Practical Radiology: A Symptom-Based

Approach 1st Edition

Visit to download the full and correct content document:
https://ebookmass.com/product/practical-radiology-a-symptom-based-approach-1st-e
dition/
2832_FM_i-xiv 21/11/12 1:38 PM Page iii

PRACTICAL
RADIOLOGY
A SYMPTOM-BASED APPROACH

Edward C. Weber, DO
Radiologist, Imaging Center
Adjunct Professor of Anatomy and Cell Biology
Volunteer Clinical Professor of Radiology and Imaging Sciences
Indiana University School of Medicine
Fort Wayne, Indiana
Joel A. Vilensky, PhD
Professor, Anatomy and Cell Biology
Indiana University School of Medicine
Fort Wayne, Indiana
Alysa M. Fog, PA-C
Physician Assistant, Ortho Northeast
Fort Wayne, Indiana
2832_FM_i-xiv 21/11/12 1:38 PM Page iv

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2013 by F. A. Davis Company

Copyright © 2013 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Andy McPhee

Developmental Editor: Jennifer Ajello
Manager of Content Development: George W. Lang
Design and Illustration Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo
changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences
from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in
this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that
may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered
drugs.

Library of Congress Cataloging-in-Publication Data

Weber, Edward C., D.O.

Practical radiology : a symptom-based approach / Edward C. Weber, Joel A. Vilensky, Alysa M. Fog.
p. ; cm.
Includes index.
ISBN 978-0-8036-2832-8
I. Vilensky, Joel A., 1951- II. Fog, Alysa M. III. Title.
[DNLM: 1. Diagnostic Imaging. 2. Radiology. WN 180]

616.07'54—dc23
2012035484

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company
for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid
directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a
separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 978-0-8036-2832-8/13 0 + $.25.
2832_FM_i-xiv 21/11/12 1:38 PM Page v
Foreword
T
he field of clinical medicine has become increasingly
complex in recent decades and imaging is now an
integral part of the diagnosis and management of most
patients. It is very difficult for health care providers to under-
stand all aspects of the wide menu of imaging studies that are
available, including limitations and appropriate utilization.
Dr. Edward Weber, Adjunct Professor of Anatomy and Cell
Biology and Volunteer Clinical Professor of Radiology and
Imaging Sciences at Indiana University School of Medicine–
Fort Wayne, and his co-authors, have written this unique book
to bridge the gap in knowledge about appropriate imaging.
The book begins with a discussion of various imaging
modalities, including positioning and resulting images.
Chapters 2–11 review the imaging of each anatomic region
of the body. The book’s organization is case-based, with clin-
ical vignettes and clear descriptions of how imaging modal-
ities may affect the work-up, diagnosis, and management of
various disease presentations. Each chapter ends with a series
of review questions.
The book has a unique emphasis on cost-effective medicine
and the use of Appropriateness Criteria, such as those from the
American College of Radiology (ACR), for proper use of
imaging. With today’s concerns about radiation exposure and
the skyrocketing costs of health care, Dr. Weber’s approach is
particularly timely.
Chapter 12, “Clinical Practice Issues in Medical Imag-
ing,” is an excellent summary of topics that bridge all areas
of imaging. There are outstanding discussions about how to
deal with incidental findings, the ACR Appropriateness
Criteria, and talking to patients about the risks and limita-
tions of various imaging studies.
The target audience for Practical Radiology: A Symptom-
Based Approach is physician assistant and nurse practitioner
students. However, this clearly written and beautifully illus-
trated book would also be valuable to medical students, as well
as residents and clinicians in a wide variety of specialties.
Valerie P. Jackson, MD, FACR
Eugene C. Klatte Professor and Chairman
Department of Radiology and Imaging Sciences
Indiana University School of Medicine
v
2832_FM_i-xiv 21/11/12 1:38 PM Page vi
Preface
Practical Radiology: A Symptom-Based Approach is designed
for mid-level clinicians, such as physician assistants and nurse
practitioners, as well as primary care physicians. The book is
organized by the clinical presentations of your patients and
the medical imaging procedures you are likely to use while
diagnosing or evaluating these conditions. We believe this
patient-oriented approach provides a uniquely practical and
useful radiology reference for the student and practicing
medical provider.
APPROACH
Because this book will teach you how to use radiology as a
clinical tool, the chapters are arranged by clinical presenta-
tion, generally with separate Modalities and Interpretation
sections for each group of conditions. For each clinical prob-
lem we present the most appropriate imaging procedures for
evaluation and diagnosis of your patients.
Practical Radiology also uniquely provides informa-
tion about when it is unlikely that a radiologic study will
change the diagnosis or treatment of your patient. In other
words, we say when history, physical, or laboratory studies
should be sufficient to diagnose a patient. We also empha-
size instances when more costly radiologic procedures such
as MRI are likely to be no more useful to diagnose your pa-
tient than less expensive procedures such as radiography.
Our last chapter is also different from other radiology texts
in that we discuss many of the issues facing the use of
medical imaging in today’s health care environment, such
as radiation risk and the finding of unrelated abnormalities
during radiologic procedures for specific clinical condi-
tions. These are issues that influence how your use of
medical imaging affects the care you provide.
FEATURES
Colored arrows on images. Within the many carefully
selected radiologic images in the book, we use red arrows
to indicate the pathology discussed in the text and blue
to indicate normal anatomy. Students thus can easily
vi
recognize and learn how to interpret normal and patho-
logic structures and conditions.
Case Studies. Each clinical chapter begins with a case
study that continues throughout the chapter, to help illustrate
and create a real-world feel for how to recognize the most
cost-effective and efficient modality, relative to a patient’s
condition, and how to interpret the associated radiologic
images based on the modalities used.
Cost-Effective Medicine. These sections emphasize
instances in which more costly radiographic procedures
such as MRIs are unlikely to be more useful than less
expensive procedures such as radiography.
Pediatric and Geriatric. Content especially pertinent to
children and the elderly receives special attention in the book
because treating these patients sometimes involves specialized
radiologic approaches.
Patient Communication. These boxed elements help
students learn how to communicate effectively with their
patients and with teams of clinicians treating the patients.
Radiology Requisition Information. These tables illus-
trate how to concisely communicate important clinical data
to radiologists.
Unique Glossary. A glossary is provided that not only
includes boldface terms throughout the text and their defi-
nitions, but also a key that identifies the modalities to which
the terms apply.
Chapter Review Questions. Each chapter concludes with
several Chapter Review Questions, many with images from
the chapter, to test knowledge of chapter content.
In all aspects of Practical Radiology: A Symptom-Based
Approach we have striven to offer images and information
of the highest quality possible, to present the most pedagog-
ically effective content, and to provide a resource that all
primary medical practitioners will find invaluable as they
seek to provide the best patient care possible.
—Edward C. Weber
Joel A. Vilensky
Alysa M. Fog
2832_FM_i-xiv 21/11/12 1:38 PM Page vii

About the Authors

Edward C. Weber has been in private practice as a radiologist for more than 30 years and
has taught radiology to first- and second-year medical students at Indiana University School
of Medicine in Fort Wayne (IUSM-FW) for almost 20 years. He guided the orientation of this
book and provided most of the radiologic images and clinical information for it.

Joel A. Vilensky is an anatomist who has been teaching at IUSM-FW for more than 30 years.
His role was primarily to ensure that all textual and graphic material presented in the book could
be completely understood by students who have taken a course in medical anatomy and who
have had some basic clinical experience.

