Part 4

THE GENERAL DESCRIPTION OF THE DISEASE.

Henpuye starts in a native of West Africa during or soon after an attack of yaws in which there is a history of the nasal mucous membrane being attacked as a small bony swelling symmetrically placed on either side of the nose. This swelling, which is generally oval with the long axis directed downwards and outwards, is attached to the nasal bones, the nasal process of the superior maxilla, and also to the superior maxilla in the more advanced cases. It is produced by the deposition of new bone under the periosteum on the external aspect of these bones and grows slowly in all directions. It in no way affects the mouth or the orbital or nasal cavities in any case which I have seen, and the nasal ducts are quite unaffected. Rarely the growth is asymmetrical, being situated only on one side of the nose. Pain in the nose and the presence of a sore in that organ are the symptoms complained of at the commencement of the disease; later headache is sometimes felt, and pain in the swelling during wet weather. As the growth becomes larger it seriously interferes with the sight by growing up in front of the eyes and even hiding them, but I have never seen it cause destruction of the eyeball. In many cases the patient has to bend his head downwards in order to be able to see over the tops of the swellings. The skin over the tumor is normal and is freely movable. The course of the disease is that the swellings may cease to grow at any period of their existence or may continue to grow for years—that is to say, they may remain quite small or may grow to be large lumps, in the latter case giving rise to the deformity and the interference with the sight, but I am unacquainted with any case in which they break down or ulcerate. Finally, the disease is much more common, in my experience, in men than in women.

DESCRIPTION OF CASES.

The following cases will be described: (1) slightly developed cases; (2) moderately developed cases; (3) an advanced case; and (4) an asymmetrical case.

_Slightly Developed Cases._—CASE I.—The patient, a boy of about seventeen years of age, said that about seven years ago he noticed two small lumps on the nose which began after yaws in which there was a sore in the nose. They increased slightly in size, but soon ceased to grow and have been in their present condition for some years. He never felt any discomfort or pain in them. The two lumps had their long axis directed downwards and outwards, the measurements being half an inch by a quarter of an inch. They were attached to the nasal bones just above the cartilages and the nasal process of the superior maxilla, and were firm, smooth, bony tumors. The skin over them was quite normal and they did not in any way project into the nasal cavity or affect the line of vision, being too small for the latter purpose. There was very little deformity and no treatment was necessary. In this case the lumps soon ceased to grow.

CASE II.—A small Grunshi girl from Kumassi, about seven years of age, who had had yaws some time previously, felt pain in the nose a few months ago and noticed a small swelling on each side of the nose, and this gradually increased in size till it reached its present condition. Her mother was most anxious to have it removed on account of the deformity. On inspection there was found to be an oval swelling on each side of the nose, attached to the nasal bones and the nasal process of the superior maxilla. The long axis of the swelling was directed downwards and outwards—an inch in length and half an inch in breadth. The nasal cartilages were not affected and the interior of the nose was normal. The orbital cavity, the mouth, and the nasal ducts were quite unaffected. The skin over the swelling was normal and freely movable. The patient felt no pain in the tumor and she had never had any headache. The growths were removed by operation. It was very difficult to obtain definite history as to the time when this patient had had yaws and as to the time when the growth appeared, but as far as I could make out the yaws were well developed when the swelling was first noticed.

_Moderately Developed Cases._—CASE III.—A young man, a Ga native, who had had yaws about seven years ago, felt pain in the nose and got a person to look into it, who said that there were yaw spots on the mucosa, and later a small swelling on each side of that organ was noticed. These small swellings grew slowly to their present size, and the patient said that they were still increasing. He complained of frontal headache and of slight pain in the swellings in wet weather. On inspection two symmetrically placed swellings were seen on each side of the nose, looking somewhat like small eggs. They were oval in shape, with the long axis directed downwards and outwards. The left measured two inches by two inches and the right three inches by two and a half inches. A profile view showed that they were slightly concave on the side towards the orbit. They did not affect the orbital or nasal cavities, nor did they project into the mouth or affect the nasal ducts or the cartilages of the nose. They were attached to the nasal bones, the nasal process of the superior maxilla, and to the superior maxilla itself. They were smooth, but on the left side the tumor rose to a central ridge. The skin over the swellings was quite normal and was freely movable. In order to see clearly, the patient often had to bend his head somewhat. The growths were removed by operation.

CASE IV.—The patient was an Akwapim woman, aged about twenty years. This case was similar to Case III., but the swellings, which had started when the patient (who had suffered from yaws) was seven years of age, were rather more rounded. She would not consent to operation.

