## SYPHILIS SECUNDARIA

### Syphilis pustulosa.

The general pustular syphilid is of much less common occurrence than the papular, and is observed most often in poorly nourished, debilitated or anemic individuals, usually in the first three to eight months of the disease. Like the papular rash it may be the first recognized cutaneous manifestation; more often it follows or develops from a prior papular eruption. Pustules do not necessarily arise from papules, they may originate as pustules. When they appear in profusion their evolution is often preceded and accompanied by fever, headache and malaise. In the earlier rashes the pusts is situated between the epidermis and the true skin. The later and relapsing forms are usually more limited in their distribution, the lesions are generally larger and the destruction deeper. In either case the pustules dry quickly with the formation of yellow, brown or greenish crusts which fall off and uncover characteristic ham colored papules with a collarette of shriveled epidermis at the periphery, or disclose shallow punched out ulcers which may leave permanent scars when they heal. The pustular rash has many characteristics in common with the papular, namely, the color, the general distribution, the moderate grouping of the lesions, the tendency for new lesions to appear for several days or weeks and for the efflorescences to be nearly all of one size, miliary, small or large. In the miliary pustular syphilid the le-

sions are usually profuse and situated about the hair follicles. A few large papules or pustules are nearly always present. The appearance of such an erup tion is quite characteristic and not easily mistaken. Slightly larger pustules may resemble those of acne or variola. The rash causes no subjective symptoms except that in the negro itching is sometimes com plained of. **DIAGNOSIS:** The pustular syphilo derm may simulate any of the pustular non-specific skin lesions. Of the very greatest importance in diagnosis is the presence of other symptoms of syphilis. Points to be considered in differentiating the pustular syphilid from *acne* are, that acne is very chronic and localized upon the face and upper trunk, it rarely arises after thirty, comedones are usually plentiful, and the nodes may be deep and are of a dusky and not a coppery red. *Variola* is distin guished by the sudden onset and intensity of its general symptoms, its acute course and definite dura tion, the shot-like feel of its papules and the full globular character of the pustules, the uniformity in character and development of the lesions and their predilection for the face, wrists and hands. In the exceedingly rare cases in which these points do not suffice for a differential diagnosis a serodiagnos tic test will resolve all difficulties. **TREATMENT:** The general mercurial treatment is as a rule all that is required, though it is particularly in these cases that mercury vapor baths are serviceable.