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Genital Manifestations in Early Filariasis1
GENITAL MANIFESTATIONS IN EARLY FILARIASIS1 EDWARD W. BEACH
Prior to World War II filariasis held little brief for the urologist who vaguely recalled a few facts: 1) The disease is a parasitic infestation of the lymphatic system due to a species of worm (Wuchereria bancrofti) carried by mosquitoes; 2) filariasis is common in tropical countries, notably: India, South China, some Pacific Islands, and indigenous to most subtropical areas such as Charleston, U.S. A., southern Spain and Brisbane, Australia; 3) that filariasis is characterized by elephantiasis. These sketchy concepts were changed during the Pacific campaign when filariasis rose from the museum of medical curiosities to the key position of menace to our troops. Thousands of men stationed in these areas complained of subjective symptoms and developed objective signs similar to those Buxton described under the native term "Mumu" (which means red). Any extraordinary physical effort caused an exacerbation of symptoms and these men were rendered useless for combat duty and jungle warfare, so that many were returned to the States. Genital manifestations were common and recurrent so that the urologist had to be on the qui vive and took much interest in this strange malady. The granulomatous nature of "Mumu" must be kept in mind as the adenopathy which characterizes this ailment may be confused, clinically and histologically, with lues, tuberculosis or early Hodgkin's disease. Most of the men previously stationed in endemic areas now live in these United States and recurrence may be anticipated. Since civilian urologists will not have had an opportunity to examine such patients, it is timely to review the subject and to take particular note of the genital manifestations. HISTORICAL BACKGROUND
Early in 1943, we 2 landed in Noumea, New Caledonia, and set up a hospital under canvas for the care of Marine personnel (mostly Marine Raiders). At first we were concerned with returning combat troops and rehabilitation work, but in May a Marine battalion came from the Russell Island campaign. Many of these men were suffering from a peculiar symptom complex which we had not previously seen. The subjective complaints were similar in nature and had affected about half of the men in this battalion. These complaints were very bitter and seemed out of all proportion when compared with the objective findings which were slight. Because of this strange symptom complex over 125 men in this group had already been surveyed. We were ordered to undertake thorough study in an effort to solve the problem, and while every Navy facility on the Island was placed at our disposal for this purpose, our laboratory facilities were necessarily limited. 1 Read before Western Section, American Urological Association, Yosemite, Calif., May 21-23, 1947. 2 Unit of 35 Navy Medical Officers, assigned to Fleet Marine Force, San Diego, attached to an auxilliary Marine Medical Battalion for overseas duty.
371
372
EDWARD W. BEACH
In this battalion of about 385 men, 160 complained grievously and showed subjective signs. It is significant that these men had all been trained, and remained approximately 5 months in the Samoan area: American Samoa, British Samoa and Wallis Island. During that period they lived in close contact and were intimate with the natives among whom the instance of filariasis is very high. Despite the fact that it had been reported a white man living in Samoan territory had never developed filariasis, we suspected early filariasis. SEARCH FOR AND DISCOVERY OF FILARIA BANCROFT!
Neither the presence of the adult worm nor the microfilaria had ever been demonstrated in the tissues of a white man. In all men suspected of having filariasis, blood smears were taken and patients were watched for 24 hours to establish the presence of filaria and possible periodicity for the disease. In some 800 smears the blood examinations for filaria were negative. Manson established the fact that this Pacific type of filariasis was unique in that it displayed no periodicity. From the inguinal region, near the femoral ring and in the axilla, palpable and tender lymph glands were removed and sectioned for histologic study by pathologists.3 No adult worm or microfilaria were found in these specimens. Many of these enlarged lymph glands were aspirated and the fluid surveyed for microfilaria. All findings were negative. X-ray studies of several very large lymph glands failed to show the presence of encysted or calcified adult worm. An antigen, using the Dirofilaria immitis (heart worm of the native dog) was prepared for us, 3 and specific antigen was sent us by the Commission on Filariasis at Samoa. Fifty of these troops, suspected of filariasis, were tested with this antigen against 50 controls (men who had never been below the MasonDixon line or near Samoa). Results were inconclusive since over half, 31, of the controls were strongly positive, and only 22 of the suspects proved positive. At this time we had 9 men hospitalized because of acute vasitis. All studies of aspirated hydrocele fluid, from these cases, were negative and did not reveal the presence of microfilaria. We then decided to expose the vas in high scrotal position in 5 cases. All injected tissues, including lymphatic vessels, were stripped off the vas proper, for perhaps 2 inches, and removed .. These specimens were studied and microfilaria were discovered and identified in 3 cases. This was the first indisputable evidence we had that these men suffered from early filariasis. Since this group had been stationed in the Samoan area and all presented the same clinical symptoms, the mystery was solved. CONSTITUTIONAL MANIFESTATOINS
Early filariasis is manifested by recurrent attacks of lymphangitis associated with adenopathy, at times regional but more often generalized. Onset is usually abrupt and characterized by a transient red or livid streak in the superficial tissues of the upper arm, forearm or leg. This streak faithfully follows the course of the subjacent lymphatic vessel. 3
U.S. Naval Mobile Hospital No. 7.
