Syphilitic disease of the long bones in the Bantu.

Although syphilitic lesions in bone have become increasingly rare in European communities, syphilis is still a common cause of bone pathology in the South African Bantu. Syphilis entirely accounts for, or complicates, 90 per cent of all bone lesions-apart from fractures-seen in the Baragwanath Hospital. Syphilis is notorious for the diverse ways in which it may present itself, and an attempt is made here to illustrate by typical examples its usual manifestations in the bones of the Bantu. The disease is usually classified according to the age at which it manifests itself-that is, in infancy, in adolescence and in the adult-and according to whether it is congenital or acquired. In establishing a diagnosis of syphilis we have relied upon the following criteria in addition to a positive \Vassermann or Eagle reaction. 1) Multiplicity of the bone lesions. 2) Typical radiographic appearances in other parts-for example, an associated gumma of the clavicle, or a “ moth-eaten “ appearance of the skull-besides the lesion in the long bones. 3) Rapid resolution of the lesion, or of the symptoms, in response to anti-syphilitic treatment, which in most cases consisted of penicillin 600,000 units daily. 4) When necessary, biopsy of the bone to exclude any other bone pathology. Pain in the affected limb was the most common symptom, although often a lesion was discovered during routine radiography in other conditions. Pain always subsided rapidly with anti-syphilitic treatment. Sometimes there was also a marked improvement in the radiographic appearance of the bone lesion, especially with gummata and with the disease in infants. In differentiating these lesions from other conditions, it might be asked how syphilis is distinguished from yaws ; but yaws does not occur in the South African Bantu. It does not extend southwards beyond Northern Rhodesia (Hackett 1946) and it is unknown in the Union of South Africa, whence all these cases are drawn. Moreover yaws does not occur as a congenital affection, and the extensive scarring and pigmentation seen in yaws were not present in these cases. Finally in the large dermatological out-patient department of Baragwanath Hospital no skin manifestations of yaws have been seen. Goldmann and Smith (1943), in discussing the radiographic features of the two diseases, stated that it is unusual for syphilis to attack the bone and leave the periosteum unscathed. The opposite occurs in yaws, which regularly attacks the compact bone of the shaft and only affects the periosteum if the lesion is superficial. Helfet (1944) emphasised the acute onset of yaws in shafts of long bones, which simulates that of pyogenic osteomyelitis, with intense pain and swelling. For these reasons, in none of these cases did yaws cloud the diagnosis.