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 Essentials of

Human

Second Edition
Disease
Leonard V. Crowley, MD
Biology Department
Century College
University of Minnesota Medical Center, Fairview
Minneapolis, Minnesota

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 Chapter 3 Autoimmune Disease Manifestations and
Mechanisms of Tissue Injury 59
Inflammation and Repair 38 Connective-­Tissue (Collagen) Diseases 59
The Inflammatory Reaction 38 Lupus Erythematosus 59
Chemical Mediators of Inflammation 41 Chapter Review 62
The Role of Lysosomal Enzymes in the
Inflammatory Process 42 Chapter 5
Inflammation Caused by Antigen–Antibody
Interaction 42
Pathogenic Microorganisms, Fungi,
Harmful Effects of Inflammation 42 and Animal Parasites 65
Infection 43 Types of Harmful Microorganisms 65
Terminology of Infection 43 Bacteria 66
Factors Influencing the Outcome of an Classification of Bacteria 66
­Infection 43 Major Classes of Pathogenic Bacteria 67
Chronic Infection 44 Antibiotic Treatment of Bacterial Infections 72
Chapter Review 44 Antibiotic Sensitivity Tests 73
Adverse Effects of Antibiotics 74
Chlamydiae 75
Chapter 4
Rickettsiae and Ehrlichiae 75
Immunity, Hypersensitivity, Allergy,
and Autoimmune Diseases 47 Mycoplasmas 75
Viruses 75
The Body’s Defense Mechanisms 47
Classification of Viruses 75
Immunity 48 Mode of Action 76
The Role of Lymphocytes in Acquired- Defenses Against Viral Infections 79
Immunity 48 Treatment with Antiviral Agents 80
Development of the Lymphatic System 48 Fungi 80
Response of Lymphocytes to Foreign Superficial Fungal Infections 80
Antigens 49
Highly Pathogenic Fungi 81
The Role of Complement in Immune Other Fungi of Medical Importance 81
Responses 52
Treatment of Systemic Fungal Infections 82
Antibodies (Immunoglobulins) 52 Animal Parasites and Their Host 82
Hypersensitivity Reactions: Immune System–Related Protozoal Infections 82
Tissue Injury 54 Malaria 83
Type I. Immediate Hypersensitivity Reactions: Babesiosis 83
Allergy and Anaphylaxis 54 Amebiasis 83
Type II. Cytotoxic Hypersensitivity Genital Tract Infections Caused by
Reactions 56 Trichomonads 84
Type III. Tissue Injury Caused by Immune Giardiasis 84
Complexes (“Immune Complex Disease”) 56 Toxoplasmosis 84
Type IV. Delayed (Cell-­Mediated) Cryptosporidiosis 85
Hypersensitivity Reactions 57 Pulmonary Pneumocystis Infection 86
Suppression of the Immune Response 57 Metazoal Infections 86
Reasons for Suppression 57 Roundworms 86
Methods of Suppression 57 Tapeworms 89
Tissue Grafts and Immunity 58 Flukes 89
Autoimmune Diseases 58 Chapter Review 91

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 Chapter 6 Autosomal Recessive Inheritance 120
Codominant Inheritance 121
Communicable Diseases 96 X-­Linked Inheritance 121
Methods of Transmission and Control 96 Intrauterine Injury 121
Methods of Transmission 96 Harmful Drugs and Chemicals 121
Methods of Control 97 Radiation 123
Immunization 97 Maternal Infections 123
Identification, Isolation, and Treatment of Multifactorial Inheritance 125
Infected Persons 97 Prenatal Diagnosis of Congential Abnormalities 125
Control of Means of Indirect Transmission 97
Amniocentesis 126
Requirements for Effective Control 97
Chorionic Villus Sampling 127
Sexually Transmitted Diseases 98
Chapter Review 127
Syphilis 99
Gonorrhea 100
Herpes 101 Chapter 8
Genital Chlamydial Infections 102 Tumors 131
Human Immunodeficiency Virus Infections and
Tumors: Disturbed Cell Growth 132
AIDS 103
HIV and Its Target 103 Tumors 132
Manifestations of HIV Infection 103 Classification and Nomenclature 132
Measurement of Viral RNA and CD4+ Comparison of Benign and Malignant
Lymphocytes as an Index of Disease Tumors 132
Progression 104 Benign Tumors 134
Complications of AIDS 104 Malignant Tumors 134
Prevalence of HIV Infection and AIDS in H
­ igh-­ Variations in Terminology 135
Risk Groups 105 Necrosis in Tumors 138
Treatment of HIV Infection 106 Noninfiltrating (in Situ) Carcinoma 139
Prevention and Control of HIV Infection 107 Precancerous Conditions 139
Case Studies 107 Etiologic Factors in Neoplastic Disease 140
Chapter Review 108 Viruses 140
Gene and Chromosomal Abnormalities 140
Failure of Immunologic Defenses 142
Chapter 7 Heredity and Tumors 143
Congenital and Hereditary Diagnosis of Tumors 144
Diseases 111 Early Recognition of Neoplasms 144
Causes of Congenital Malformations 111 Cytologic Diagnosis of Neoplasms 144
Frozen-­Section Diagnosis of Neoplasms 145
Chromosomal Abnormalities 112 Tumor-­Associated Antigen Tests 145
Chromosome Nondisjunction During
Gametogenesis 112 Treatment of Tumors 146
Chromosome Deletions and Translocations Surgery 146
During Gametogenesis 112 Radiotherapy 146
Chromosome Nondisjunction in the Hormone Therapy 146
Zygote 114 Anticancer Drugs 147
Sex Chromosome Abnormalities 114 Adjuvant Chemotherapy 147
Autosomal Abnormalities 117 Immunotherapy 147
Genetically Transmitted Diseases 118 Leukemia 148
Autosomal Dominant Inheritance 119 Classification of Leukemia 148

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 Clinical Features and Principles of
Treatment 148
Precursors of Leukemia: The Myelodysplastic
Syndromes 149
Multiple Myeloma 149
Survival Rates in Neoplastic Disease 150
Chapter Review 152
Chapter 9
Blood Coagulation
Abnormalities and Circulatory
Disturbances 155
Hemostasis 156
Factors Concerned with Hemostasis 156
Blood Vessels and Platelets 156
Plasma Coagulation Factors 156
Coagulation Inhibitors and Fibrinolysins
Calcium and Blood Coagulation 158
Clinical Disturbances of Blood Coagulation
Abnormalities of Small Blood Vessels 158
Abnormalities of Platelet Numbers or
Function 158
Deficiency of Plasma Coagulation Factors 158
Liberation of Thromboplastic Material into the
Circulation 160
Laboratory Tests to Evaluate Hemostasis 160
Case Studies 161
Circulatory Disturbances: Thrombosis and
Embolism 163
Venous Thrombosis and Pulmonary Embolism
Large Pulmonary Emboli 163
Small Pulmonary Emboli 165
Diagnosis of Pulmonary Embolism 165
Treatment of Pulmonary Embolism 166
Arterial Thrombosis 167
Intracardiac Thrombosis 167
Thrombosis Caused by Increased Blood
Coagulability 167
Thrombosis in Patients with Cancer 168
Embolism as a Result of Foreign Material 168
Fat Embolism 168
Amnionic Fluid Embolism 168
Air Embolism 168
Edema 168
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Factors Regulating Fluid Flow Between
Capillaries and Interstitial Tissue 169
Pathogenesis and Classification of Edema 169
Shock 170
Chapter Review 172
Chapter 10
The Cardiovascular System 176
Cardiac Structure and Function 177
Normal Cardiac Function 177
Cardiac Chambers 177
Cardiac Valves 177
Blood Supply to the Heart 178
Conduction System of the Heart 179
The Cardiac Cycle 179
Blood Vessels 180
Blood Pressure 180
158 The Electrocardiogram 181
Cardiac Arrhythmias 181
158 Atrial Fibrillation 181
Treatment of Atrial Fibrillation 181
Ventricular Fibrillation 182
Heart Block 182
Heart Disease as a Disturbance of Pump Function 182
Congenital Heart Disease 183
Cardiac Development and Prenatal Blood
Flow 183
Pathogenesis and Manifestations of Congenital
Heart Disease 183
Common Cardiovascular Abnormalities 185
163 Patent Ductus Arteriosus 185
Patent Foramen Ovale 185
Atrial and Ventricular Septal Defects 185
Pulmonary or Aortic Valve Stenosis 185
Coarctation of the Aorta 186
The Tetralogy of Fallot and Transposition of the
Great Arteries 186
Prevention of Congenital Heart Disease 187
Valvular Heart Disease 187
Rheumatic Fever and Rheumatic Heart
Disease 187
Nonrheumatic Aortic Stenosis 189
Mitral Valve Prolapse 191
Infective Endocarditis 192
Coronary Heart Disease 194
Risk Factors 195
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 Manifestations 195
Diagnosis of Coronary Artery Disease 196
Coronary Disease Manifestations with
Apparently Normal Coronary Arteries 196
Treatment of Coronary Artery Disease 197
Severe Myocardial Ischemia and Its Complications:
A “Heart Attack” 198
Cardiac Arrest 199
Myocardial Infarction 200
Location of Myocardial Infarcts 200
Major Complications of Myocardial
Infarcts 200
Survival After Myocardial Infarction 201
Diagnosis of Myocardial Infarction 201
Evaluation and Treatment of Patients with
Suspected Myocardial Infarction: The Acute
Coronary Syndrome Classification 203
Restoring Blood Flow Through a Thrombosed
Coronary Artery 204
Subsequent Treatment of Myocardial
Infarction 205
Case Studies 205
Taking Aspirin to Reduce the Risk of Cardiovascular
Disease 207
Cocaine-Induced Arrhythmias and Myocardial
Infarcts 207
Blood Lipids and Coronary Artery Disease 207
Neutral Fat 207
Cholesterol 208
Transport of Cholesterol by Lipoproteins
Alteration of Blood Lipids by Change in
Diet 209
Hypertension and Hypertensive Cardiovascular
Disease 209
Primary Hypertension 209
Secondary Hypertension 210
Isolated Systolic Hypertension 210
Treatment of Hypertension 210
Primary Myocardial Disease 210
Myocarditis 210
Cardiomyopathy 210
Heart Failure 211
Pathophysiology and Treatment of Heart
Failure 211
Comparison of Systolic and Diastolic
Dysfunction in Heart Failure 212
Acute Pulmonary Edema 212
Aneurysms 213
Arteriosclerotic Aneurysm 213
Dissecting Aneurysm of the Aorta 214
Diseases of the Veins 217
Venous Thrombosis and
Thrombophlebitis 217
Varicose Veins of the Lower Extremities 217
Chapter Review 219
Chapter 11
The Hematopoietic and Lymphatic
Systems 223
The Hematopoietic System 223
Composition and Function of Human
Blood 223
Normal Hematopoiesis 225
Development, Maturation, and Survival of Red
Cells 225
Regulation of Hematopoiesis 226
Anemia 226
Etiologic Classification of Anemia 226
Morphologic Classification of Anemia 226
Iron Metabolism and Hematopoiesis 227
Iron Deficiency Anemia 228
Vitamin B12 and Folic Acid Deficiency 230
Acute Blood Loss 231
Accelerated Blood Destruction 231
Diagnostic Evaluation of Anemia 234
208
Polycythemia 235
Secondary Polycythemia 235
Primary Polycythemia 235
Complications and Treatment of
Polycythemia 235
Iron Overload: Hemochromatosis 235
Thrombocytopenia 236
The Lymphatic System 236
Diseases of the Lymphatic System 237
Inflammation of the Lymph Nodes
(Lymphadenitis) 237
Infectious Mononucleosis 237
Neoplasms Affecting Lymph Nodes 238
Alteration of Immune Reactions in Diseases of
the Lymphatic System 238
The Enlarged Lymph Node as a Diagnostic
Problem 238

