Abdomen and Superficial Structures

(Diagnostic Medical Sonography

Series)
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 CONTRIBUTORS vii

Rechelle A. Nguyen, RDMS Dana C. Walker, BS, RDMS, RVT

Clinical Sonographer Radiology Manager-Ultrasound
DepartinentofUltrasound University of Wisconsin Hospitals and Clinics
Nationwide Children's Hospital Madison, Wisconsin
Columbus, Ohio
Michelle Wilson, EdD, RDMS, RDCS
Aubrey J. Rybyinski, BS, RDMS, RVT Clinical Sonographer/Educator
Lead Technologist/Technical Director Kaiser Permanente
Navix Diagnostix Napa, California
Thunton, Massachusetts

Kellie A. Schmidt, BS, RDMS, RVT, RDCS

Clinical Instructor
Division of Ultrasound and Prenatal Diagnosis
University of Colorado Hospital
Aurora, Colorado
REVIEWERS

Brent Bereska. ARDMS. RDMS, RDCS
Sonography Canada: CRGS, CRCS
Northern Alberta Institute of Technology
Edmonton, Canada
Martie Grant, ARDMS
General and Cardiac and Breast Sonography Canada:
Generalist and Cardiac
Northern Alberta Institute of Technology
Edmonton, Canada
Kellee Stacks, BS, RTR, RDMS, RVT
Cape Fear Community College
Wilmillgton, North Carolina
Stacey Rider, RDMS (Abdomen, OB/Gyn, Breast), RVT,
RDCS (Adult Echo)
Keiser University
Ft. Lauderdale, Florida

DwJshtGunte~BS.RDMS
Cambridge College of Healthcare and Technology
Atlanta, Georgia

viii

T he fourth edition of Diagnostic Medical, Sonogmphy:
Abdomen and Superficial Structures is updated to reflect
the major developments that have occurred since the last
edition. Educators and colleagues encouraged us to produce
a fourth edition to incorporate new advances used to im-
age, to refresh the foundational content, and to continue to
provide information that recognizes readers have diverse
backgrounds and experiences. The result is a textbook that
can be used as either an introduction to the profession or
a reference for the profession. The content lays the foun-
dation for a better understanding of anatomy, physiology,
and pathophysiology to enhance the caregiving role of the
sonographer practitioner, sonographer, sonologist, or student
when securing the imaging information on a patient.
The first chapter introduces terminology on anatomy,
scanning planes, and patient positions. Adopting universal
terminology permits every sonographer to communicate
consistent information on how he or she positioned the pa-
tient, how he or she scanned the patient, and how anatomy
and pathology are sonographically represented.
The next four sections are divided into specific content
areas. Doing this allowed the contributors to focus their
attention on a specific organ or system. This simulates
PREFACE
application in that while scanning, the sonographer inves-
tigates the organ or system, moves systematically to the
next organ or system, and completes the examination by
synthesizing all the infonnation to obtain the total picture.
We made every attempt to produce an up-to-date and
factual textbook while presenting the material in an interest-
ing and enjoyable format to capture the reader's attention.
To do this, we provided detailed descriptions of anatomy,
physiology, pathology, and the normal and abnormal so-
nographic representation of these anatomic and pathologic
entities with illustrations, summary tables, and images,
many of which include valuable case study information.
Our goal is to present as complete and up-to-date a
text as possible, while recognizing that by tomorrow, the
textbook must be supplemented with new information
reflecting the dynamic sonography profession. With every
technologi.c advance made in equipment, the sonographer's
imagination must stretch to create new applications. With
the comprehensive foundation available in this book, the
sonographer can meet that challenge.
Diane M. Kawamura
'Cm.ya D. Nolan
ix
ACKNOWLEDGMENTS
A special recognition to Bridgette Lunsford, co-editor
of the third edition. As a sonographer, educator, and
author, Bridgette's contributions made it possible to have
made the giant leap that occurred between the second and
the third editions. While preparing the fourth edition, we
appreciated the support, ideas, and collaboration of Anne
Marie Kupinski, Susan Stephenson, and Julia Dmitrieva
as we worked on the three volumes of Diagnostic Medical
Sonogmphy. Their input and ideas were a significant con-
tribution to the project.
Our thanks and gratitude go to all the contributors of
the fourth edition who gave of their expertise, time, and
energy, updating the content with current information to
use in obtaining a more accurate imaging examination for
our patients.
The image contributions became treasured moments.
We thank the many sonographers and physicians for their
assistance. A special thank you and recognition for ongoing
support in image acquisition goes to Taco Geertsma, MD,
Ede, the Netherlands, at Ultrasoundcases.info and Siemens
x
Medical Solutions USA, Inc. Thank you to the contributors
of the third edition: Philips Medical Systems, Bothell, Wash-
ington; GE Healthcare, Wauwatosa, Wisconsin; Joe Anton,
MD, COchin, India; Dr. Nakul Jerath, Falls Church, Vuginia;
and Monica Bacani and Rechelle Nguyen at Nationwide
Children's Hospital in Columbus, Ohio.
Many thanks to all the production team at Wolters
Kluwer, who helped edit, produce, promote, and deliver
this textbook. We especially thank in the development
of this edition Jay Campbell, acquisitions editor; Heidi
Grauel, freelance product manager; Jennifer Clements, art
director; and John Larkin, Editorial Coordinator, for their
patience, follow-through, support, and encouragement.
'lb our colleagues, students, friends, and family, who
provide continued sources of encouragement, enthusiasm,
and inspiration-thank. you.
Diane M. Kawamura
Tanya D. Nolan
 USING THIS SERIES

T he books in the Diagnostic Medi.cal Sonography series will help you develop an under-
standing of specialty sonography topics. Key learning resources and tools throughout the
textbook aim to increase your understanding of the topics provided and better prepare you for
your professional career. This User's Guide will help you
familiarize yourself with these exciting features designed
to enhance your learning experience.

Chapter Objectives
Measurable objectives listed at the beginning of each Introduction
chapter help you understand the intended outcomes for
the chapter, as well as recognize and study important
concepts within each chapter.

Glossary
Key terms are listed at the beginning of each chapter
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Critical Thinking Questions

Throughout the chapter are critical thinking questions
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CRITICAL THINKING QUESTIONS
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Resources thePoinf
You will also find additional resources and exercises on thePoint, including a glossary with
pronunciations, quiz bank, sonographic video clips, and weblinks. Use these interactive
resources to test your knowledge, assess your progress, and review for quizzes and tests.
CONTENTS

Introduction I
DIANE M. KAWAMURA

PART ONE I ABDOMINAL SONOGRAPHY

2 The AbdominaJ Wall and Diaphragm 13
TERRI L. JURKIEWICZ

3 The Peritoneal Cavity 41

JOIE BURNS

4 Vascular Structures 59
AUBREY J. RYBYINSKI

5 The Liver IOI

M. ROBEIU DE JONG

6 The GaJlbladder and Biliary System 171

TERESA. M. BIEKER

7 The Pancreas 213

KEWEA 50-IMIDT

8 The Spleen 229

TANYAD. NOLAN

9 The Gastrointestinal Tract 247

llAABAAA HALL-TERRACCIANO

I0 The Kidneys 271

SARAM. BAKER I DANAC. WALKER

11 The Lower Urinary System 335

DANA C. WALKER. I SARA M. WER

12 The Prostate Gland 357

GEORGE M. KENNEDY->NTILLON

13 The AdrenaJ Glands 377

DARLA MATTHEW

14 The Retroperitoneum -405

JOIE BURNS

PART TWO SUPERFICIAL STRUCTURE SONOGRAPHY

15 The Thyroid Gland, Parathyroid Glands, and Neck 421
DIANE M. KAWAMURA

xii
 CONTENTS xiii

16 The Breast 455

CATHERINE CARR-HOEFER

17 The Scrotum 51 I
MICHELL£ WILSON

18 The Musculoskeletal System 551

KEYlN D. EVANS

PART THREE NEONATAL AND PEDIATRIC SONOGRAPHY

19 The Pediatric Abdomen 611
SASHA P. GORDON

20 The Pediatric Urinary System and Adrenal Glands 655

ALYSSA FREDERICK

21 The Neonatal Brain 687

MONICA M. Bll.CANI

22 The Infant Spine 715

RECHELL£A. NGUYEN

23 The Infant Hip Joint 729

CHARILOTIE HENNINGSEN

PART FOUR SPECIAL STUDY SONOGRAPHY

24 Organ Transplantation 739
KEYlN D. EVANS

25 Point-of-Care Sonography 757

J. P. MORELAND I MICHELLE WILSON

26 Foreign Bodies 779

TIMS. GIBBS

27 Sonography-Guided lnterventional Procedures 795

AUBREY J. RYBYlNSKI

Index 813
 Introduction

DIANE M. KAWAMURA

OBJECTIVES KEY TERMS

-----------------------------------------------------

■ Identify anatomic definitions in regard to directional terms, anatomic position, and anatomic accuracy
planes. anechoic
■ Demonstrate the sonographic examination to include patient position, transducer coronal plane
orientation, and image presentation and labeling.
echogenic
■ Define the terms used to describe image quality.
echopenic
■ Describe the sonographic echo patterns to demonstrate how normal and~ tholagic
heterogeneous
conditions can be defined using image quality definitions.
■ List and recognize the sonographic criteria for cystic, solid, and complex co 01tions.
homogeneous

