I I

Lymphogranuloma Inguinale

7

Volume VII . Thursday, May 14, 1936 Number 28 1 UNIVERSITY OF Mr~SOTA HOSPITALS Volume VII Thursday, May 14, 1936 Number 28

I. ABSTRACT

LYMPHOGRANULOMA INGUINALE ••••••••••• 330 - 337

I I. CASE REPORTS ••••••• •• ., ,••• • • • ",333 - 334

III• LAST WEEK •• •. •. •• .. ••••,• ,. •, • •. •• • 338

IV. MOVIE.. ••••• •. •• .. .. •. •••••• ., .. • •. • 338

c 0 U R T E b Y 0 F CIT I ZEN SA IDS 0 C lET Y 330 r I. ABSTRACT Confusing Terms LYMPHOGRANULOMA INGUInALE The relationship of lymphogranuloma (Lymphopathia Ve~-~ inguinale to granuloma inguinale, syphilis tuberculosis, Hodgkin's disease, chancroi­ J. W. Tedder dal bubo., tularemia, pyogenic infections, and in certa.in parts of the world, bubonic Historical plague, has been clearly defined. Pre­ viously, many cases of this disease have, r Lymphogranuloma inguinale is a chronic no doubt, been classified and treated as low grade inflammation of the lyn~hatic tllberculosis or syphilis. It is well to nodes, of venereal origin, resulting in further differentiate lymphogranuloma complications of fistulae, esthiomene, or inguinale from granuloma inguinale. Their anorectal syndrome in an estimated 50% greatest s imile,rit y is in name. The lat.. of infected persons. This clinical pic­ ter disease must be remembered as one of ture has been described under a variety the skin and subcutaneous tissues and the of titles since the middle of the 19th Donovan bodies are found in scrapings fron Century. How long previous to this time the lesion. Their only relationship is the disease has existed cannot be definite­ that both are disseminated by venereal ly stated. Coutts interestingly traces contacts. reports of a similar condition which was known to the Greeks and Romans as "pannus" The term, lymphogranulomatosis, or llinguen" and to the Arabs as llal...thun." (Hodgkin's disease) is also confused with Incan pottery depicts lesions very much lymphogranuloma inguinale where their like our present day genito-anorectal similarity is limited to their names. syndrome. According to some authors, the disease was common among Negro women in 1 Africa long before the discovery of Bacteriology and Etiology i. America. "" The filterable virus thought to be responsible for lymphogranuloma inguinale Synonyms h~s been the subject of much study.. It has been successfully transmitted to apes, Durand, Nicoles and Farve, in 1913, mice, rabbits and other laboratory animals and again in 1922, recognized and pointed In the ape, the virus appears to have a out the specificity of this disease, and special affinity for the central nervous its probable venereal origin and described system tissue where it causes an en­ it as llsubacute inguinal lymphogranulo­ cephalitis. After passage through apes, matosis." Previous to this time and it has been used to reinoculate human • subsequently, this entity has been de­ paralytic pa.tients. The fact that the scribed under a variety of titles, in­ nerve tissue in apes is involved proves cluding climatic bubo, tropical bubo, that the virus does not limit its actions non-venereal bubo, subacute inguinal to the lymphatic tissue. The virus loses poroadenitis, the fourth venereal. disease, its virulence very rapidly in glycerine, strumous bubo of the groin, non-tuber­ but retains it for 22 days in the frozen culous granulomatous lymphadenitis, sub­ state. acute lymphadenitis, maladie de Nicolas­ Farve, hypertrophic bubo, and l~rmpho­ That the disease is predominately one p<-,thia venere~. This last name, l~rmpho­ of venereal origin cannot be doubted. pathia venereum, was suggested by Wolf and Nichols reported the cate of 3 soldiers Sulzberger in 1932, and much can be said exposed to the same source, all of whom in its favor. The older and better known developed lymphogranuloma inguinale. One name has a confusing resemblance to that of the soldiers was married, and subse­ of other diseases and does not embrace quently infected his wife. Cases are the various extra-inguinal