YAWS AND SYPHILIS 279 
four to twelve years before tertiary symptoms appear. He adds that it is the 
general impression that the lesions of this stage are or may be due to syphilis. 
With reference to bone and joint lesions as tertiary manifestations of yaws, 
Maul,' in the Philippines, found such lesions in twenty per cent of yaws cases. 
Commonly x-ray examination showed rarefying osteitis affecting the inner parts 
of the bones and sometimes the outer surfaces, later with marked deformity of 
the bone outline. The condition was thought to differ from syphilis in that 
there was no periosteal proliferation and no thickening of the cortex of the bone. 
He points out that these conditions are very commonly described clinically under 
the term periostitis. Soetomo and Eichhorn ” have also described bone atrophy as 
revealed by x-rays as being characteristic of yaws in contradistinction to syphilis. 
Clapier * has also noted osteitis of both the short bones and of the epiphyses of 
the long bones, while Egyedi‘ has described framboesial lesions in joints, ten- 
dons, sheaths and bursae among the natives of Nias, where he states yaws is com- 
mon and syphilis uncommon. 
Among others who have emphasized the frequency of the tertiary lesions of 
yaws is Van Nitsen ° who examined 699 cases of yaws and found tertiary lesions 
in the majority, either appearing at the end of the secondary stage or from ten 
to twenty-five years later. Tertiary lesions chiefly take the form of serpiginous 
ulceration on the trunk and limbs. 500 cases presented ulcerated lesions, 178 
cases of arthralgia, 74 arthritis, 72 ostealgia, 77 periostitis, 27 necrosis, and 2 
bone rarefication. Hunt and Johnson ° state that twenty per cent of their 2000 
cases of yaws in Samoa, where syphilis is said to be absent, had periostitis. 
Gutierrez ‘ who studied 229 cases of yaws with tertiary lesions present in a 
third of their number, found periostitis, gummata, and keratosis to be common. 
Differentiation of Yaws from Syphilis. While there is no difficulty clinically 
in distinguishing from syphilis the granulomatous eruption upon the skin which 
occurs as a manifestation of yaws, with reference to distinguishing the tertiary 
lesions of syphilis from those of yaws there is usually the greatest difficulty. 
Penris ® emphasizes how commonly such tertiary yaws and tertiary syphilis 
lesions are confounded. Spittel * points out that tertiary yaws closely simulates 
tertiary syphilis and like it has two kinds of manifestations, gummata, and 
fibroid indurations. He believes gummata are as common in yaws as in syphilis. 
With reference to the differential diagnosis he says one may have to rely on the 
history of the case for the diagnosis. While he has not met with definite nervous 
symptoms in yaws, he thinks the nervous system is affected mildly and transi- 
torily in some cases in this disease. 
Stannus !° also emphasized the difficulty in diagnosis between what are con- 
1 Maul: Philippine Jour. Sci. (1918), XIII, 63. 
2 Soetomo and Eichhorn: Trop. Dis. Bull. (1926), XXIII, 18. 
8 Clapier: Trop. Dis. Bull. (1923), XX, 176. 
4 Egyedi: Trop. Dis. Bull. (1925), XXIII, 17. 
5 Van Nitsen: Ann. Soc. Belge de Méd. Trop. (1920), I, 39. 
6 Hunt and Johnson: Trop. Dis. Bull. (1923), XX, 840. 
7 Gutierrez: Trop. Dis. Bull. (1926), XXIII, 17. 
8 Penris: Trop. Dis. Bull. (1924), X XI, 794. 
9 Spittel: Loc. cit. 10 Stannus: Loc. cit., p. 10. 