■ Describe the appropriate patient preparation for a sonographic evalua 10n.

hyperechoic
hypoechoic
■ State what should and what should not be included in a prelimi ~ ry ejJO .
isoechoic
■ Calculate sensitivity, specificity, and accuracy using the four o tco es of true positive, false
positive, true negative, and/or false negative. sagittal plane
sensitivity
GLOSSARY specificity
transverse plane
anechoic describes the portion of an image that appears echo-free
echogenic describes an organ or tissue that is capable of producing echoes by refiecting
the acoustic beam
echopenic describes a structure-that is less echogenic or has few internal echoes
heterogeneous describes tissue or organ structures that have several different echo
characteristics
homogeneous refers to imaged echoes of equal intensity
hyperechoic describes image echoes brighter than surrounding tissues or brighter than
is normal for that tissue or organ
hypoechoic describes portions of an image that are not as bright as surrounding tissues
or are less bright than normal
isoechoic describes structures of equal echo density

T his chapter focuses on the sonography examination of

the abdomen and superficial structures. It was written to
assist sonographers in acquiring, using, and understanding
the sonographic imaging terminology used in the remainder
of this textbook. Accurate and precise terminology allows
communication among professionals.
ANATOMIC DEFINITIONS
The profession adopted standard nomenclature from the
anatomists' terminology to communicate anatomic direction.
Table 1-1 and Figure 1-1 illustrate how these simple terms help
avoid confusion and convey specific information. A person
l PART ONE ABDOMINAL SONOGAAPHY

TABLE 1-1 Dlrectlonal Terms

'llrm Daftnldan Eample
Superior (cranial) Toward the head, doser to the head, the upper portion of the body, the The left adrenal gland is superior to the left
upper part d a structure, or a structure higher than another structure kidney
Inferior (caudal) Toward the feet, away from the head, the lower portion of the body. The lo>.Ver pole d each kidney is inferior to the
toward the lower part of a structure, or a structure lower than another upper pole
structure
Anterior (ventral) Toward the front or irt the front of the body or a strud.\Jre in front of The main portal vein is anterior to 1he inferior
another strud.\Jre venacava
Posterior (dorsal) Toward the back or the bade d 1he body or a structure behind anotiier The main portal vein is posterior to the
structure common hepatic artery
Medial Toward the middle or mid line of the body or the middle of a structure The middle vein is medial tD the ri.!trt hepatic vein
Lateral Away from the middle or the midline of the body or perlaining to the side The ri.!trt lciciiey is lateral tD the inferior vena caw.
Ipsilateral Located on the same side of1he body or afecting the same side of the body The gallbladder and right kidney are ipsilateral
Contralateral Located on the opposite side of1he body or affecting the opposite sided The pancreatic: tail and pancreatic head are
the body contralateral
Proximal Ooser to the attachment of an extremity to the trunk or 1he ori_i;n of a The abdominal aorta is proximal to the
body part bifurcation of the iliac arteries

Distal Farther from the attachment of an extremity to 1he trunk or the origin of a The iliac arteries are distal to the abdominal
body part aorta

Superficial Toward or on the body surface or external The thyroid and breast are consiclered
superficial strud.\Jres
Deep Away from the body surface or internal The peritoneal organs and great vessels are
deep strudures

Cranial
Cephalic
Superior

II
+- ~ ~
-~
Anterior
Ventral 001881
Lateral

Distal

J Caudal
Inferior

FIGURE 1-1 Directional tenns. The drawir« depicts a body in the anatomic position (standing erect. arms by 1he side, face and palms directed forward) with the
directional terms. The directional terms COl'Telate with 1he terms in Table 1-1.
 I INTRODUCTION l

in the conventional an.atomic position is standing erect, feet
together, with the arms by the sides and the palms and face
directed forward, facing the observer. When sonographers
use directional terms or descnbe regions or anatomic planes,
it is assumed that the body is in the anatomic position.
There are three standard anatomic planes (sections) that
are imaginary flat surfaces passing through a body in the
standard anatomic position. The sagittal plane and coronal
plane follow the long axis of the body and the transverse
plane follows the short axis of the body1 (Fig. 1-2).
Superior
The word sagittol. literally means "flight of an arrow"'
and refers to the plane that runs vertically through the body
and separates it into right and left portions. The plane that
divides the body into equal right and left halves is referred
to as the median sagittal or midsagittal plane. Any vertical
plane on either side of the midsagittal plane is a parasagit-
tal. plane (para means "alongside of"). In most sonography
cases, the term sagittal usually implies a parasagittal plane
unless the term is specified as median sagittal or midsag-
ittal. The coronal plane runs vertically through the body
from right to left or left to right, and divides the body into
anterior and posterior portions. The transverse plane passes
through the body from anterior to posterior and divides the
body into superior and inferior portions and runs parallel
to the surface of the ground.

SCANNING DEFINITIONS
Patient Position
Positional terms refer to the patient's position relative to
the surrounding space. For sonographic examinations, the
patient position is described relative to the scanning table
or bed (Table 1-2; Fig. 1-3). In clinical practice, patients are
scanned in a recumbent, semierect (reverse 'Jl'endelenburg
or Fowler), or sitting position. On occasion. patients may be
placed in other positions, such as the lrendelenburg (head
lowered) or standing position, to obtain unobscured images
of the area of interest. Sonographers frequently convey
information on patient position and transducer placement
simultaneously. This terminology most likely was adopted
from radiography, where it describes the path of the X-ray
beam through the patient's body (projection). which results

TABLE 1-2 Patient Positions

'R9rm DelCl'lptlon
Decubltu1 or The act d lying dOIMl. The adjective
Recumbent before 1he word desaibes the most
dependent body surface
Supine or dorsal Lying on 1he bac:k
Prone or ventral Lying face cbNn

RLD Lying on 1he right side

LLD Lying on 1he left side

Oblique Named for the body side dosest to

the scanning table
RPO Lying on 1he right posterior surface,
the left posterior surface is elevated
LPO Lying on 1he left posterior surface,
1he right posterior surface is elevated
RAO Lying on 1he right anterior surface,
the left anterior surface is elevated

Inferior LAO Lying on the left anterior surface, the

FIGURE 1-1 Anatomic: planes. The standard anatomic: position is use<J to
depict 1he three imafjnary anaromic: flat surface planes. Both the~ and
coronal planes !>i1S$1tirough ttie long axis and the 1ransvel'$C plane passes
through the short axis.
right anterior S\Jrface is elevated
LAO, left anterior oblique; LLD, left lateral de<:ubitus; LPO, left posterior
oblique; RAO. right anterior oblique: RlD. right lareral de<:ubitus; RPO. right
posterior oblique.
 PART ONE ABDOMINAL SONOGRAPHY
Supine
Lateral
~
RAO
LPO
FIGURE I·3 Patient positioos. The various patient positions depicted in the illustration correlate with the descriptions in Table 1-2. lAO, left anterior oblique; I.PO,
left posterior oblique: RAO, right anterior oblique: RPO. right posterior oblique.
in a radiographic image {view). There is no evidence in the
literature that this nomenclature has been adopted as a
professional standard for sonographic imaging. Describing
sonograms using the terms projection or view should be
avoided. It is more accurate to describe the sonographic image
stating the anatomic plane visualized, which is due to the
transducer's orientation (i.e., transverse). A more specific
description of the image would include both the anatomic
plane and the patient position (i.e., transverse, oblique).
Transducer Orientation
The transducer's orientation is the path of the insonating
sound and the path returning echoes is viewed on the
monitor. 'Itansducers are manufactured with an indicator
(notch, groove, light) that is displayed on the monitor as
a dot, arrow, letter of the manufacturer's insignia, and so
forth. Scanning plane is the term used to describe the trans-
ducer's orientation to the anatomic plane or to the specific
organ or structure. The sorwgraphi.c image is a representa-
tion of sectional anatomy. The term plane combined with
the adjectives sagittal, parasagittal, coronal, and transverse
describes the section of anatomy represented on the image
(e.g., transverse plane).
Because many organs and structures lie oblique to the
imaginary body surface planes, sonographers must identify
sectional anatomy accurately to utilize a specific organ and
structure orientation for scanning surfaces. The sonography
imaging equipment provides great flexibility to rock, slide,
and angle the transducer to obtain sectional images of organs
oriented obliquely in the body. For example, to obtain the
~
Prone
Oblique
LAO
RPO
long axis of an organ, such as the kidney, the transducer is
oblique and is angled off of the standard anatomic positions:
sagittal, parasagittal, coronal, or transverse plane. Sonog-
raphers frequently use the terms sagittal. or parasagittal to
mean longitudinal in depicting the anatomy in a long-axis
section. Although some images in this text are labeled sagittal
or parasagittal, they are, in fact, longitudinal planes because
the image is organ specific. For organ imaging, transverse
planes are perpendicular to the long axis of the organ, and
longitudinal and coronal planes are referenced to a surface.
All three planes are based on the patient position and the
scanning surface (Fig. 1-4A-C).
Image Presentation
When describing image presentation on the display monitor,
the body, organ, or structure plane terminology, coupled with
transducer placement. provides a very descriptive portrayal of
the sectional anatomy being depicted. CUrrent flexible, free-
hand scanning techniques may lack automatic labeling of the
scanning plane. With the free-hand sc.anning technique, quan-
titative labeling may be limited, which means reduced image
reprodUCJ.'bility from one sonographer to another sonographer.
Sonographers usually can select from a wide array of protocols
for image annotation or em.ploy postprocessing annotation.
This is extremely important when the image of an isolated
area does not provide other anatomic structures for a reference
location. 1b ensure consistent practice, sonographers must
correctly label all sonograms. With today's equipment, stan-
dard presentation and labeling is easily achieved along with
additional labeling of specific structures and added comment.
 I INTRODUCTION s

Longitudinal section Sonogram

Anterior

Posterior

Coronal plane Coronal section Sonogram

Right

Tulnswrae plane Tulnswrae section Sonogram

Anterior

Posterior

FIGURE 1-4 Transduair orientation. A:. A parasagittal plane provides a longitudinal section of the kidney on the sonogram. B: The coronal plane provides a coro-
nal section on the sonogram. C: The trar\Sllerse plane provides a tranwerse section on the sonogram. The sonogram is the image the sonographer observes on
1he monitor.