localizations known in which the female acts as a host now recognized as being of identical for the virus and can infect exposed part­ etiology. ners without developing either clinical I f 331 I signs of the disease or a positive Frei Qther diseases that must be considered r test. in every case of inguinal adenopathy are ­ syphilis, chancroid, granuloma inguinale, Hellerstrom reports the case of a tuberculosis, Hodgkin's disease, tularemia young surgeon who in 1904 acquired an in­ and pyogenic infections. In the case of fected finger, through a traumatic wound, syphilis, either the chancre or signs of while operating upon a patient with in­ its past existence can be located, the guinal adenitis of unknown origin. The nodes are sharply defined, hard and pain­ axillary nodes later became enlarged and less, and rarely suppurate unless compli­ r fluctuating. Extirpation was necessary. cated by other infections. The dark field 1 Years later, in 1927, Hellerstrom did a examination and repeated Wassermann test Frei test on this individual and found it are the deciding factor. Granuloma to be strongly positive. inguinale, as stated before, is a skin and subcutaneous disease of venereal ori­ The earliest cases of lymphogranuloma gin. Chancroids and their accompanying inguinale reported were in two children. gland changes are probably the most diffi­ The first was a girl of 8 years who cult to differentiate from lymphogranuloma developed rectal manifestations. The inguinale. It must be remembered that second was a ~egro girl of 10 years who the primary lesion is on the penis, and r reported to the hospital with an adenitis. the glands are secondary in chancroids, ., i While under observation, the Frei test while this is not true in lymphogranuloma became positive. The child's mother and inguinale. The type of suppuration a boarder in the home had positive Frei occurring in the lymph glands also differ­ tests. The husband's test ~as negative. entiates the two diseases. In the acute painful adenopathy associated with chan­ Several extragenital cases h~ve been croids, there is typically a massive , reported involving the oral cavity with suppuration, while in lymphogranuloma 4 I subsequent cervical adenopathy and fis­ inguinale the nodes are less acutely in­ I I. tulae. In these cases, after being con·­ flamed and less painful and there are f- fronted with positive Frei tests, a multiple foci of suppuration. The bacil­ history of irregular sex habits were ob­ lus Ducrey can be found in smears of the tained. chancroid, and later there is a positive r Ito-Reenstierna reaction. (Unfortunately, Cases reported by Curth, and by neither the m~terial for this test nor Buschke and Curth, had the primary lesion Delmoc's vaccine for the treatment of of lymphogranulo~~ in5~inale on the chancroid can be obtained in the United tongue. Later, the cervical glands were States because of existing import laws.) enlarged and fistulae developed. The Tuberculosis and Hodgkin's disease are reaction at the site of primary inocula­ usually of a more generalized distribution tion appears to be greater in these cases and if sections are made, should offer th~n when the primary lesion develops on little diagnostic difficulty. Tularemia the penis. Here, the early lesions ere and pyogenic lymphopathies reveal their co"olperable with the esthiomene and point of origin to the careful examiner. elephantiasis of the vulvae. r 1 fJ J Differential Diagllosis 1 The greatest individual aids towards In the differential dinbnosis of the correct diagnosis of the (lisease lyrl1:Jhogranuloma inguinale, the history of entity now recognized and diagnosed as ~h6 temporary presencre of a suall inocuous­ lymphogranuloma inguinale are: (1) its E..ppearing lesion on the glans penis 3 to recog:nization as 'a specific disease of 10 days subsequent to sexual contacts, venereal origin, and (2) the discovery and followed by an inguinal adenitis, in by W. Frei of a specific diagnostic test. from 10 to 30 days should immediately