373
GENITAL MANIFESTATIONS IN EARLY FILARIASIS
At times this lymphangitis appears to be of descending or centrifugal type, and there is temporary swelling in the affected limb, most noticeable in the arm, Soreness and deep-seated aching is complained of in the parts. Recurrent attacks culminate in great thickening and nodosity of the lymph vessels, most frequently noted in the brachia! group. Regional glands may be enlarged, palpable and tender. Table 1 lists the involvement of the various glands in these 160 men suspected of "Mumu". There was no great prostration, no temperature elevation and no increased white count with these attacks of lymphangitis. Most patients had a slight eosinophilia, but since many suffered intestinal parasites, and all had some degree of dermatomycosis ("gook rot") it appeared of little diagnostic value. It is believed that these recurrent attacks of lymphangitis in early filariasis represent a sensitivity response or an allergic phenomena occasioned by toxins TABLE
1 Instances
Glands involved: Both inguinal.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right inguinal group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left inguinal group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Both femoral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right femoral group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left femoral group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Both epitrochlear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right epitrochlear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left epitrochlear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Both axillary glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right axillary group............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left axillary group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Brachial lymph vessels: Both................................................................. Right side... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119 15 13 70 22 16 17 19 20 88 14 30 39 27 12
from the body of the adult worm, captured and retained in the lymphatic system at some distant point. Elephantiasis is a late development in the disease likely conditioned upon the choked lymphatic system. Much remains to be learned with regard to the life cycle of this parasitic nematode (Wuchereria bancrofti) in the tissues of the host, and also with reference to the defense mechanism of the host in both early and later phases of this infestation. It is remarkable to examine a blood smear from a native, to find the field literally alive with squirming adult forms and yet to have this native manifest no distress or inconvenience prior to the onset of sequelae. GENITAL MANIFESTATIONS
Of the 160 men examined, 37 showed genital implication. Acute vasitis or funiculitis was most common, being unilateral in 16, and bilateral in 3 instances. It began suddenly with pain and tenderness in the structures near the internal
374
EDWARD W. BEACH
ring and in a matter of hours had rapidly descended through the inguinal canal and into the scrotum. The vas seemed twice the usual size because there was symmetrical swelling in the tissues, and it soon became exquisitely tender to palpation. In the recurrent type of vasitis, there was considerable irregularity and thickening, with scattered concentration along the course of the vas, and nodes could be felt. However, the vas was never so large or changed (pipestemmed) as is seen in tuberculosis. When the vas was surgically exposed the swelling and injection seemed limited to the tissues about the vas and the latter per se was not involved. In 2 cases, with bilateral involvement, semen specimens taken during the height of the attack showed many motile, perfectly formed sperm, which again tended to prove that the lumen of the vas was unobstructed thereby. The globus minor was usually tender to palpation during an acute attack of funiculitis, but did not appear to be directly implicated, nor was the body or the globus major of the epididymis. A characteristic finding in these cases was a rolled-up, dough-like mass of tunica vaginalis, just beneath the globus minor, which remained palpable long after the attack had subsided. This mass had a somewhat triangular configuration with apex toward the globus minor. The "sentinel" lymph gland near the epididymis mentioned by Fogel and Huntington3 was not conspicuous in our cases. The testicle on the side affected was always tense, swollen and increased in size, was extraordinarily sensitive to pressure, but in the wake of an attack no atrophic change followed. During an attack there was always an increase in hydrocele fluid, which was grossly clear in all the 10 cases we aspirated for diagnostic purposes. Transitory puffiness of the scrotal tissues on the affected side in several cases was noted at the height of an attack, but rapidly disappeared. These attacks of acute funiculitis usually lasted about 3 or 4 days. There was little elevation of temperature, never over 100°F., no remarkable increase in white count (usually 7 to 8,000), and no evidence of sepsis or severe constitutional reaction. However, there was always a psychic complexion since most of the men were greatly worried about future loss of sexual power and sterility. Obviously, there was no dearth of progeny among the natives, so that these fears were readily allayed. An unusual manifestation in 3 individuals was a lymphangitis of recurrent nature involving the dorsal lymphatics of the penis. One patient suffered 6 attacks during which these red streaks were prominent and the organ temporarily swollen and painful. DIFFERENTIAL DIAGNOSIS
This acute vasitis manifested in early filariasis must be distinguished from subacute appendicitis, incomplete and indirect inguinal hernia, especially when the omentum is included, hydrocele of the cord, varicocele, torsion of the testicle and subacute epididymitis. The blood picture is of diagnostic importance as is the history and the objective findings.