The anterior, posterior, right, or left body surface is
usually scanned in the sagittal (parasagittal), coronal, and
transverse scanning planes. For organ or structure imag-
ing, these same body surfaces are scanned with different
angulations and obliqueness of the transducer to obtain
longitudinal, coronal. or transverse scanning planes. With
few exceptions. the transducer at the scanning surface is
presented at the top of the image. 1.2 Images obtained using
an endovaginal probe are usually flipped so that they are
presented in the more traditional transabdominal transducer
orientation, whereas images obtained using an endorectal
probe are presented in the transducer-organ orientation.
With the neonatal head (neurosonography, neurosonology),
the superior scanning surface is presented at the top of the
image when the transducer is placed on the neonate's head.
These six scanning surfaces, anterior or posterior, right
or left. endocavitary (vaginal or rectal), and the cranial
fontanelle coupled with three anatomic planes (sagittal,
coronal, and transverse) produce a combination of 14 dif·
ferent image presentations.
Longitudinal: Sqittal Planes
When scanning in the longitudinal, sagittal plane, the trans-
ducer orientation sends and receives the sound from either
an anterior or posterior scanning surface. For a longitudinal
plane, the transducer indicator is in the 12 o'clock position
to the organ or to the area of interest. This always places the
superior (cephalic} location on the image. From either the
anterior or posterior body surface, the patient can be scanned
in either erect, supine, prone, or an oblique position. The
6 PART ONE ABDOMINAL SONOGAAPHY

image presentation includes either the anterior or posterior,
the superior (cephalic), and the inferior (caudal) anatomic
area being ex:amined.1•2 (Fig. 1-SA). Because the longitudinal,
sagittal image presentation does not demonstrate the right
and left lateral areas, adjacent areas can be evaluated and
documented with transducer manipulation, changing the
transducer orientation, or changing the patient position.2
Lonsitudinal: Coronal Planes
When scanning in the longitudinal, coronal plane, the
transducer orientation sends and receives the sound from
either the right or left scanning surface. Because the trans-
ducer indicator is in the 12 o'clock position to the organ or
to the area of interest, the superior (cephalic) location is
always imaged. From either the right or left body surface,
the patient can be scanned in either an erect, decubitus, or
an oblique position and the image presentation includes
either the left or right, the superior (cephalic), and the in-
ferior (caudal) anatomic area being examined1.2 (Fig. 1-SB}.
Because the longitudinal, coronal image presentation does
not demonstrate the anterior or posterior areas, adjacent
areas can be evaluated and documented with transducer

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FIGURE 1-5 Image presentl.tions. k Longitudinal, sagittll plane. With 1he patient being scanned from either 1he anterior or 1he posterior surface with or without
obliquity. the image seen on the monitor demonstrates the scanning wrface (anterior or posterior) and the wperior (cephalic) and inferior (caudal) area being ex-
amined. 8: Lon,P!clinal, ooronal plane. Wrth the patient bei~ scanned from either the right or left surface with or without obliquity, the image seen on the monitor
demonstrates the sanni~ surface (right or left) and the superior (cephalic) ind inferior (caudal) areas being examined. C: Transverse plane, anterior or posterior
S\Jrfaae. Wth the patient being scanned from either the anterior or posterior surface with or without obliquity. the image seen on the monitor demonstrates the
scanning surface (anterior or posterior) and the right and left areas being examined. 0: Transverse plane, right or left wrface. Wilh 1he patient being scanned from
either the right or the left surface wi1h orwittlout obliquity. the image seen on the monitor demonstrates the scanning surfate (right or left) and the anterior and
posterior areas being examined.
 I INTRODUCTION 7

manipulation, changing the transducer orientation, or
changing the patient position.1
Transverse Plane: Anterior or Posterior Surface
Using the anterior or posterior surface, the transducer orien-
tation for a transverse plane places the transducer indicator
in the 9 o'clock position on either the anterior or posterior
surface to the organ or to the area of interest. The right and
left location is always imaged. From either the anterior or
posterior surfaces, the patient can be scanned in either an
erect, decubitus, or an oblique position. The image pre-
sentation includes either the anterior or posterior and the
right and left anatomic area being examined1..2 (Fig. 1-SC).
Transverse Plane: Right or Left Surface
Using the right or left surface, the transducer orientation
for a transverse plane places the transducer indicator in
the 9 o'clock position on either the right or left surface to
the organ or to the area of interest. From either the right or
left surfaces, the patient can be scanned in either an erect,
decubitus, or an oblique position. The image presentation
includes either the right or left and the anterior and posterior
anatomic area being examined1..2 (Fig. 1-SD).
Endovaginal Planes
The patient is in the supine position for endovaginal imag-
ing. The image presentation does not change if the system

E F

cauclalllnferior caudal/Inferior Posterior (Rectum) Posterior (Rectum) ~

...
~
... £!
i
0
"C
'I:
s i l:
.2'
::I ac .E
Cl
~
j
~
to
~
a: ~ICll
scD
-g
'if. I
s=
a.
tj ~
Cephalic/Superior Cephalic/Superior Anterior Anterior

