604 ANAPHYLAXIS IN RELATION TO INFECTION AND IMMUNITY 



latter effect is usually met with among cases of secondary syphilis under 

 regular mercurial treatment in which there are no manifest lesions at 

 the time of making the skin test. Cases of congenital syphilis also show 

 this reaction. 



"(b) Pustular Form. The beginning and course of this reaction 

 resemble the papular form until about the fourth or fifth 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 cen- 

 tral 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 content becomes quickly covered 

 by a crust that falls off within a few days. About this time the indura- 

 tion 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 

 constantly in cases of tertiary syphilis, as well as in cases of secondary 

 or hereditary syphilis which had been treated with salvarsan. 



"(c) Torpid Form. In rare instances the injection sites fade away 

 almost to invisible points within three or four days, so that they may 

 be passed over as negative reactions. But sometimes these spots sud- 

 denly light up again after ten days or even longer and progress to small 

 pustular formation. The course of this pustule is similar to that de- 

 scribed for the preceding form. 



"This form of reaction has been observed in a case of primary 

 syphilis, in one of hereditary syphilis, and in two cases of secondary 

 syphilis, all being under mercurial treatment." 



Aside from these three types of reactions, there have since been 

 described several cases of the formation of a hemorrhagic exudate, the 

 lesion usually rupturing spontaneously and not running a more severe 

 or a longer course than the pustular. Two such reactions have been 

 reported by Kilgore. 1 



"Neither in syphilitics nor in parasyphilitics did a marked consti- 

 tutional effect follow the intradermic inoculation of luetin. In most 

 positive cases a slight rise in temperature took place, lasting for one day. 

 1 Jour. Amer. Med. Assoc., Ixii, 1236. 