GENITAL MANIFESTATIONS IN EARLY FILARIASIS
375
TREATMENT
At present, the best treatment is early evacuation from the endemic area. None of the many drugs used have proven completely satisfactory. According to Culbertson and Rose the pentavalent antimonial neostibosan is most satisfactory and promising. ·while this drug is well tolerated and quite efficient, its action on the filaria is relatively slow. SUMMARY
Many troops stationed in Pacific areas endemic for filariasis developed a strange symptom complex, and recurrent attacks of lymphangitis with adenopathy were common constitutional manifestations; 1 man in 4 developing acute vasitis or funiculitis. This early filariasis loomed as a menace since it incapacitated our troops. Detailed study was undertaken of 160 Marine Raiders, but at first all search for the adult filaria and microfilaria was uniformly negative. ·when the lymphatics were stripped from the vas, microfilaria was discovered and identified in 3 of the 5 specimens taken from cases of acute funiculitis. Constitutional and genital manifestations of early filariasis are considered in detail. Pending more specific therapy against this parasitic nematode, evacuation of afflicted men from the endemic area proves most effective. 2500 L St., Sacramento, Calif. REFERENCES BUXTON P. A.: Researches in Polynesia and l\!Ielanesia. An account of investigations in Sam~a, Tonga, the Ellice Group and the New Hebrides in 1924, 1925. London School of Hygiene and Tropical Medicine, 1928. MANSON-BAHR, PHILIP H.: Manson's Tropical Diseases. 12 ed., 1945. FOGEL, R. HARWOOD AND HUNTINGTON, R. W., JR.: Genital manifestations in early filariasis. U.S. Naval Med. Bull., 43: 263, 1944. CULBERTSON, J. T. AND RosE, H. l\!I., ET AL.: The experimental chemotherapy of filariasis Bancrofti. The Puerto Rico J. Public Health & Tropical Med., 22: 139, 1946.
Prior to World War II filariasis held little brief for the urologist who vaguely recalled a few facts: 1) The disease is a parasitic infestation of the lymphatic system due to a species of worm (Wuchereria bancrofti) carried by mosquitoes; 2) filariasis is common in tropical countries, notably: India, South China, some Pacific Islands, and indigenous to most subtropical areas such as Charleston, U.S. A., southern Spain and Brisbane, Australia; 3) that filariasis is characterized by elephantiasis. These sketchy concepts were changed during the Pacific campaign when filariasis rose from the museum of medical curiosities to the key position of menace to our troops. Thousands of men stationed in these areas complained of subjective symptoms and developed objective signs similar to those Buxton described under the native term "Mumu" (which means red). Any extraordinary physical effort caused an exacerbation of symptoms and these men were rendered useless for combat duty and jungle warfare, so that many were returned to the States. Genital manifestations were common and recurrent so that the urologist had to be on the qui vive and took much interest in this strange malady. The granulomatous nature of "Mumu" must be kept in mind as the adenopathy which characterizes this ailment may be confused, clinically and histologically, with lues, tuberculosis or early Hodgkin's disease. Most of the men previously stationed in endemic areas now live in these United States and recurrence may be anticipated. Since civilian urologists will not have had an opportunity to examine such patients, it is timely to review the subject and to take particular note of the genital manifestations. HISTORICAL BACKGROUND
Early in 1943, we 2 landed in Noumea, New Caledonia, and set up a hospital under canvas for the care of Marine personnel (mostly Marine Raiders). At first we were concerned with returning combat troops and rehabilitation work, but in May a Marine battalion came from the Russell Island campaign. Many of these men were suffering from a peculiar symptom complex which we had not previously seen. The subjective complaints were similar in nature and had affected about half of the men in this battalion. These complaints were very bitter and seemed out of all proportion when compared with the objective findings which were slight. Because of this strange symptom complex over 125 men in this group had already been surveyed. We were ordered to undertake thorough study in an effort to solve the problem, and while every Navy facility on the Island was placed at our disposal for this purpose, our laboratory facilities were necessarily limited. 1 Read before Western Section, American Urological Association, Yosemite, Calif., May 21-23, 1947. 2 Unit of 35 Navy Medical Officers, assigned to Fleet Marine Force, San Diego, attached to an auxilliary Marine Medical Battalion for overseas duty.