Sagittal Coronel Saglttal Coronel orTranswrse

Ceudalllnferlor Caudal/Inferior
FIGURE 1-5 {CDntinued) E: Endovaginal planes. The image preserrtrtion on
1t1e left illustrates a sat')ttal plane and 1t1e one on the right is the coronal plane.
On either presentation, the apex of the image seen on the monitor cor-
responds t.o the il'\ilt.omy dose st to the faced the transducer: F: Endomc:IAI ...
.9
planes. The image presentdioo on the left illustral:es a sagill2l plane and the
one on 1t1e right is 1t1e transverse or coronal plane. On either presentation,
1t1e apex of the image seen on the bottom c:J1t1e monitor corresponds to the
anatomy closest to the face of the transducer. G: Cranial fontanelle planes.
I
With the patient being scanned from either the anterior or the posterior sur- Cephalic/Superior Cephallc/Superlor
face wi1t1 or without obliquity. the image seen on the monitor demonstrates
1t1e scanning surface (anterior or posterio1' and the superior (cephalic) and
inferior (caudal) areas being examined. Sagittal: Anterior Fontanelle Coronal: Anterior Fontanelle
8 PART ONE ABDOMINAL SONOGRAPHY
employs either an end-firing or an angle-firing endovagi-
nal transducer. For the sagittal Oongitudinal) plane, the
transducer is placed at the caudal end of the body with the
indicator in the 12 o'clock position. Orientations of both
the endovaginal sagittal and the translabial transducer produce
the same image presentation. The inferior (caudal) anatomy
is presented at the top of the monitor with visualization of
the anterior and posterior anatomic areas.
The coronal plane is obtained with the transducer at the
caudal end of the body and the indicator in the 9 o'clock
position. The top (apex) of the image is the inferior (caudal)
area and the right and left anatomic areas can be visualized
on the display monitor. The coronal plane is sometimes
described using an older description reference to the trans-
verse plane1 (Fig. 1-SE).
Endorectal Planes
The patient is most often in a left lateral decubitus position for
placement of either the end-firing or the bi-plane endorectal
transducer. When used for biopsy, both the end-firing and
the bi-plane endorectal transducers place the biopsy guide
anterior toward the prostate. For either the sagittal plane or
the transverse or coronal planes, the anterior rectal wall is
the scanning surface and is assigned to the bottom of the
display monitor (Fig. 1-SF).
Cranial Fontanelle Planes
For neonatal brain examinations, the sagittal and coronal
planes are most commonly accessed using the anterior
fontanelle. For the sagittal plane, the transducer indicator
is in the 6 o'clock position and indicates the anterior side
of the brain. For the coronal plane, the transducer indicator
is in the 9 o'clock position and indicates the right side of
the brain (Fig. 1-SG).
IMAGE QUALITY DEFINITIONS
Evaluation of sonographic image quality is learned and
communicated using specific definitions. Normal tissue and
organ structures have a characteristic echographic appearance
relative to surrounding structures. An understanding of the
normal appearance provides the baseline against which to
recognize variations and abnormalities. These definitions
describe and characterize the sonographic image.
An eclw is the recorded acoustic signal. It is the reflection
of the pulse of sound emitted by the transducer. Prefixes
or suffixes modify the quality of the echo and are used to
describe characteristics and patterns on the image.
Echogenic describes an organ or tissue that is capable
of producing echoes by reflecting the acoustic beam. This
term does not describe the quality of the image; it is often
used to describe relative tissue texture (e.g., more or less
echogenic than another tissue) (Fig. 1-6A,B). An aberration
from normal echogenicity patterns may signify a pathologic
condition or poor examination technique such as incorrect
gain settings.
Aneclwic describes the portion of an image that appears
echo-free. A urine-filled bladder, a bile-filled gallbladder,
and a clear cyst all appear anechoic (Fig. l -6C). Sonolu-
cent is the property of a medium allowing easy passage of
sound (i.e., low attenuation). Sonolucent or transonic are
misnomers that are often substituted for anechoic. 3 When
the sonographic appearance is anechoic, sonographers fre-
quently use the term cystic. When describing the appearance
of the echo, the term anechoic is correct. When describing
the histopathologic nature of an anechoic structure, cystic
or cyst-like is correct (see "Interpretation of Sonographic
CharacteristicsH section).
If the scattering amplitude changes from one tissue to
another, it results in brightness changes on an image. These
brightness changes require terminology to describe normal
and abnormal sonographic appearances. Hyperechoic describes
image echoes brighter than surrounding tissues or brighter
than normal for a specific tissue or organ. Hyperechoic
regions result from an increased amount of sound scatter
relative to the surrounding tissue. Hypoechoic describes
portions of an image that are not as bright as surrounding
tissues or less bright than normal. The hypoechoic regions
result from reduced sound scatter relative to the surrounding
tissue. Eclwpenic describes a structure that is less echogenic
than others or has few internal echoes. Isoeclwic describes
structures of equal echo density. These terms can be used
to compare echo textures (Fig. 1-60).
Homogeneous refers to imaged echoes of equal intensity.
A homogeneous portion of the image may be anechoic,
hypoechoic, hyperechoic, or echopenic. Heterogeneous de-
scribes tissue or organ structures that have several different
echo characteristics. A normal liver, spleen, or testicle has
a homogeneous echo texture, whereas a normal kidney is
heterogeneous, with several different echo textures.
Acoustic enhancement is the increased acoustic signal
amplitude that returns from regions lying beyond an ob-
ject that causes little or no attenuation of the sound beam
such as fluid-filled structures. The opposite of acoustic
enhancement is acoustic shadowing and both are types of
sonographic artifacts. Acoustic shadowing describes reduced
echo amplitude from regions lying beyond an attenuating
object. An example is seen with echogenic calculi (choleli-
thiasis, urolithiasis) which does not allow ultrasound to pass
through (it is attenuated) resulting in a sharp, distinctive
shadow (Fig. l-6E). Air bubbles (bowel gas) do not allow
transmission of the sound beam and most of the sound is
reflected.4 Often, sonographers refer to the shadowing caused
by low reflectivity as soft or dirty shadowing.
INTERPRETATION OF SONOGRAPHIC
CHARACTERISTICS
Three other definitions are frequently used to describe
internal echo patterns: cystic, solid, and complex.
The diagnosis of a cyst is made on many asymptomatic
patients based on specific sonographic characteristic ap-
pearances and only in certain situations, with a correlation
with the patient's history. The sonographic criteria for cystic
structures or masses are as follows: (1) Cysts retain an an-
echoic center, which indicates the lack of internal echoes
even at high instrument gain settings. (2) The mass is well
defined, with a sharply defined posterior wall indicative of
a strong interface between cyst fluid and tissue or paren-
chyma. (3) There is an increased echo amplitude in the tissue
beginning at the far wall and proceeding distally compared
to surrounding tissue. This increased amplitude is better
known as through-transmission or the acoustic enhancement
 I INTRODUCTION 9

A B

c D

FIGURE 1-6 Tissue texture5. A:. On this longitudinal section in the supine
position, 1he diaphl"llglll (v.hite solid <Jm1N) is described as more ediogenic
1han 1he normal texture of1he right liver lobe (RU.), which is more echogenic.
1han 1he renal parendiyma (...Alite am:1N) (FV, portal vein; l'llite solid <XIT1N, dia-
phragm). B: In 1his patient. the transver.;e section demonstr.rtes 1hat tne liver
and panen!aS 11!!X:t!Jres have a similar ediogenicity (ISOl!d'loic) (Ao. aorta; NC,
inferiorvena cava; PH, pancrealic head; PT, pancre.alic. tail; RRA, right renal
artery; SMV, ruperior mesenteric. vein). C: On 1his longitudinal section made
in tne supine position, 1he bile-filled gallbladder (GB) appear$ anecnoic.. 0: On
a longitlldinal section of the right kidney, the renal c.ipsule is normally a specu-
lar reflector and is hyperechoic compared to surrounding tissues. Tne renal
cortex is homogeneously echogenic: and 1he pyramids (P) seel'1 in 1he medulla
become more prominent and can diange from hypoechoic. to anechoic with
increased diuresis. Tne area labeled shadowing is caused by bowel gas and is
due 10 low reflectivity (referred to as soft or dirty shadow). E: The transverse
gallbladder is from a patient with diolecy,;ti1is (1hiclcened wal~ and a diolelithia-
sis aealing an acoustic. shadow due to atteN.lation. Compare f\gure I-OE with
Figure I-OD with the appearance of a shadow due to low reflec!Mo/. (Images
courtesy of Philips Medical System, Bothell, WA) E
10 PART ONE ABDOMINAL SONOGRAPHY
artifact. It occurs because tissue located on either side of
the cystic structure attenuates more sound than does the
cystic structure. (4) Reverberation artifacts can be identified
at the near wall if the cyst is located close to the transducer.
(S} Edge shadowing artifacts may appear, depending on the
incident angle {refraction) and the thickness of the cystic
wall at the periphery of the structure. The tadpole tail sign
occurs with a combination of an edge shadow next to the
echo enhancement (Fig. l-7A).
A solid structure may have a hyperechoic, hypoechoic,
echopenic, or anechoic homogeneous echo texture, or it
may be heterogeneous because it contains many different
types of interfaces. Usually, solid structure exhibit the fol-
lowing characteristics: (1) internal echoes that increase with
an increase in instrument gain settings; (2) irregular, often
poorly defined walls and margins; and (3) low-amplitude
A B
c System, Bothell, WA)
echoes or shadowing posterior to the mass due to increased
acoustic attenuation by soft tissue or calculi (Fig. 1-78).
A complex structure usually exhibits both anechoic and
echogenic areas on the image, originating from both fluid
and soft tissue components within the mass. The relative
echogenicity of a soft tissue mass is related to a variety
of constiwents, including collagen content, interstitial
components, vascularity, and the degree and type of tissue
degeneration (Fig. l-7C).
The amplitude of echoes distal to a mass, structure, or
organ can be used to evaluate the attenuation properties of
that mass. Thlnsonic or sonolucent refers to masses, organs,
or tissues that attenuate little of the acoustic beam and result
in images with distal high-intensity echoes. An example is a
cystic structure with the associated acoustic enhancement
artifact. Masses that attenuate large amounts of sound
FIGURE 1-7 lnterpretition. A:. Cystic. A longitlJdinal seaion d the right
kidney demonstrates a renal cyst. The following sonographic criteria for a cyst
are present (I) anechoic: center; (2) cle.ilr definition witn a sharply defined
posterior wall, (3) acoustic enhancement, (4) reverberation artifac:ts (~
art'CN>head), and (S) edge shadowing artifact. 8: Solid. A transverse section
1hrough 1he right lobe of the liver demonstrates a hemanjjoma. The benign
solid mass presents wi1h 1he following sonographic aiteria for a solid mass:
(I) internal ed:loes that increase witn increased gain settings and (2) low-
amplitude echoes (arrow) or shadowing posterior to the mass. l~larwalls
may be present when the solid mass is a calculus or a malignant tumor. C:
Complex. The encapsulated mass is a complex struc:llJre exhibiting septa.
between echogenic and aned10ic areas. (Images courtesy cl Philips Medical