Contents xi

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 The Role of the Spleen in Protection Against
Systemic Infection 239
Chapter Review 239
Chapter 12
The Respiratory System 241
Oxygen Delivery: A Cooperative Effort 241
Structure and Function of the Lungs 242
Bronchi, Bronchioles, and Alveoli 242
Ventilation 244
Gas Exchange 244
Pulmonary Function Tests 245
The Pleural Cavity 245
Pneumothorax 246
Atelectasis 248
Obstructive Atelectasis 248
Compression Atelectasis 249
Pneumonia 250
Classification of Pneumonia 250
Clinical Features of Pneumonia 251
Pneumocystis Pneumonia 251
Tuberculosis 251
Course of a Tuberculous Infection 251
Miliary Tuberculosis and Tuberculous
Pneumonia 254
Extrapulmonary Tuberculosis 254
Diagnosis and Treatment of Tuberculosis
Bronchitis and Bronchiectasis 255
Chronic Obstructive Lung Disease 255
Derangements of Pulmonary Structure and
Function 256
Pathogenesis of Chronic Obstructive Pulmonary
Disease 257
Prevention and Treatment 258
Bronchial Asthma 259
Respiratory Distress Syndrome 259
Respiratory Distress Syndrome of Newborn
Infants 259
Adult Respiratory Distress Syndrome 260
Pulmonary Fibrosis 260
Lung Carcinoma 261
Chapter Review 263
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Chapter 13
The Breast and Female
Reproductive System 268
The Breast 269
Structure and Physiology of the Breast 269
Mammograms 269
Abnormalities of Breast Development 270
Accessory Breasts and Nipples 270
Unequal Development of the Breasts 271
Breast Hypertrophy 272
Gynecomastia 272
Benign Cystic Change in the Breast 272
Fibroadenoma 272
Carcinoma of the Breast 273
Breast Carcinoma Risk Related to Hormone
Treatment 273
Breast Carcinoma Susceptibility Genes 273
Classification of Breast Carcinoma 274
Evolution of Breast Carcinoma 274
Clinical Manifestations 274
Treatment 276
Examination of Axillary Lymph Nodes: The Role
of the Sentinel Node 276
Estrogen and Progesterone Receptors in Breast
Carcinoma 276
HER-2 Gene Amplification in Breast
Carcinoma 277
Adjuvant Therapy for Breast Carcinoma 278
254 Treatment of Recurrent and Metastatic
Carcinoma 278
Sarcoma of the Breast 278
A Lump in the Breast as a Diagnostic Problem 278
Female Reproductive System 279
Infections of the Female Genital Tract 279
Vaginitis 279
Cervicitis 279
Salpingitis and Pelvic Inflammatory
Disease 279
Condylomas of the Genital Tract 280
Endometriosis 280
Cervical Polyps 282
Cervical Dysplasia and Cervical Carcinoma 282
HPV Vaccine 282
Diagnosis and Treatment 283
Endometrial Hyperplasia, Polyps, and Carcinoma 283
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 Uterine Myomas 283
Irregular Uterine Bleeding 285
Dysfunctional Uterine Bleeding 285
Other Causes of Uterine Bleeding 286
Diagnosis and Treatment 286
Dysmenorrhea 286
Cysts and Tumors of the Ovary 286
Diseases of the Vulva 289
Vulvar Dystrophy 289
Carcinoma of the Vulva 289
Toxic Shock Syndrome 289
Contraception 289
Emergency Contraception 290
Chapter Review 291
Chapter 14
Prenatal Development and Diseases
Associated with Pregnancy 296
Fertilization and Prenatal Development
Fertilization 297
Early Development of the Fertilized Ovum
Stages of Prenatal Development 300
Duration of Pregnancy 301
Decidua, Fetal Membranes, and Placenta
The Decidua 301
The Chorion and Chorionic Villi
The Amnionic Sac 302
The Yolk Sac 302
The Placenta 302
Amnionic Fluid 304
Polyhydramnios and Oligohydramnios 304
Hormone-Related Conditions in Pregnancy 304
Nausea and Vomiting During Early
Pregnancy 304
Hyperemesis Gravidarum 304
Gestational Diabetes 304
Spontaneous Abortion (“Miscarriage”)
Ectopic Pregnancy 306
Consequences of Tubal Pregnancy
Abnormal Attachment of the Placenta 307
Placenta Previa 307
Twins and Multiple Pregnancies 307
Fraternal Twins 307
Identical Twins 308
Determination of Zygosity of Twins from
Examination of Placenta 308
Twin Transfusion Syndrome 309
Vanishing Twins and Blighted Twins 311
Conjoined Twins 312
Disadvantages of Twin Pregnancies 312
Preeclampsia and Eclampsia: Toxemia of
Pregnancy 312
Hydatidiform Mole and Choriocarcinoma 313
Benign Hydatidiform Mole 313
Invasive Mole 314
Choriocarcinoma 314
Treatment of Gestational Trophoblast
Disease 314
Hemolytic Disease of the Newborn (Erythroblastosis
Fetalis) 314
Changes in Hemoglobin and Bilirubin After
Delivery 314
Rh Hemolytic Disease 315
Diagnosis of Hemolytic Disease in the Newborn
Infant 315
297 Treatment of Hemolytic Disease 316
Fluorescent Light Therapy for
298 Hyperbilirubinemia 317
Prevention of Rh Hemolytic Disease with
Rh-Immune Globulin 317
ABO Hemolytic Disease 318
301
Chapter Review 320
301
Chapter 15
The Urinary and Male Reproductive
Systems 324
Structure and Function of the Urinary System 325
The Kidneys 325
The Ureters 325
The Bladder and Urethra 325
Function of the Kidneys 326
The Nephron 326
305 Renal Regulation of Blood Pressure and Blood
Volume 328
Requirements for Normal Renal Function 329
306
Developmental Disturbances 329
Glomerulonephritis 330
Immune-Complex Glomerulonephritis 330
Anti-GBM Glomerulonephritis 331
Nephrotic Syndrome 331