371
372
EDWARD W. BEACH
In this battalion of about 385 men, 160 complained grievously and showed subjective signs. It is significant that these men had all been trained, and remained approximately 5 months in the Samoan area: American Samoa, British Samoa and Wallis Island. During that period they lived in close contact and were intimate with the natives among whom the instance of filariasis is very high. Despite the fact that it had been reported a white man living in Samoan territory had never developed filariasis, we suspected early filariasis. SEARCH FOR AND DISCOVERY OF FILARIA BANCROFT!
Neither the presence of the adult worm nor the microfilaria had ever been demonstrated in the tissues of a white man. In all men suspected of having filariasis, blood smears were taken and patients were watched for 24 hours to establish the presence of filaria and possible periodicity for the disease. In some 800 smears the blood examinations for filaria were negative. Manson established the fact that this Pacific type of filariasis was unique in that it displayed no periodicity. From the inguinal region, near the femoral ring and in the axilla, palpable and tender lymph glands were removed and sectioned for histologic study by pathologists.3 No adult worm or microfilaria were found in these specimens. Many of these enlarged lymph glands were aspirated and the fluid surveyed for microfilaria. All findings were negative. X-ray studies of several very large lymph glands failed to show the presence of encysted or calcified adult worm. An antigen, using the Dirofilaria immitis (heart worm of the native dog) was prepared for us, 3 and specific antigen was sent us by the Commission on Filariasis at Samoa. Fifty of these troops, suspected of filariasis, were tested with this antigen against 50 controls (men who had never been below the MasonDixon line or near Samoa). Results were inconclusive since over half, 31, of the controls were strongly positive, and only 22 of the suspects proved positive. At this time we had 9 men hospitalized because of acute vasitis. All studies of aspirated hydrocele fluid, from these cases, were negative and did not reveal the presence of microfilaria. We then decided to expose the vas in high scrotal position in 5 cases. All injected tissues, including lymphatic vessels, were stripped off the vas proper, for perhaps 2 inches, and removed .. These specimens were studied and microfilaria were discovered and identified in 3 cases. This was the first indisputable evidence we had that these men suffered from early filariasis. Since this group had been stationed in the Samoan area and all presented the same clinical symptoms, the mystery was solved. CONSTITUTIONAL MANIFESTATOINS
Early filariasis is manifested by recurrent attacks of lymphangitis associated with adenopathy, at times regional but more often generalized. Onset is usually abrupt and characterized by a transient red or livid streak in the superficial tissues of the upper arm, forearm or leg. This streak faithfully follows the course of the subjacent lymphatic vessel. 3
U.S. Naval Mobile Hospital No. 7.
373
GENITAL MANIFESTATIONS IN EARLY FILARIASIS
At times this lymphangitis appears to be of descending or centrifugal type, and there is temporary swelling in the affected limb, most noticeable in the arm, Soreness and deep-seated aching is complained of in the parts. Recurrent attacks culminate in great thickening and nodosity of the lymph vessels, most frequently noted in the brachia! group. Regional glands may be enlarged, palpable and tender. Table 1 lists the involvement of the various glands in these 160 men suspected of "Mumu". There was no great prostration, no temperature elevation and no increased white count with these attacks of lymphangitis. Most patients had a slight eosinophilia, but since many suffered intestinal parasites, and all had some degree of dermatomycosis ("gook rot") it appeared of little diagnostic value. It is believed that these recurrent attacks of lymphangitis in early filariasis represent a sensitivity response or an allergic phenomena occasioned by toxins TABLE
1 Instances
Glands involved: Both inguinal.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right inguinal group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left inguinal group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Both femoral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right femoral group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left femoral group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Both epitrochlear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right epitrochlear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left epitrochlear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Both axillary glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Right axillary group............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left axillary group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Brachial lymph vessels: Both................................................................. Right side... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Left side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119 15 13 70 22 16 17 19 20 88 14 30 39 27 12