show a marked decrease in the amplitude of distal echoes.
An example is calculi, with the associated shadow artifact.
PREPARATION
Before the patient is scanned, it is important for the so-
nographer to obtain as much information as possible. The
sonographer should be aware of the indications for the
study and of any additional clinical information such as
laboratory values, results of previous examinations, and
related imaging examinations. The sonographic examination
should be tailored to answer the clinical questions posed
by the overall clinical assessment.
Patient apprehension is reduced when the examination
is explained. Apprehension may be lessened further by pro-
viding a clean, neat examination room, extending common
courtesies and a smile, and letting the patient know that
the sonographer enjoys providing this diagnostic service.
It is important that patients know that they are the focus
of the sonographer's attention.
The region of interest is visualized by planning the
sonographic examination to image in multiple planes, two
of which are perpendicular. Any abnormalities are imaged
with differing degrees of transducer and patient obliquity
to collect more information. The patient is released only
after sufficient information is documented, because being
called back for a repeat examination increases apprehension.
EXAMINATION DOCUMENTATION
AND THE SONOGRAPHER'S
PRELIMINARY REPORT
The minimum documentation on sonographic images includes
(I) the patient's name and other identifying information,
(2) the facility's identifying information, (3) date of the
examination, and (4) the image orientation if appropriate.5
In many departments, sonographers provide a preliminary
report. Legally, physicians can provide a diagnosis or an
interpretive report, whereas sonographers cannot. Sonog-
raphers function as a delegated agent of the physician and
do not practice independently. 6 The preliminary report is
more commonly referred to as the technical impressions or
the examination worksheet. The minimum documentation
on a technical impression worksheet should include (I)
the patient's name and other identifying information, (2)
date of the examination, (3) relevant clinical information
which may include classification of disease code, (4) specific
examination requested, and (S) the name of the patient's
health-care provider and contact information. 5 The techni-
cal impressions worksheet should give key sonographic
findings. Ideally, the sonographer has an opportunity to
discuss these findings with the sonologist. As a team, the
sonographer and sonologist determine when the documenta-
tion is sufficient to complete the sonography examination.
When immediate action is indicated by the sonographic
findings and the sonologist is unavailable to provide the
final interpretive report, the sonographer should provide the
referring physician with as much information as possible
immediately following the examination.
The sonographer's report should describe the sono-
graphic findings only on what is documented, without
I INTRODUCTION 11
offering a conclusion regarding pathology. The terminology
presented previously is very helpful. Include the scanning
plane, normal tissue echogenicity, abnormal tissue texture
(anechoic, hyperechoic, hypoechoic, isoechoic, cystic, solid
or complex, focal or diffused, and shadowing or acoustic
enhancement), measurements (vessels, ducts, organs, wall
thickness, masses), location of measurements, and abnormal
amounts of fluid collections. For example, describing an
echogenic mass attached to the gallbladder wall that does
not move as the patient changes position discusses the
sonographic findings, whereas stating that the patient has
a polyp located in the gallbladder is a diagnosis.
The department should have a policy regarding the docu-
mentation to include on the image and interpretive report
worksheet as well as the final report from the interpreting
physician. Sonographers should be competent, through
education and experience, to provide images of adequate
quality and written documentation of the sonographic find-
ings without legal obligation. 6 Sonographers should not
provide any verbal or written sonographic findings to the
patient or the patient's family.
While demonstrating their sonographic evaluation ex-
pertise, sonographers should always adhere to the codes of
medical ethics and/or professional conduct available from
professional associations. 6 These codes and clinical prac-
tice standards should also be included in the sonographer
employment Gob) description.
SENSITIVITY, SPECIFICITY,
AND ACCURACY
Sonographers should be aware of a few statistical parameters
developed to judge the efficacy of sonographic examinations.
These statistics are frequently reported in the literature.
Knowing these statistics allows the sonographer to provide
a sound rationale for why a diagnostic procedure should or
should not be performed.
There are four possible results for each sonographic
examination correlated with an independent determination
of disease, such as a biopsy or a surgical procedure. (1) A
true-positive result means that the sonographic findings were
positive and the patient does have the disease or pathology.
(2) A true-negative result means that the sonographic findings
were negative and the patient does not have the disease or
pathology. (3) A false-positive result means that the sono-
graphic findings were positive but the patient does not have
the disease or pathology. (4) A false-negative result means that
the sonographic findings were negative but the patient does
have the disease or pathology. Sonographers should strive
to increase both the true-positive and true-negative results.
The examination's sensitivity describes how well the
sonographic examination documents whatever disease or
pathology is present. Mathematically, it is determined by
the equation [true positive + (true positive + false nega-
tive) x 100]. If the number of false-negative examinations
decreases, the sensitivity of the examination increases.
The examination's specificity describes how well the sono-
graphic examination documents normal findings or excludes
patients without disease or pathology. Mathematically, it is
determined by the equation [true negative + (true negative
+ false positive) x 100]. If the number of false-positive
12 PART ONE ABDOMINAL SONOGRAPHY
examinations decreases, the specificity of the examination
increases.
The accuracy of the sonographic examination is its abil-
ity to find disease or pathology if present and to not find
disease or pathology if not present. Mathematically, it is
determined by the equation [true positive + true negative+
(all patients receiving the sonographic examination) x 100].
There are two other statistics that sonographers should
be aware of. The positive predictive value indicates the
likelihood of disease or pathology if the test is posi-
tive. Mathematically, it is detennined by the equation
SUMMARY
• Learning and understanding accurate and precise ter-
minology allows commUIJication among professionals.
• Developing standard protocols based on understanding
patient positions, transducer orientations, and image
presentations increases the accuracy of the sonography
examinations.
• Sonographers describe sonographic findings with ter-
minology that defines echo amplitude, echo texture,
structural borders, characteristics of organs and anatomic
relationships, sound transmission, and acoustic artifacts
and identifies cystic, solid, and complex masses.
• The sonography examination relies on the skill, knowl-
edge. and accuracy of the sonographer who must pay
attention to the texture, outline, size. and shape of both
normal and abnormal structures.
• The patient will benefit most when the sonographic
appearance is correlated with patient history, clinical
presentation. laboratory function tests, and other imag-
ing modalities to compose a clinically helpful picture.
REFERENCES
1. American Institute of Ultrasound in Medicine. AlUM Tuchnical
Stan.d/l1'ds Comm.itttt: Stmu1.a:rd Presentation and Labeling of
Ultmsound Images. Stb ed. Laurel, MD: American lns!itute of
Ultraaound in Medicine; 2013.
2. Tempkin BB. Scanning planes and scanning methods. In: Tumpkin
BB, ed. Sonography Scanning: Principles and 1'1:otDaJU. 4th ed. St.
Louis, MO: msmer; 2013:15-28.
3. American lnalitute of Ultrasound in Medicine. .AruM Recommended
Ultmsound 'n!rminology. 3rd ed. Laurel, MD: American Institute
af Ultrasound in Medicine; 2008.
[true positives+ (true positives+ false positives) x 100].
The negative predictive value indicates the likelihood
of the patient being free of disease or pathology if the
test is negative. Mathematically. it is determined by
the equation [true negatives + (true negatives + false
negatives) x 100].
The mathematical formulas presented provide a percent-
age. If sensitivity, specificity, accuracy, and positive and
negative predictive values are expressed by fractions between
0 and 1 rather than by a percentage, the parameters were
not multiplied by 100.
CRITICAL THINKING QUESTIONS
1. If the patient is lying on his or her right side and the
transducer indicator is at the 12 o'clock position on the
left Jateral abdominal wall, what is the scanning plane
and how is the image presented on the display monitor1
2. What anatomic areas are not visualized on a longitu-
dinal, sagittal image presentation and how does the
sonographer evaluate these areas?
3. Explain the mechanism and differentiate between acous-
tic shadowing and low refiectivity due to air bubbles.
MEDIA MENU
Student Resources available on thePoint• include:
• Audio glossary
• Interactive question bank
• Internet resources
4. Lunsford BM. Basic principles. In: Sanders RC, Hall-Turracciano
B, eds. Clinical Sonogruphy: A Practical Gaide. Stb ed. Baltimore,
MD: WOltm Kluwer; 2016:106-118.
S. American Institute of Ultrasound in Medicine. AlUM Practice
Pammeter for Docu.numtaJ:iDn of an Ultnzsound Emmination.
Laurel, MD: .American Institute of Ultrasound in Medicine; 2014.
6. Society of Diagnostic Medical Sonography. Scope of Practice and
Clinical Standards for the Diagnostic Mediml Sonographer. Plano,
TX: Society of Diagnostic Medical Sonography; 2013-2015.
 ABDOMINAL SONOGRAPHY

The Abdominal Wall and

Diaphragm
TERRIL. JURKIEWICZ

OBJECTIVES KEY TERMS

■ Locate the nine regions of the abdomen and the four quadrants of the abdominopelvic abdominal hernia
cavity. abdominopelvic cavity
■ Discuss the extent, the muscles , and the subcutaneous layers of the abdominal wall a'.E abscess
diaphragm.
aponeurosis
■ Describe the role of sonography, the sonographic technique, and the normal onographic
desmoid tumor
appearance of the abdominal wall and diaphragm.
diaphragm
■ Identify the etiology and sonographic appearance of acute and t,;,to~ic al5~inal wall
infiammatory process to include resolution, organization, and absces's::fom;iation. diaphragmatic hernia
■ Describe the common etiologies and sonographic appearanQ -abeiominal wall diaphragmatic inversion
hematomas and trauma. diaphragmatic paralysis
■ Identify the different types of abdominal hernias and hieir s01\1ographic appearance. endometrioma
■ List the neoplasms that affect the abdominal ~I an<:l tlesc[i oe their sonographic appearance. eventration
■ Identify diaphragmatic pathologies that can be e~a~ d with sonography. fascia
■ Identify technically satisfactory and unsatisfacto sonographic examinations of the hematoma
abdominal wall and diaphragm.
inguinal canal
inguinal hernia
GLOSSARY
lipoma
abscess a cavity containing dead tissue and pus that forms due to an infectious process neuroma
ascites an accumulation of serous fiuid in the peritoneal cavity pleural effusion
ecchymosis skin discoloration caused by the leakage of blood into the subcutaneous tis-
rectus abdominis
sues, which is often referred to as a bruise
rhabdomyolysis
erythema redness of the skin due to infiammation
linea alba fibrous structure that runs down the mid line of the abdomen from the xiphoid sarcoma
process to the symphysis pubis separating the right and left rectus abdominis muscles seroma
omphalocele a congenital defect in the midline abdominal wall that allows abdominal
organs, such as the bowel and liver, to protrude through the wall into the base of the
umbilical cord
peristalsis rhythmic wavelike contraction of the gastrointestinal tract that forces food
through it
pneumothorax collapsed lung that occurs when air leaks into the space between the
chest wall and lung