Contents xiii

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 Arteriolar Nephrosclerosis 332 Treatment 355
Diabetic Nephropathy 333 Carcinoma of the Testis 356
Gout-Associated Nephropathy 333 Carcinoma of the Penis 356
Infections of the Urinary Tract 333 Chapter Review 357
Cystitis 334
Pyelonephritis 334
Vesicoureteral Reflux and Infection 335 Chapter 16
Calculi 335 The Liver, Biliary System, and
Foreign Bodies 336 Pancreas 363
Obstruction 337 Structure and Function of the Liver 364
Renal Tubular Injury 339 Bile 366
Formation and Excretion 366
Renal Cysts 339 Composition and Properties 366
Solitary Cysts 339
Congenital Polycystic Kidney Disease 339
Causes and Effects of Liver Injury 367
Tumors of the Urinary Tract 340 Viral Hepatitis 367
Renal Cortical Tumors 340 Clinical Manifestations and Course 368
Transitional Cell Tumors 340 Hepatitis A 368
Hepatitis B 369
Nephroblastoma (Wilms Tumor) 340
Hepatitis C 371
Diagnostic Evaluation of Kidney and Urinary Tract Hepatitis D (Delta Hepatitis) 372
Disease 341 Hepatitis E 372
Urinalysis 341 Other Hepatitis Viruses 372
Clearance Tests 341 Sexually Transmitted Hepatitis 372
Additional Techniques 342 Fatty Liver 372
Renal Failure (Uremia) 342 Alcoholic Liver Disease 372
Acute Renal Failure 342 Cirrhosis 374
Chronic Renal Failure 342 Derangements of Liver Structure and
Hemodialysis 343 Function 375
Peritoneal Dialysis 344 Procedures to Treat Manifestations of
Renal Transplantation 345 Cirrhosis 378
Structure and Function of the Male Reproductive Biliary Cirrhosis 378
System 346 Reye Syndrome 380
Gonorrhea and Nongonococcal Urethritis 348 Cholelithiasis 380
Prostatitis 348 Factors Affecting the Solubility of Cholesterol
in Bile 380
Benign Prostatic Hyperplasia 348
Complications of Gallstones 381
Carcinoma of the Prostate 350 Treatment of Gallstones 381
Cryptorchidism 351 Cholecystitis 382
Testicular Torsion 352 Tumors of the Liver and Gallbladder 382
Scrotal Abnormalities 353 Jaundice 382
Hydrocele 353 Hemolytic Jaundice 383
Varicocele 353 Hepatocellular Jaundice 383
Erectile Dysfunction 354 Obstructive Jaundice 383
Physiology of Penile Erection 354 Biopsy of the Liver 383
Causes of Erectile Dysfunction 354 The Pancreas: Structure and Function 383

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 Pancreatitis 384 Inflammatory Diseases of the Intestine 406
Acute Pancreatitis 384 Acute Enteritis 406
Chronic Pancreatitis 384 Chronic Enteritis 406
Cystic Fibrosis of the Pancreas 385 Crohn Disease 407
Antibiotic-Associated Colitis 408
Diabetes Mellitus 385 Appendicitis 408
Type 1 Diabetes Mellitus 386 Meckel Diverticulum 409
Type 2 Diabetes Mellitus 387
Pregnancy-Associated Diabetes 387 Disturbances of Bowel Function 409
Diabetes and the Metabolic Syndrome 388 Food Intolerance 409
Irritable Bowel Syndrome 410
Actions of Insulin on Metabolic Processes 388
Fat Metabolism and Formation of Ketone Eating Disorders 410
Bodies 388 Obesity 410
Biochemical Disturbances in Diabetes 389 Causes of Obesity 410
Monitoring Control of Diabetes 390 Health Consequences of Obesity 411
Treatment of Diabetes 391 Treatment of Obesity 411
Complications of Diabetes 391
Anorexia Nervosa and Bulimia Nervosa 412
Other Causes of Hyperglycemia 391
Anorexia Nervosa 412
Hypoglycemia 392 Bulimia Nervosa 413
Tumors of the Pancreas 393 Binge Eating Disorder 413
Chapter Review 393 Diverticulosis and Diverticulitis of the Colon 414
Intestinal Obstruction 415
Chapter 17 Adhesions 416
Hernia 416
The Gastrointestinal Tract 399 Volvulus and Intussusception 417
Structure and Functions 400 Tumors of the Bowel 417
Cleft Lip and Cleft Palate 400 Mesenteric Thrombosis 418
Abnormalities of Tooth Development 400 Hemorrhoids 419
Missing Teeth and Extra Teeth 400
Abnormalities of Tooth Enamel Caused by Diagnostic Evaluation of Gastrointestinal
Tetracycline 400 Disease 420
Dental Caries and Its Complications 401 Chapter Review 420
Prevention and Treatment 402
Periodontal Disease 402 Chapter 18
Inflammation of the Oral Cavity 402 Nutrition and Disease 424
Tumors of the Oral Cavity 402 Nutrient Requirements and Their Functions 424
Diseases of the Esophagus 402 Food and Water 425
Cardiac Sphincter Dysfunction 403 Vitamins and Minerals 426
Gastric Mucosal Tears 403 Achieving a Balanced Diet: Food Groups and Food
Esophageal Obstruction 404 Guides 426
Gastritis 404 Malnutrition 426
Acute Gastritis 404 Causes of Malnutrition 426
Chronic Gastritis and Its Complications: The Malnutrition in Children 427
Role of Helicobacter pylori 404 Malnutrition in Adults 427
Peptic Ulcer 405 Alcohol: Its Role in Malnutrition 428
Carcinoma of the Stomach 406 Vitamins: Their Sources and Functions 428

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 Fat-Soluble Vitamins 428 Pituitary Hypofunction 448
Water-Soluble Vitamins 430 Pituitary Tumors 449
Minerals 431 Overproduction of Growth Hormone 449
Overproduction of Prolactin 450
Chapter Review 432
The Thyroid Gland 450
Goiter 451
Chapter 19 Hyperthyroidism 452
Fluids and Electrolytes 434 Hypothyroidism 453
Chronic Thyroiditis and Hashimoto
Body Water and Electrolytes 434
Thyroiditis 453
Interrelations of Intracellular and Extracellular Tumors of the Thyroid 454
Fluid 435 The Parathyroid Glands and Calcium Metabolism 455
Units and Concentration of Electrolytes 435 Hyperparathyroidism 456
Regulation of Body Fluid and Electrolyte Hypoparathyroidism 456
Concentration 435 The Adrenal Glands 456
The Adrenal Cortex 456
Disturbances of Water Balance 435
Disturbances of Adrenal Cortical Function 457
Dehydration 435
Overhydration 436 The Adrenal Medulla 458
Disturbances of Electrolyte Balance 436 Tumors of the Adrenal Medulla 458

Acid–Base Balance 436 The Pancreatic Islets 460

Buffers 436 The Gonads 460
Control of Carbonic Acid by the Lungs 437 Hormone Production by Nonendocrine Tumors 461
Control of Bicarbonate Concentration by the
Kidneys 437 Stress and the Endocrine System 461
Relationship Between pH and Ratio of Buffer Acute Stress Response 461
Components 437 Chronic Stress Response 461
Disturbances of Acid–Base Balance 438 Chapter Review 462
Compensatory Mechanisms Responding to
Disturbances in pH 438 Chapter 21
Metabolic Acidosis 439
Compensatory Mechanisms 440 The Nervous System 465
Respiratory Acidosis 440 Structure and Function 466
Metabolic Alkalosis 441
Respiratory Alkalosis 441
Development of the Nervous System 467
Diagnostic Evaluation of Acid–Base Muscle Tone and Voluntary Muscle Contraction 467
Balance 442 Muscle Paralysis 468
Chapter Review 443 Cerebral Injury 468
Neural Tube Defects 469
Chapter 20 Anencephaly 469
The Endocrine Glands 445 Spina Bifida 470
Endocrine Functions and Dysfunctions 445 Prenatal Detection of Neural Tube Defects 471

The Pituitary Gland 446 Hydrocephalus 471

Pituitary Hormones 447 Stroke 473
Anterior Lobe Hormones 447 Cerebral Thrombi and Emboli 474
Physiologic Control of Pituitary Hormone Stroke Caused by Arteriosclerosis of Extracranial
Secretion 447 Arteries 475

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 Cerebral Hemorrhage 476 Arthritis 496
Manifestations of Stroke 476 Rheumatoid Arthritis 496
Rehabilitation of the Stroke Patient 477 Osteoarthritis 498
Transient Ischemic Attack 477 Gout 499
Cerebral Aneurysm 477 Fracture 501
Infections of the Nervous System 479 Osteomyelitis 501
Meningitis Caused by Bacteria and Fungi 479 Hematogenous Osteomyelitis 501
Viral Infections 480 Osteomyelitis as a Result of Direct Implantation
Manifestations of Nervous System Virus of Bacteria 501
Infection 480 Clinical Manifestations and Treatment 501
Arbovirus Infections 480 Tumors of Bone 501
Creutzfeldt–Jakob Disease 481 Osteoporosis 502
Mad Cow Disease 481 Structure and Function of the Spine 503
Alzheimer Disease 482 Chest Wall Abnormalities 504
Multiple Sclerosis 482 Pectus Excavatum 504
Parkinson Disease 483 Marfan Syndrome: Connective Tissue Disease 504
Scoliosis 505
Huntington Disease 484
Intervertebral Disk Disease 506
Degenerative Diseases of Motor Neurons 484
Structure and Function of Skeletal Muscle 506
Tumors of the Nervous System 484 Contraction of Skeletal Muscle 506
Tumors of the Peripheral Nerves 484 Factors Affecting Muscular Structure and
Tumors of the Brain 485 Function 507
Tumors of the Spinal Cord 485
Inflammation of Muscle (Myositis) 507
Peripheral Nerve Disorders 485 Localized Myositis 507
Polyneuritis (Peripheral Neuritis) 485 Generalized Myositis 507
Neurologic Manifestations of Human Immunodeficiency Muscular Atrophy and Muscular Dystrophy 507
Virus Infections 486
Myasthenia Gravis 508
HIV Infections of the Nervous System 486
Opportunistic Infections of the Nervous Chapter Review 509
System 486
AIDS-Related Tumors 486 General References 513
Chapter Review 487
Answers to Interactive
Chapter 22 Activities 515
The Musculoskeletal System 491
Structure and Function of the Skeletal System 491 Glossary 519
Bone Formation 492
Bone Growth 493
Congenital Malformations 494 Index 531
Abnormal Bone Formation 494
Congenital Clubfoot (Talipes) 494