Alysa M. Fog is a practicing PA who specializes in orthopedics. She ensured that the material
was ideally presented for students and beginning medical professionals. Alysa also contributed
much of the organization and clinical material for Chapter 2.

vii
2832_FM_i-xiv 21/11/12 1:38 PM Page viii

Contributors

Thanks to Peter Miller, MD; LCDR Kevin Preston, MD; and Keith Newbrough, MD for their generous
contribution of images:

Peter Miller, MD, Indiana University School of Medicine

Chapter 1: Figure 1-3
Chapter 2: Figures 2-5, 2-12, 2-14, 2-28, 2-33, 2-36, 2-43, 2-47, 2-65, 2-67, 2-70, 2-76, 2-78
Chapter 3: Figures 3-3, 3-4, 3-5, 3-6, 3-7, 3-9, 3-11, 3-12, 3-28, 3-29
Chapter 4: Figures 4-1, 4-4, 4-5, 4-6, 4-7, 4-11, 4-13, 4-16, 4-18, 4-19, 4-20, 4-29, 4-33
Chapter 5: Figures 5-6, 5-13, 5-15, 5-17, 5-18, 5-19, 5-21, 5-22, 5-23, 5-24, 5-29, 5-30, 5-31, 5-33
Chapter 6: Figures 6-25, 6-43, 6-44
Chapter 8: Figures 8-1, 8-2, 8-3, 8-4, 8-6, 8-7, 8-9, 8-10, 8-11, 8-12, 8-13
Chapter 9: Figures 9-1, 9-2, 9-3, 9-4, 9-5, 9-10, 9-11, 9-17, 9-22, 9-24, 9-26, 9-27, 9-28, 9-29, 9-32
Chapter 10: Figures 10-15, 10-16, 10-17

LCDR Kevin Preston, MD, Indiana University School of Medicine

Chapter 2: Figures 2-35, 2-38, 2-39, 2-40, 2-41, 2-45, 2-56, 2-63, 2-79, 2-81, 2-83, 2-84
Chapter 6: Figures 6-5, 6-7, 6-12, 6-14, 6-18, 6-19, 6-21, 6-22, 6-23
Chapter 8: Figures 8-18, 8-20

Keith Newbrough, MD, Indiana University School of Medicine

Chapter 2: Figures 2-8, 2-9, 2-18, 2-29
Chapter 6: Figure 6-17
Chapter 7: Figure 7-5

viii
2832_FM_i-xiv 21/11/12 1:38 PM Page ix

Reviewers

Linda G. Allison, MD, MPH

Associate Professor, Pharmacy Practice
Belmont University School of Pharmacy
Nashville, Tennessee

Jesse A. Coale, PA-C

Assistant Professor
Physician Assistant Studies
College of Science, Health & the Liberal Arts
Philadelphia University
Philadelphia, Pennsylvania

Randy Danielsen, PhD, PA-C

Senior Vice-President
National Commission on Certification of Physician Assistants Foundation
Johns Creek, Georgia

Steve B. Fisher, MHA, PA-C

Senior Surgical Physician Assistant
Department of Neurosurgery, Kentucky Neuroscience Institute
University of Kentucky
Lexington Kentucky

Charlene Morris, MPAS, PA-C, DFAAPA

Family Medicine
Pamlico Medical Center, PA
Bayboro, North Carolina

ix
2832_FM_i-xiv 21/11/12 1:38 PM Page x
Acknowledgments
This book originated in a spring 2010 meeting at a coffee
shop near the Pennsylvania Turnpike between ECW and
F.A. Davis Senior Acquisitions Editor, Andy McPhee. Andy
showed immediate enthusiasm for the project, and we are
grateful to him for that enthusiasm and his support and guid-
ance throughout the project. We deeply appreciate the editing
provided by our developmental editor, Jennifer Ajello, who
managed this project. The book has a high level of consis-
tency and organization because of her guidance. Liz Schaeffer
ably guided the writing and assembly of ancillary materials
available to instructors who adopt our book.
The medical images we present here offer superior clarity
because of the skills and knowledge of Roberta Shadle, our
graphic artist, who turned our raw images into the polished
figures needed for the book. We are thankful to have had
Roberta as part of our team.
Most of the clinical images in this book were acquired by
ECW while in clinical practice at The Imaging Center, Fort
Wayne, IN, and as consulting radiologist for The Medical
Clinic of Big Sky in Big Sky, MT. However, in the outpatient
setting in which ECW practices, appropriate images to accom-
pany our text were not always available. Fortunately, many
clinical images were provided by Peter Miller, MD, Lieutenant
Commander Kevin Preston, MD, and Keith Newbrough, MD,
while they were radiology residents at the Indiana University
School of Medicine (p viii).
x
We are very grateful to Fen-Lei Chang, MD, for critically
reviewing the chapter on brain imaging.
We extend our appreciation to Robert Conner, MD, and
the technical staff at The Imaging Center, Fort Wayne, IN, for
their support and their dedication to high-quality patient care.
We would also like to offer deep appreciation to the many
scientists and engineers whose work has made possible the
fantastic tools used in modern medical imaging. Further-
more, we acknowledge the commercial enterprises whose
software and hardware make practical the analysis of the vast
image datasets now produced in medical imaging facilities.
ECW collected most of the clinical images for this book while
using an advanced radiology workstation from Carestream
Health, which provided the means for managing, viewing,
and processing images from digital radiography, mammog-
raphy, sonography, CT, and MRI.
We are very grateful to our spouses, Ellen Weber, Deborah
Vilensky, and Daniel Fog, for their support of our efforts and
toleration of our often spending more weekend time with
each other than with them. We also acknowledge that two of
the spouses have already been asking when we are going to
begin our next project.
Finally, we would like to thank our students, who have
taught us to shed our assumptions and years of experience
and see radiology from the viewpoint of new immigrants to
the strange and wonderful landscape of medical imaging.
2832_FM_i-xiv 21/11/12 1:38 PM Page xi

Contents

Chapter 1: Modalities of Medical Imaging 1 WRIST AND HAND 33

RADIOGRAPHY 1 Acute Pain and Trauma 33
Radiographic Densities 1 Modalities 33
Types of Resolution 2 Interpretation 33
Radiographic Projections 3 Chronic Conditions Including Soft Tissue Masses 36
PA/AP Views 3 Modalities 36
Lateral Views 4 Interpretation 36
Oblique Views 4 PELVIS, HIP, AND THIGH 37
Viewing Radiographic Projections 5 Trauma and Acute Pain 37
CROSS-SECTIONAL IMAGING, TOMOGRAPHY, AND Modalities 37
BODY PLANES 7 Interpretation 37
COMPUTED TOMOGRAPHY: CROSS-SECTIONAL Chronic Conditions Including Soft Tissue Masses 38
IMAGES AND RECONSTRUCTIONS 7 Modalities 39
MAGNETIC RESONANCE IMAGING 11 Interpretation 40
ULTRASOUND 12 KNEE AND LOWER LEG 41
NUCLEAR MEDICINE 14 Acute Pain and Trauma 41
INTERVENTIONAL RADIOLOGY 15 Modalities 41

STRENGTHS AND WEAKNESSES OF IMAGING Interpretation 42

MODALITIES 16 Chronic Knee and Lower Leg Pain 47
CONTRAST ENHANCEMENT 16 Modalities 47

