Peter de Smet
Nijmegen, Netherlands

The Ibibio and Igbo peoples in southern Nigeria commemorate their deceased ancestors in masquerades, in which beautiful masks depict good ancestors, while ugly masks portray those who roam about as spirits inflicting illness and misfortune if moral laws are broken. These ugly masks may show twisted or eaten-away noses and lips, sores, and flapped (blind) eyes (Figs 1-2) to remind spectators what could happen to them if they leave the path of righteousness.^1-8

An interesting clinical question is whether one could submit such grotesque masks to a diagnostic gaze. This issue is discussed in an art catalogue about African “deformity masks.”⁸ Semantically, the label “deformity masks” is not optimal, since it only covers masks with a distorted or misshapen appearance (Fig 1) and does not include masks with signs of other conditions such as blindness (Fig 2). Other sources label such masks as “disease masks,” “illness masks,” or “sickness masks.” Hofmann associates these terms, respectively, with a professional perspective, a first-person perspective, and a societal perspective.⁹ This explains why the term sickness mask is preferred in the present article: disease is too much of a biomedical label, while illness does not reflect very well that the masks are meant to provoke a response in their spectators.

The second chapter of the aforementioned catalogue offers the etic perspective of an outsider by reviewing which diseases may be portrayed by African sickness masks.¹⁰ In contrast, the first chapter offers an emic perspective by looking at the sickness masks from the cultural inside. This first chapter emphasizes that such masks may defy identification as specific biomedical conditions because their carvers were at liberty to distort or exaggerate signs of disease and could even create novel disease-like features.¹¹

At first glance, these two approaches seem to be conflicting: the emic view seems to invalidate the viability of etic medical interpretations. However, as long as one keeps in mind that the masks do not have the same accuracy as a Frank Netter anatomy atlas, there is no compelling need to abandon the biomedical perspective altogether. In his book review of the catalogue, Imperato acknowledges that some sickness masks are not manifestations of a specific disease, but he adds that other masks clearly depict disease states.¹² A good argument for this latter point of view is that some Ibibio and Igbo informants have associated certain sickness masks with diseases such as leprosy.^13,14

Although it is permissible to suggest Western disease labels for some West African sickness masks, it would be unwise to do so unreservedly. There is also an important biomedical reason to be cautious: it can be difficult to distinguish a specific medical condition from differential diagnostic possibilities. A good example is the Ibibio sickness mask in Fig 1. The nasal destruction of such masks has often been regarded as a sign of gangosa, a condition characterized by destruction of the nose that occurs in the late stages of yaws.^3,6,13,15,16 However, Klaas Marck, the former president of the Dutch Noma Foundation (personal communication), cautioned that this type of sickness mask could also represent noma, a gangrenous condition of the face that usually occurs in poorly nourished children.⁵ Marck added that the mask in Fig 1 might also depict syphilis, Buruli ulcer, skin cancer, or a traumatic injury. According to Marck, the Ibibio mask in Fig 3 could not only represent noma, but also skin cancer or goundou, which is a thickening of the upper jaw from yaws that results in large swellings on either side of the nose (Fig 4).

In publications about the sickness masks from southern Nigeria, the most common biomedical suggestions are gangosa, leprosy, and facial paralysis. It should be noted that facial paralysis may be due to leprosy.^{3-5,10,13,17-20} Another biomedical suggestion that surfaces is noma.^21-23 More rarely, a mask may be associated with blindness,^1,24 large skin lesions,²⁵ or Burkitt’s lymphoma.⁴

The masks in Figs 4 and 5 add another possibility. Chinyere Pedro-Egbe, a professor of ophthalmology at the University of Port Harcourt (personal communication) believes that the lump on the eyeball in Fig 4 may represent anterior staphyloma, a localized protrusion of uveal tissue that results from a defect in scleral thickness. A major underlying cause is traumatic injury that may occur in activities such as chopping firewood²⁶ or with the use of traditional eye medications.²⁷ Staphyloma may also follow an infection. For instance, it may result from corneal ulceration from measles in malnourished children.^28,29

The two lumps on the eyeball in Fig 5 could likewise portray staphylomas (Chinyere Pedro-Egbe, personal communication). According to Simmons, the twisted nose of such masks most likely represents a tertiary form of yaws.¹³ However, yaws does not typically have a direct effect on the eyes. A more plausible possibility might be leprosy, which can produce both nasal asymmetry^30,31 and staphyloma³² (Fig 6). The theme of a twisted nose is also present in the False Face masks of the Native American Haudenosaunee (Iroquois) people, who regard it as the mythological result of a traumatic injury,³³ which might also lead to staphyloma. Last but not least, the Ibibio carver of the mask in Fig 5 could also have taken the liberty of combining two unrelated signs.⁵

Acknowledgments

The author gratefully acknowledges the expert help of Herbert Cole, Klaas Marck, and Chinyere Pedro-Egbe and the kind permissions of Jo De Buck and Alexander Poon to reproduce Figs 4 and 6.

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