) excite one's suspicions to the diagnosis The material for the preparation of .. of this disease• the Frei antigen is obtained from the I 332 r suppureting glandular tissue of a known Evaluation of Laboratory Tests I case of lymphogranuloma inguinale. This r material must be obtained under aseptic By the judicial use of Frei antigen, r conditions and it is preferable that the the diagnosis of lymphogranuloma inguinale j subject h~s not had any other venereal can be satisfactorily made. . It must be disease. The material may be obtaine4 realized that the lim~tations of the Frei by aspiration or incision. Following its test are the same as those of other bio­ collection in sterile containers it is logic tests, that is the presence of a placed in the sterilizer pt 60oC'for 2 positive Frei test does not always classi­ hours the first day, and for 1 hour the fy the disease under observation because 0 second day. Following sterilization, ,con­ the fact that a previously acqui~ed in­ trol cultures are made and if no growth fection could account forthe positive re­ occurs, the material is diluted with from action. 5 to 10 parts of sterile normal saline, depending upon its thickness. The antigen It is well to remember that the very is then placed in sterile ampules for early case of lymphogranuloma inguinale future use. The virulence and specificity will not give a positive Frei test. It iE of the newly prepared antigen should be believed by some authorities that the tested upon a known case of lymphogranu­ test does not become positive until the loma inguinale and upon a control. The glands have increased in size and become patient from whom the antigen W&s made fused to the skin. A more probable ex­ cannot be used for this test of specificity. p~anation is that the test becomes posi­ The technic of the Frei test consists of tive only after the petient's allergic the intracutaneous injection of 0.1 cc. mechanism has been stimulated. of the antigen. The reading is made in from 36 to 72 hours. If positive, there Early cases of lymphogranuloma in­ will be an elevated erythema several guinale have a tendency to cause a false millimeters in diameter. In strongly positive Wassermann reaction. Many cases positive individuals, small areas of ne­ have been treated as syphilis on the basi~ crosis may occur, of these tests. If there is no evidence of a chancre, Was~ermann tests shuuld be Frei antigen prepared as outlined r repeated several times before treatment above, and kept sterile, may retain its is started. potency for as long as 6 months or a year, but one must continuously test its viru­ Several investigators heve found thet lence upon known cases and its sterility the serum of early cases of lymphogranu­ by cultural methods. The ·first Frei anti­ loma inguinale when injected intracutan­ gen prepared here in 1933 from a case in eously into a known case gives a positive the Minneapolis General Hospital was suc­ test, but this could not be repeated by cessfully used for over one year. Due to other workers, contamination, its further use was dis­ continued. Once the Frei test becomes positive, it remains so for life, ~roviding. of Frei antigen prepared from the brains course, that the patient s allergic statur of mice infected with the virus of lympho­ is not disturbed by infection or lowered It granuloma inguinale were found to be un­ resistance. In such cases, a known i I suitable for routine diagnosis by Strauss positive Frei test may become negptive. and Howard. They found that the brain emulsion from non-infected mice gave a reaction that is indistinguishable from a Clinical Course and Incidence true positive test. The nature of this reaction is unknown. This perhaps can The clinical course of l:rmphogranulo­ account for several unaccountable reac­ ma inguinale begins with the initial le­ tions we have seen here after using the sion, usually on the gle~s penis or in the commercially prepared antigen. urethra in the male, and on the,external • 333