THE RADIOLOGY WORKSTATION AND PACS SYSTEMS 17 Interpretation 47

THE RADIOLOGY REQUISITION AND THE ANKLE AND FOOT 49

RADIOLOGY REPORT 18 Acute Pain and Trauma 49
HOW SAFE IS MEDICAL IMAGING? 19 Modalities 49
Interpretation 50
Chapter Review Questions 20
Chronic Ankle and Foot Pain 54
Chapter 2: Shoulder, Pelvis, and Limbs 21
Modalities 54
EXTREMITIES 21
Interpretation 55
FUNDAMENTALS OF MUSCULOSKELETAL IMAGING 21
LOWER LIMB VASCULAR DISEASE: PERIPHERAL
SHOULDER AND ARM 23 ARTERIAL INSUFFICIENCY AND VENOUS
Trauma and Acute Pain 23 THROMBOSIS 57
Modalities 23 Modalities 57
Interpretation 25 Interpretation 57
Chronic Conditions of the Shoulder Including Chapter Review Questions 60
Soft Tissue Masses 27
Modalities 27
Chapter 3: Spine and Spinal Cord 65
Interpretation 28
FUNDAMENTALS OF SPINE AND SPINAL CORD
IMAGING 65
ELBOW AND FOREARM 30
SPINAL TRAUMA 65
Trauma and Acute Pain 30
Modalities 66
Modalities 30
Interpretation 66
Interpretation 30
Cervical Spine 66
Chronic Conditions of the Elbow 32
Thoracolumbar Spine 68
Modalities 32
Interpretation 32

xi
2832_FM_i-xiv 21/11/12 1:38 PM Page xii

xii Contents

NECK AND BACK PAIN (No Neurologic Signs Chapter 5: EENT Imaging 105
or Symptoms) 70 FUNDAMENTALS OF EYES, EAR, NOSE, AND
Modalities 70 THROAT IMAGING 105
Interpretation 72 NASAL CONGESTION AND SINUSITIS 105
Cervical Spine 72 Modalities 105
Thoracolumbar Spine 73 Interpretation 105
NECK OR BACK PAIN WITH RADICULOPATHY OR NECK LUMPS 107
MYELOPATHY 77 Modalities 108
Modalities 77 Interpretation 108
Interpretation 78 FACIAL DROOP (Bell’s Palsy) 111
Chapter Review Questions 82 Modalities 111
Chapter 4: Brain 85 Interpretation 112
FUNDAMENTALS OF BRAIN IMAGING 85 DYSPHAGIA AND SORE THROAT 112
TRAUMA 85 Modalities 112
Modalities 85 Interpretation 113
Interpretation 85 VISUAL PROBLEMS 113
ACUTE NON-TRAUMA NEUROLOGIC EMERGENCY Modalities 114
(Stroke and Hemorrhage) 87 Interpretation 115
Modalities 87 HEARING PROBLEMS 115
Interpretation 88 Modalities 116
HEADACHE 90 Interpretation 116
Modalities 90 VERTIGO AND TINNITUS 116
Chronic Headache 91 Modalities 117
Recent Onset or Change in Character of Headache 91 Interpretation 117
With Other Neurologic Symptoms and Signs 91 FACIAL TRAUMA AND TEMPOROMANDIBULAR
INTERPRETATION 91 JOINT (TMJ) 117
With Signs of Meningeal Irritation 93 Modalities 117
INTERPRETATION 93 Interpretation 117
In the Pregnant Patient 93
CAROTID ARTERY DISEASE 119
INTERPRETATION 94
Modalities 119
Unilateral Headache 94
Interpretation 119
MODALITIES 94
Chapter Review Questions 122
INTERPRETATION 94
MOVEMENT DISORDERS 94 Chapter 6: Chest 125
Modalities 95 FUNDAMENTALS OF CHEST RADIOGRAPHY 125

Interpretation 95 ROUTINE CHEST RADIOGRAPHY 125

FOCAL NEUROLOGIC DYSFUNCTION 95 Technique 125

Modalities 96 Interpretation 126

Interpretation 96 TRAUMA 131

NEUROENDOCRINE DYSFUNCTION 98 Modalities 131

Modalities 98 Interpretation 132

Interpretation 98 DYSPNEA 134

EPILEPSY AND SEIZURES 98 Modalities 134

Modalities 99 Interpretation 135

Interpretation 99 HEMOPTYSIS 138

DEMENTIA 100 Modalities 139

Modalities 100 Interpretation 139

Interpretation 100 NON-TRAUMATIC CHEST WALL AND PLEURITIC PAIN 140

Chapter Review Questions 102 Modalities 140

Interpretation 140
2832_FM_i-xiv 21/11/12 1:38 PM Page xiii

Contents xiii

CARDIAC DISEASE: GENERAL CONSIDERATIONS 141 Chapter 9: Male and Female Urinary Tract
Modalities 141 and Male Genital Tract 181
Interpretation 142 FUNDAMENTALS OF IMAGING THE MALE AND
ACUTE CHEST PAIN 143 FEMALE URINARY TRACT AND MALE GENITAL
TRACT 181
Modalities 143
TRAUMA 181
Interpretation 144
Modalities 181
CHRONIC CHEST PAIN 144
Interpretation 182
Modalities 144
SUSPECTED RENOVASCULAR HYPERTENSION 183
Interpretation 145
Modalities 183
CONGESTIVE HEART FAILURE 145
Interpretation 183
Modalities 145
ACUTE ONSET FLANK PAIN 184
Interpretation 145
Modalities 184
Chapter Review Questions 147
Interpretation 185
Chapter 7: Breast 151
ACUTE SCROTAL PAIN AND SCROTAL MASSES 186
FUNDAMENTALS OF BREAST IMAGING 151
Modalities 186
BREAST CANCER SCREENING 151
Interpretation 186
The Screening Mammogram 152
HEMATURIA AND RENAL MASSES 188
Modalities 152
Modalities 188
Interpretation 153
Interpretation 188
THE PALPABLE BREAST MASS OR POSITIVE
DIFFICULTY VOIDING 191
FINDINGS ON SCREENING MAMMOGRAPHY 154
Modalities 191
Modalities 156
Interpretation 191
Interpretation 156
URINARY TRACT INFECTION 192
BREAST CANCER SCREENING IN THE HIGH-RISK
PATIENT 159 Modalities 192
Modalities 159 Interpretation 192
Interpretation 160 RENAL FAILURE/INSUFFICIENCY 194
Chapter Review Questions 161 Modalities 194
Interpretation 194
Chapter 8: Abdomen 163
THE PROSTATE GLAND 194
FUNDAMENTALS OF ABDOMINAL IMAGING 163
Modalities 194
TRAUMA 163
Interpretation 195
Modalities 163
Chapter Review Questions 196
Interpretation 164
ABDOMINAL PAIN 164 Chapter 10: Female Pelvic Imaging 199
Modalities 164 FUNDAMENTALS OF FEMALE PELVIC IMAGING 199
Interpretation 166 FERTILITY IMAGING 200
JAUNDICE 172 Modalities 200
Modalities 172 Interpretation 200
Interpretation 172 OBSTETRIC IMAGING 201
GI BLEEDING 173 Modalities 202
Modalities 173 Interpretation 202
Interpretation 174 ACUTE PELVIC PAIN IN PATIENTS OF
REPRODUCTIVE AGE 205
NON-SPECIFIC ISSUES, SUCH AS WEIGHT LOSS,
VOMITING, AND ABNORMAL LABORATORY Modalities 205
STUDIES 174 Interpretation 206
Modalities 174 The Pregnant Patient 206
Interpretation 176 The Non-pregnant Patient 206

