YAWS AND SYPHILIS 277 
Both processes may even be found in different parts of a single extensive ulcer. 
The edges may be slightly swollen and undermined or the ulcer may lie in a 
plaque of smooth, light pink skin which is firm but elastic on palpation and which 
is so firmly adherent as to be quite immovable. The bases of such ulcers may be 
comparatively clean, and the exudate from them, instead of being purulent, is 
often the color of clear amber and noticeably viscid. Dr. Shattuck regarded 
such lesions as gummata of the skin. 
Periostitis and bony thickening in cases of n’gonde, and likewise in syphilis, 
are common accompaniments of these ulcerative lesions. Joint lesions. Chronic 
or subacute arthritis, swellings probably gummatous, or ulcers in the neighbor- 
hood of the joints are, in addition, common manifestations of n’gonde. Such 
conditions are also seen without other important manifestations of trepone- 
miasis. 
Dactylitis. A few cases of dactylitis with fusiform swelling of one or more 
fingers, with or without active ulceration or destruction of bone, were seen. 
Case 385 (Illust. No. 219) showed loss of phalanges. Leprosy was excluded. 
Dr. Shattuck remarks that the largest number of cases of dactylitis of this type 
that he had seen were observed at Catbalogan in Samar in 1907 where for the 
first time he observed many cases corresponding to n’gonde. Some of them had 
gangosa or dactylitis with or without absorption of phalanges or spontaneous 
amputation. These cases had been collected as leprosy suspects for examination 
by Dr. V. G. Heiser, but no positive evidence of leprosy was found. Dr. Cullen, 
then Health Officer for Samar, said that the cases had resisted treatment with 
mercury and iodide. Many of these Catbalogan cases had severe contractures 
resulting apparently from destruction and scarring rather than from nerve 
lesions. Cases of n’gonde showed the same type of contracture without sensory 
changes. The Catbalogan cases were then regarded by Shattuck as tertiary 
syphilis. He believes now that lesions of this type may be produced either by 
syphilis or yaws. 
Elephantoid swellings were also occasionally seen in Liberia on the legs, in 
association with extensive scarring and ulceration. 
A striking fact observed regarding n’gonde is that even when active lesions 
are extensive, the general health of the patient may be affected comparatively 
little, and that the mucous membranes may be of normal color and no evidences 
of a marked anaemia visible. 
The cases of n’gonde varied very much in their clinical manifestations, as 
will be seen in a further discussion of some of the individual cases which will be 
used to illustrate special features of the condition. Case 553 (Nos. 208-210) 
is exceptional in that there appear to have been at one stage of the infection 
large abscesses in the muscles which may have originated from periostial disease 
in the deep-lying bones. 
Gangosa or more or less destructive nasopharyngeal lesions were not un- 
commonly associated with n’gonde. 
Both clavus and ‘“‘crab yaws,” the latter characterized by cracking of the 
1 Shattuck: Philippine Jour. Sci. (1907), II, 551. 