or internal genitalia in the female. The this, these vessels become thrombosed primary lesion may be anyone of four types, and result in inflammatory changes fol­ as described by Phylactos: lowed by scar tissue formation with narrowing of the rectal lumen. These r 1. Herpetic type che~ges occur for the greater part in 2. Ulcerative type the lower 6 em. of the rectum and rarely 3. Nodular type extend higher than 10 cm. Occasional 4. A specific urethritis cases have been reported by Hevaditi and Revant in which the rectum of homo­ -~ All of these lesions may be transitory sexual males have been involved. i, and pass unnoticed by the infected individua.l. Seneque concludes that there are 4 types of lymphogranulomatosus stric­ Within from 5 to 30 days after tures of the rectum. eA~osure, the patient becomes aware ofa gradual enlargement of the inguinal 1. A pure stricture limited to the nodes. His attention may be directed to rectum. this condition by the limitation of mo­ .2. A rectal stricture with tion of the lower extremity rather than elephantiasis of the external parts. by pain. 3. Rectal stricture complicated by fistulae, and formally classified In the male, the inguinal adenopathy as tuberculosis, even when Koch is accounted for by the fact that the bacillus was not found. inguinal nodes and the deep iliac nodes 4. Rectal strictures with pelVic drain the genital regions. The female cellulitis. genitalia drain directly to the lymph I. I' pleA~ses about the rect1~, With the ex­ These tJ~es, therefore, include anorec­ ception of the clitoris and external tal syphiloma with stricture of vulvae that drain to the inguinal nodes. Fournier and esthiomene. (Chronic ulcer This accounts for the difference in the of vulva with elephantiasis.) clinical picture presented ~ the male and female and explains the former belief Associated with these glandular

..i that males were more frequently infected changes, which may become generalized, than females. are constitutional signs and symptoms that range from polyarthritis to various Following the development of lymph­ types of skin eruptions such as, erythe­ adenopathy or associated with its occur­ ma multiforme or erythema nodosum. rence, the patient may have an elevation of tempereture associated with malaise, The course of the disease may be anorexia and headache. The Ij~ph nodes very prolonged or the patient may be gradually become matted together and able to overcome the infection with the painful as they increase in size and fuse aid of supportive measures in a short with the overlying skin. After this time. These extremes are well-exempli­ fusion occurs, the skin assumes a reddish­ fied by two pf~tients that we have violet hue described by Phylactos as the observed. "adenite violette" and considered to be very diagnostic. As the tension on the skin increases, it becomes shiny, and II. CASE REPORTS many areas of necrosis develop in the underlying glands. Perforation occurs A white male, 'age 32, unmar­ and multiple fistulae are formed. This ried, had observed an inguinal adeno­ ... process may be repeated as other glnnds pathy following numerous sexual ex­ become involved. posures. The glands continued to en­ large and become more painful until he In the female, the draining lymph was obliged to report to the hospital for glands about the rectum develop an inflam­ care. mation that spreads to the rectal walls by way of the lymph chalmels. Following At the time of the first examination, Il. I 334 1 , there was no sign of penile scar. There The patient was extremely emaciated and i was a bilateral inguinal adenopathy with in spite of selected diets and insulin numerous fluctuating points on the right she had not gained weight. Biopsy of r side beneath a very tense and bluish the drainage tract did not give specific r skin, Temperature 1010 F. Leucocyte information. It was decided that she count l2~400. Wassermann test neg8tive, should be given the possible benefit of Kahn test negative. No foci of infec­ heat treatments and a course of diathermy tion or generalized disease could be held treatments was given, The results were accountable for the lumphadenopathy. Frei gratifying, The patient began to gain antigen of proven value was obtained and weight and after several months ~as able the result of the test was a strongly to leave the hospital in excellent condi­ positive reaction•. tion.