Chapter Review Questions 179

2832_FM_i-xiv 21/11/12 1:38 PM Page xiv

xiv Contents

IMAGING OF ABNORMAL VAGINAL BLEEDING AND Chapter 12: Clinical Practice Issues in
PELVIC MASSES 208 Medical Imaging 223
Modalities 208 “INCIDENTALOMAS” 223
Interpretation 208 Incidental Findings on Chest CT 224
Chapter Review Questions 212 Incidental Hepatic Lesions 224

Chapter 11: Imaging of Bone Disease and Incidental Pancreatic Cysts 224
Endocrine Disorders. 215 Incidental Adrenal Masses 224
FUNDAMENTALS OF IMAGING OF BONE DISEASE Incidental Renal Masses 224
AND ENDOCRINE DISORDERS 215 Incidental Bone Findings 225
OSTEOPOROSIS AND PAGET DISEASE 215 Incidental Thyroid Nodules 225
Modalities 215 THE AMERICAN COLLEGE OF RADIOLOGY ACR
Interpretation 216 APPROPRIATENESS CRITERIA® 225
THYROID AND PARATHYROID DYSFUNCTION 217 TALKING TO PATIENTS ABOUT THE RISKS OF
Modalities 218 IMAGING PROCEDURES 225
Interpretation 218 CLAUSTROPHOBIA AND MRI 228
ADRENAL DYSFUNCTION AND NEUROENDOCRINE COMMUNICATION AND COLLABORATION
TUMORS OF THE PANCREAS 219 AMONG MEDICAL PROFESSIONALS 228
Modalities 219 QUALITY PATIENT CARE IN IMAGING 229
Interpretation 220 Appendix A: Glossary 231
PITUITARY DYSFUNCTION 220 Appendix B: Answers to Chapter
Modalities 221 Review Questions 235
Interpretation 221 Index 237
Chapter Review Questions 222
2832_Ch01_001-020 15/11/12 1:51 PM Page 1
1 MODALITIES OF MEDICAL
IMAGING
RADIOGRAPHY
Radiography, discovered in 1895, is still the foundation of
medical imaging. It is one type of imaging modality under the
broader heading of radiology, which includes computed to-
mography (CT), magnetic resonance imaging (MRI), nuclear
medicine (NM), and ultrasonography (sonography [US]).
Radiographic Densities
Radiography refers to the medical images that are the “shad-
ows” projected onto a flat plane when x-rays pass through a
patient. Similar to any shadow, they show the shape of the
object causing the shadow. Figure 1-1 is a magnified small
section of a chest radiograph. How many different anatomic
structures do you see in this figure?
FIGURE 1-1 Magnified section of a PA chest radiograph.
TABLE 1-1 Radiographic Densities and Associated Structures
Metal Calcium (Bone)
Surgical clips, bullet frag- Cortical bone; medullary
ments, orthopedic hardware bone is summation of
bone density and marrow
(fat, soft issue density)
Radiographic and fluoroscopic images are sometimes shown as a “negative” of the standard representation given above, so that metallic objects
are black and air density is white.
The untrained eye and mind may only perceive several
different structures. Careful and educated observation, how-
ever, reveals many more.
Radiographic shadows have different shades of gray that
provide important information. These gray tones are referred
to as radiographic densities. There are five radiographic den-
sities, four biologic and one artificial/metallic density that is
distinguishable from biologic calcium density (Table 1-1).
You will see all four biologic densities if you look for them in
Figure 1-1. It is normal to look at radiographs and just look
at the shape of structures, but in order to fully comprehend
the visual information in those images you must distinguish
among radiographic densities.
The different shades of gray on a radiograph (radi-
ographic densities) result from differences in the absorption
and scattering of x-ray photons in their path from the x-ray
source toward the digital x-ray detector. The degree to which
x-rays are prevented from reaching the detector is referred to
as radiographic attenuation. Different tissues attenuate the
x-ray beam based upon the average atomic number and
thickness of the tissue. These physical properties of tissue are
also referred to as density, which can be confusing when ra-
diographic density is often abbreviated as just “density.”
Calcified tissue attenuates more of the beam than fat or
water because it has a higher average atomic number, and
therefore calcified tissue has a higher radiographic density
than fatty tissue or fluid. The final shade of gray that you see
in any one location on a film or on a monitor reflects the at-
tenuation of the x-ray beam by all of the tissues along the
path of the x-ray beam to that part of the image. The sum-
mation density at any particular point on a radiographic
image thus reflects both the density and thickness of the
Soft Tissue (Water) Fat Air (Gas)
Muscle, tendons, solid or- Subcutaneous fat, inter- Any collection of air or gas
gans such as liver, fluid- muscular and other deeper such as lungs, loop of
filled structures such as fat planes bowel
gallbladder
1
2832_Ch01_001-020 15/11/12 1:51 PM Page 2
2 Chapter 1
intervening structures in the path of the x-ray beam at that
anatomic position. There may of course be many overlapping
structures that contribute to a particular summation density.
Now look at Figure 1-2.
You may have noted the vertebral column initially (A in
figure), but did you also notice the horizontal, very bright
white lines representing the dense, compact bone of the ver-
tebral body end-plates? These are brighter (more dense) than
medullary bone in the remainder of the vertebral bodies.
Medullary bone is not pure calcium density because marrow
fat contributes to its summation density.
The first time that you looked at this figure, did you rec-
ognize correctly the border of the heart, or did you include
epicardial fat as part of the heart shadow? Appreciating the
lower radiographic density of epicardial fat allows you to ac-
curately determine the border of the cardiac apex.
For an example of a summation density in Figure 1-2
look at the thick vertical band of very bright (white) density
that is a summation density representing the descending
aorta (B in figure) and other structures along the path of the
x-ray beam. Note that the right side of the spine, visible
through the heart shadow, is darker than the left side of the
spine, visible through the heart shadow and the shadow of
the aorta. You probably did not think, initially, that this image
could show you the position or size of the descending aorta,
but now you can ascertain that this patient has a normal left-
sided aorta and it does not appear to be dilated.
E G2
A B
J and in identifying pathology, such as the presence of gas and
C
D
G contrast materials (or “media” or “agents”) may be admin-
H
F istered to the patient. Contrast materials have a higher radi-
G visibility of structures that may not be seen on images with-
J2
H2
FIGURE 1-2 Same image as depicted in Figure 1-1 but labeled to high-
light features visible if you look for subtle density differences. (A) Spine
(calcium density); (B) Spine and aorta (calcium and soft tissue density);
(C) arrow points to a disc space that is bordered by horizontal, very
dense bone of vertebral endplates; (D) left border of spine and aorta;
(E) right border of aorta; (F) right border of spine; (G) heart (soft tissue
density); G2) muscle (soft tissue density); (H) fine dark stripe of inter-
muscular fat plane (fat density); (H2) epicardial fat pad (fat density);
(J) lung (air density); (J2) air in gastric fundus (air density).
Untrained viewers just look at the shape of structures in
radiographic images. However, by searching for subtle differ-
ences in radiographic density of different tissue, and appre-
ciating summation densities, far more information can be
discerned.
In later chapters, we will discuss the need for high quality
radiography to show these shades of gray in specific clinical
situations. Poor radiographs may fail to show important
density differences. Even when radiographs are satisfactory,
clinically important information that is visible may be over-
looked if subtle differences in radiographic densities are not
appreciated. For example, knee radiographs may not show a
fracture but should not be interpreted as “negative” if the
normal fat density deep to the quadriceps tendon is replaced
by soft tissue or water density, perhaps indicating blood
within the knee joint.
The interpretation of a radiograph and every other type
of diagnostic image is an active rather than a passive process.
You must look for normal anatomic structures and for evi-
dence of pathology. In looking for the large number of im-
portant findings that may appear on a medical image, you
must develop a consistent and thorough search pattern.
In radiography (and in CT), any edge that appears in an
image is an interface between tissues that have different de-
grees of attenuation of the x-ray beam, such as the interface
between air and soft tissue. When there is a horizontal edge
between air and fluid in any medical image, it is called an air-
fluid level. Identifying an air-fluid level on an image helps
identify anatomic structures that contain air and fluid and
the orientation or position of the patient when imaged. The
search for abnormal air-fluid levels is often crucial in finding
fluid (pus) in an abscess.
To improve the contrast resolution of an image, specific
ographic density than air, fat, or soft tissue, resulting in the
out their use. (See section on Contrast Enhancement.)
COST-EFFECTIVE MEDICINE
High quality radiographs and interpretation provide
diagnostic information that may avoid the need for
more expensive cross-sectional imaging and may be critical in
avoiding missed diagnoses.
Types of Resolution
Resolution refers to the ability to perceive two adjacent objects
or points as being separate. Within radiology, the term is sub-
divided into spatial, contrast, and temporal resolutions.
2832_Ch01_001-020 15/11/12 1:51 PM Page 3