from the body of the adult worm, captured and retained in the lymphatic system at some distant point. Elephantiasis is a late development in the disease likely conditioned upon the choked lymphatic system. Much remains to be learned with regard to the life cycle of this parasitic nematode (Wuchereria bancrofti) in the tissues of the host, and also with reference to the defense mechanism of the host in both early and later phases of this infestation. It is remarkable to examine a blood smear from a native, to find the field literally alive with squirming adult forms and yet to have this native manifest no distress or inconvenience prior to the onset of sequelae. GENITAL MANIFESTATIONS
Of the 160 men examined, 37 showed genital implication. Acute vasitis or funiculitis was most common, being unilateral in 16, and bilateral in 3 instances. It began suddenly with pain and tenderness in the structures near the internal
374
EDWARD W. BEACH
ring and in a matter of hours had rapidly descended through the inguinal canal and into the scrotum. The vas seemed twice the usual size because there was symmetrical swelling in the tissues, and it soon became exquisitely tender to palpation. In the recurrent type of vasitis, there was considerable irregularity and thickening, with scattered concentration along the course of the vas, and nodes could be felt. However, the vas was never so large or changed (pipestemmed) as is seen in tuberculosis. When the vas was surgically exposed the swelling and injection seemed limited to the tissues about the vas and the latter per se was not involved. In 2 cases, with bilateral involvement, semen specimens taken during the height of the attack showed many motile, perfectly formed sperm, which again tended to prove that the lumen of the vas was unobstructed thereby. The globus minor was usually tender to palpation during an acute attack of funiculitis, but did not appear to be directly implicated, nor was the body or the globus major of the epididymis. A characteristic finding in these cases was a rolled-up, dough-like mass of tunica vaginalis, just beneath the globus minor, which remained palpable long after the attack had subsided. This mass had a somewhat triangular configuration with apex toward the globus minor. The "sentinel" lymph gland near the epididymis mentioned by Fogel and Huntington3 was not conspicuous in our cases. The testicle on the side affected was always tense, swollen and increased in size, was extraordinarily sensitive to pressure, but in the wake of an attack no atrophic change followed. During an attack there was always an increase in hydrocele fluid, which was grossly clear in all the 10 cases we aspirated for diagnostic purposes. Transitory puffiness of the scrotal tissues on the affected side in several cases was noted at the height of an attack, but rapidly disappeared. These attacks of acute funiculitis usually lasted about 3 or 4 days. There was little elevation of temperature, never over 100°F., no remarkable increase in white count (usually 7 to 8,000), and no evidence of sepsis or severe constitutional reaction. However, there was always a psychic complexion since most of the men were greatly worried about future loss of sexual power and sterility. Obviously, there was no dearth of progeny among the natives, so that these fears were readily allayed. An unusual manifestation in 3 individuals was a lymphangitis of recurrent nature involving the dorsal lymphatics of the penis. One patient suffered 6 attacks during which these red streaks were prominent and the organ temporarily swollen and painful. DIFFERENTIAL DIAGNOSIS
This acute vasitis manifested in early filariasis must be distinguished from subacute appendicitis, incomplete and indirect inguinal hernia, especially when the omentum is included, hydrocele of the cord, varicocele, torsion of the testicle and subacute epididymitis. The blood picture is of diagnostic importance as is the history and the objective findings.
GENITAL MANIFESTATIONS IN EARLY FILARIASIS
375
TREATMENT
At present, the best treatment is early evacuation from the endemic area. None of the many drugs used have proven completely satisfactory. According to Culbertson and Rose the pentavalent antimonial neostibosan is most satisfactory and promising. ·while this drug is well tolerated and quite efficient, its action on the filaria is relatively slow. SUMMARY
Many troops stationed in Pacific areas endemic for filariasis developed a strange symptom complex, and recurrent attacks of lymphangitis with adenopathy were common constitutional manifestations; 1 man in 4 developing acute vasitis or funiculitis. This early filariasis loomed as a menace since it incapacitated our troops. Detailed study was undertaken of 160 Marine Raiders, but at first all search for the adult filaria and microfilaria was uniformly negative. ·when the lymphatics were stripped from the vas, microfilaria was discovered and identified in 3 of the 5 specimens taken from cases of acute funiculitis. Constitutional and genital manifestations of early filariasis are considered in detail. Pending more specific therapy against this parasitic nematode, evacuation of afflicted men from the endemic area proves most effective. 2500 L St., Sacramento, Calif. REFERENCES BUXTON P. A.: Researches in Polynesia and l\!Ielanesia. An account of investigations in Sam~a, Tonga, the Ellice Group and the New Hebrides in 1924, 1925. London School of Hygiene and Tropical Medicine, 1928. MANSON-BAHR, PHILIP H.: Manson's Tropical Diseases. 12 ed., 1945. FOGEL, R. HARWOOD AND HUNTINGTON, R. W., JR.: Genital manifestations in early filariasis. U.S. Naval Med. Bull., 43: 263, 1944. CULBERTSON, J. T. AND RosE, H. l\!I., ET AL.: The experimental chemotherapy of filariasis Bancrofti. The Puerto Rico J. Public Health & Tropical Med., 22: 139, 1946.