Contents xvii

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43898_FMxx_FINAL.indd 18 8/16/12 11:00 AM
 Preface
Purpose and Scope of the Book
Essentials of Human Disease is a consolidated and
modified version of the very successful An Intro-
duction to Human Disease, now in its ninth edition.
This book is designed to appeal to allied health
and health education students who have limited
time to master basic disease concepts. Despite
time limitations, these students want to learn the
essential structural and functional characteristics
of common and important diseases, as well as the
principles of diagnosis and treatment, and they
want the material presented in a user-friendly,
non-intimidating manner. In order to accomplish
these objectives, some diseases considered in An
Introduction to Human Disease had to be eliminated
or reduced in content. On the other hand, other
items of interest were added to appeal to students,
and the format was modified in order to encour-
age students to take an active role in the learning
process.
Most students have had some previous exposure
to anatomy and physiology, and they are often
pleasantly surprised to find the basic concepts
relating to human disease are quite straightforward,
easy to understand, and extremely interesting.
Every organ system has key structural features
and physiologic functions, which are reviewed at
the beginning of most chapters. All is well when
these systems perform properly, but when they
do not function correctly students discover that
disease may be the culprit. Moreover, when the
student understands the anatomic and physio-
logic changes associated with a given disease, it is
not difficult to deduce the clinical manifestations
of the disease and how to formulate appropriate
treatment that favorably influences the course and
outcome of the disease.
Many students derive tremendous satisfaction
from watching their knowledge base relating to
human disease grow by leaps and bounds through-
out the course. Many students who have taken a
human disease course have gone on to careers in
biology, medicine, nursing, and other health fields.
Each chapter in the book begins with learning
objectives, followed in most cases by a brief review
of the anatomy and physiology of the organ system
43898_FMxx_FINAL.indd 19
discussed in the chapter, which leads into a sys-
tematic survey of the pathology, pathophysiology,
clinical manifestations, and principles of treatment
of the specific diseases covered.
Each chapter ends with a chapter summary,
questions for review, student exercises, and an
annotated bibliography that summarizes the con-
cepts in the articles cited.
Features that will facilitate learning include the
following:
• In-text key terms are set in bold and defined
in the margin of the page where the term
appears, as well as in the glossary at the end
of the book.
• Tables are used to reinforce and summarize
key material in the text. For example,
essential features of bacterial, fungal, and
parasitic diseases, characteristics of various
types of congenital heart disease, and
principles of diagnosis and treatment of
heart attacks.
• Chapters dealing with similar or related
subjects are consolidated, and a separate
chapter on nutrition and disease is
included.
• “A Closer Look” boxes are included in some
chapters. These boxes discuss important
physicians and scientists who made key
contributions to the diagnosis or treatment
of specific diseases.
• Interactive Activities are included at the end
of each chapter. They consist of multiple-
choice, matching, true or false, and fill-
in-the-blank questions. Critical thinking
questions raise a “real world” question
about a disease-related subject as would
be proposed by a fellow student, parent,
or friend. This format requires students
to evaluate their knowledge of the subject
and then come up with an appropriate,
scientifically based answer to the question.
Answers to odd-numbered questions
are provided at the back of the book.
(Instructors may obtain electronic access to
all answers.) The questions and answers can
serve as a focus for classroom discussion.
xix
8/16/12 11:00 AM
 Organization
The book is organized into two main sections.
The first section, comprising the first 9 chapters,
deals with general concepts and diseases affecting
the body as a whole. The second section, which
includes the remaining 13 chapters, considers the
various organ systems and the primary diseases
associated with each.
In the first section, Chapter 1 discusses mani-
festations of disease, classification, diagnosis, and
principles of treatment. Chapter 2 considers the
organization and basic function of cells and tissues,
genes, chromosomes, cell division, and chromo-
some analysis, as well as the HLA system and its
relationship to disease. Chapters 3 and 4 consider
the body’s defenses, the inflammatory reaction, the
immune system, and their major disorders.
Chapters 5 and 6 are concerned with the vari-
ous pathogenic microorganisms, fungi, parasites,
and the diseases they cause. Chapter 7 considers
congenital and hereditary diseases, and Chapter 8
deals with tumors. Chapter 9 describes coagulation
of the blood and the conditions that occur when
blood does not clot normally or when blood clots
too readily and its complications—thrombosis and
embolism.
In the second section, the final 13 chapters, indi-
vidual organ systems are considered in a systematic
manner, with emphasis on the more common and
critical diseases. Basic pathophysiology, pathol-
ogy, and principles of diagnosis and treatment
are discussed.
Chapter 10 describes diseases of the cardio-
vascular system and related aspects, including
the acute coronary syndrome classification of
coronary heart disease. Diseases of the hema-
topoietic and lymphatic systems are considered
together in Chapter 11, followed by diseases of
the respiratory system in Chapter 12. Chapters 13
and 14 are best considered as a unit: diseases of
the breast, the female reproductive system, pre­
natal development, and diseases associated with
pregnancy. Chapter 15 considers kidney diseases
and the closely associated diseases of the male
reproductive system, which are best considered
together as a unit.
xx Preface
43898_FMxx_FINAL.indd 20
Chapter 16 describes derangements of the liver,
biliary system, and pancreas, including diabetes
mellitus. Gastrointestinal tract diseases follow in
Chapter 17, including sections on eating disorders
and their treatment, and Chapter 18 deals with
nutrition and disease. Chapter 19 departs from
the organ system approach and considers distur-
bances in fluid, electrolyte, and acid–base balance,
which follows the discussion in earlier chapters of
the diseases in which these conditions occur. The
final three chapters deal, respectively, with major
diseases of the endocrine glands, nervous system,
and musculoskeletal system.
New to the Second Edition
• Chapter 1 contains current information on
ultrasounds.
• Chapter 6 contains updated information on
AIDS, HIV prevention, and mother-to-infant
transmission of HIV.
• Chapter 15 includes new text on renal
transplantations.
• Chapter 18 reflects the newest BMI data
updated from the 2010 USDA Dietary
Guidelines.
• Chapter 22 has new sections on Pectus
Excavatum and Marfan Syndrome.
• Tables and figures have been updated
throughout the text with the latest data and
statistics.
Study Aids and Special Features
Various learning and study aids are included to
enhance the usefulness of the book. Learning
objectives, review questions, and chapter sum-
maries are provided for each chapter. Literature for
further study is listed at the end of each chapter,
and a listing of general references is included at
the end of the book. These additional resources
should prove useful to students who wish to pur-
sue a subject in greater detail. A glossary with a
pronunciation guide is appended to the end of the
text. This may provide extra support to students
who have not had a course in medical terminology
and can serve as a convenient reference for other
students who wish to have a quick review of a
8/16/12 11:00 AM
 particular term. Words appearing in the glossary
are set in boldface type in the text.
Additional Resources
Student Companion Website:
go.jblearning.com/CrowleyEssentials
The website to accompany Essentials of Human
Disease offers the following resources to enhance
student learning and comprehension: Anatomy
and Physiology Review, Chapter Outlines, Web
Links, Practice Quizzes, an Interactive Glossary,
Flashcards, and Crossword Puzzles.
Instructor’s Media CD
The Instructor’s Media CD includes PowerPoint
Presentations and an extensive PowerPoint Image
and Table Bank. For more information about these
resources, please contact your sales representative.
Acknowledgments for the Second Edition
Jones & Bartlett Learning would like to extend
a warm thank you to Dr. Jim Van Elsywk for his
work in reviewing this text and accompanying
ancillaries throughout the production process.
Acknowledgments from the First Edition
Many people helped with the initial edition of
Introduction to Human Disease, on which the Essen-
tials of Human Disease is based. Several colleagues
with whom Dr. Crowley practiced at hospitals
43898_FMxx_FINAL.indd 21
in Minneapolis and St. Paul made helpful sug-
gestions, as did colleagues in the Department
of Laboratory Medicine and Pathology, and the
Department of Family Practice and Community
Health at the University of Minnesota, College of
Medicine. Staff members at the West Side Com-
munity Health Center in St. Paul were also very
helpful, and some of the case studies used in the
book were based on these clinical contacts.
Judie Coulter, the senior departmental secretary
in the Biology Department at Century College,
provided invaluable assistance in converting the
ninth edition of Introduction to Human Disease to
the new Essentials book, by organizing the book
chapters and preparing the book for publication.
It would have been very difficult to accomplish
this task without her help.
Reviewers of the First Edition of
Essentials of Human Disease
Jeanne M. Clerc, EdD, MT(ASCP)SH
Western Illinois University
Dorothy M. Hendrix, PhD, RHIT
East Los Angeles Community College
Sara S. Plaspohl, DrPH, MHS, CIM, CIP
Armstrong Atlantic State University
Peter C. Sayles, PhD
North Country Community College
Preface xxi
8/16/12 11:00 AM
43898_FMxx_FINAL.indd 22 8/16/12 11:00 AM