Modalities of Medical Imaging 3

The value of “sharp” images—that is, images with high

spatial resolution—is obvious. Contrast resolution allows the
differentiation among types of tissue. A third type of resolu-
tion may also be important: temporal resolution, the ability
to image a structure during a very narrow window of time.
As we discuss techniques and imaging protocols used to ac-
quire clinically useful information, all three types of image
resolution may be addressed, often with discussion of the
strengths and weaknesses of different imaging modalities for
different kinds of resolution. Heart

COST-EFFECTIVE MEDICINE
These fundamental issues of spatial, contrast, and
temporal resolutions are important in all imaging
Breast shadow
modalities. This is not a “technical” matter, it is a clinical issue.
Does “X” imaging procedure have the temporal resolution that
you need for a patient whose breath holding ability is limited?
Does “Y” imaging procedure have the spatial resolution
needed to see a very fine fracture of bone cortex? Does “Z”
imaging procedure have the tissue contrast resolution to tell
you if a tissue is edematous, although its size and shape are
unchanged? Doing the ideal imaging procedure initially is less
expensive than when a suboptimal procedure needs to be fol-
lowed with additional studies.
Heart

Radiographic Projections
Note the apparent differences in the chest radiographs de-
picted in Figure 1-3. And yet they are the same patient! One
cannot interpret radiographic images without understanding
FIGURE 1-3 PA and AP chest radiographs of the same patient. The top
the various projections used.
image is a standing PA chest radiograph; the bottom image is an AP up-
Radiographic projections describe the relationship be- right chest radiograph done in an ED using a portable x-ray machine.
tween the patient (body part) and the path of the x-ray beam.
It is important to understand these projections in order X-ray detector X-ray detector
to make sense of the anatomy shown and to understand
why anatomic structures may appear differently in various
X-ray source X-ray source
projections.

PA/AP Views
In a PA projection, the path of the x-ray beam is from (the
patient’s) posterior to anterior (Fig. 1-4, left). In an AP pro-
jection, the path of the x-ray beam is from (the patient’s) an-
terior to posterior (Fig. 1-4, right). Together, AP and PA
projections are referred to as frontal views.
Because of the geometry of the diverging x-ray beam,
anatomic structures may appear magnified, and this is
often apparent when PA and AP projections are compared
(Fig. 1-3). Those structures near the detector appear closer
to true size than structures further from the detector
FIGURE 1-4 Diagram illustrating how PA and AP chest radiographs
(Fig. 1-4). The heart, an anterior structure in the thorax, is are done, with insets showing the relative representation of heart size
closer to the detector in the typical PA projection of an on each.
2832_Ch01_001-020 15/11/12 1:51 PM Page 4
4 Chapter 1
upright patient and is thus more accurately depicted in a
PA than in the AP projection (Figs. 1-3 and 1-4). In the
portable AP radiograph shown in Figure 1-3, which was
done on a semiupright patient in an emergency department
(ED), the heart appears to be enlarged because of the geo-
metric effect caused by the diverging beam.
Limitations of medical imaging, whether imposed by
physics, imperfections of technology, or a variety of patient
factors, such as metallic implants, and patient motion during
imaging, can result in artifacts in a medical image. Countless
times, a portable AP radiograph has been misinterpreted as
showing cardiomegaly because of the geometric issue dis-
cussed above when in fact the heart was normal in size; there-
fore, never assume that a radiographic image perfectly
represents “reality.”
Lateral Views
In a lateral projection the path of the x-ray beam is from one
side of the patient or body part to the other side. You may
hear the phrase “true lateral,” indicating that care was exer-
cised in positioning the path of the x-ray beam in the coronal
plane (Fig. 1-5). A “Left” or “Right” side marker is usually
placed to indicate which side of the patient was closest to the
detector. This is a different use of the markers than in frontal
FIGURE 1-5 Left lateral radiograph of the lumbar spine. In lateral views the
side indicator (LT) indicates the patient’s side closest to the x-ray detector.
or oblique projections, in which the markers indicate the
right or left side of the patient.
Oblique Views
There are many oblique projections that demonstrate
anatomic features more clearly than in frontal or lateral pro-
jections. The designation of an oblique projection is based
upon the orientation of the patient relative to the path of the
x-ray beam. For example, for a right posterior oblique (RPO)
projection, one may start with the patient oriented for an AP
projection and then rotate the patient so that his or her right
side is closer to the detector than the left side. It is understood
that the x-ray beam passed from the left anterior aspect of
the patient toward the right posterior aspect of the patient.
Figure 1-6 is an example of a common posterior
oblique projection of the shoulder, described by Grashey
30º
FIGURE 1-6 Grashey (oblique shoulder) view radiograph (top) and a
schematic drawing of patient orientation for the Grashey view (bottom).
2832_Ch01_001-020 15/11/12 1:51 PM Page 5
Modalities of Medical Imaging
in 1923, used for ideal visualization of the glenohumeral
joint.
In Figure 1-6, the patient is rotated to his right in relation
to the x-ray beam. The most important issue when viewing
oblique images is that there is no uncertainty about which
anatomic structures are on the right side of the patient and
which are on the left side. In other words, if an oblique projec-
tion of the cervical spine clearly reveals cervical neuroforamina,
the important issue is that there must be certainty as to
whether these are the right or left neuroforamina. It does not
matter if the oblique view was done as a right posterior oblique
or a left anterior oblique, as long as an “R” marker indicates to
the viewer which side of the image is the right side of the
patient or an “L” marker indicates the left side of the patient.
Oblique radiographic projections may not only be angled
in a left-to-right (or mediolateral) direction. There are also
numerous special projections that use cranio-caudal (or its
opposite) angulation, and in some cases an angle that is
oblique in two planes. However, many of the numerous spe-
cial radiographic projections, often done with highly creative
patient positioning, are now performed rarely, if at all, be-
cause cross-sectional imaging has becomes the procedure of
choice for viewing abnormalities that formerly presented a
great challenge to demonstrate radiographically.
COST-EFFECTIVE MEDICINE
Good radiography including proper use of oblique
and other special radiographic views can some-
times obviate the need for more expensive procedures. You
will provide the best patient care if you use the simplest, safest,
and least expensive medical imaging, such as radiography and
ultrasonography (or no imaging), as appropriate to establish a
diagnosis.
Viewing Radiographic Projections
The traditional practice of viewing radiographs is simple
and consistent: For almost every body part, except those listed
in the next paragraph, the radiograph is viewed as if the
patient is looking at you. This is true for any AP, PA, or
oblique projection.
The exceptions are these: Hands, wrists, and feet are
viewed as if you are looking at your own. Forearms may be
viewed either as if the patient is looking at you with elbows
extended (anatomic position) or you are looking at your own
forearms.
Examples of the first rule can be found by looking at
Figure 1-3. These were done differently, one AP and the other
PA, but both are printed the same way. The patient’s left is to
the viewer’s right. The patient is looking at you.
5
Another example is the oblique view of a right shoulder
(Fig. 1-6; Grashey view). Imagine that this patient was facing
you and then turned toward his right but can still look at you
out of the corner of his eye. An oblique view may be obtained
in different ways, but that does not change how it is viewed
(Fig. 1-7).
This standardized method of displaying radiographic im-
ages provides a consistency of anatomic identification and
recognition that is essential to minimize confusion and error.
It is the expectation that every radiographic image be prop-
erly marked with a Left or Right indicator to avoid a poten-
tially serious error such as trying to drain fluid from the right
hemithorax when it is the patient’s left hemithorax that re-
quires drainage. However, in the real world, the side markers
may not be clearly seen, may be absent, or may be misplaced.
In an emergency situation it is critical to have instant appre-
ciation of which side of the patient has an emergent condi-
tion, rather than needing to search for the “R” or “L”
identifiers.
The reason for standard image display that is independ-
ent from image acquisition can be explained through the fol-
lowing example: Imagine a patient is admitted to the ED and
a portable AP chest radiograph is obtained. The next day, the
patient is capable of standing for a PA chest radiograph. The
patient’s condition then worsens, and a portable AP chest ra-
diograph is again obtained, this time in the intensive care unit
(ICU). When evaluating this series of images and looking for
changing or new radiographic findings, imagine viewing the
series of images if they were viewed from the perspective of
how they were done, rather than in a standard presentation.
An abnormal pulmonary density might be in the side of the
image toward the viewer’s left in the first image, the right on
the second image, and then back again toward the left. With
multiple radiographic findings, viewing such a series of im-
ages would be very confusing.
A consistent appreciation of the patient’s side of a radio-
logic finding (e.g., which knee is arthritic on bilateral knee
radiographs) is far more important when viewing radi-
ographs than how a radiograph was done (AP or PA).
The presentation of lateral views is more complex and
less consistent than the other projections. A traditional prac-
tice has been to orient lateral radiographs to match the posi-
tion of the patient when the radiograph was made. An
alternate practice that provides a more consistent viewing ex-
perience when radiographs are viewed with cross-sectional
images is to match the common presentation of sagittal CT
and MRI images (Fig 1-8). These are, almost universally,
shown as if the anterior aspect of the patient is to the viewer’s
left. This varies from the traditional practice of viewing sagit-
tal ultrasound images, discussed later.
2832_Ch01_001-020 15/11/12 1:51 PM Page 6

