THE LVET1N REACTION 295 



the two sides in syphilitic persons. Noguchi here distinguishes three 

 types of reaction at the points where the luetin has been injected. 

 In the first or papular form "a large, raised, reddish, indurated 

 papule, usually from 5 to 10 mm. in diameter, makes its appearance 

 in twenty-four to forty-eight hours. The papule may be surrounded 

 by a diffuse zone of redness and show marked telangiectasis. The 

 dimensions and the degree of induration slowly increase during the 

 following three or four days, after which the inflammatory processes 

 begin to recede. The color of the papule gradually becomes dark 

 bluish-red. The induration disappears within one week, except in 

 certain instances in which a trace of the reaction may persist for a 

 longer period. This latter effect is usually seen among patients with 

 secondary syphilis under regular mercurial treatment in whom there 

 are no manifest lesions at the time of making the skin test. Patients 

 with congenital syphilis also show this reaction in the early period of 

 life." In the second pustular form "the beginning and course of the 

 reaction resemble the papular form until about the fourth day, 

 when the inflammatory processes commence to progress. The 

 surface of the indurated, round papule becomes mildly edematous, 

 and multiple miliary vesicles occasionally form. At the same time, 

 a beginning central softening of the papule can be seen. Within 

 the next twenty-four hours the papule changes into a vesicle filled 

 at first with a semi-opaque serum that later becomes definitely 

 purulent. Soon after this the pustule ruptures spontaneously or 

 after slight friction or pressure. The margin of the broken pustule 

 remains indurated, while the defect caused by the escape of the 

 pustular contents becomes quickly covered by a crust that falls off 

 within a few days. About this time the induration usually disappears, 

 leaving almost no scar after healing. There is a wide range of 

 variation in the degree of intensity of the reaction described in 

 different cases, as some show rather small pustules, while in others 

 the pustule is much larger. This reaction was found almost constant 

 in patients with tertiary or late hereditary syphilis" (see Plate X). 

 In the third or torpid form, which was only noted in rare instances, 

 "the injection sites fade away to almost invisible points within 

 three or four days, so that they may be passed over as negative 

 reactions. But sometimes these spots suddenly light up again after 

 ten days, or even longer, and progress to small pustular formation. 

 The course of this pustule is similar to that described for the 

 preceding form. 