_An Advanced Case._—CASE V.—A man, a native of Appolonia, about forty years of age, stated that the swellings began with pain in the nose after yaws, when he was about six years old. They grew steadily and slowly till eight years ago, when they stopped, and they have not increased in size since then. On inspection there were two oval swellings situated on each side of the nose, the left measuring two and a half inches by one inch and the right three-quarters of an inch by half an inch. They projected upwards over the orbit, the long axis in each case being directed downwards and outwards. They did not project into the mouth, the nose, or the orbit, and the nasal duct was free. They were attached to the nasal bones, the nasal process of the superior maxilla, and to the maxilla itself. The skin over the tumor was normal and it was freely movable. The patient complained of headache and found that the swellings interfered with his vision considerably, particularly on the left side. He refused to submit to operation.

_An Asymmetrical Case._—CASE VI.—An Ashanti boy, aged six years, from Donkeo Inquanta, had yaws, and while suffering therefrom, just a year previous to his consulting me, the swelling appeared on one side of the nose, and had been growing ever since. There was no sign of any lump on the other side. He was advised to go to Kumassi for operation.

THE TREATMENT.

I have attempted to reduce these swellings by the administration of iodide of potassium, but have not met with any success. The only treatment appears to be the removal by operation. The method I adopt is as follows. The eyes being protected by a pad over each, an incision is made along the long axis of the tumor and the skin is freed on all sides so that its base is exposed. If the swelling is very small in a child it may be necessary to make a cross cut through the skin as well, in order to get sufficient room to work in. The bone being exposed, a portion of the swelling can easily be cut away by bone forceps, because it is very soft. If large, a few nicks with a Hey’s saw are found most useful in enabling a large portion of the mass to be removed entire. After as much has been removed as possible with the bone forceps, more may be got away by means of the gouge or the gouge forceps or the nibbling forceps. I have experienced difficulty in removing the deeper portions, particularly those close to the orbit. I need hardly say that in the latter the eye has to be carefully guarded from injury. After removal of the bone the wound is well washed out with an antiseptic lotion. The bleeding is slight and is easily controlled by pressure. The wound is closed by a continuous suture and it heals up readily.

THE MORBID ANATOMY.

I have never had any chance of examining the growth _post mortem_, but the portions which I have removed _en masse_ by operation have enabled me to make some investigations. The periosteum strips off readily, and under this is a thin shell of compact bone, which appears somewhat ridged on the side towards the periosteum. The rest of the tumor consists of cancellous bone. The whole swelling cuts readily with bone forceps and consists of quite soft bone. On making microscopical preparations there were signs of ossification in membrane proceeding under the periosteum, and the rest appeared like ordinary wide-meshed cancellous bone. The whole process appeared to be that of a slow “osteoplastic periostitis.”

ÆTIOLOGY.

Two views on the ætiology of this disease have been brought forward up to the present time, as far as I know—viz., that the swellings were of a racial character and that the process was started by the larva of some insect. With regard to the first I have only to mention that the disease is found in Ashantis, Grunshis, Fantees, Abantas, the Ga people, etc., races quite different from one another, to show that this cannot be entertained. As to the second, I have never met with evidence which would support the idea that the disease was started by a larva. On the other hand there is always the history of yaws and of the tumor starting during the attack of yaws—_i. e._, during the period of eruption or soon after. Then, again, the patients complain of pain in the nose with, in some cases, distinct history of a sore and sometimes discharge preceding the swelling. This might be due to some irritation or ulceration of the nasal mucous membrane by the yaws. I have never had the opportunity of examining any person at this stage of the disease, but in the more developed cases I have examined the nose for marks or signs of old ulceration, but have not found them. If, however, the nasal process of the superior maxilla be examined a few foramina are to be seen, and these are often joined together by a small groove indicating the position of a bygone suture. The foramina are for small bloodvessels, which are said to communicate with those of the mucosa of the nose. The site of these foramina is the situation where henpuye starts, and I venture to bring forward the theory that the causation of this peculiar disease is due to an osteoplastic periostitis brought about by the absorption of the poison of yaws from the nasal mucous membrane through the small vessels (or lymphatics) keeping open the foramina which indicate the suture above mentioned.

THE GEOGRAPHICAL DISTRIBUTION.

I am only aware of cases reported from the Gold and Ivory Coasts of West Africa and the West Indies. I never met with it in Mamprusia, nor have I met any trader coming from Moshi with it, nor have I met with it in Fra Fra, and I can find no one who has seen it in the eastern parts of the colony. But in the following districts it has been noted: Ahanta, Appolonia, Fantee, Accra, Aquapim, Akim, Assin, Sefwhi, Ashanti, Attabubu, Kwahu, Kintampo, Berekum, Gaman, the Neutral Zone, and Wassaw. It is perhaps most common in the Sefwhi, Wassaw, and Appolonia districts which adjoin the French Ivory Coast, where cases are also known.