6 Chapter 1

R L

R L

Top view of patient

Right posterior Left anterior

oblique projection oblique projection
FIGURE 1-7 Illustration of how right posterior oblique and left anterior oblique projections are done. The figure shows that the resulting radiographic images are
viewed the same way—as if the patient was (obliquely) facing the viewer.

Mammography presents an interesting issue with respect

FIGURE 1-8 Sagittal MRI of the head and brain. Sagittal cross-sectional
images, by convention, are presented as if the patient is facing the
viewer’s left.
to how the images are shown. The original standard was for
the images to be shown as mirror images with the anterior
aspect of the right breast toward the viewer’s left, and vice
versa (Fig. 1-9). However, this standard is not consistently
used among radiology practices.
Exceptions to standard radiology practices of viewing
radiographs have always been common “in the clinic,” often
for logical reasons. For example, because at one time almost
all spinal surgery involved a posterior approach, many spine
surgeons viewed AP and PA spine films as if the patient was
looking away from them—that is, they were looking at the
back of the patient and the patient’s right was to the viewer’s
right. The rationale for viewing spine radiographs this way
has lessened with the increase in anterior approaches in spine
surgery. Furthermore, such a practice results in left-right ori-
entation of radiographs that are opposite that of CT and
2832_Ch01_001-020 15/11/12 1:51 PM Page 7

Modalities of Medical Imaging 7

R L

90°

FIGURE 1-9 Normal cranio-caudal (CC) mammo-

graphic views; the anterior aspect of the right
breast is typically toward the viewer’s left and vice
versa, but this is not always the case; thus, label-
ing of the right and left breasts is essential in
mammograms. The lateral aspect of each breast is
at the top of the image.

MRI, which are often viewed along with those radiographs.

Consistency of image orientation reduces the chance of error.