Under conservative treatment and strict bed rest, the suppurating glands Incidence were drained. Potassium and antimony tartrate was given intravenously biweekly Probably a dozen cases of lympho­ in increasing dosage. The patient became granuloma inguinale have been observed in very comfortable and began to gain we ight,. the Minneapolis General Hospital and the The glands decreased in size and 11 weeks University of Minnesota Hospitals. These after admission he was discharged as an cases have presented a variety of findingr arrested case, There has been no attempt to do routine Frei tests and in our patients the males Nine months later this same patient have outnumbered the females three to one.· returned to the hospital with a recurrence of the same physical findings except The incidence of lymphogranuloma that the glands of the left side were inguinale has been surprisingly high where necrotic. The recurrence had developed routine Frei tests have been done, In following eA~osure and lowered resistance. the stries of 1,010 persons tested by The condition did not respond readily De Wolf £illd Van Cleve, there were 58 posi­ this time to symptomatic treatment. He tive reactions. Gray and others in St. was given a course of four diathermy Louis made a. study of patients in the treatments and was unable to leave the city hospitals and found that of 790 Frei hospital 14 weeks after admission. tests on white and colored patients the incidence of lymphogrenuloma inguinale in the white race was 3.4% and in the The second ~ to be described to colored race 40%. The factor of race show the association of cutaneous lesions susceptibility is very striking in this ,.. was that of a white female, age 23. This series. Another point emphasized by I these workers was the absence of a his­ !'l patient had been hospitalized for 28 months, There was a history of gradual tory of previous infection in 50% of but continuous loss of weight associrted the patients tested_ with anorexia, headache and multiple draining fistulae in the inguinal region, Goldblatt found that 32% of the There was no history of sexual eA~osure prisoners quarantined. for venereal dis­ but the patient admitted having kept com­ Gases in the Cincinnati workhouse gave pany ~ith the opnosite sex, The chest positive Frei tests ~hen tested with plates WE;re nege.tive. Mantoux test nega­ several antigens~ tive in various dilutions. Anemia pres­ ent. Urine normal, Wassermann and Kahn tests negative. Loss of weight, 40 lbs. Frei test positive. The general pathological picture of On examination of this girl, in addi­ lymphogranuloma inguinale is that of a tion to the draining fistulae in the left subacute lympnadenitis, Difficulty is inguinal region, there were n1lIDerous occasionally experienced in differen­ lesions of erythema nodosum extending tiati~g this condition from tuberculosis r down the anterior surface of the left leg. and syphilis microscopically. In certain r j 335 i , of the cases, however, the microscopic specifity. Treatment may be divided picture is very characteristic. The dis­ into four groups: ease has been diagnosed from a biopsy of the penile lesion before lymphadeno­ 1. Physica.l r pathy occurred. 2. Surgical 3. Biologic When the involved glands are removed 4. Chemotherapeutic by surgical excision, there appears to be an enormous amount of peri-glandular The nhysical agents employed in the treat­ exudate that has resulted in the matting ment of lymphogranuloma inguinale are together of the lymph nodes. If the heavily filtered x-rays, diathermy, nodes are removed early, there is only an ultraviolet light, hot air, and hot baths. inflammatory congestion and a small Of these methods, our experience has been amount of eA~date. On section, the glands limited to the use of diathermy and hot .. can be seen to have numerous individual baths. The object is to elevate the stellate abscesses of various sizes. The general body temperature for periods necrotic material is of a whitish-gray ranging from 15 to 30 minutes daily in color and is very thick. the hot bath, and from 4 to 6 hours of continuous temperature elevation weekly The histologic picture, as described by me8ns of diathermy. The latter treat­ by Nicolas, appears to be a definite one ments are given until a course of from and he believes it to be specific. There 4 to 8 have been completed, Our results are numerous stellate abscesses with from the use of diathermy compare favor­ epitheloid foci and giant-cells together ably with those from other therapeutic with numerous polymorphonuclear and agents, especially in the late cases. ,. round cells. The inflammation of the glandular epithelial structure is dif­ Surgically, it has been suggested fuse and causes the normal shape of the that the entire glandular adenopathy be glands to be lost. The changes are great­ removed. The contra-indication to this est in the medullary portion of the gland. procedure is the possibility of subsequent The gummas are formed of a central de­ lymph stasis of the lower extremity. generated nucleus which is finely granu­ Nichols, Barthels and Biberstein agree lar and surrounded by a wide band of with Frei that partial removal of the in­ .. epithelial cells. The leucocytes migrate volved glands gives ~ood results. This through the epithelial borders of the is espeCially to be recommended in the gummas and abscesses are formed. These earl~r cases. may assume any one of a variet~.r of shapes, depending upon the portion of the gland The histologic agents suggested in­ involved. In their borders, typical clude foreign protein, autohemotherapy giant~cells of large size with numerous and the intracutaneous injections of nuclei are found. The entire glandular Frei antigen at regular intervals as wall may be lost in the larger abscesses. recommended by Wein and Perlstein of The degenerated portion is made up of Chicago. many polymorphonuclear cells and le.rge acidophilic mononuclears. Numerous Chemotherapeutic agents gener­ epi thel~al foci are found. throughout the ally used in the treatment of lympho­ gland and parenchymal tissue that do not granuloma inguinale are: 1% antimony and have giant-cells. The follicular lesions potassium tartrate given biweekly in doses of the lymph nodes and the type of beginning with 5 cc.and increasing cellular exudate represent the morphologic gradually to 10 cc. for a period of from r characteristics of lymphogrnnuloma in­ 6 to 8 weeks. Potassium iodide by mouth !" guinale. and intravenously. The salts of coppe~, arsenic .and mercury have been used. With the exception of a.ntimony and potassium Treatment tartrate, the use of these drugs has been disappointing. The large number of suggested thera­ peutic aids convinces one of their non- rn summarizing the effectiveness of ! r j 336