13
14 PART ONE ABDOMINAL SONOGRAPHY

T he human body contains two major cavities: the ven-

tral (anterior) cavity and the dorsal (posterior) cavity.
The dorsal cavity is divided into the cranial cavity and the
spinal cavity. In the ventral cavity, the diaphragm muscle
separates the thoracic cavity from the abdominopelvic
cavity. The abdominopelvic cavity has an upper portion
(the abdomen). a lower portion (the pelvis). and it is sur-
rounded by the abdominal wall This chapter focuses on
the abdominal wall and diaphragm.
REGIONS AND QUADRANTS
For clinical reasons used to descnoe the location of organs,
pain, or pathology, the abdomen is divided into nine region&
and the abdominopelvic cavity is divided into four quad-
rants. The nine regions are delineated by two horizontal
(transverse) planes and two vertical (longitudinal) planes
and the four quadrants are delineated by one horizontal
(transverse) plane and one vertical {longitudinal, midsagit-
tal, or sagittal} plane. 1.2 The nine regions are the (1) right
hypochondrium. (2) epigastrium, (3) left hypochondrlum,
(4) right lumbar. (5) umbilical, (6) left lumbar, (7) right iliac
fossa, (8) hypogastrium, and (9) left iliac fossa. 1.2 The four
quadrants are the (1) right upper quadrant (RUQ}, (2) left
upper quadrant (LUQ). (3) right lower quadrant {RLQ), (4)
and left lower quadrant (LLQ)M (Fig. 2-lA,B).
ANATOMY
The abdominal wall is continuous but, for descriptive
reasons, it is divided into the anterior wall, right and left
lateral walls, and posterior wall. Because the anterior and
lateral wall boundaries are indefinite, they will be combined
in the presentation as they are combined in other refer-
ences1.2 (Fig. 2·2).
Anterolateral Abdominal Wall
The anterolateral wall extends from the thoracic cage to the
pelvis. Superiorly, it is bounded by the cartilages of the 7th
to 10th ribs and the xiphoid process. Inferiorly, it is bounded
by the inguinal ligament and iliac crests, pubic crests, and
pubic symphysis of the pelvic bones.4
Layers
To better understand abdominal wall anatomy, it is important
to distinguish between fascia and aponeurosis. A fasci.a. is
a fibrous tissue network located between the skin and the
underlying structures. It is richly supplied with both blood
vessels and nerves. The fascia is composed of two layers: a
superficial layer and a deep layer. The superficial fascia is
attached to the skin and is composed of connective tissue
containing varying quantities of fat. The deep fascia underlies
the superficial layers to which it is loosely joined by fibrous
strands. It serves to cover the muscles and to partition them
into groups. Although the deep fascia is thin, it is more
densely packed and is stronger than the superficial fascia;
however, neither the superficial fascia nor the deep fascia
possesses any notable internal strength since they are a
condensation of connective tissue organized into definable
homogeneous layers within the body.s

Median plane

- - - ----Transumblllcal
Transtubercular plane
plan&-l"'f""·~...-

Midinguinal
r-!->-=t=:-~--!--Publc
point
symphysis

Antartor view• A Nine abdominal region• B Four abdominal quadranta

- Right hypochondriac (RH) 1=i Left lateral (lumbar) (LL) 1=i Right upper quadrant (RUQ)
1=i Eplgastrtc (E) c::::::::J Right Inguinal (groin) (RI) c:::::::::i Left upper quadrant (LUQ)
c:::::::::i Left hypochondriac (LH) c:::::::::i Pubic (hypogastric) (P) c:::::::::i Right lower quadrant (RLQ)
c:::::::::i Right lateral (lumbar) (RL) - Lsft inguinal (groin) (LI) c:::::::::i Left lower quadrant (LLQ)
c:::::::::i Umbilical (U)

FIGURE 2-1 AbdominopeMc cavity subdivisions. k The regions are formed by two sagittal ('lelt.icaf) and two tranMrse {horiz.onrt.11) planes. B: The quadrams are
funned by the midsagittal plane and atranMlrse plane passing through the umbiliws at the iliac creit or the disk level between the 13--4 vertebrae. (Reprinted with
pennissionfrom Moore KL.~rAM. Essential C/inica/Anaumy. 3rd ed. Baltimo~. MD: Lippincott Wiiiams& Willcins: 2007:119.)

Linea
alba
Lumbar vertebra
Inferior vi..,,,
FIGURE 2-2 Abdominal wall subdivisions. The 1ransverse section illuWates
the structural relationships of the abdominal wall. (Reprinted with permission
from Moore K. Dalley A >€ur A OinicaJ/y Orientlld Anattxrtf. 6th ed. Philadel-
phia, PA: Lippinaitt Williams & Wilkins; 20 I0: 186.)
The aponeurose.s are layers of fl.at tendinous fibrous sheets
fused with strong connective tissue that serve as tendons to
attach muscles to fixed points. An aponeurosis is minimally
served by blood vessels and nerves. The aponeuroses are
primarily located in the ventral abdominal regions with
a primary function to join muscles to the body parts that
the muscles act upon. An aponeurosis possesses excellent
strength.3
The multilayered abdominal wall appean as a laminated
structure when viewed from the superficial, outermost
layer to the deep layer.4 It consists of skin, subcutaneous
tissue (superficial fascia), muscles and their aponemo-
ses, a deep fascia, extraperitoneal fat, and the parietal
peritoneum.l,M The skin attaches loosely to most of the
subcutaneous tissue except that it normally adheres firmly
at the umbilicus.u
The subcutaneous tissue anterior to the muscle layers
makes up the superficial fascia. Superior to the umbilicus,
Superficial tatty layer of
subcutaneoustlBSue(Camperfascla)--;- . 1 : ~:
·-·:.:..•
Deep membranous layer of ~ ;-. · · · • · · • · · ~External oblique muse!&
subcutaneous ti$11ue (Scarpa fascia)/~ lnt al bl.
• • ~ ""!"" s ~ ern o 1quemusce
lnv&Sting (deep) fascia: ~ :;; -::s ;;z..,,,lhlnswrse abdominal muscle
superficial, intermediate, deep ~ :::<'.
~ Extraperttoneal fat
Endoabdominal (transversalis)~ • • ·· ~~ ' '
fascia
FIGURE 2-3 Anterolateral abdominal wall. The section of1he anterolateral abdominal wall inferior to 1he umbilicus illustrates the multilayered, laminar-appeari~
tissue and musdes located anterior to 1he peritoneal cavity.
2 THEABDOMINAL WALLAND DIAPHRAGM IS
it is consistent with that found in most regions. Inferior to
the umbilicus, the deepest part of the subcutaneous tissue
is reinforced with elastic and collagen fibers and is divided
into two layers. The first is a superficial fatty layer (Camper
fascia) containing small vessels and nerves. camper fascia
gives the body wall its rounded appearance. The second layer
is a deep membranous layer {Scarpa fascia) and it consists
of a combination of fat and fibrous tissue that blends with
the deep fascia. 1.2 The membranous layer continues into
the perineal region as the superficial perinea! fascia (Coll.es
fascia) 1 {Fig. 2-3).
The three anterolateral abdominal muscle layers and
their aponeuroses (flat extended tendons) are covered by
the superficial, intennediate, and deep layers of extremely
thin investing fascia. 1 The investing layer of fascia is lo-
cated on the external aspects of the three muscle layers
and is not easily separated from the external muscle layer.
Varying thicknesses of membranous and areolar sheets
of endoabdominal fascia line the internal aspects of the
wall. Although the endoabdominal fascia is continuous,
different names account for the muscle or aponeurosis it
is lining. For ex.ample, the portion liniDg the deep surface
of the transversus abdominis muscle and its aponeurosis
is the transversalis fascia. Internal to the transversalis
fascia is the parietal peritoneum. The distance separating
the parietal peritoneum from the transversalis fascia is
determined by the variable amounts of extraperitoneal
fat in the fascia. 1 The parietal peritoneum is a glistening
lining of the abdominopelvic cavity formed by a single
layer of epithelial cells and supporting connective tissue1•2
(see Fig. 2·3).
Muscles
There are five bilaterally paired muscles in the anterolat-
eral abdominal wall and one unpaired. muscle (Tu.ble 2-1).
Located bilaterally on the anterior abdominal wall are
the rectus abdorninis muscles (see Fig. 2-2). The rectus
abdominis is a long, broad, vertical, strap-like muscle that
is mostly enclosed in the rectus sheath. Also located on the
anterior abdominal wall in the rectus sheath is the pyrami-
dal.is muscle. The pyramidali.s, a small triangular muscle,
is considered insignificant and is absent in approximately
20% of people1•2 {Fig. 2-4A).
There are three flat, bilaterally paired muscles of the
anterolateral group: (I} the external oblique (most su-
perficial), (2} the internal oblique (middle layer), and
(3) the transversus abdominis (also known as transverse
Skin SUperftclal
" . : ';. :.~
!
1
.7"' Parietal peritoneum Deep
16 PART ONE ABDOMINAL SONOGRAPHY