CROSS-SECTIONAL IMAGING,
TOMOGRAPHY, AND BODY PLANES
It has always been a challenge to differentiate anatomic fea-
tures shown within various patterns on radiographs because
of the projection of “shadows” of overlapping anatomic struc-
tures. Overlapping results in the summation densities dis-
cussed earlier. By the middle of the twentieth century, an
advanced radiographic technique called tomography was in
widespread use to improve visualization of specific anatomic
structures in radiographic images. Standard radiographic to-
mography is a technique that blurs out features in front of and
behind an anatomic plane of clinical interest by linear motion
of the x-ray tube and detector (in opposite directions) during
the exposure; only structures in the focal plane appear sharp.
Thus, tomography could be considered a cross-sectional
imaging technique because it clearly showed the structures
in only one section or slice of the body. Cross-sectional im-
aging today, whether CT, MRI or ultrasound, similarly reveals
slices or sections of the body. Originally, CT only showed
axial (transverse) sections of the body. Subsequently, software
was developed enabling sagittal, coronal, and oblique sections
to be depicted (Fig. 1-10).
MRI was a multiplanar cross-sectional imaging technique
from its first clinical use. Ultrasound examinations are a
handheld technique that can display cross-sectional images
in any plane.
Modern cross-sectional imaging has revolutionized med-
ical diagnosis through the clear visualization of internal
FIGURE 1-10 Anatomic planes. Purple, coronal; pink, sagittal; green,
transverse (axial); orange, oblique. Cross-sectional images may be done
in these conventional orthogonal anatomic planes here but may also be
oriented in non-conventional multiple oblique planes.
anatomy. But as with radiography, cross-sectional imaging
involves making compromises and is subject to false positive
and false negative results. These will be discussed with the in-
dividual cross-sectional imaging techniques.
COMPUTED TOMOGRAPHY:
CROSS-SECTIONAL IMAGES AND
RECONSTRUCTIONS
CT is an advanced computer-based form of tomography in
which cross-sectional images are produced from the mathe-
matical analysis of a large number of measurements.
Through several generations of CT equipment, different
arrangements and movements of x-ray tubes and detectors
were developed. During each rotation of the x-ray tube and
detector array, measurements of the attenuation of x-rays at
millions of locations and angles in the axial plane are
acquired (Fig. 1-11). The specific levels of gray used for
each pixel of a displayed CT scan have a numerical value
(Hounsfield number) ranging from –1,000 to +1,000, in
which air is –1,000, water is 0, and compact bone is +1,000.
2832_Ch01_001-020 15/11/12 1:51 PM Page 8
8 Chapter 1
X-ray source
X-ray beam
X-ray detector array
FIGURE 1-11 Illustration of basic CT scanner mechanisms with a pho-
tograph of a CT scanner.
Initially CT scanners were only able to acquire one axial
section while the patient was motionless on a table, and then
the patient table moved for each additional axial section, and
so forth. More recent technology has resulted in the develop-
ment of helical (spiral) scanners in which the patient table
continuously moves during the CT scan. The most recent ad-
vance was the introduction of multidetector scanners that
could acquire CT data from more than one slice simultane-
ously during each rotation of the x-ray tube and detector
array. The first multidetector CT (MDCT) scanners were dual
slice scanners. Progress has been rapid with the development
of an increasing slice number on newer scanners. At this time,
64 slice scanners are common and the newest generation of
scanners can image 256 or 320 slices in a single rotation. In
addition, rotation speed has increased to where these many
slices can be obtained in approximately 1/3 of a second.
Inherent to the process of CT image acquisition are
variables that must be set by the operator of the unit and that
influence the duration of the scan, radiation exposure, and
quality of the images. Furthermore, a large number of differ-
ent image reconstructions are possible. The specific recon-
struction algorithms used may be critical in determining
what can be seen on the images. For example, the apparent
density of an anatomic structure seen on CT can be mislead-
ing. Thicker reconstructed slices may have some advantages
but may lead to an artifact called partial volume averaging,
which results because each pixel (picture element) on the
computer screen represents a voxel (volume element) of
tissue (Fig. 1-12).
If a thickly reconstructed slice includes tissues of different
CT densities, the apparent Hounsfield density measurement
will be an average of all these tissues, and not an accurate
measurement of any one of the individual anatomic struc-
tures included (partial volume averaging). A classic example
would be the pulmonary nodule. A 5 mm thick slice that in-
cludes a 3 mm nodule and some normal lung tissue will not
truly represent the density of the nodule.
Depending upon the relationship between visualized
structures and the orientation of a cross-sectional image, geo-
metric shapes of anatomic structures may be distorted. For
example, as shown in Figure 1-13, a round tubular structure
that runs obliquely to the long axis of the body will appear
as an oval structure on a conventional axial scan. Addition-
ally, a structure such as the splenic vein that meanders cra-
nially and caudally as it traverses from the spleen in the
extreme upper left abdominal quadrant to the portal vein in
the upper right quadrant may pass into and out of a specific
image section and might be misinterpreted as separate struc-
tures when viewed in a single slice. This is why radiologists
must review a number of adjacent sections, and view CT
scans in multiple planes, in order to be absolutely certain they
are identifying an anatomic structure correctly.
You might be surprised to know that the spatial resolu-
tion (sharpness) of CT images is often not as good as that
available in conventional radiography. But the contrast reso-
lution for soft tissues is much better in CT.
Subsequent to the development of helical CT scanning,
continued software and computer development resulted in
the ability to reformat the CT image data so that sagittal,
coronal, and oblique CT images could be viewed. Special
image displays, such as maximum intensity projections
(MIP; Fig. 1-14) and minimum intensity projections (MinIP;
Fig. 1-15) are used to improve visualization of pathology.
Very life-like three-dimensional representations (volume ren-
dered or 3D displays) of anatomic regions or structures may
also be produced (Fig. 1-16).
Because CT is a procedure that relies on ionizing radia-
tion, the same intravenous (IV) iodinated contrast materials
that are used in conventional radiography may be used in CT.
2832_Ch01_001-020 15/11/12 1:51 PM Page 9
Modalities of Medical Imaging
a
b
d
FIGURE 1-12 Partial volume averaging. Voxel (volume element) of tissue
is represented as a pixel (picture element) on a computer screen (A and
B) and how a CT or MR slice (C) that is thicker (acquired thickness or dis-
played thickness) than a structure of interest (e.g., tumor) may not accu-
rately represent the tissue density or signal intensity on the 2D image (note
differences in gray color in the lower two images) because of the averaging
of all the tissue within the voxel that are represented by the pixel (D).
The kinetics of the distribution of these agents must be con-
sidered when protocols are set up for contrast-enhanced CT
studies. Thus, there are very specific protocols for contrast
injection rates and timing between contrast injections and
scanning for the imaging of various body regions. Another
9
a b c d e
FIGURE 1-13 Schematic illustration of geometric distortion and/or possible
misinterpretations in cross-sectional imaging. “Monitors” show projected
axial images. (A) An axial “slice” may show only a small section of a tu-
bular structure that meanders cranially and caudally. (B) Two sections of
the same structure could give the false impression that the two are entirely
different structures. (C) Cross-section of one end of a tubular structure.
Note that the other end is not in the lowest slice so that a radiologist may
have to follow such structure in serial images “down” and then back “up”
again. (D) A rectangular structure in cross-section appears to be a square
structure. (E) The round cross-section of a tubular structure appears as
round only if the structure is perpendicular to the slice, while if the structure
runs obliquely to the image slice, it appears as an ovoid structure.
FIGURE 1-14 Coronal maximum intensity projection (MIP) of a chest CT.
protocol issue relative to CT is the exposure to radiation. A
typical CT scan exposes a patient to significantly more radi-
ation than a standard radiographic study. But it should be
noted that the exposure in a typical CT exam is about a third
of the radiation a person receives from background radiation
in a year. Nevertheless, as a primary care provider you need
to be aware of patient radiation exposure concerns, especially
if the patient is subjected to multiple CT scans or if the
patient is a child (see Patient Safety section later in this chapter).
Axial CT images are presented as if the viewer is standing
at the foot of the patient’s bed; the patient’s right is to viewer’s
left; the anterior aspect of the patient is toward the top of the
image (Fig. 1-17). Coronal images are viewed the same way
that the majority of radiographs are viewed; the images are
oriented as though the patient is looking at you (Fig. 1-18).
2832_Ch01_001-020 15/11/12 1:51 PM Page 10
10
FIGURE 1-15 Coronal minimum intensity projection (MinIP) of a chest CT.
FIGURE 1-16 Three-dimensional volume-rendered display (CT) of the
hindfoot showing multiple fractures of the calcaneus (red arrowheads).
Anterior
Liver
Right
Posterior
FIGURE 1-17 Axial CT of the abdomen.
Sagittal CT images are shown as though the patient is looking
toward the viewer’s left (Fig. 1-19).
CT is capable of capturing a much greater range of radi-
ographic densities than can be appreciated by our visual sys-
tem, which typically can differentiate about 16 shades of gray.
Chapter 1
Right Left
Heart
Liver
FIGURE 1-18 Coronal CT of the chest.
Liver 1st
lumbar
vertebrae
Right Anterior Posterior
FIGURE 1-19 Sagittal CT of the abdomen.
MRI also captures more than 16 levels of tissue signal inten-
sity. Therefore, decisions must be made for the mapping of
CT density levels and MR signal levels to the gray-scale values
Spleen
on an image used for viewing. These choices are referred to
as windowing and leveling.
Because windowing and leveling in CT is a more impor-
Left
tant and clearly ordered process than in MRI, the following
discussion will focus on CT. However, a similar process is fol-
lowed when viewing MR scans.
The CT window is the range of densities that will be com-
pressed into the shades of gray for viewing. In a narrow window
CT image, only the CT densities within a limited range are as-
signed to various shades of gray, with tissues that have a CT
density below that range depicted as black and tissue above that
range depicted as white. The CT level refers to the mid density
of the window. Narrow window CT images are perceived as
high contrast, or very black and white, images. These images
make conspicuous very slight differences in CT density among
tissues but depict little contrast resolution for tissues outside
the range chosen. A wide window CT image assigns broad
2832_Ch01_001-020 15/11/12 1:51 PM Page 11
Modalities of Medical Imaging
ranges of CT density to each visible shade of gray but is per-
ceived as a very low contrast, or very gray, image (Fig. 1-20).
MAGNETIC RESONANCE IMAGING
MRI does not involve patient exposure to ionizing radiation.
MRI is based on the principle that protons may emit radio
FIGURE 1-20 Three axial chest CT images using different window set-
tings. The top image was made using a soft tissue window. In this image,
the different soft tissue densities (note: muscles and intermuscular fat
planes) and the bright contrast enhancement of blood in the heart are
very conspicuous. The middle image was made using a lung window
setting, in which lung markings, mainly pulmonary veins, are visible. The
lower image was made using a bone window setting. With these win-
dow and level settings, you can see the distinction between marrow and
cortical bone in the ribs.
11
waves in the presence of strong magnetic fields and pulses of
radiofrequency energy, neither of which have been shown to
have significant biologic effects. Each set of images is the result
of a series of radiofrequency pulses and variations in the mag-
netic field, known as a “pulse sequence.” The physics of MRI is
very complex and only a simplified description is provided here.
A typical MRI scanner looks grossly like a larger and
thicker CT scanner (Fig. 1-21). Some MRI scanners, however,
have different configurations, such as those open at the sides
or vertically oriented. These “open” and “vertical” scanners
may have some advantages for the claustrophobic patient but
also may acquire images more slowly and may have reduced
image quality compared with the closed scanners.
MRI scanners are often described by the strength of their
primary magnet, typically 1.5 Tesla (unit of magnetic field
strength). The primary magnetic field is modified by addi-
tional magnetic fields, resulting in varied magnetic field
strengths or “gradients” that are used in the production of
images. These fields affect the “spin” of hydrogen protons
within the patient’s body. Radiofrequency pulses are applied
to these protons, which then emit radio waves (not that dif-
ferent from those received by your car radio) that are detected
by antennas, called receiver coils. The output from those coils
is used to create cross-sectional images. The specific gradient
fields and radio pulses chosen for each set of images (known
as a “pulse sequence”) not only result in cross-sectional im-
ages in any chosen plane but also in the different appearance
of tissues on the images.
The pulse sequences used in clinical MRI are quite varied,
the most common of which are T1 or T2 spin echo, T1 or T2
fast spin echo, or T1 or T2* gradient echo sequences, as well
as commonly used FLAIR and STIR sequences. Proprietary
names for many pulse sequences available on MR scanners
from different manufacturers are often referred to on radiol-
ogy reports. However, sequences are often just referred to as
either T1 or T2 sequences (or T1-weighted or T2-weighted)
sequences.
FIGURE 1-21 Photograph of a magnetic resonance (MR) scanner.
2832_Ch01_001-020 15/11/12 1:51 PM Page 12