General Concepts of
Disease: Principles
of Diagnosis
1. Define the common terms used to describe dis-
ease, such as lesions, organic and functional disease,
symptomatic and asymptomatic disease, etiology, and
pathogenesis.
2. List the major categories of human disease.
Characteristics of Disease
Any disturbance of structure or function of the body
may be regarded as disease. A disease is often asso-
ciated with ­well-­defined, characteristic structural
changes, called lesions, that are present in various
organs and tissues. One can recognize lesions by exam-
ining the diseased tissue with the naked eye, which is
called a gross examination, or with the aid of a micro-
scope, which is called a histologic examination. Some-
times histologic examinations are supplemented by
specialized studies that evaluate the properties of the
43898_CH01_6204.indd 1
Chapter
1
3. Explain the approach that a practitioner uses to make
a diagnosis and decide on a patient’s treatment.
4. Describe the various types of diagnostic tests and
procedures that can help the practitioner in making
a diagnosis and deciding on proper treatment.
cell membranes and the proteins within the cells. A
disease associated with structural changes is called an
organic disease. In contrast, a functional disease is
one in which no morphologic abnormalities (morphe =
structure or shape) can be identified even though body
functions may be profoundly disturbed. However, as
we develop new methods for studying cells, we can
sometimes identify previously unrecognized abnor-
malities that disturb cell functions. Consequently,
many of the traditional distinctions between organic
and functional disease are no longer as sharply defined
as in the past.
8/16/12 8:54 AM
 Pathology is the study of disease, and a pathologist is Congenital and Hereditary
a physician who specializes in diagnosing and classify-
ing diseases primarily by examining the morphology
Diseases
Congenital and hereditary diseases are the result of
of cells and tissues. A clinician is any physician or
disease developmental disturbances. They may be caused by
Any other health practitioner who cares for patients.
genetic abnormalities, abnormalities in the numbers
disturbance A disease may cause various subjective
of the structure
and distribution of chromosomes, intrauterine injury
manifestations, such as weakness or pain,
or function of the as a result of various agents, or an interaction of genetic
in an affected individual: These are called
body. and environmental factors. Hemophilia, the w ­ ell-­known
symptoms. A disease may also produce
lesion (le´shun) Any hereditary disease in which blood does not clot properly,
objective manifestations, detectable by
structural abnormality and congenital heart disease induced by the German
or pathologic change. the clinician, that are called signs or
measles virus are examples of diseases in this category.
physical findings. In many diseases,
organic disease A
disease associated with the quantity of blood cells in the cir-
structural changes in the culation may change, and so may the Inflammatory Diseases
affected tissue or organ. biochemical constituents in the body Inflammatory diseases are those in which the body
pathology The study of the fluids. These alterations are reflected reacts to an injurious agent by means of inflammation.
structural and functional as abnormal laboratory test results. Many of the diseases characterized by inflammation,
changes in the body caused
A disease that causes the affected such as a sore throat or pneumonia, are caused by
by disease.
individual no discomfort or dis- bacteria or other microbiologic agents. Others, such as
etiology (e-te-ol´o-je) The
cause, especially the cause ability is called an asymptomatic “hay fever,” are a manifestation of an allergic reaction
of a disease. disease or i­ llness. A disease is often or a hypersensitivity state in the patient. Some ­diseases
pathogenesis (path- asymptomatic in its early stages. If in this category appear to be caused by antibodies formed
o-jen´e-sis) Manner the disease is not treated, however, against the patient’s own tissues, as occurs in some
in which a ­disease it may progress to the stage where uncommon diseases classified as autoimmune diseases.
develops. it causes subjective symptoms and The etiology of still other inflammatory diseases has
pathogen (path- abnormal physical findings. Therefore, not been determined.
o-jen´) A
disease-​causing
the distinction between asymptomatic
bacterium or and symptomatic disease is one of degree, Degenerative Diseases
other harmful depending primarily on the extent of the In degenerative diseases, the primary abnormality is
organism. disease. degeneration of various parts of the body. In some
The term etiology means cause. A disease of cases, this may be a manifestation of the aging pro-
unknown etiology is one for which the cause is not cess. In many cases, however, the degenerative lesions
yet known. Unfortunately, many diseases fall into this are more advanced or occur sooner than would be
category. If the cause of a disease is known, the agent expected if they were age related, and they are distinctly
responsible is called the etiologic agent. The term abnormal. Certain types of arthritis and “hardening of
pathogenesis refers to the manner by which a disease the arteries” (arteriosclerosis) are common examples
develops, and a pathogen is any microorganism, such of degenerative diseases.
as a bacterium or virus, that can cause disease.
Metabolic Diseases
Classifications of Disease The chief abnormality seen in metabolic diseases is a
disturbance in some important metabolic process in
Diseases tend to fall into several large categories, the body. For example, the cells may not be utilizing
although the diseases in a specific category are not nec- glucose normally, or the thyroid gland may not prop-
essarily closely related. Rather, the lesions produced by erly regulate the rate of cell metabolism. Diabetes,
the various diseases in a category are morphologically disturbances of endocrine glands, and disturbances of
similar or have a similar pathogenesis. Diseases are fluid and electrolyte balance are common examples of
conveniently classified in the following large groups: metabolic diseases.
1. Congenital and hereditary diseases
2. Inflammatory diseases Neoplastic Diseases
3. Degenerative diseases Neoplastic diseases are characterized by abnormal cell
4. Metabolic diseases growth that leads to the formation of various types of
5. Neoplastic diseases benign and malignant tumors.