the variously recommended therapeutic 8. The differential diagnosis should agents, it is very probable that sup­ be made from syphilis, chancroid, granu­ .. portive measures, as bed rest and a loma inguina.le, tuberculosis, Hodgkin's nourishing diet in connection with the disease, tularemia and pyogenic infec­ partial extirpation glands in the early tions. cases, of the institution of full drain­ ag~ in the late cases together with 9. Frei antigen tests are of great potassium and antimony tartrate offer value in making the diagnosis. our most effective therapeutic attack. In the late cases of esthiomene and of 10. Be sure the antigen is potent at anorectal stricture, the results of the time of use. treatment are routinely poor. 11. Limitations of the Frei test are identical with those of other biological Impressions tests. Early cases of lymphogranuloma inguinale have a tendency to give a 1. Lymphogranuloma inguinale is a negative Frei and a false positive chronic, low grade inflammation of the Wassermann reaction. lymphatic nodes of venereal origin, resulting in complications of fistulae, 12. Once a Frei test becomes positive, esthiomene, or the anorectal syndrome in it remains so for life providing of course an estimated 50% of infected persons. that the patient's allergic status is not disturbed by infection or lowered re­ 2. This clinical picture has been de­ sistance. scribed under a variety of titles since the middle of the 19th century. It was 13. Through this test, it has been probably known before that time. . learned thet many people have had this disease. 3. It has also been known for some time that the disease was a specific 14. In the male, the inguinal adeno­ entity and wa.s probably venereal in pathy is accounted for by lymph-drainage. origin. Many confusing terms are found In the female, involvement about the in the literature, including conditions rectum is explained on a similar basis. .. with similar names without any other re­ lationship. 15. As the disease progresses, the infected lJ~ph nodes mat together and 4. A filterable virus is thought to become painful. Fusion with the overly­ be responsible for the disease. The dis­ ing skin produces an appearance which is ease has been successfully transmitted highly suggestive of the disease. to apes, mice, rabbits and other labora­ tory animals. 16. The rectal involvement may give confusing clinical pictures. 5. In the ape,the virus appears to have a special affinity for the central 17. The course of the disease may be nervous system tissue causing an en­ prolonged or the patient may be able to cephalitis. overcome the infection within a rela­ tively short time. 6. The disease is mainly one of adult­ life although occasional cases are report­ 18. Frei tests done on groups in .the ed in children. population in which the venereal disease /l I ranks high often show a large number of 7. The history of a small innocent positive tests. appearing lesion on the glans penis, 3 to 10 days after sexual relation, followed 19. The treatment is physical, surgical, by inguinal adenitis in from 10 to 30 biological, and chemotherapeutic. days, should make one suspicious of lymphogranuloma inguinale. 20. Supportive measures, bed rest and a 337

nourishing diet with partial extirpation 8. De Wolf, H. F. and Van Cleve, J~ V. (to avoid lymphastasis) of the nodes in Lymphogranuloma inguinale, the early cases or full drainage and J.A,M.A. 99: 1065, (Sept. 24) 1932. potassium and antimony tartrate in the late cases are the most effective. In 9. Cole, H. N. the late cases of anorectal involvement Lymphogranuloma inguinale, the the results are routinely poor. fourth venereal disease. J.A.M.A. 101: 1067, (Sept. 30) 1933.