12 Chapter 1

In T1 image sequences, fluid has low signal and appears either MRI or CT would be equally appropriate for diagnostic
dark on the image. Lipids and other specific tissues may have evaluation, but in which intravenous contrast administration
high signal and be bright (T1 hyperintensity). With contrast (either iodinated- or gadolinium-based) is contraindicated
enhancement by a gadolinium-based contrast agent, tissue by issues such as renal failure, unenhanced MRI is usually
that contains the agent has high signal on T1-weighted im- superior to unenhanced CT.
ages. In T2-weighted images, fluids (or tissue with high water Because of the very strong magnetic fields associated with
content) have a high signal and appear bright (T2 hyper- MRI, most metal objects should be removed from the patient
intensity) (Fig. 1-22 and Table 1.2). PD (proton density) before he or she enters the MRI room. Any other object that
sequences are neither T1 nor T2 weighted. could also be affected by the magnet, such as credit cards,
There are both T1 and T2 sequences that use a variety of should also be removed. For surgically implanted (or other-
techniques to suppress the MR signal from lipid, so that high wise embedded) metallic devices and objects, the issue be-
signal from a lipid-containing tissue does not obscure high sig- comes quite complicated, both with respect to safety and
nal from adjacent high signal fluid or a gadolinium-enhanced reduced image quality (because of the effect of such metal on
tissue. These are referred to as fat suppressed (“FS”) sequences. the magnetic field). Do not make the assumption that be-
MRI has intrinsically better soft tissue contrast resolution cause your patient has such an implanted metallic device he
than CT. For that reason, there are many imaging examina- or she cannot undergo MRI. It depends upon the metals
tions, such as internal derangement of the knee, in which used, the shape of the objects, and the specific anatomic lo-
MRI is vastly superior to CT. In other situations in which cation involved. Many patients are given cards for their de-
vices pertaining to MRI safety. Consult with the imaging
facility you are referring the patient to in order to determine
whether the patient can undergo MRI. A valuable resource
to use is the web site www.MRIsafety.com.
MRI is an expensive diagnostic modality and may be dif-
ficult for the patient to undergo for psychological reasons,
most notably claustrophobia. It has very high contrast reso-
lution but is not the ideal imaging modality for every case.
For example, compact bone has little or no MRI signal and
therefore CT is better than MRI for cortical bone. The pre-
sentation of axial, sagittal, and coronal MR images is the same
as in CT.
CSF
CSF
ULTRASOUND
Ultrasound was first developed for medical diagnostics in the
middle of the twentieth century. In ultrasound, high fre-
FIGURE 1-22 T1-weighted and T2-weighted axial MR lumbar spine im- quency sound waves (1 to 30 MHz) are produced by a trans-
ages. Note that the cerebrospinal fluid (CSF) is hyperintense (bright) in ducer, usually in contact with the skin. Pulses of sound waves
T2 image and hypointense (dark) in T1 image.
are reflected back (echoed) to the transducer at interfaces be-
tween and within body tissues. Using an estimate of the speed
TABLE 1-2 Comparison of the Typical Appearance of Tissues on of sound, the ultrasound unit places a dot (typically white)
T1 and T2 MR Images* on the monitor screen at the locations that represent the po-
Tissue Type T1-Weighted Images T2-Weighted Images sitions from which each echo occurred. These dots create a
Fluid Dark Bright cross-sectional image of the anatomy at the projected plane
Air Black Black
of the transducer on the body (Fig. 1-23).
Muscle Intermediate Intermediate to dark
Tendon Very dark Very dark A fluid-filled structure that contains no debris, precipi-
Bone cortex Black Black tate, or cells will not have any interfaces within it to reflect
Bone marrow Bright Intermediate to bright
Fat Very bright Intermediate to bright
sound. The fluid will be anechoic; on the image there will not
Gadolinium Bright to very bright No change from non-contrast be any echoes within a homogenous fluid collection. The
(dark in high concentrations) echogenicity (level of gray or brightness on an ultrasound
*Dark means low signal intensity, shown on images as darker shades of gray or black; bright image) of soft tissue is described in relation to other tissues.
means high signal intensity, shown on images as lighter shades of gray or white; intermediate
signal intensity is assigned to an intermediate shade of gray on images. Tissue that has the same echogenicity as the predominate
Another random document with
no related content on Scribd:
 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