I look upon henpuye as a localized osteoplastic periostitis in the region of the nasal process of the superior maxilla, generally symmetrical, due to yaws, and found among the natives of West Africa and the negroes of the West Indies.

THE MADDOX ROD OR THE PHOROMETER; WHICH?

In the last issue of the Journal there appeared an abstract with the above title, and believing the subject to be of much interest at the present time, our readers have been invited to send us their opinions on the matter, as based on the experience obtained in practice. The communications below have been received and are presented in the order of their reception. We shall be glad to hear from any physicians who are interested [ED.].

DEAR DR. DEADY: In reply to your favor requesting my opinion regarding the respective merits of the Maddox rod and the diplopia test, I wish to say that my experience leads me to rely more and more upon the obscuration test, and while I have not followed out the comparison to any great extent, such as is shown by your tables, results obtained by relying upon the rod test in the detection of heterophoria, as well as in determining when the weak muscles have been sufficiently developed, have been such as to warrant my continuance of its use.

E. D. BROOKS.

I have with interest watched the discussions of late, as to the relative value of the Maddox or Stevens tests for heterophoria, as I have for years used them both.

My muscle tests have been made for the last five years at least, with a Risley phorometer, which combines both tests upon one arm and has proven for me a most satisfactory instrument.

I am sorry to say that I have not kept any comparative statistics of my examinations; at the same time they have all left an impression upon my mind, which is this: that I feel more confidence in the results obtained from the use of the Maddox test in the routine tests that I always make of refractive cases. If this test shows any marked degree of heterophoria it has been my habit to retest the patient by the Stevens method, which is usually the same, provided the patient has a sufficient amount of intelligence to give correct answers to the questions put to him. During this test the patient is allowed to sit for some time in front of the prisms, and the eye muscles allowed to relax from that first impulse at muscular effort that follows the placing of the prisms in front of the eyes.

To my mind both tests are good and fairly accurate in the hands of one who is thoroughly familiar with their use and shortcomings, provided your patient is able to answer correctly.

Many times, on re-examining a patient, I have discovered what appeared to be a great change in the muscular conditions, but after repeated examinations I have usually found it was the patient, and not the muscles, that was erratic.

When Dr. Hubbell speaks of ¼° of difference between the Maddox and Stevens tests, he has more confidence than I have in the average judgment of patients that come under our care.

SAYER HASBROUCK.

DEAR DOCTOR: Your note asking my opinion of the comparative usefulness of the Maddox rod and the phorometer is at hand.

In the detection of heterophoria I regard the rod as the most convenient and trustworthy instrument used.

The distance at which the test is made and the dissimilarity of the images seen usually eliminate all actual effort to hold the eyes in any particular position other than that in which they stand the most easily. Accordingly the deviation is quickly noted and readily measured.

So satisfactory has this modest little instrument been in my examinations that I now rarely resort to other methods. The amount of deviation sometimes shown between this and other instruments is so slight as to make little or no difference in the measures employed for correction.

It is to be noted that cases not unfrequently occur in which a hyper-sensitive, or, on the contrary, an enervated condition exists, which is not fully indicated by any instrument. An educated judgment will here have to supply conclusions not to be drawn by any hard-and-fast rules.

After the rod and the phorometer came into use and an opportunity was presented to compare the results obtained by each, I made a careful test of eighty pronounced cases of errors of refraction accompanied by heterophoria. Of this number only nine showed a persistent difference of deviation and in none of them a difference greater than 1½°. But this was not always on the one side or the other, as six out of the nine showed a higher degree of deviation by the rod than by the phorometer. Eighty cases may not be enough upon which to base an orthodox conclusion; but my experience with the rod has been so satisfactory that I now seldom use the phorometer at all. It appears quite possible practically to estimate the degree of heterophoria as accurately with the one instrument as with the other; and while it is true that a correction of the error of refraction will commonly correct the deviation, still all cases of optical defect should be tested with the rod or phorometer before the lenses are prescribed.

WM. A. PHILLIPS.

MY DEAR DR. DEADY: Dr. Hubbell limits the discussion “to the comparative value of the diplopia test, by Stevens’ phorometer” and the Maddox rod test.

It would be interesting to follow out the idea with other phorometers,—and with the Wilson phorometer my records do not show quite such a marked difference in results,—but I have not taken pains to get comparative results in any considerable number of cases.

Dr. Hubbell says: “In the diplopia test, the dissociation is effected by changing the visual axis of one eye by means of a prism. The displacement of one image cannot be done without associating with it, more or less, an impulse to some form of ocular effort.... In the obscuration test (Maddox rod) no such effort is invited, no change of innervation takes place.” But in the rod test the light seems nearer to the patient than in the prism test. This may account for much of the difference in results and amount to “an extraneous impulse to muscular contraction.”