2 Chapter 1 General Concepts of Disease: Principles of Diagnosis

43898_CH01_6204.indd 2 8/16/12 8:54 AM

 Health and Disease:
A Continuum
Health and disease may be considered two extremes of
a continuum. At one extreme is severe, l­ ife-­threatening,
disabling illness with its corresponding major effect on
the physical and emotional ­well-­being of the patient.
At the other extreme is ideal good health, which may
be defined as a state of complete physical and mental
­well-­being. The healthy person is emotionally and
physically capable of leading a full, happy, and pro-
ductive life that is free of anxiety, turmoil, and physi-
cal disabilities that limit activities. Between these two
extremes are many gradations of health and disease,
ranging from mild or ­short-­term illness that limits
activities to some extent through moderate good health
that falls short of the ideal state. The midpoint in this
continuum may be considered a “neutral” position in
which one is neither ill nor in ideal good health. In
this continuum, most of us are somewhere between
midposition and the ideal state.
The goal of traditional medicine is to cure or amelio-
rate disease. This is accomplished by various means,
ranging from administering an antibiotic to cure an
infection to very complex ­“high-­technology” treat-
ments such as kidney transplants and heart surgery.
The advances of modern medicine have done much
to relieve suffering and advance human welfare, but
modern medicine does not guarantee good health.
Health is more than an absence of disease; it is a condi-
tion in which body and mind function efficiently and
harmoniously as an integrated unit. Consequently,
we must take an active part in achieving good health
by assuming some responsibility for our own physical
and emotional ­well-­being. This means practicing such
commonsense measures as eating properly, exercising
moderately, and avoiding harmful excesses such as
overeating, smoking, heavy drinking, or using drugs,
which can disrupt physical or emotional w ­ ell-­being.
Taking responsibility for one’s health also requires
using one’s mind constructively, expressing emotions,
and feeling good about oneself. Positive mental atti-
tudes are essential for good health because negative
feelings may be reflected in disturbed bodily functions
that are manifested as disease.
Principles of Diagnosis
The determination of the nature and cause of a patient’s
illness by a physician or other health practitioner is
called a diagnosis. It is based on the practitioner’s
evaluation of the patient’s subjective symptoms, the
43898_CH01_6204.indd 3
physical findings, and the results of vari-
ous laboratory tests, together with diagnosis
other appropriate diagnostic pro-
cedures. When the practitioner
The determination
of the nature and cause of
a patient’s illness.
has reached a diagnosis, he or
she can then offer a prognosis: prognosis The probable
outcome of a disease or a
an opinion concerning the even- ­disorder; the outlook
tual outcome of the disease. Then for recovery.
a course of treatment is instituted.
The History
The clinical history is a very important part of the
evaluation. It consists of several parts:
1. The history of the patient’s current illness
2. The past medical history
3. The family history
4. The social history
5. The review of systems
The history of the present illness elicits details con-
cerning the severity, time of onset, and character of the
patient’s symptoms. Many diseases have characteristic
symptoms. The patient’s description of the oppressive
substernal pain of a heart attack or the pain and uri-
nary disturbances associated with a bladder infection,
for example, may provide very helpful information
that suggests the correct diagnosis. The past medical
history provides details of the patient’s general health
and previous illnesses. These data may shed light on
the patient’s current problems as well. The family
history provides information about the health of the
patient’s parents and other family members. Some
diseases, such as diabetes and some types of heart
disease, tend to run in families. The social history
deals with the patient’s occupation, habits, alcohol
and tobacco use, and similar data. This information
may also relate to the patient’s general health and cur-
rent problems. The review of systems inquires as to
the presence of symptoms other than those disclosed
in the history of the present illness; such symptoms
might suggest disease affecting other parts of the body.
For example, the practitioner inquires about such
symptoms as pain or burning on urination, which sug-
gest an abnormality of the urinary tract, and coughing,
shortness of breath, or chest pain, which may indicate
disease of the respiratory system. In this way, possible
dysfunctions of other organ systems are evaluated by
systematic inquiry.
The Physical Examination
The physical examination is a systematic examina-
tion of the patient. The practitioner places particular
Principles of Diagnosis 3
8/16/12 8:54 AM
 emphasis on the part of the body affected by the
illness, such as the ears, throat, chest, and lungs in
the case of a respiratory infection. Any abnormalities
detected on the physical examination are correlated
with the clinical history. At this point, the practitioner
begins to consider the various diseases or conditions
that would fit with the clinical findings. Sometimes,
more than one possible diagnosis needs to be consid-
ered. In a differential diagnosis the practitioner consid-
ers a number of diseases that are characterized by the
patient’s symptoms. For example, if a patient complains
of shortness of breath and abnormalities are detected
when the lungs are examined with a stethoscope, the
practitioner may consider both chronic lung disease
and chronic heart failure in the differential diagnosis.
Often the practitioner can narrow the list of diag-
nostic possibilities and arrive at a correct diagnosis
by using selected laboratory tests or other specialized
diagnostic procedures. In difficult cases, the clinician
may also wish to obtain the opinion of a medical con-
sultant, who is a physician with special training and
experience in the type of medical problem presented
by the patient.
Treatment
After the diagnosis has been established, a course of treat-
ment is initiated. There are two different types of treat-
ment: specific treatment and symptomatic treatment.
A specific treatment is one that exerts a highly spe-
cific and favorable effect on the basic cause of the
disease. For example, an antibiotic may be given to
a patient who has an infection that is responsive to
the antibiotic, or insulin may be given to a patient
with diabetes. Symptomatic treatment, as the name
implies, makes the patient more comfortable by alle-
viating symptoms but does not influence the course
of the underlying disease. Examples are the treatment
of fever, pain, and cough by means of appropriate
medications. Unfortunately, there are no specific treat-
ments for some diseases. Consequently, the clinician
must be content with treating the manifestations of
the disease without being able to influence its ultimate
course.
When dealing with patients who have ­long-­standing
chronic disease such as chronic heart, kidney, or lung
disease, or some types of cancer, the physician may
be assisted by a disease management team composed
of a group of persons with special skills that are use-
ful in the care and treatment of patients with these
diseases. The management team may include persons
who can explain to patients the nature of their disease,
the goals of treatment, and how patients can contrib-
4 Chapter 1 General Concepts of Disease: Principles of Diagnosis
43898_CH01_6204.indd 4
ute to their own care. Other health-care team mem-
bers such as dieticians, nurse clinicians, physician’s
assistants, respiratory therapists, physiotherapists, and
pharmacists can bring their own special skills to help
physicians care for patients with chronic illnesses who
require ­long-­term care and who have special needs.
Often the team approach to management of patients
with chronic diseases reduces the long-term costs of
medical care, improves the patient’s satisfaction with
the quality of his or her medical care, and contributes
to a more favorable response to treatment.
Screening Tests for Disease
Purpose and Requirements for
Effective Screening
Many diseases that respond to treatment are asymp-
tomatic initially. If untreated, however, the disease
often progresses slowly, causing gradual but progres-
sive organ damage until eventually the person is seri-
ously ill with far advanced organ damage caused by the
disease. Unfortunately, treatment of l­ ate-­stage disease
is often much less effective and may not be able to
restore the function of the organs that have been dam-
aged. Had the disease been identified and treated in
its early asymptomatic stage, the d
­ isease-­related organ
damage could have been prevented or minimized, and
the affected person would have been spared the dis-
comfort, disability, and shortened survival associated
with ­late-­stage disease.
A successful screening program should fulfill the
following requirements:
1. A significant number of persons must be at risk
for the disease in the group being screened.
2. A relatively inexpensive noninvasive test must be
available to screen for the disease that does not
yield an excessively high number of ­false-­positive
or ­false-­negative results.
3. Early identification and treatment of the disease
will favorably influence the health or welfare of
the person with the disease.
Groups Suitable for Screening
Screening tests should target a group of persons in
whom there is a relatively high frequency of disease,
and tests should also target the age group in whom
the disease is likely to be present. If the disease, for
example, has its onset in middle age, then screening
adolescents and children in the target group would
not be productive.
8/16/12 8:54 AM
 Suitable Screening Tests
Screening a group of persons for a disease in its
early asymptomatic stage requires some type of test
that can identify some characteristic manifestation
of the disease, such as high blood sugar in the case
of diabetes, or the presence of blood in the stool in
the case of a colon tumor. A test used for screening
should be reasonably inexpensive and should have few
­false-­positive results (test is positive when no disease is
present) and few ­false-­negative results (test is negative
when disease is present). If the test produced a large
number of f­alse-­positive results in the group being
screened, many persons with ­false-­positive test results
would have to undergo more extensive and sometimes
invasive testing, as well as a comprehensive medical
evaluation, only to find that the test result was a “false
alarm” and that they did not have the disease. On the
other hand, less sensitive screening tests would yield
an excess of ­false-­negative tests, and many persons
who actually had the disease would not be detected.
Benefits of Screening
Screening test results should provide some benefit to
the person being screened. Generally, there is no point
in screening for a disease if no treatment is available
to arrest the progression of the disease.
Examples of widely used ­cost-­effective screening
tests for disease include urine tests to detect glucose
in the urine as a screening test for diabetes, tests to
detect blood in the stools to screen for colon tumors,
Papa­nicolaou smears (Pap tests) to screen for abnor-
malities in the epithelium of the uterine cervix that
predispose to cancer, and breast ­x-­ray examinations
(mammograms) to screen for very early breast cancer
at a stage when it can be treated most effectively.
Screening for Genetic Disease
Screening tests can also be used to screen for carriers
of some genetic diseases that are transmitted from
parent to child as either dominant or recessive traits.
When many persons in a population carry a recessive
gene that can be detected by relatively simple screening
tests, identifying carriers allows the affected persons to
make decisions regarding future childbearing or man-
agement of a future pregnancy. One ­high-­incidence
recessive gene for which screening is available is the
sickle hemoglobin gene, which occurs in about 8 per-
cent of the black population. A child born to two car-
riers of the sickle hemoglobin gene who receives the
sickle hemoglobin gene from each parent will develop
a severe anemia called ­sickle cell anemia.
43898_CH01_6204.indd 5
Diagnostic Tests
and Procedures
A wide array of diagnostic tests and procedures are
available to help the practitioner diagnose and treat the
patient properly. They fall into two classifications: inva-
sive procedures and noninvasive procedures. Invasive
procedures are ­so-­named because the patient’s body is
actually “invaded” in some way in order to obtain diag-
nostic information. Such procedures involve introducing
needles, catheters, or other instruments into the patient’s
body. Noninvasive procedures are those that entail no
risk or minimal risk or discomfort to the patient, such
as a chest ­x-­ray or an examination of the urine.
Many diagnostic procedures entail some degree of
risk or discomfort to the patient. The risk is greater
with invasive procedures, but even some noninvasive
procedures are not completely harmless. A chest ­x-­ray,
for example, exposes the patient to radiation. Even a
relatively simple procedure such as the collection of a
blood sample for a laboratory test may be complicated
by bleeding around the vein or by formation of a blood
clot in the vein at the site of puncture. Therefore, with
any diagnostic procedure, the practitioner must balance
the possible disadvantages to the patient against the ben-
efits that may be derived from the information obtained
by the procedure. Patients also must be fully informed
about the possible risks and benefits so that they can
make informed decisions as to whether to consent to the
procedure. It would be unwise to perform a potentially
risky diagnostic procedure if the information gained
would not contribute significantly to the diagnosis or
would not greatly influence the course of treatment.
The physician would be much more likely to employ a
diagnostic procedure that could provide much useful
information at little or no risk to the patient.
Diagnostic tests and procedures can be classified in
several major categories:
1. Clinical laboratory tests
2. Tests that measure the electrical activity of the body
3. Tests using radioisotopes
4. Endoscopy
5. Ultrasound procedures
6. ­X-­ray examinations
7. Magnetic resonance imaging (MRI)
8. Cytologic and histologic examination of cells and
tissues removed from the patient
Clinical Laboratory Tests
Clinical laboratory tests have many uses. They can
be used to determine the concentration of various
Diagnostic Tests and Procedures 5
8/16/12 8:54 AM
 constituents in the blood and urine, which are fre-
quently altered by disease. For example, the
endoscopy concentration of a substance in the blood
(en-däs´ko-pe) called urea is elevated if the kidneys are
An examination
of the interior of not functioning properly, because this
the body by means of constituent is normally excreted by the
various lighted tubular kidneys. The concentrations of hemo-
­instruments. globin and the quantity of red cells
laparoscope (lap´-A-ro- are reduced in patients with anemia.
skop) A long tubular One can also determine the level of
telescopelike instrument
enzymes in the blood. Sometimes the
passed through the
abdominal wall to enzyme level is elevated because (1)
­examine structures enzymes are leaking from diseased or
within the perito- injured organs, (2) enzyme synthesis is
neal cavity.
increased as a result of disease, or (3) excre-
tion of enzymes is impaired because disease has
caused blockage of normal excretory pathways.
Clinical laboratory tests are also used to evaluate
the functions of organs. Clearance tests measure the
rate at which a substance such as urea or creatinine
is removed from blood and excreted in the urine.
This provides a measure of renal (kidney) function.
­Pulmonary function tests measure the rate at which
air moves in and out of the lungs. Determinations of
the concentration of oxygen and carbon dioxide in the
blood also can indicate how well the lungs are work-
ing. A simple device is available that can be applied
to the finger that can calculate rapidly the amount of
oxygen carried by hemoglobin as another measure of
pulmonary function. Tests that measure the uptake
and excretion of various substances by the liver are
used as a measure of liver function. Microbiologic tests
detect the presence of ­disease-­producing organisms in
urine, blood, and feces. Other tests can determine the
responsiveness of the organisms to antibiotics. Serologic
tests detect and measure the presence of antibodies as
an indication of response to infectious agents.
Tests of Electrical Activity ​​​
Several different tests measure the electrical impulses
associated with various bodily functions and activi-
ties. These include the electrocardiogram (ECG), the
electroencephalogram (EEG), and the electromyogram
(EMG). The most widely used of these tests is the ECG.
Electrodes attached to the arms, legs, and chest are used
to measure the serial changes in the electrical activity
of the heart during the various phases of the cardiac
cycle. The ECG also identifies disturbances in the heart
rate or rhythm and identifies abnormal conduction of
impulses through the heart. Heart muscle injury, such
as occurs after a heart attack, can also be recognized by
means of characteristic abnormalities in the cardiogram.
The EEG measures the electrical activity of the brain,
6 Chapter 1 General Concepts of Disease: Principles of Diagnosis
43898_CH01_6204.indd 6
often called brain waves, by means of small electrodes
attached to different areas in the scalp. Brain tumors,
strokes, and many other abnormalities of cerebral struc-
ture or function may cause altered brain wave patterns
that are detected by this examination. The EMG mea­
sures the electrical activity of skeletal muscle during
contraction and at rest. Abnormal electrical activity is
often encountered in various inflammatory or degenera-
tive diseases involving the skeletal muscles.
Radioisotope Studies
The function of various organs can be evaluated by
administering a substance labeled with a radioactive
material called a radioisotope. Specially designed radia-
tion detectors then measure the uptake and excretion
of the labeled substance. For example, the ability of the
thyroid gland to concentrate and utilize radioactive
iodine is used to measure thyroid function and can also
be used to detect tumors within the thyroid gland.
Another procedure can be used to detect the presence
of blood clots in the lung that impede blood flow to
parts of the lung. ­Phosphorus-­containing isotopes are
concentrated in the skeletal system. If there are depos-
its of tumor in bone, the isotopes are concentrated
around the tumor deposits and can be easily identified
( Figure 1-­1 ). Radioactive materials injected intravenously
can also be used to evaluate blood flow to heart muscle
and to identify areas of damaged heart muscle.
Endoscopy and Laparoscopy
An endoscopy, or endoscopic examination (endo =
within + skopeo = examine), is an examination of
the interior of the body by means of various types of
rigid or flexible tubular instruments that are named
according to the part of the body they are designed to
examine. These instruments have a system of lenses
for viewing and a light source to illuminate the region
being examined. An esophagoscope, for example, is
used to examine the interior of the esophagus, a gas-
troscope to examine the stomach, and a bronchoscope
to examine the trachea and major bronchi. An instru-
ment for viewing the interior of the bladder is called
a cystoscope. A sigmoidoscope is a rigid tube used
to examine the rectum and the sigmoid colon, and
a colonoscope is a flexible tube that can be used to
examine the entire length of the colon.
An instrument called a laparoscope is used to visu-
alize the abdominal and pelvic organs, and the pro-
cedure is called laparoscopy, which can be used not
only to examine abdominal and pelvic organs, but
also to perform various surgical procedures, such as
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Figure 1-1 Radioisotope bone scan of head, chest, and pelvis. Dark areas
(arrows) indicate the concentration of radioisotope around tumor deposits
in bone.
Figure 1-2 Ultrasound examination of a 22-­week-­old fetus. (Image courtesy of Belinda Thresher.)
43898_CH01_6204.indd 7
removal of the gallbladder (cholecystectomy), appen-
dix (appendectomy), ovary (oophorectomy), and other
surgical procedures that formerly required much larger
abdominal incisions. To perform a laparoscopic proce-
dure the peritoneal cavity is inflated first with carbon
dioxide that separates the organs within the perito-
neal cavity so that they can be visualized more eas-
ily. Then the laparoscope is inserted through a small
incision in the abdominal wall, often in or near the
umbilicus. If a surgical procedure is to be performed
such as an appendectomy (removing the appendix) or
cholecystectomy (removing the gallbladder), one or
two additional small incisions are needed to insert the
instruments used to perform the surgical procedure
and remove the organ from the abdominal cavity.
Ultrasound
Ultrasound is a technique for mapping the echoes pro-
duced by h ­ igh-­frequency sound waves transmitted
into the body. Echoes are reflected wherever there is
a change in the density of the tissue. The reflected
waves are recorded on sensitive detectors, and images
are produced. This method is widely used to study the
uterus during pregnancy because it does not require
the use of potentially harmful radiation and poses no
risk to the fetus ( Figure 1-­2 ). The technique can be used
to determine the position of the placenta and the fetus
within the uterus; it can also identify some fetal abnor-
malities and detect twin pregnancies. Ultrasound is
also often used to examine the cardiovascular system.
When used for this purpose the procedure is usually
Diagnostic Tests and Procedures 7
8/16/12 8:54 AM
 called echocardiogram. The term “echo” refers to the
reflection of sound waves back to their source. Ultra-
sound is used to study the structure and function of
the heart valves. The procedure can detect valve abnor-
malities and identify blood clots that sometimes form
on the heart valves in association with infection of the
valve. Ultrasound can determine the thickness of the
ventricular walls and septum and the size of the ven-
tricular chambers during the contraction and relaxation
of the heart (systole and diastole). Ultrasound can iden-
tify gallstones in the gallbladder and abnormalities in
the prostate suspicious for prostate cancer. The tech-
nique has many other applications in medicine.

