254 The Philippine Journal of Science 192s 



especially clavos, are likely to be less severe when the disease 

 develops during infancy. 



DIAGNOSIS 



For public-health purposes, the diagnosis of the typical gran- 

 ulomatous stage is a simple matter. Secondary pyogenic in- 

 fection may mask or confuse the diagnosis. Some of the 

 atypical infections may require a little care in differentiating 

 them from cutaneous leishmaniasis, from granuloma inguinale, 

 and from syphilis. Indeed, in obscure cases, it may be impos- 

 sible, even with the most-refined means of investigation, to 

 differentiate absolutely some of the tertiary lesions of yaws 

 from tertiary syphilis. The X-ray is of assistance in differ- 

 entiating the bone lesions of the two diseases. Real difficulty 

 arises in the case of ulcers. The history may be wholly un- 

 reliable ; and the clinical manifestations, the laboratory findings, 

 and the response to treatment are inadequate for differentiating 

 syphilitic and frambcesial ulcerations. 



For the purpose of simply checking the spread of yaws in 

 a community it is perhaps sufficient to treat only the primary 

 and secondary stages. We have found no reliable indications 

 in the histories of patients that a mother yaw has been con- 

 tracted from a tertiary case. On a priori grounds it seems 

 improbable that a tertiary ulcer would afford a serious focus 

 of infection for the spread of the disease. 



On humanitarian grounds, and for the sake of relieving the 

 extensive incapacitation caused by the late lesions of yaws, 

 it is imperative to extend the treatment to latent cases. In some 

 regions, the condition known as clavos is especially important. 

 Multiple granulomata develop in the thickened epidermis of 

 the soles of the feet. An attempt at healing takes place and 

 a hard core of tissue forms in the center which eventually falls 

 out leaving deep "nail" holes. Hence, in Spanish-speaking coun- 

 tries, this condition is often called "clavos." Excoriation and 

 Assuring of the epidermis continues, and the pain persists. 

 The results of the serological tests and the therapeutic response 

 indicate strongly that active infection with the causative trepo- 

 nema is responsible for the continuance of these lesions. 



Finally, a word must be said in regard to the control of 

 field work by the Wassermann reaction. The decision regard- 

 ing the advisability of including a Wassermann outfit in the 