TABLE 2-1 Muscles of the Abdominolateral Wall 1.2

Rectus abdominis Bilaterally paired, vertical muscle
(Rgs. 2-2 and 2-4A) Origin: Arises from the front of the pubic bone and pubic symphysis
Insertion: Inserts into the frfth, sixth, and seventh costal cartilages and the xiphoid process
Action: Acts to flex the trunk, compress abdominal viscera, and stabilize and control pelvic tilt

Pyramidal is Small, insignificant triangular musde

(Rg. 2-4A) Origin: Arises from the anterior surface of the pubis
Insertion: Inserts into the linea alba; lies anterior to the lower part of the rectus abdominis
Action: Acts to draw the linea alba inferiorly

External oblique Bilaterally paired, flat muscle

(Rgs. 2-2 and 2-4B,q Origin: Arises from the external surface ofthe lower eight ribs
Insertion: Inserts in linea alba via an aponeurosis and into the iliac crest and pubis via the inguinal ligament
Action: Acts to compress and support abdominal viscera, flexes and rotate trunk

Internal oblique Bilaterally paired, flat muscle

(Rgs. 2-2 and 2-4B,q Origin: Arises from the thoracolumbar fascia and the anterior two-thirds of the iliac crest
Insertion: Inserts into the inferior borders of 'ttle lower three ribs, linea alba, and pubis via a conjoint tendon
Action: Acts as a postural function of all albdominal muscles

Transversus abdominis Bilaterally paired, fla:t muscle

(transverse albdominal; Origin: Arises from the internal surfaces of the lower eight cost.al cartilages,7- 12 the thoracolumbar fascia, the anterior
Figs. 2-2 and 2-4B,q two-thirds of the iliac crest, and the lateral 'ttlird of the inguinal ligament
Insertion: Inserts into the xiphoid process, linea alba with aponeurosis of internal oblique, pubic crest, and pectin pubis
via a conjoint tendon
Action: Same as external oblique; acts to compress and support albdominal viscera

abdominal) 1- 3 (see Fig. 2-2 and Table 2-1). Coupled with
the vertical orientation of the fibers of the rectus abdominis,
the fibers in the three flat muscles are arranged to provide
maximum strength by forming a supportive muscle gird.le
that covers and supports the abdominopelvic cavity. In the
external oblique, the muscle fibers have a diagonal inferior
and medial orientation. The fibers of the internal oblique,
the middle muscle layer, have a perpendicular orientation
at right angles to those of the external oblique. The fibers
of the innermost muscle layer, the transversus abdominis,
are oriented transversely or horizontally. 1- 3
Structures
The other structures within the anterolateral abdominal
wall include the rectus sheath, linea alba, umbilical ring,
and the inguinal canal.
The rectus sheath is the strong, fibrous compartment for
the rectus abdominis and pyramidalis muscles as well as
for some arteries, veins, lymphatic vessels, and nerves. The
anterior and posterior layers of the rectus sheath compart-
ment are formed by the intercrossing and interweaving of
the aponeuroses of the flat abdominal muscles. The lateral
aspect of the rectus abdominis, the aponeuroses, fuses to
form the linea semilunaris.3 The arcuate line is located half
way from the umbilicus to the pubis symphysis and refers
to the transition terminating the posterior rectus sheath
covering the proximal, superior three-quarters of the rectus
abdominis muscle.3 The distal, inferior quarter is covered
by the transversalis fascia, which lies below the rectus
muscles and is all that separates the rectus muscles from
the peritoneum3 (Fig. 2-SA,B).
Throughout its length, the linea alba is formed as fibers
of the anterior and posterior layers of the sheath interlace
in the anterior median line. 1- 3 The linea alba is oriented
vertically and courses the length of the anterior abdominal
wall. It separates the bilateral rectus sheaths. Superiorly, the
Iinea alba is wider and it narrows inferior to the umbilicus to
the width of the pubic symphysis. The linea alba transmits
small vessels and nerves to the skin (Figs. 2-2, 2-4A, and
2-SA,B). In thin, muscular people, a groove is visible in the
skin overlying the linea alba.
The umbilicus is the area where all layers of the antero-
lateral abdominal wall fuse.1 The umbilical ring is a defect
in the linea alba and is located underlying the umbilicus. 1•2
This is the area through which the fetal umbilical vessels
passed to and from the umbilical cord and placenta. After
birth, fat accumulation in the subcutaneous tissue raises
the umbilical ring and depresses the umbilicus.
The inferior border of the external oblique extends be-
tween the anterior superior iliac spine and the pubic tubercle
forming the inguinal ligament.3 Located in the inguinal
region superior and medial to the inguinal ligament is the
inguinal canal, which is formed during fetal development.
It is an important canal where structures exit and enter
the abdominal cavity, and the exit and entry pathways are
potential sites of herniation. 1- 3 In adults, the inguinal canal
is an oblique passage approximately 4 cm long. It has an
inferior-to-medial orientation through the inferior part of the
anterolateral abdominal wall and lies parallel and superior
to the median half of the inguinal ligament.2 Functionally
and developmentally distinct structures located within the
canal are the spermatic cord in males and the round uterine
ligament in females. Other structures included in the canal
in both sexes are blood and lymphatic vessels and the ilio-
inguinal nerves. The inguinal canal has two openings. The
deep (internal) inguinal ring serves as an entrance and the
superficial (external) inguinal ring serves as the exit for
the spermatic cord or the round ligament in females. Normally,
the inguinal canal is collapsed anteroposteriorly against the
 2 THEABDOMINAL WALLAND DIAPHRAGM 17

A Antwtor view

External Extemal
oblique obllque
(cut) (cut)
Internal
Internal Rectus oblique--.'Hf
oblique-~"' sheath (cut)
(anterior
layer)

-"'---Inguinal
ligament

B c D
Lateralvltwa
FIGURE 2-4 Abdominolateral wall muscles. A; The bilaterally pai~. vertially oriented redl.Js abdcminis muscles and the small triangular pyramidalis muscle are
located on 1he anterior wall. ~: The 1hree flat, bilaterally paired muscles comprising the anterolateral group include the external oblique, 1he intemal oblique,
and 1he transverse abdcminal. The strength of1he muscles can be contributed to 1he collaborative relationship of1he orientation of1he fiber d eacn muscle. (Re-
printed with permission from Moore KL, ~r AM. Essential Oinkal /\nat.txrrt. 3rd ed. Baltimore, MD: Lippincott Williams & Wikins; 2007: 122.)

sperm.atic cord or round ligament. Between the two open-
ings (rings), the inguinal canal has two walls (anterior and
posterior), a roof, and a fl.oor1· 2 (Table 2-2; Fig. 2-6A,B).
Posterior Abdominal Wall
The posterior abdominal wall is composed of the lumbar
vertebra, posterior abdominal wall muscles, diaphragm,
fascia, lumbar plexus, fat, nerves, blood vessels, and lym-
phatic vessels.
Layers
The posterior abdominal wall is covered with a continu-
ous layer of endoabdominal fascia, which is continuous
with the transversalis fascia. 1.2 The posterior wall fascia is
located between the parietal peritoneum and the muscles.
The psoas fascia (sheath) is attached medially to the lumbar
vertebrae and pelvic brim. Superiorly, the psoas fascia is
thickened and forms the medial arcuate ligament. Laterally,
the psoas fascia fuses with both the quadratus lumborum
fascia and the thoracolumbar fascia. Inferior to the iliac
crest, the psoas fascia is continuous with that part of the
iliac fascia that covers the iliacus1 (Fig. 2-7).
On the posterior abdominal wall, the thoracolumbar
fascia is an extensive complex. Medially, it attaches to the
vertebral column. In the lumbar region, the thoracolumbar
fascia has posterior, middle, and anterior layers with enclosed
muscles between them. The fascia is thin and transparent in
18 PART ONE ABDOMINAL SONOGRAPHY

Anterior layer of
rectus shealh
APoneurosis of extemal oblique
Rectus
abdomlnls Aponeurosis of intemal oblique
(Anterior and posterior laminae)

Subcutaneous
tissue
Extemal oblique
Posterior layer of Internal oblique
rectus sheath
Transversus
A abdominis
TransversalI&
Anterior layer of rectus sheath fascia
Uneaalba