Dr. Hubbell is entirely justified in his conclusion as made upon experiments with the Maddox rod and the Stevens phorometer. I shall watch cases along similar lines with the Wilson phorometer and report later.

In the mean time the rod and the prism tests may well be taken in each case and let judgment decide as to treatment.

THOS. M. STEWART.

I agree with the writer that the rod test is the more scientific test for heterophoria, and of late years have virtually discarded the prism test, except in special cases. The tables are interesting, but their value would be materially increased if the author would supplement them with tables showing the refraction, and inflammation or its results.

Was it an accident that Stevens’ phorometer showed the same amount of right hyperphoria in one-ninth of the cases, and in thirteen of thirty-three cases of left hyperphoria? In which of these cases was there anisometropia and of what kind was it?

What was the refraction of the two cases of exophoria, two of left and one of right hyperphoria by the phorometer; and was the refraction the same in the six cases which were orthophoric by both rod and prism?

Such studies are necessary to a clear understanding of the relative value of these tests.

JOHN L. MOFFAT.

DEAR DR. DEADY: Your letter and inclosed article on “The Maddox Rod or Phorometer; Which?” has been received and examined with interest.

I have examined a good many cases in my office by both methods and find variable results, but where there is a radical difference I have found the Maddox rod the more accurate, and from experience I have learned to rely upon it instead of the phorometer, as in prescribing prisms in hyperphoria in connection with glasses for constant use I rely wholly upon the rod test.

J. M. FAWCETT.

DEAR DOCTOR: Concerning the discussion of Maddox Rod vs. Phorometer about which you wrote me—can say that I believe that the Maddox rod is the more reliable test. My reasons on theoretical grounds for so believing are briefly these.

Given a case for examination; the test which _least disturbs_ the muscular co-ordination under investigation must give the best result. Now I think that when we throw the images into non-corresponding retinal points that we almost certainly cause some tension of certain muscles, because it is putting the eyes in an _unnatural_ relation with one another; and this is done by the phorometer. The Maddox rod is theoretically free from this objection.

_Practically_ the deviations are more certainly measured, because a patient _knows_ when the streak cuts the light; and you cannot trust their eye alone to tell when the lights are exactly in a line. Have used _both_ tests in every case I have examined in my private practice, and I find the Maddox the more reliable test. It is more to be depended upon.

EDW. HILL BALDWIN.

ABSTRACTS FROM CURRENT LITERATURE.

=Grant, Dundas.—Case of Emphysema of the Orbital Wall of the Anterior Ethmoidal Cells, Caused by blowing the Nose.=—_Jour. Lar., Rhin. and Otol._, March, 1900.

This case was shown to the British Laryngological, Rhinological and Otological Association.

W. M., twenty-eight years, came under my care yesterday on account of a sudden swelling of his eye which had taken place two hours previously, and which had occurred suddenly as he was blowing his nose without a handkerchief, and which gave him the impression as if something were running out of his eye. The swelling crackled in a manner characteristic of emphysema, and the first suspicion was that he must have had some disease of the orbital wall of the anterior ethmoidal cells, and that on examination there would be found some evidence of ethmoidal disease. None such was to be elicited, and the only history obtainable was that he received several kicks on the nose and back of the ear two months ago. This has probably resulted in a fracture of the orbital wall of certain of these cells.

PALMER.

=Lack, Lambert.—Case of Nasal Polypi, with Suppuration and Absence of Maxillary Sinuses.=—_Jour. of Lar., Rhin. and Otol._, April, 1900.

A man, aet. twenty-eight years, complains of nasal obstruction and purulent discharge, with a disagreeable odor in the nose. The polypi having been removed, the pus appeared to flow from under the anterior ends of the middle turbinates. After wiping the discharge away and bending the patient’s head forward, it reappeared in large quantity. On transillumination the cheek on both sides appeared quite dark, and the patient had no subjective sensation of light. The diagnosis of antral suppuration was now considered almost certain, and the patient was advised to have both antra punctured from the alveolar margins. This was accordingly attempted under gas, but although the antrum drill was forced in for its full length, no cavity was reached.

Puncture from the inferior meatus was next attempted, and considerable force was used in two different points; but with no better result. It would seem therefore that the antra must be very small, if not entirely absent.

_Discussion._—Mr. Spencer thought it might be one of those convoluted inferior turbinals which form a gutter in which pus collects. The majority considered it suppuration in the ethmoidal region.

PALMER.

=Lawson, Arnold.—Cicatrix Horn Growing from the Cornea.=—_The Lancet_, February 3, 1900.