, Note: 10. Gray, S. H., George, A. H., Von Haam .. E. and D'Aunoy, R., J.A. Hunt, G. A., Wheeler, P., M.A. 106: 1642, (May 9) 1936, demonstrated Blache, B.J. the virus in the spinal fluid of human Lymphogranuloma inguin~le, its cases. They believe that the disease is incidence in St. Louis. a systemic one and suggest that the fever J.A.M.A. 106: 919 (Rar, 14) 1936, and headache support this idea, 11. Hellerstrom, S. A contribution to the knowledge of Biblio,graphy lymphogranuloma inguinale. Acta Dermato, Venereologica .. 1, Coults, W. E• Supplementum 1, 1929. Contribution to history, origin and distribution of lymphogranulomatosis 12. Frei, W. venerea in South America. Eine neue Hantreaktion bei lympha T. Trep. Med. 37: 9.7, (April 2) 1934. granuloma inguinale. Klin. Wchnschr. 45: 2148, 1925, 2. Durand, M., Nicholas, J. and Favre, M. Lymphogranulomatose inguinale sub­ 13, Wien, M. S. and Perlstein, M. O. aigue ------Intradermal treatment of lympho­ Soc. Med. d. Hosp. de Paris, 35: 274, granuloma inguinale. (Feb. 6) 1913, Arch. of Denn. and Syph. 28: 42, 1933.

Lymphogranulomatose inguinale 14. Pardo-Costello, V. subaigue ------Lymphogranulomatous inguinalis. Presse Med. 30 : 571, 1922. Arch, of Derm. and Syph. 14: 35, 1926.

3. Wolf, J. and Sulzberger, M. 15. Hillmans, Wishusen and Zimmermann Lymphopathia venereum. Lymphogranulomatosis inguinalis. Brit, J. Dermat. 44: 192, 1932. Arch. of Derm. and Syph. 18: 383, 1928

4. Curth, W. 16. Goldblatt, S. Extragenital infection with the Skin diseases in prison populations. virus of lymphogranuloma inguinale. Med. Bull., Univ. of Cincinnati, Arch. ,of Derm. and Syph. 28: 376, 7: 117,· (Nov.) 1935. 1933. 17. Strauss, M. J. and Howard, M. E. 5. SUlzberger, M.D. and Wise, Fred The Frei test for lymphogranulomatous Lymphopathia venerea. inguinalis. J.A.M.A. 99: 1,407, 1932. J.A.M.A. 106: 517 (Feb. 15), 1936.

6. Dummers, C. and Tamura, J. Juvenile lymphopathia venerea. Med. BUll., Univ. of Cincinnati 7: lll~ (Nov. ) 1935.

7. Buschke, A. and Curth, W. Uber Die Extragenita1e Lokalisation Klin. Wchnschr. 10: 1709, (Sept.)1931, r 338 r IV. MOVIE t"" May 7, 1936 Title: Sunny Worthersee

;r Recreation Room, Released by: Austrian State Nurses t Hall Tourist Department.

Time: 12:15 to 1:15

Program: Movie: Attention - Suckers, Tumors of Jaw Introduction of Dr. T, B. Cooley by I. McQMarrie

Present: 101

Discussion: Carl Waldron L. G. Rigler ~ K. W. Stenstrom f fl· i ~ Gertrude Gunn, I Record Librarian rI r. t ~ rI ~, I r t !'t J ; l I r r!

t~ I rl. If 1,

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