Anterior layer of
rectus sheath
(consisting of all thme
aponeurotlc layers) FIGURE 2-5 Abdominal wall structures.
Trar6Verse sections of the anterior abdom-
Layers lft A A B inal wall (A) superior to 1he umbilicus with
the posterior layer of the redu!; sheath. B:
i=i External oblique
Inferior 101he UT1bilicus, the rectus shea!h
- lntemal oblique is separated from 1he parietal peritoneum
i = i Transversus abdominis
i = i Transversalis fascia
only by 1he transversalis fascia. (Reprinted
i = i Parletal perttoneum
witk permission from Moore KL, Af}Jr AM.
Essential Oinica! Anatomy. 3rd ed. Ba~
- Membranous layer of more, MD: Lippincott Wiiiams & Wikins;
subcutaneous tissue
2007:123.)

the thoracic region it covers, whereas it is thick and strong
in the lumbar region it covers. The posterior and middle lay-
ers of the thoracolumbar fascia, which enclose the bilateral
erector spinae muscles or the vertical deep back muscles,
are comparable to the enclosure of the rectus abdominis
by the rectus sheath on the anterior wall.1 When compar-
ing the posterior sheath to the rectus sheath, the posterior
sheath is stronger because it is thicker and has a central
attachment to the lumbar vertebrae. The rectus sheath has
no bony attachment and fuses with the linea alba. Ll.ke
the rectus sheath, the lumbar part of the posterior sheath
extending between the 12th rib and the iliac crest attaches
laterally to the internal oblique and transversus abdominis
muscles. The rectus sheath attaches to the external oblique
muscle, but the thoracolumbar fascia attaches to the latis-
simus dorsi1 (see Fig. 2-7).
The anterior layer of the thoracolumbar fascia is the qua-
dra.tus lwnborum fasda and it covers the anterior surface
of the quadratus lumborum muscle. 1•2 Compared to the
middle and posterior layers of the thoracolumbar fascia, it
is a thinner and more transparent layer. The anterior layer
attaches to the anterior surfaces of the lumbar transverse
processes, to the iliac crest, and to the 12th rib. Laterally, the
anterior layer is continuous with the aponeurotic origin of

TABLE 2-2 Boundaries of the Inguinal Canal"

Boundary Deep RI.,..._... Third
Posterior wall Transversalis fascia
Anterior wall Internal oblique plus lateral CNS of
aponeurosis of external oblique
Transversalis fascia
Mlclclle Third
Transversalis fascia
Aponeurosis of external oblique
(lateral crus and intercrural fibers)
Musculoaponeurotic arches of
internal oblique and 1ransverse
abdominal
....._.. Thlrd/Superftclal Rlns
Inguinal falx (conjoint tendon) plus reflected inguinal
ligament
Aponeurosis of external oblique (inten:Nral fibers),
with fascia of external oblique continuing onto cord as
external spermatic fascia
Medial CNS of aponairosis of external oblique

Floor lliopubic 1ract Inguinal ligament l..acunar ligament

°See figure 2-6.
Reprinted with permission from Moore K. Dalley A. Af}Jr A Oinicalfy Orientlld Anatomy. 6tk ed. Philadelphia. PA: Lippincott Williams & Wilkins; 2010:204.
 2 THEABDOMINAL WALLAND DIAPHRAGM 19

ll'ansverse abdomlnal muscle

Skin-----
Fatty layer--:...:....
Retroinguinal space
(of Bogros)
Membranous Peritoneum
layer of sub· Inguinal falx (conjoint
ct.ttaneous tendon) forming
tissue posterior wall of canal
Anterior wall lllopublc tract
of lngulnal canal Inguinal ligament
(lntercrural forming •gutter" (floor
ftbers)
of inguinal canal)
Superior ramus
of pubis
~----Fascia lata
of thigh

B Schematic aglttal section of lngulnal canal

Superficial inguinal ring

Extemal spermatlc fascia
Reflected inguinal ligament

=al spermatlc,

Spermaticcord~~
~

External spermatlc fascia

Testis ~
?
• Musculoaponeurotic arcades of
Internal oblique & transverse abdominal

A Anf.911or vltw
FIGURE W Inguinal canal. The anrerior and posterior wall, the roof. and tne floor cl ttie inguinal canal are illustr.ired. A: Tne abdominal wall layers and the c<N-
erings d the spermaiic cord and testis an! seen in the anterior view. In females, the canal serves as the passageway for the f't)Und ligament. 8: At the plane shewn
in (A), the sagittal seaion illustrates the composition of the canal. (Reprinted wi1h permission from Moore K, Dalley A. A(}Jr A Oinicaity Oriertte<J Anatomy. 6th ed.
Philadelphia, PA: Lippincott Vvllliams & Vvllkins; 20 I 0:20<!.)

the transversus abdominis muscle. Superiorly, it thickens to Diaphragm

form the lateral arcuate ligament and inferiorly, it is adher-
ent to the ili.olumbar ligaments1 {see Fig. 2-7).
Muscles
The muscles of the posterior abdomen are categorized as
the superficial and intermediate extrinsic back muscles and
the superficial layer, intermediate layer, and deep layer of
intrinsic back muscles1•2 (Table 2-3). The three main, bilat-
erally paired muscles comprising the posterior abdominal
wall are the psoas major, iliacus, and quadratua lumborum
(Fig. 2-8).
The diaphragm is a doubl~med, musculotendinous partition
separating the thoracic cavity from the abdominal cavity.1•6•7
The convex superior surface faces and forms the floor of the
thoracic cavity and the concave inferior surface faces and
forms the roof of the abdominal cavity. The concave surfaces
form the right and left domes with the right dome slightly
higher because of the presence of the liver and the central
part slightly depressed by the pericardium. 1 Its periphery is
the fixed muscle origin. which attaches to the inferior margin
of the thoracic cage and the superior lumbar vertebrae.2•6 .As
10 PART ONE ABDOMINAL SONOGRAPHY

Anterior
layer (quadratus
lumborum fascia}
Middle Thoracolumbar
layer fas<:ia

I
Intrinsic (deep} back muscles
FIGURE 2-7 Posterior abdominal wall fascia. The relationship of the psoas fuscia, the 1hree layers of1he thoracolumbar fascia, and quadratus lumborum fascia
with the musde5 and vertebrae are illustrated on this 1ransvel'$C section of the posterior abdominal wall. (Reprinted with permi$ion from Moore KL. At/}Jr AM.
Essemia/ Oinical Anatomy. 3rd ed. Baltimore, MD: Lippincott 'Mlliams & Wilkir'6; 2007:300.)

TABLE 2-3 Muscles of the Posterior Abdomen Wan•.z

Psoas major (Rgs. 2-6 and 2-7)
llia.cus (lig. 2-7)
Bilaterally paired, long, thick, fusiform mus:cle
Origin: Arises from the bodies and transverse proce!.'Se:S of lumbar vertebrae
Insertion: Inserts into the lesser trochant:er of femur with iliacus via iliopsoa.s tendon
Action: Ads to flex the thigh; flexes and laterally bends the lumbar vertebral column
Bilaterally paired, triangular musde
Origin: Arises from the iliac fossa and iliac aest and ala of the samJm
Insertion: Inserts into the lesser trochant:er of1he femur
Action: Ads to flex the thigh; if thigh is fixed, it flexes the pelvis on the thigh

Quadratus Jumborum Bilaterally paired, thick muscular sheet

(ligs. 2-6 and 2-7)
Psoas minor(lig. 2-7)
Origin: Arises from the iliolumbar ligament and iliac aest
Insertion: Inserts into the 12th rib and tran~ process of first four lumbar vertebrae
Action: Ads to flex vertebral column laterally and depress the last rib
Bilaterally paired, Jong, slender muscle anterior to psoas major
Origin: Arises from the bodies of the 12th thoracic and first lumbar vertebrae
Insertion: Inserts into the iliopubic eminence at the line of junction of the ilium and the superior pubic ramus
Action: Ads to flex and laterally bends the lumbar vertebral column

lliopsoa.s Formed by the psoas and iliacus muscles

Latissimus dorsi (Fig. 2-6)
Origin: Arises from the iliac fossa, bodie5 and transverse processes of lumbar vertebrae
Insertion: Inserts into the lesser trochanter of the femur
Action: Ads to flex the thigh, flexes and laterally bends the lumbar vertebral column
Bilaterally paired, broadest back. muscle
Origin: Arises from the lower six thoracic vertebrae, lumbar vertebrae, iliac CteSt via thoracolumbar fascia,
sac.rum, lower three or four ribs, and inferior angle of scapula
Insertion: Jr.sens into the interll.Jbercular (bicipital) f!OCNe on the medial side of the humerus
Action: Ads to abduct, medially rotate, and extend arm a:t shoulder

Erector spinae (Rg. 2-6) Location: A group of three columns d muscle loc:ated on each side of the vertebral column
Action: Ads as the chief extensor d the vertebral column

TranSllef'SOSpinaJ (Fig. 2-6) Location: An oblique group d three muscles dee? to the erector spinae
Action: In the abdominal area, they a.ct to stabilize vertebrae and assist with e><tension and rotation movements
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

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

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

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

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

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

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

MAKONDE LOCK AND KEY AT JUMBE CHAURO

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

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

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

Some consolation was afforded me by a brassfounder, whom I

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

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

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

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

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