­X-­Ray Examination
X-­ray examinations are conducted in many ways, but the Figure 1-3  ­X-­ray film after injection of radiopaque barium sulfate suspen-
basic principle is the same for all types of x ­ -­ray studies. sion into colon (barium enema), illustrating narrowed area (arrow) that
impedes passage of bowel contents.
­X-­rays are passed through the part of the body to be
examined, and the rays leaving the body expose an x ­ -­ray
film. The extent to which the rays are absorbed by the tis-
sues as they pass through the body depends on the
density of the tissues. Tissues of low density,
roentgenogram such as the ­air-­filled lungs, transmit most
(rent´gen-o-gram) of the rays, and thus, the film exposed to
A photograph taken ­x-­rays passing through them appears
with x-rays.
black. Tissues of high density, such
mammogram (mam´o- as bone, absorb most of the rays; the
gram) An x-ray of the
breast, used to detect film remains unexposed and appears
tumors and other white. Tissues of intermediate densi-
­abnormalities within ties appear as varying shades of gray.
the breast. The ­x-­ray image produced on the film is
called a radiograph or roentgenogram. The
same basic principle is used to obtain ­x-­ray films
of the breast. This procedure is called a mammogram.
Although the linings of internal organs such as the
intestinal tract, urinary tract, bronchi, fallo­pian tubes, Figure 1-4 Bronchogram illustrating normal branching of bronchi and
and biliary tract have little contrast, they can be exam- bronchioles that are normal in caliber and appearance.
ined by administering a dense radiopaque substance
called contrast medium. It coats and adheres to the
lining of the structure being examined and enhances is excreted in the urine as the blood flows through the
its visibility. To examine the interior of the gastroin- kidney, outlining the contour of the urinary tract. This
testinal tract, for example, one gives the patient a is called an intravenous pyelogram (IVP) ( Figure 1-5 ).
suspension of barium sulfate to swallow or adminis- Another method is to introduce the dye directly into
ters it as an enema. The opaque barium coats the lining both ureters through tubes that are inserted into both
of the intestinal tract, and an abnormality in the lining ureters by means of a cystoscope introduced into the
shows on the film as an irregularity in the column of bladder. This procedure is called a retrograde pyelo-
barium ( Figure 1-­3 ). The lining of the bronchi can be gram. To visualize the gallbladder, the patient ingests
visualized by instilling a radiopaque oil into the bron- tablets of radiopaque material that is absorbed into the
chi. The oil forms a thin film on the bronchial mucosa circulation, excreted by the liver in the bile, and con-
and delineates the contours of the bronchi. This pro- centrated in the gallbladder. Gallstones can be identi-
cedure is called a bronchogram ( Figure 1-­4 ). fied because they occupy space in the gallbladder and
One uses the same principle to visualize the urinary cause irregularities in the radiopaque material concen-
tract. A radiopaque substance is injected into a vein and trated there ( Figure 1-­6 ).

8 Chapter 1 General Concepts of Disease: Principles of Diagnosis

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 Figure 1-5 Intravenous pyelogram (IVP). Arrows outline filling defect caused by a large cyst in the kidney that
­distorts the renal pelvis and calyces. The opposite kidney appears normal.

A B

Figure 1-6 A, Gallstones demonstrated by means of radiopaque material concentrated in bile. Gallstones occupy space and appear as radiolucent (dark) areas
within radiopaque (white) bile. Note the large radiolucent area, indicating a large gallstone, surrounded by smaller radiolucent areas, representing multiple
smaller stones. B, Opened gallbladder removed surgically from the same patient. Compare appearance and location of stones with ­x-­ray appearance.

One can also use contrast material to study the flow ( Figure 1-­7 ). Obstruction of the pul- arteriogram
(är-ter´e-o-gram) An
of blood in large arteries and to identify areas of nar- monary arteries by blood clots x-ray ­technique for studying
rowing or obstruction. This procedure is called an also can be identified by the caliber of blood vessels
arteriogram or angiogram (angio = blood vessel). A arteriography. In this by injection of radiopaque material
small flexible catheter is inserted into a large artery case, the catheter used into the vessel.
in the arm or leg and advanced into the aorta until it to inject the radiopaque angiogram
is positioned at the opening of the artery that is to be material is inserted into (an´je-o-gram) Same as arteriogram.
examined. Radiopaque material is then injected a large vein in the arm, cardiac catheterization
through the catheter. It mixes with the blood, and its threaded up the vein A specialized technique to determine
the blood flow through the chambers
flow through the vessel is followed by means of a and through the right side of the heart, and to detect abnor-
series of x
­ -­ray films. If the vessel is narrowed by dis- of the heart, and positioned mal ­communications between
ease, the film will show areas in which the column of in the pulmonary artery. ­cardiac chambers.
opaque material is narrowed. A complete obstruction This same basic method can
of the vessel appears as an interruption of the column. be used to study the flow of blood
Arteriography is often used to detect narrowing or through the heart and can detect abnormal
obstruction of the coronary arteries or of the carotid communications between cardiac chambers. This
arteries in the neck, which carry blood to the brain type of study is called cardiac catheterization.

