274 REPORT OF THE HARVARD AFRICAN EXPEDITION 
amount of primary syphilis. Dr. Shattuck, in his clinical studies, observed but 
one case (No. 213), showing both primary and secondary lesions of syphilis, in 
Liberia. 
Nogue ! as chief of the venereal clinic at Dakar, has had an unusual oppor- 
tunity for the observation of syphilis, and also points out that primary chancre 
and early ulceration of the throat are but seldom seen. The rarity of observations 
of primary lesions in syphilis in Africa also has been noted by Stannus and others. 
Neither primary sore nor secondary manifestation may give symptoms for which 
the native will seek treatment. 
On the other hand, many cases of serpiginous ulcers, of periostitis, of swelling 
or destructive processes in the joints, of dactylitis, and of lesions resembling 
nasopharyngeal gummata in early or late stages, were observed by us in Liberia 
and the Congo, which might have been diagnosed from a clinical standpoint as 
lesions of tertiary syphilis. However, neither from a clinical or pathological 
standpoint did it seem to be possible to distinguish such lesions from those which 
have been described as tertiary in yaws. For this reason they were generally 
described clinically as forms of ‘‘treponemiasis.’’ The ulcerative and joint and 
bone lesions observed by us in connection with treponemiasis are referred to on 
pages 276-277. 
With reference to the clinical observations regarding syphilis, it may be re- 
marked that cirrhosis of the liver and syphilis of the heart and aorta, and marked 
arteriosclerosis were not observed in the natives of Liberia or the Congo, nor 
were typical advanced cases of general paralysis of the insane seen in Liberia. 
It seems likely that even if cases of the latter condition occurred in certain parts 
of the interior of Liberia they would not be permitted by the other natives to 
live long. 
Congenital syphilis was, however, observed in children in Liberia in Monrovia 
only, and one of these cases is illustrated in No. 28 (p. 49). This child showed 
also characteristic alteration in the shape of the cranium, general glandular en- 
largement, poor nutrition, anterior bowing of the tibiae and geographical tongue. 
Maass * whose observations were made since our return from Liberia, states 
that while yaws is very common, syphilis is said to be absent in the northwestern 
portions of Liberia near the border of Sierra Leone. 
It is also interesting to refer to the prevalence of cases of yaws and syphilis 
in the regions contiguous to Liberia and in the Belgian Congo. These observa- 
tions have recently been collected by Stannus ® in his excellent critical review of 
the subject. In Sierra Leone, in 1923, 144 cases of yaws, 48 cases of secondary 
syphilis, and 494 cases of the inherited disease were observed and treated. In 
the Ivory Coast, Botreau-Roussel points out that yaws is widespread in the 
hinterland, while Thiroux states that fifty per cent of the women in urban centers 
are infected with syphilis, many children showing signs of the congenital dis- 
1 Nogue: Ann. d’Hyg. Publique Industrielle et Sociale (1924), No. 3, p. 149. 
? Maass: Arch. f. Schiffs. u Tropen-Hyg. (1928), XXXII, 221. Jour. Trop. Med. and Hyg. (1928), 
XXXI, 102. ; 
3 Stannus: Trop. Dis. Bull. (1926), XXIII, 1. 
