)

1Until now we were under the impression that it was J.M. May1 whose paper of 1950 on medical geography provided a framework that helped remove the obstacles in the medical geography tradition placed by Louis Pasteur's germ theory, which laid emphasis that diseases are caused by germs rather than environment. It was erroneously thought that it was May's contribution. Maximilien Sorre2 stated in 1933 that his paper provides a conceptual and methodical framework of research in medical geography. Sorre asserts that the examination of the ecology of pathogenic complexes reveals, "a more or less important dependence upon the environmental conditions. More often, the medium agent is the most sensitive one and it is its needs that play the determinant role in the ecology of the complex. Yet, its influence is not the only one. Conditions for the life of the pathogenic germs as well as seasonal, geographical or ethnic variations of the human organism should also be taken into account"3 (Sorre, 1933). Sorre further elaborated that: "[the notion of pathogenic complex] could serve as a basis for one of the most important parts in the field of medical geography. The extended area of an endemic or epidemic disease is that of a pathogenic complex. To explain that extended area, its contraction and expansion movements, is to first solve an ecological problem, an essential goal in biological geography. It is also to look into external circumstances that favour or obstruct the constitution or the maintenance of the complex. [...] it quickly appears that most of those circumstances deal with human geography: population density, migration, lifestyles. To study them, we need not change our set of mind. With the introduction of the notion of pathogenic complex we now have, indeed, a perspective and a method."4 (Sorre, 1933)

M. Sorre’s studies in medical geography

M. Sorre and medical geography

2G.R. Crone vividly described the humanistic perspective of Sorre. According to Crone, "His field was 'life of man on the earth', and his special contribution was the development of the relations of geography with biology, medicine and sociology. He had a fine appreciation of the delicate balance between communities and their environment, and abhorred those economists who operated in terms of statistics rather than human beings." (Crone, 1963)

3In the obituary of Max Sorre, Pierre George (1962) writes that M. Sorre had a deep interest in medical geography and established contacts with doctors, biologists and sociologists. He was the first academic geographer who gave impetus to the studies of medical geography in France. Sorre focused his attention to the regions which are affected by serious epidemics and outlined geographical framework for the study of infectious diseases. Sorre published a series of studies with focus on the relationship between the human organisms and the geographical surroundings and presented the synthesis of his work in the very original and monumental book: Biological Fundamentals of Human Geography, first published in 1943 (Sorre,1943). Sorre initiated discussions with the associations of doctors and hygienists, and imposed his authority in the medical circle to such an extent that he was invited in 1934 to write an important part of the book: Medical and Biological Climatology, by M. Piery (1934). M. Sorre's contribution in this book covers physical climatology and chemical climatology with focus on normal physioclimatology and pathology.

4Regarding Sorre's source of inspiration, George writes that Sorre, "liked reading about Alexander von Humboldt and Karl Ritter as well as Elisée Reclus and Vidal de la Blache ». Sorre applied Vidal's concept in his geographical work. According to him, the role of geography is to address the balance of reality of different types of 'genre de vie', and by its impartial analysis of facts and evolutive tendencies and to make the balance and tilt towards the sides of evolution which are less inhuman.

5M. Sorre's research methods, applied by botanists to study the relations between the inert milieu and the association of vegetation, were not able to inspire the research in Human Geography in a certain direction and he took the charge of constructing human ecology. He proposed on three themes: i. influence of climate on man and the way he adapts to the climate. ii. the actions of the complex pathogens and, iii. the qualitative and quantitative effects of food systems. The third theme, i.e. the food system, was elaborated by Sorre in his work on Geography of Diet (1952). Sorre's medical geography was not exclusively for geographers, but he presented his ideas before the medical fraternity hoping for elaborate interactions.

M. Sorre’s pathogenic complexes

  • 5 « Les acquisitions de la biologie générale au cours des trois derniers quarts de siècle ont amené u (...)
  • 6 « Le nombre de maladies que nous pouvons mettre en relation directe avec le climat, c’est-à-dire av (...)

6In 1933, M. Sorre published his pioneering research entitled, "Complexes pathogènes et géographie médicale" in the Annales de Géographie. As already stated, this paper is the first fundamental contribution by a geographer on the conceptual and methodological aspects of medical geography. Despite being a geographer, Sorre incorporated biological contents in the study of medical geography. He asserts in 1933, "over the past 25 years, progress in biology has led to new insights in medical geography"5 (Sorre, 1933). The determining factors for the spatial expansion of endemic diseases have appeared to be much more complex than they had believed to be. He emphasised that human beings can have a determining effect both on the occurrence and on the disappearance of endemic diseases. Here Sorre was more concerned with socio-cultural aspect. While distinguishing diseases on the basis of physical, biological and anthropogeographical factors, Sorre stated in just one sentence, "The number of diseases which can be shown to be directly linked to climatic conditions (atmospheric conditions) is very limited"6. J.M. May took four pages in his article of 1950 to conclude the same; well of course with more relevant examples based on his experience in the tropical world, and his communication with D.H.K. Lee who according to May, "analyzes the scientific study of the influence of climate on man" (May, 1950).

7M. Sorre was one of the very few who were closest to Vidal de la Blache. It was natural that Sorre developed that ecological paradigm in medical geography by incorporating both physical and social milieu. Sorre has taken up an interesting aspect i.e "genre de vie" (the specific pattern of life of a community in its geographical set up), which is responsible for the differences in the risks of infections among human beings.

8M. Sorre used the term "complexes" instead of "association". The term "complex" according to M. Sorre is more general and prevents its users from thinking that there is any kind of finality in the formation of those complexes. These groups (complexes) are formed by all kinds of organisms, at all stages of differentiation, and inside them (human beings), they are both agents and patients. Sorre called these complexes "pathogenic" because their existence and their activity have led men to suffer from the disease.

9M. Sorre highlighted the difficulty to present classification of those complexes. He classify them into the following groups: Simple types: Those are complexes with only two factors: man and fungus or a worm. Examples of numerous skin diseases may be cited. Complex types: Which have three or more factors. This is often the case with complexes that include worms, as very often domestic animals come into the picture. Most often, according to Sorre, there is then a superposition of parasitism, where a worm can live both on human beings and on animals, thus extending the cycle.

Sorre’s disease distribution map

10Regarding the disease distribution maps, M. Sorre's book of 1943 contains a number of world maps showing the distribution of breeding places, great endemic regions, and the distribution of filariasis, bilharziasis, leishmaniasis and rickettsiasis. These maps were prepared on the basis of smaller units-smaller than the country, in order to explain the geographical distribution of diseases at global level.

11In his methodical report entitled: Principes de Cartographie Appliquée à L'Ecologie Humaine, submitted to the International Geographical Union Commission on Medical Geography in 1952, M. Sorre commented critically on the disease distribution maps published by J.M. May in The Geographical Review during 1950-1951 (Sorre,1978). In his report Sorre appreciated J.M. May for using Briesemeister elliptical equal area projection for his disease distribution maps at global level but criticised him for chosing shading pattern in the index of cholera distribution map: "Dans les cartes du choléra dressées par le Dr. May, on a avec raison indiqué au moyen d'une teinte les surfaces supérieures à 500 mètres, et cette notation est utile, mais la teinte neutre gagnerait à être légèrement accentuée."(Sorre, 1978)

12Sorre was of the opinion that a world atlas or a regional atlas of human ecology should be prepared with medical geography playing a central role. According to Sorre, a work like a world atlas demands an immense documentation. He, therefore, suggested an international collaboration between International Geographical Union and the World Health Organization and the UNESCO, Rockefeller Foundation, and the Pasteur Institute.

Was J.M. May aware of Max Sorre’s work?

On J.M. May’s antecedents

13There has been no critical evaluation of the work of J.M. May, although some scholars did refer to the controversy regarding the concept of geogens and pathogens propounded by May. A.T.A. Learmonth was the first western geographer who conclusively stated that J.M. May borrowed the idea of a disease complex or pathogenic complex from Maximilien Sorre's great Les Fondements de la Géographie Humaine (1951) (Learmonth, 1988). It is surprising to note that Learmonth cited Sorre's later work- reprint of the book published in 1951, after the publication of J.M. May's paper in 1950 (May, 1950). Learmonth should have quoted from Sorre's 1933 paper (Sorre, 1933). Similarly G.F. Pyle, an American medical geographer, highlighted J.M. May's contribution to medical geography significantly, and asserts that, "the earlier contribution of Max Sorre, a French geographer, more concerned with cultural complexes and disease ecology, were largely ignored by American geographers in their subsequent and various interpretations of May's statements" (Pyle, 1983). It should be mentioned here that Max Sorre died in 1962, and the reprint of 1978, as quoted by Pyle has not the full gist of his analysis of his essay of 1952 in 1933 paper. Even J.M. Hunter's seminal introduction of 1974 begins with the reference of May's 1950 paper, with no mention of M. Sorre (Hunter, 1974 ).

14In a chapter that deals with the development of medical geography in France, Yola Verhasselt, a Belgian medical geographer, and a former chairperson, IGU Commission on Health and Development, asserts that most prominent geographer who made a substantial contribution to the progress of medical geography in France is Maximilien Sorre. "In his extensive study on human geography he developed the essential notion of a pathogenic complex as an ecological way of thinking. Later in his first volume on human geography (Sorre, 1943), Sorre devotes a first chapter to climate and man, studying the relationship between climatic elements and human organic functions. His second chapter describes the living environment and human nutrition, establishing the base of a geography of nutrition; the third, the human organism in struggle with the living environment. In this chapter on medical geography Sorre analyses pathogenic complexes as links between environment and transmission processes of tropical diseases, such as trypanosomiasis, malaria and yellow fever. The distribution of diseases is treated as a zonal pathology with a distinction between Atlantic, Pacific and Asian areas. The work of Sorre is an ecological approach to human geography, in a sense of human ecology, long before this became a widespread scientific movement." (Verhasselt, 1983)

15The general comments made by these scholars regarding the originality of the concept of pathogenic complexes were not taken seriously until the publication of F.A. Barrett's book entitled: Disease and Geography: The History of an Idea (2000). In his book Barrett questioned as to why J.M. May had ignored the 1933 work of his fellow countryman and a geographer- M.Sorre, in his first paper on medical geography published in 1950.


  • 7 On the basis of information contained in the Minutes of the meetings of the American Geographical S (...)
  • 8 The author of this paper obtained the list of members of the delegation from the Archives of the Am (...)
  • 9 It is worthwhile to mention that M. Sorre was President (Rector) of the University at Clermont-Ferr (...)

16Was J.M. May aware of Max Sorres’work? The answer is probably yes. J.M. May was very well aware about Sorre's contribution to medical geography. Two instances may be cited. Firstly in his first paper on Medical Geography:Its Methods and Objectives, published in 1950, May had included under basic references M. Sorre's book: Les Fondements de la Géographie Humaine, Vol. I : Les fondements biologiques : essai d'une écologie de l'homme, 1947 edition (first published in 1943), but ignored to cite Sorre's basic paper of 1933. It is interesting to note that May in his 1950 paper quoted a number of references in the text, including some French medical contributions such as S. Gard on the epidemiology of the poliomyelitis, and J. Casaux and E. Houdemer, on human and animal sparganosis, but no mention was made of Sorre's work in the main text of the paper. It is not believable that J.M. May did not knew the fundamental contribution of 1933 by M. Sorre in Medical Geography. Secondly, the minutes of the American Geographical Society7 of 1949 reveal that in the month of June 1949, a tea was held in honour of a visiting group of members of the Société de Géographie de Lille, France8. M. Sorre who was Professor of Geography at Sorbonne in 1949, had been Professor of Geography at Lille9. It is just impossible to think that this group of geographers had had no interaction with J.M. May (originally a French physician working at the Society) on the subject of medical geography, and contribution of M.Sorre in medical geography.

J.M. May and the American Geographical Society

  • 10 It is to be noted that the meeting of the Steering Committee on Medical Geography of the American G (...)

17Another evidence comes from the minutes of the meeting of the American Geographical Society, which was held in 1949, in which details were outlined about the joining of the Society by J.M. May on 15th of November 1948. It was wrongly mentioned that till date no geographical centre attempted research in medical geography: "The programme of studies in medical geography described in October, 1944 issue of the Geographical Review (pp.642-652) was formally inaugurated on November 15, 1948 when Dr. Jacques M. May took charge10. He will set forth the order and character of the investigations to be pursued and enter personally upon some of them. Though some exploration has been carried in the geographical aspects of medicine, never before has this been done under geographical direction" (Minutes, 1949). Frank Barrett, a Canadian medical geographer commented on this statement of American Geographical Society, in his book: Disease and Geography, that, "This is a significant point. Throughout this book, it has been repeatedly pointed out that it was physicians and not geographers who had made the major contributions. Now for the first time a geographical society was the initiater". (Barrett, 2000) It is undoubtedly clear that M. Sorre was the first geographer and the Department of Geography, University of Lille was the first where medical geography research was attempted by a Geographer way back in early 1930s. Moreover, May was not a geographer by training. He was conducting research independenly with no collaboration or supervision by a geographer. The Society's name was just for namesake. Barrett himself noted that at the time of the publication of the book: American Geography:Inventory and Prospects (1954), all chapters barring the chapter on Medical Geography, were edited by a Committee (Barrett, 2000, p.455). It would be interesting to note that in the chapter written on medical geography by J.M. May, was a revised version of his own 1950 article, and most of the old references including the reference of M. Sorre (1947 edition of the book), which was under basic references in May's 1950 paper, were also deleted.


18It is evident from the above discussion that it was Max. Sorre who should have been credited to have developed the basic concept of pathogenic complexes as well as the theme of geography of food and nutrition. As outlined in his paper published in 1933, and later he developed these ideas further in his book published in 1943. Despite the fact that J.M. May was very well aware of Sorre's fundamental work, May deliberately ignored it so as to present these ideas as his own, to become the first conceptual and methodological contributor in the emerging field of medical geography. American Geographical Society was also incorrectly informed by J.M. May that no geographical centre has attempted studies in medical geography, so as to give full credit to the Society as the sole centre where research in medical geography is being conducted.

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American Geographical Society (1949), Minutes of the American Geographical Society, Geographical Review, Vol.39, p.145.

American Geographical Society (1944), A proposed atlas of diseases; Minutes of the meeting of the American Geographical Society, Geographical Review, Vol.34, p.647.

Barrett F.A. (2000), Disease and Geography: The History of An Idea, Toranto.

Crone G.R. (1963), M.Sorre, Geographical Journal, Vol.29, p.128.

de Martonne E. (1924), Geography of France, American Geographical Society, New York, p.30.

George P. (1962), La vie et l'oeuvre de Max Sorre, Annales de Géographie, No.387, Sept.-Oct., p.454.

Hunter J.M. (1974), The challenge of medical geography, In J.M. Hunter (ed), The Geography of Health and Disease, Studies in Geography series no. 6, Dept. of Geography, University of North Carolina at Chapel Hill, pp.1-31.

Learmonth A.(1988). Disease Ecology, Basil Blackwell, Oxford, p.8.

May J.M. (1950 ), Medical geography: Its methods and objectives, Geographical Review, Vol.40, pp.9-41.

May J.M. (1954), Medical geography, In P.E. James, and C.F. Jones, (eds), American Geography: Inventory and Prospects, Syracuse, pp.453-468.

Murray M.A. (1974), The geography of chronic diseases, In J. M. Hunter (ed), The Geography of Health and Disease , op. cit., p.106.

Piery M.(1934), Traité de Climatologie Biologique et Médicale, Paris, Masson.

Pyle G.F. (1983), Medical geography in the United States, In N.D. McGlashan and J.R. Blunden (eds), Geographical Aspects of Health, Academic Press, London, p.83.

Sorre M. (1933), Complexes pathogènes et géographie médicale, Annales de Géographie, No.235, January, pp.1-18.

Sorre M. (1943), Les Fondements de la Géographie Humaine, Vol. I : Les Fondements Biologiques :Essai d’une Ecocologie de l' Homme, Librairie Armand Colin, Paris.

Sorre M. (1962), The geography of diet, In P.L. Wagner and M.W. Mikesell (eds), Readings in Cultural Geography, Chicago, pp.445-456.

Sorre M. (1978), Principes de cartographie appliquée à l'écologie humaine, Social Science & Medicine, Vol.12D, pp.238-250 (Report submitted to the IGU Commission on Medical Geography, by M.Sorre in 1952).

Thouez J-P. (1983), Jacques M. May, In T.W. Freeman, and Ph. Pinchemel, (eds), Geographers/Geographes, British Institute of Geographers, BIT and CNRS, Centre National de la Recherche Scientifique, 6, pp.85-88.

Verhasselt Y.(1983), The geography of health in France and in Benelux countries, In N.D. McGlashan and J.R. Blunden (eds), Geographical Aspects of Health, Academic Press, London, pp.63-64.

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1 J.M. May was born in Paris on January 27,1896, and took his preliminary degrees at the Sorbonne (1913-14) and after service in World War I received his medical degree from the University of Paris in 1925. He received in 1932 a three-year appointment as chief surgeon in the French Mission Hospital in Bangkok. He had also served as chief surgeon in French West Indies. J.M. May came to the United States in 1947, and in 1948 joined the American Geographical Society as Head, Medical Geography section.

2 Maximilien Sorre had served in a number of universities including the University of Lille,and famous university at Sorbonne in Paris. He was a student of Vidal de la Blache, and it is natural that he incorporated his Master's ideas in his geographical work. He developed the framework of Biological Geography. He wrote his doctoral dissertation entitled: Les Pyrénées Méditerranéennes: Etude de Géographie Biologique, in 1913. He began publishing his scientific works on L'organisme humain et le milieu biologique naturel, L' organisme humain et le milieu géographique, L'organisme humain et le climat, in the Bulletin de la Société de Géographie de Lille, during the period 1926-1929. He published his conceptual and methodical paper on "Complexes pathogènes et géographie médicale" in 1933, in Annales de Geographie. His book on Les Fondements de la Géographie Humaine, Vol. I: Les Fondements Biologiques was first published in 1943.

3 « [Ces complexes manifestent] une dépendance plus ou moins marquée à l’égard des conditions de milieu. En général, l’agent vecteur présente la plus grande sensibilité, et ses exigences jouent le rôle déterminant dans l’écologie du complexe. Son influence ne s’exerce pas seule : les conditions de vie du germe pathogène, des variations saisonnières, géographiques ou ethniques de l’organisme humain doivent être prises en considération. » (p. 14)

4 « [la notion de complexe pathogène est] une sotion susceptible de servir de fondement à l’une des parties les plus vastes de la géographie médicale. L’aire d’extension d’une maladie endémique ou épidémique, c’est l’aire d’extension d’un complexe pathogène. Expliquer cette aire d’extension, ses mouvements de contraction ou de dilatation, c’est, d’abord, résoudre un problème d’écologie, démarche fondamentale en géographie biologique. C’est, ensuite, rechercher les circonstances extérieures qui favorisent ou contrarient la constitution du complexe ou son maintien. […] on s’aperçoit que la plupart de ces circonstances relèvent de la géographie humaine : densité de population, migrations, genre de vie. Pour les étudier, nous n’avons pas besoin de prendre une autre attitude d’esprit que celle qui nous est familière. Avec l’introduction de la notion de complexe pathogène, nous nous trouvons donc en possession d’un point de vue et d’une méthode. » (p. 18)

5 « Les acquisitions de la biologie générale au cours des trois derniers quarts de siècle ont amené un changement de position à l’égard de la géographie médicale. » (p. 1)

6 « Le nombre de maladies que nous pouvons mettre en relation directe avec le climat, c’est-à-dire avec l’ensemble des propriétés de l’atmosphère, est très limité. » (p. 1)

7 On the basis of information contained in the Minutes of the meetings of the American Geographical Society, and the unpublished information obtained from Society's archives, it emerged that Dr. R.U. Light, a surgeon and the President of American Geographical Society at the time when J.M. May joined the Society, was very much interested in J.M. May joining the Society. It may be recalled that R.U. Light wrote a paper in medical geography entitled: "The progress of medical geography", published in The Geographical Review in 1944 (Vol.34, pp.36-41). R.U. Light (R.Upjohn Light) was also owner of one UPJOHN pharmaceutical company. It is this Company that granted financial assistance of $1500 for the studies in medical geography during 1948-1949. There is a good scope of research in historical medical geography as to why R.Upjohn Light was keen in appointing J.M. May as Head of Medical Geography Section, despite unfavourable comments by other members of the Society. The website of this company is:

8 The author of this paper obtained the list of members of the delegation from the Archives of the American Geographical Society, New York, and discussed it with geographers in Paris, particularly with Alain Vaguet of the University of Rouen, who served the Dept. of Geography at Lille, during my November/December 2001 visit to France. I was informed that the delegation does not comprise prominent geographers from Lille. Besides the American Geographical Society could not provide any record of information about the discussions between J.M. May and the Lille delegation.

9 It is worthwhile to mention that M. Sorre was President (Rector) of the University at Clermont-Ferrand in 1933 when his monumental paper on medical geography was published.

10 It is to be noted that the meeting of the Steering Committee on Medical Geography of the American Geographical Society, in which J.M.May, has outlined his plan and programme of research in medical geography, was held on January 21, 1949. According to May medical geography could be conceived in terms of the geographical influences on disease or of the pathological aspects of the various geographical regions. In contrast to what J.M. May had proposed in 1949, M.Sorre, in 1933, outlined in a clear manner that the occurrence of diseases may be dependent on physical, biological and social factors: those which depend mainly on the climate, those which depend mainly on the natural biological environment (milieu), those which depend mainly on anthropogeographical environment (milieu).

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Rais Akhtar, « Medical geography: has J.M. May borrowed M. Sorre's 1933 concept of pathogenic complexes? », Cybergeo: European Journal of Geography [En ligne], Epistémologie, Histoire de la Géographie, Didactique, document 236, mis en ligne le 12 mars 2003, consulté le 01 avril 2023. URL : ; DOI :

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Rais Akhtar

Professor of Geography, University of Kashmir, Srinagar 190006 J&K, India

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