Diagnostic Tests and Procedures 9

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 Computed Tomographic Scans
A computed tomographic (CT) scan is performed by
a highly sophisticated ­x-­ray machine that produces
images of the body in cross section by rotating the
­x-­ray tube around the patient at various levels. The
­x-­ray tube is mounted on a movable frame opposite
an array of sensitive radiation detectors that encircle
the patient. As the ­x-­ray tube moves around the
patient, the radiation detectors record the amount of
radiation passing through the body ( Figure 1-­8 ). In com-
puterized scanning, the amount of radiation absorbed
is not read directly on an ­x-­ray film. Instead, the data
from the radiation detectors are fed into a computer,
which reconstructs the data into an image that repro-
duces the patient’s anatomy as a ­cross-­section picture.
The image is displayed on a television monitor and
can be recorded on film ( Figure 1-­9 ). As with conven-
tional ­x-­rays, dense substances are white and less
dense substances appear darker in proportion to the
amount of radiation they transmit. The individual
Figure 1-7 Narrowing of carotid artery in neck (arrow) demonstrated by
carotid angiogram.

X-ray detector CT scanner X-ray source

rotates to remain generates the
opposite the beam of x-rays
x-ray source and rotates
around patient
Direction of
rotation of x-ray
source

X-ray beam

Motorized
table moves
patient into
scanner
Figure 1-8 Computed tomographic (CT) scan. The patient lies on a table that is gradually advanced into
the scanner. ­X-­ray tube mounted in scanner rotates around patient, and radiation detectors also rotate so that
detectors remain opposite the ­x-­ray source. Data from radiation detectors generate ­computer-­reconstructed
images of the patient’s body at multiple levels.

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 Figure 1-10 CT views of the abdomen at the level of kidneys, illustrating
Figure 1-9 CT scan of chest. Mediastinum and heart appear white in the a ­fluid-­filled cyst in the kidney (arrow). The cyst appears less dense than
center of scan, with less dense lungs on either side. The arrow indicates a ­surrounding renal tissue. The opposite kidney (right side of photograph)
lung tumor, which appears as a white nodule in the lung. appears normal.

organs appear sharply separated from one another on the response of hydrogen protons (positively
because the various parts of the body are separated charged particles in the nucleus around which
by planes of fat, which have very low density. These electrons rotate) contained within water
computed
separations increase contrast between adjacent organs. molecules when they are placed in a
tomographic
Abnormalities of internal organs that cannot be identi- strong magnetic field. Body tissues,
(CT) scan
fied by means of standard x ­ -­ray examinations can which have a high water content,
(to-mo-graf´ik) An x-ray
often be discovered with CT scans. Figure 1-­10 shows a are a rich source of protons capable technique producing
renal cyst located by CT scan. of excitation. The intensity of the detailed cross-sectional
CT delivers a much greater dose of radiation than signals produced is related to the images of the body by
a standard ­x-­ray examination, such as a chest ­x-­ray, varying water content of body tis- means of x-ray tube and
detectors connected to
and some physicians are concerned that repeated CT sues. Because an MRI does not use a computer. Some-
examinations may deliver a significant and possibly ionizing radiation, the patient does times called a
excessive amount of radiation to the patient. Ultra- not receive radiation exposure. An MRI CAT scan.
sound examination, which sometimes can provide the does expose the patient to strong magnetic
same information without any radiation exposure, is fields and radio waves, but this appears relatively
recommended whenever it can substitute for CT to safe, on the basis of current knowledge.
provide comparable diagnostic information.
Applications
Magnetic Resonance Imaging An MRI detects many of the same types of abnormali-
Magnetic resonance imaging (MRI) produces ties detected by a CT, and a CT is superior to an MRI
­c omputer-­c onstructed images of various organs for many applications. An MRI, however, offers dis-
and tissues somewhat like CT scans. The device tinct advantages over CT in special situations, as, for
consists of a strong magnet capable of developing example, when attempting to detect abnormalities
a powerful magnetic field, coils that can transmit in tissues surrounded by bone, such as lesions in the
and receive radio frequency waves, and a computer, spinal cord, orbits, or near the base of the skull
which receives impulses from the scanner and forms (Figure 1-­11 ). In these locations, bone interferes with
them into images that can be interpreted. The MRI scanning because of its density, but it does not pro-
scanner with the enclosed magnet and coils appears duce an image in MRI because the water content of
similar to a CT scanner. The patient lies on a table bone is low. MRI also provides a sharp contrast
that is gradually moved into the scanner, as is between gray and white ­matter within the brain and
done in CT scans. The principle of MRI, however, spinal cord, which differ in their water content. For
is quite different from that of CT scanning, which this reason, the technique is useful for demonstrating
uses ionizing radiation to construct images based areas where myelin sheaths of nerve fibers have been
on the density of tissues. In contrast, the computer- damaged, as in a neurologic disease called multiple
generated images obtained by MRI scans depend sclerosis.

Diagnostic Tests and Procedures 11

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 Figure 1-11 MRI view of the brain, which is clearly visible because skull bones are not visualized by MRI. The
white line surrounding the brain represents scalp tissue. The arrow indicates a malformation composed of blood
vessels within the brain stem.

Cytologic and Histologic Examinations
Cells covering the surfaces of the body are continu-
ally cast off and replaced by new cells. Abnormal cells
can often be identified in the fluids or secretions that
come in contact with the epithelial surface. This type of
examination is called a Papanicolaou smear, or simply
Pap smear, after the physician who developed the proce-
dure. It is widely used as a screening test for recognizing
early cancer of the uterus and can be used to detect
cancers in other locations as well.
Diseased tissues have abnormal structural and cel-
lular patterns that can be recognized by the patholo-

Figure 1-12 Two samples of bone marrow (adjacent to scale) obtained from pelvic bone by means of a specially
designed needle, shown in the upper part of the photograph.

12 Chapter 1 General Concepts of Disease: Principles of Diagnosis

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 gist. Consequently, it is often possible to determine
the cause of a patient’s disease by histologic examina-
tion of a small sample of tissue removed from the
affected tissue or organ. This procedure is called a
biopsy. Samples of tissue can be obtained from any
part of the body. Gastroscopes, bronchoscopes, and
other instruments used for endoscopic examination,
for example, are constructed so that specimens for
biopsy can be obtained while the internal organs are
In the late nineteenth century a Canadian physician
completely revolutionized medical education and medi-
cal practice in the United States and moved American
medicine into the twentieth century.
His name was William Osler. He was born in Ontario, Can-
ada, in 1849. He received his MD from McGill University
in Montreal, followed by postgraduate studies in London,
Berlin, and Vienna. In 1874 he returned as professor to
McGill University, where he taught medicine, anatomy,
physiology, and pathology. In 1888, he was recruited as
­physician-­in-­chief at a ­soon-­to-­open Johns Hopkins Hospi-
tal, and professor of medicine at a planned Johns Hopkins
medical school in Baltimore, Maryland. Osler revolution-
ized the medical curriculum, shifting emphasis from didac-
chapter review
Summary
Disease is a disturbance of the structure or function of
the body that produces various manifestations consisting
of symptoms and signs, and is associated with abnormal
laboratory test results. Symptoms are what the patient
tells the physician or health practitioner about how the
disease is affecting the patient, such as causing a head-
ache, sore throat, burning on urination, or chest pain.
Signs are objective manifestations that the practitioner
can identify by examining the patient, such as identi-
fying a skin rash, a throat inflammation, or enlarged
tender lymph nodes in the neck. Often the practitioner
will perform various laboratory tests to obtain further
information about the disease, such as performing a
urinalysis or urine culture if a urinary tract infection is
suspected, or a chest x­ -­ray if pneumonia is suspected.
Many different types of tests are described, each having
43898_CH01_6204.indd 13
being examined. Biopsy specimens can Pap smear
also be taken directly from internal A study of cells
organs such as the liver or kidney by from various sources,
inserting a thin needle through the ­commonly used as a
screening test for cancer.
skin directly into the organ. Samples
of bone marrow are obtained in this biopsy (bi´op-se) Removal
of a small sample of tis-
way, and ­bone-­marrow biopsy is sue for examination
often performed to diagnose blood and ­diagnosis by a
disease ( Figure 1-­12 ). ­pathologist.
tic lectures to clinical instruction of medical students in
the hospital wards, where the students learned by doing:
obtaining a clinical history from the patient, performing
a physical examination, and formulating diagnostic pos-
sibilities and prognoses under the watchful eye of the phy-
sician–instructor. He was soon recognized as a superb
clinician, teacher, and clinical investigator who treated stu-
dents as colleagues. He wrote one of the first textbooks of
medicine, The Principles and Practice of Medicine, which
remained the standard medical textbook for the next 40
years. In 1905, Osler left Baltimore to accept a very pres-
tigious appointment at Oxford University in England as
Regius Professor of Medicine, where he continued until
his death in 1919.
specific applications and limitations as described in the
chapter. The clinician’s task is to determine the nature
of the disease (make a diagnosis), estimate the probable
outcome of the disease (prognosis), and then treat the
patient (symptomatic and specific treatment).
Often, screening tests are used to identify persons
in a population who have a h ­ igher-­than-­normal risk
of a specific disease, or who have an early asymptom-
atic disease that can be treated successfully before the
disease can cause significant organ damage. Screening
requires (1) a “screenable population” (significant
frequency of disease in the population selected for
screening), (2) a reliable c­ ost-­effective test to identify
the disease that can be performed without risk to the
patient, and (3) evidence that early detection of the
disease will favorably influence outcome.
Chapter Review 13
8/16/12 8:54 AM
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN