Professional Documents
Culture Documents
Lee F. Rogers, MD
Professor Emeritus
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Wake Forest School of Medicine
Wake Forest University
Winston-Salem, North Carolina
O. Clark West, MD
Director
Emergency Radiology Section
Department of Diagnostic and Interventional Imaging
Level 1 Trauma Center
Memorial Hermann Hospital
Texas Medical Center
Professor
University of Texas Health Science Center
Houston Medical School
Houston, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
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Notices
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our understanding, changes in research methods, professional practices, or medical treatment may become
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material herein.
And last, to my wife, Donna B., who made this and all other of my works possible.
I am most grateful for her forbearance and tolerance of my preoccupations
through the four editions of this book. It is hard to imagine having completed
these works without her constant love, encouragement, and support.
Lee F. Rogers
To my recently deceased uncle, Emory Guth West, MD, FACR, born in Des Moines,
Iowa, and educated in Medicine and Radiology at Northwestern University in Chicago.
He practiced Radiology in Mountainview, California. In my “tween” years, spending days
watching him work in his office and conversing with him about “automotive medicine” – the precursor
of modern trauma care – provided the spark for my career.
To my father, George Guth West, MBA, JD, born in Des Moines,
Iowa, and currently resident of Henderson, Nevada. His support throughout my medical training
and his encouragement to pursue a career in an unorthodox field – academic
trauma imaging – have been invaluable.
I
t has been 12 years since the previous edition of this work. A lot has happened in the
interim. Microprocessors have revolutionized imaging; not only the means of medi-
cal imaging but how images are viewed and reported; how these reports are recorded,
transmitted, and communicated; how images are stored and retrieved; and even how one
seeks information regarding the imaging characteristics of disease or searches the literature
to learn of or substantiate their findings. Microprocessors have made images, reports, and
the clinical, pathologic, and imaging characteristics of disease instantaneously accessible.
We have achieved the potential of “real-time radiology.”
As a result of microprocessor-driven innovations in information accessibility, the nature
of textbooks has changed. Because of the online availability of medical images and accurate
and reliable information, the demand for and need of larger general texts has diminished
while readers’ requests for shorter, portable single-topic works that might be downloaded
on desktop computers, laptops, iPads, and smart phones has risen. Our work has been
revised in its fourth edition to accommodate readers’ requests.
But we did not start out that way. In planning for the fourth edition of my text I was
fortunate to secure the assistance of Professor O. Clark West of the University of Texas
Health Science Center at Houston Medical School, an internationally recognized authority
in the field of Emergency Radiology, as a partner and fellow author in this endeavor. Dr.
West heads the Emergency Radiology Section of the Department of Diagnostic and Inter-
ventional Imaging, which services the active Level 1 Trauma Center of Memorial Hermann
Hospital in Houston’s sprawling Texas Medical Center and has a particular interest and
extensive clinical experience in the application of multidetector CT (MDCT) to trauma
imaging. In view of his interest and expertise Dr. West accepted responsibility for author-
ship of the chapters devoted to the axial skeleton: cervical spine, thoracolumbar spine, and
pelvis, and I authored eight chapters devoted to the peripheral skeleton: shoulder, elbow,
wrist, hand, hip, knee, ankle, and foot.
The previous three editions of Radiology of Skeletal Trauma were two-volume texts of
1400 to 1700 pages. In preparing a manuscript for a fourth edition the publisher asked that
we provide a single-volume text of approximately 300 pages. This substantial reduction
presented a significant challenge. Dr. West and I hesitantly agreed to undertake the task.
We gave it our all, but found the results of the required shortening produced chapters far
short of our goal to provide a useful, informative, and instructional resource. The product
of our labors was simply unacceptable.
However, all was not lost. While working on the revision, I became increasingly aware
of the troubling thought that I had written three two-volume editions of a book containing
considerable information but had never informed the reader precisely how I used this infor-
mation in the assessment and interpretation of images of skeletal trauma. To this end we had
decided to add what I called a “primer” at the beginning of each chapter containing the basic
information needed to make an informed judgment and confident interpretation of images
of skeletal trauma. We then stopped working on the revision and turned our attention to
writing a primer for each anatomic area. It took three to four years to complete this undertak-
ing. Ultimately, we came to the conclusion that the primers alone had the making of a good
short text and abandoned our attempt to make a standard revision of the previous edition.
We define a primer as a small exploratory book on a subject – a collection of short infor-
mative pieces of writing that cover the basic elements. Our intent is that the information
provided in this primer should enable users to confidently and accurately identify as many
as 90% to 95% of fractures and dislocations that they encounter.
The Primer begins with checklists for each of the following:
1. Radiographic examination listing views required
2. Common injuries in adults
3. Common injuries in children and adolescents.
4. Injuries likely to be missed
5. Avoiding satisfaction of search: Now that you have seen this what else should you be
looking for
6. What you do when you see nothing at all: Indications for CT and MRI
vii
viii Preface
The checklists are followed by “The Primer,” a brief description with illustrative images
for each separate checklist.
I personally designed the layout for the Primer in a Word document. Then I typed the
manuscript, made the drawings, and downloaded the images into each primer. I used tif
images in the primer documents, the same high-quality images that would be sent to the
publisher for publication. This was done to show the publisher precisely how I wanted the
manuscript laid out.
One day I was reading out with a resident, Dr. Ravi Shastri, now a Fellow in Neurora-
diology at the University of Michigan. Ravi had seen printouts of a few of the chapters. He
asked if he could download one of the primer Word documents on his iPad to show me
what it would look like. I was curious. “Why not?” We copied one of the documents on his
thumb drive and soon thereafter he showed me the primer document on his iPad. I was
amazed. The images were dazzling. The ability to enlarge the images on the iPad was spec-
tacular. Dr. Shastri’s demonstration on the iPad convinced me of the advantages and added
value of the digital electronic presentation. I then showed the primers on my iPad to many
radiologists—residents, fellows, and experienced practitioners—and all were impressed
and found this format potentially useful.
Subsequently, I met with Don Scholz and Jacob Hart of Elsevier to show them several
primer chapters on an iPad. They were also impressed. Ultimately Elsevier decided that
the fourth edition of the text, now named Imaging of Skeletal Trauma would be published
and available in both print and electronic forms. We are pleased by Elsevier’s decision to
proceed in this fashion and grateful for their support.
Each chapter describes what I refer to as a “directed search” in viewing and interpreting
radiographs of musculoskeletal trauma. Know specifically what you are looking for and
look for it. Know what images to obtain, what injuries are likely and what they look like,
what injuries are likely to be missed and why, how to avoid satisfaction of search—where
else to look when you find certain injuries, and when to obtain CT and MRI.
This work would be of value to physicians in Emergency Medicine and Orthopedics as
well as Diagnostic Radiologists. As written it is suitable for self-instruction or self-evaluation
as well as an everyday go-to aid in the throes of reading images of musculoskeletal trauma
from emergency rooms and elsewhere during the regular workday or when on call at night
or weekends. This work could also form the basis of an introductory instructional course
for beginners as well as a refresher course for the more experienced.
Dr. West and I could not have completed this work without the assistance of many oth-
ers. My particular thanks to Michele Dalmenday for her attention to detail and exceptional
secretarial support and to Duane Cookman for his assistance in acquiring the numerous
images that were required from the files of the Department of Medical Imaging at the Uni-
versity of Arizona Medical Center in Tucson. The vast majority of the images are new; less
than 10% were repeated from the third edition.
Dr. West’s principle coauthors were Susanna C. Spence for the spine chapters and
Suresh K. Cheekatla for the pelvis chapter. His colleagues Naga Ramesh Chinapuvvula and
Nicholas M. Beckmann contributed case material and their ideas.
The noun “primer” is recognized by many as a small book used to teach children to read
such as the McGuffey Readers, so popular in elementary schools in the latter nineteenth
and early twentieth centuries. McGuffey’s Readers may have been small but they produced
essentially universal literacy among the American populace, no small achievement. Dr.
West and I can only hope that we should be so fortunate as to achieve similar results with
this primer, the elimination of “illiteracy” among those who interpret images of skeletal
trauma and a noticeable improvement and greater confidence in the performance and
interpretation of imaging examinations in skeletal trauma.
Read, mark, and inwardly digest. Dr. West and I are pleased to be of service.
Lee F. Rogers, MD
Tucson, Arizona
June 8, 2014
Contents
CHAPTER 1
Introduction.............................................................................. 001
CHAPTER 2
The Shoulder............................................................................ 005
CHAPTER 3
The Elbow................................................................................ 015
CHAPTER 4
The Wrist.................................................................................. 024
CHAPTER 5
The Hand.................................................................................. 035
CHAPTER 6
The Cervical Spine................................................................... 043
CHAPTER 7
The Thoracolumbar Spine........................................................ 090
CHAPTER 8
The Pelvis................................................................................. 128
With Suresh K. Cheekatla, MD
CHAPTER 9
The Hip..................................................................................... 172
CHAPTER 10
The Knee.................................................................................. 186
CHAPTER 11
The Ankle................................................................................. 199
CHAPTER 12
The Foot................................................................................... 211
ix
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CHAPTER 1
Introduction
The primary objective in interpreting radiographs of skeletal sign of intraarticular fracture or ligamentous injury. This is
trauma is to identify any and all skeletal injuries. However, particularly true of the knee and elbow and, to a lesser extent,
despite the essentially universal availability and liberal use of the ankle and glenohumeral joint. Unfortunately, joint effu-
radiographs, failure to diagnose fractures is a leading source of sions in other joints are difficult to identify on radiographs.
oversights in emergency departments and urgent care centers. Periarticular soft tissue swelling is nonspecific but does direct
Failure to recognize fractures on radiographs accounts for a your attention to the underlying bone, particularly in the
significant percentage of diagnostic errors in these settings. ankles, fingers, and toes, but is more difficult to identify in
The interpretation of images obtained for the assessment the more proximal joints. Conversely, the absence of soft tis-
of skeletal trauma is not intuitively obvious. Not surprisingly, sue swelling reduces, but does not rule out, the possibility of
experts in image interpretation recognize abnormalities more underlying injury.
rapidly and with greater diagnostic accuracy than the novice Fourth, have knowledge of those subtle injuries that have
with less knowledge and experience. An efficient and accurate a tendency to be overlooked or missed. Look deliberately for
approach is required and must be learned through study and evidence of such injuries. A passing glance at such sites is
practice. insufficient. Most often overlooked fractures are fine, incom-
Learn to do what the experts do. The expert search of plete, or nondisplaced fractures at common sites, such as the
images is not random. They know what they are looking for femoral neck, carpal scaphoid, distal radius, or lateral malleo-
and what it should look like and where to find it. They seek lus, that would be readily apparent if more pronounced. Or
out soft tissue signs that are known to point to underlying they are fractures at less common sites of injury, blind spots,
bony injury. They know the common sites of injury and look where the observer simply fails to search and observe, such as
there. Experts are aware of the subtleties, know what they are the bases of the fourth or fifth metacarpals with or without
likely to miss, and are mindful of the need to avoid satisfaction dislocations of the associated carpohamate joints.
of search. Fifth, remain alert to the ever-present danger of satisfac-
What are the characteristics of an efficient and effective tion of search. Certain injuries tend to be associated with a
approach to the interpretation of images of skeletal trauma? second less-obvious injury. Having identified the first, the
First, obtain the proper radiographs. Insist upon proper observer is satisfied and fails to seek the second. For example,
radiographs. Standard views have been established for each fractures of the metatarsals and metacarpals are often mul-
anatomic part to ensure accurate assessment of potential inju- tiple. Once you identify a metacarpal or metatarsal fracture,
ries. High-quality and properly positioned images in these look closely at the adjacent bones for a similar though often
standard projections must be obtained to lessen the chance of less-obvious fracture. After identifying a fracture of the lateral
errors and oversights. One view is no view. Fractures and dis- or medial malleolus, look closely at the opposite malleolus and
locations cannot be excluded on one view alone. A minimum then the posterior malleolus for additional fractures.
of two views is required to safely exclude fractures of the shaft In most cases, as above, the additional fracture is to be
of long bones. A minimum of three views — AP, lateral, and found on the same radiographic examination as the first. No
oblique — is required to safely exclude fractures of the ends additional images are required. However, this is not always the
of bone and dislocations of joints in the peripheral skeleton. case.
Oblique views are essential. If the examination centered on In certain situations a second, additional examination is
joints is limited to just the AP and lateral views, 7% to 9% of required. For instance, in a Maisonneuve fracture, a fracture
fractures may be overlooked. of the ankle is associated with a fracture of the proximal fibula.
Second, be familiar with the sites and appearance of the The presenting injury of the ankle is commonly either a wid-
common fractures and injuries. Look specifically at these ening of the syndesmosis or an isolated fracture of the poste-
sites for evidence of injury. Staring at a radiograph or other rior malleolus, whereas the distal fibula and lateral malleolus
form of image in hopes you will note an abnormality is usu- characteristically remain intact. In this setting, having seen
ally unproductive. In trauma the sites of injury are predictable no fracture of the lateral malleolus or distal fibula, additional
and repetitive. Use what I term a “directed search”; develop a radiographs of the proximal tibia and fibula are required to
pattern of search to look specifically at the common sites of disclose the accompanying fracture of the proximal shaft or
injury. neck of the fibula, the hallmark of a Maisonneuve fracture.
Third, know where to look for soft tissue signs that point Be aware of these associations and, having identified the first,
to underlying bony injury. The presence of joint fluid, a visible obtain the appropriate additional radiographs, and look for
joint effusion, in the setting of trauma is almost always a sure the oft-associated second injury.
1
2 Introduction
5. Where else to look when you see something by the unwary. The indications for the use of CT and MRI are
obvious: In order to prevent errors due to satisfaction presented. In general, if you note a finding on the radiograph
of search, a listing of primary injuries encountered in this but are uncertain if it represents a fracture, computed
anatomic region commonly associated with secondary local or tomography (CT) will clarify this problem by either disclosing
remote injuries is presented. The primary injuries are readily or excluding the possibility of a fracture. On the other hand,
diagnosed, but secondary injuries may not be suspected and if even in the face of a negative radiographic examination the
are easily overlooked. clinical findings are such that the clinician remains seriously
concerned about the possibility of a significant injury, then
5. Where else to look when you see something obvious MRI is warranted in search of a radiographically imperceptible
Obvious Look for fracture or ligamentous injury.
Fx proximal ulna Dislocation proximal radius 6. Where to look when you see nothing at all
(Monteggia) Look for joint effusion – the fat pad sign
Fx shaft of either radius Fx or dislocation of the other If present intraarticular fracture likely
or ulna In adults look at
Fx radial head and neck Fx olecranon Radial head and neck for fine fracture line
Make certain you have external oblique view.
Check tip of coronoid process for small avulsion.
6. Where to look when you see nothing at all: a
In children check anterior humeral line to
listing of those features and sites that should be more closely Identify subtle supracondylar fracture.
examined for evidence of an abnormality. This includes
soft tissue findings that identify a joint effusion and sites of
injuries that often can be subtle or obscure and overlooked
The Primer
The Primer is a short, illustrated text highlighting the specific
imaging features of the common fractures and dislocations
related to the area under consideration. This discussion is aug-
mented with anatomic drawings of the skeletal system as seen
on radiographs (Figures 1-1A and B). They show the sites and
course of the common fractures in red lines: the most common
fractures in thick red lines and the less common in thin red lines.
A series of select high-quality clinical radiographs, CT, and
MRI images illustrates the principal findings described in the
text covering each separate checklist. Fractures of the radial
head (Figure 1-2A) and olecranon (Figure 1-2B) are shown.
Once armed with this disciplined approach, the ability to
interpret images of skeletal trauma is enhanced. One becomes
more comfortable and confident in an ability to assess skeletal
A B trauma. The end result is greater accuracy and a substantial
FIGURE 1-1 A, B, Anatomic drawings of the skeletal system as reduction in the ever-present fear of overlooking and failing
seen on radiographs. to diagnose significant injuries.
A B
FIGURE 1-2 Fractures of the radial head (A) and olecranon (B).
4 Introduction
The Shoulder
5
6 The Shoulder
A B C D
FIGURE 2-1 The standard radiographic examination of the traumatized shoulder. Two AP views should be obtained, one with the humerus in
external rotation (A) and the second with the humerus in internal rotation (B). C, The Grashey or posterior oblique view is a tangential view of
the glenohumeral joint obtained with 35° posterior rotation of the shoulder. D, The axillary view depicts the glenohumeral joint and margins of
the glenoid to good advantage.
A B C
FIGURE 2-4 A, Normal acromioclavicular joint where the inferior cortex of the outer end of the clavicle aligns with the under-surface of the
acromion. B, Acromioclavicular dislocation with slight elevation of the clavicle with intact coracoclavicular ligaments. C, Complete disruption of
the joint with elevation of the outer end of the clavicle and tears of the coracoclavicular ligaments increasing the coracoclavicular distance.
Type I Type II
Type V Type VI
FIGURE 2-5 Rockwood classification of AC joint dislocations. Type I consists of a sprain of the ligaments about the joint. There is no
displacement of the clavicle or widening of the joint. The radiographic findings are normal. Type II is a subluxation of the AC joint. The outer
end of the clavicle is slightly elevated in relation to the acromion, and the AC joint may be widened, but the clavicular ligaments remain intact,
and the coracoclavicular distance is normal. In Type III the coracoclavicular ligaments are disrupted, and the distance between the clavicle and
coracoid is increased, >1.2 cm. The clavicle is elevated. Type IV is a posterior dislocation of the clavicle. The outer end of the clavicle pierces
into or through the trapezius muscle. The clavicle may be elevated or, at times, depressed. Posterior displacement can be seen on the axil-
lary or Y views. In Type V the clavicle is markedly elevated and lies subcutaneously. The clavicle is at least partially detached from its muscle
attachments. Type VI is an inferior dislocation wherein the outer end of the clavicle comes to rest beneath the coracoid process posterior to the
coracobrachialis tendon.
8 The Shoulder
joint. There is no displacement of the clavicle or widening of inferior dislocation of the glenohumeral joint (Figure 2-6B).
the joint. The radiographic findings are normal. Type II is a The displacement is due to a large volume hemarthrosis that
subluxation of the AC joint. The outer end of the clavicle is commonly accompanies these fractures and is not considered
slightly elevated in relation to the acromion, and the AC joint to be a true dislocation. It is therefore referred to as a “pseu-
may be widened, but the clavicular ligaments remain intact, dodislocation.” As the hemarthrosis resorbs, the normal rela-
and the coracoclavicular distance is normal. In Type III the tionship of the humeral head and glenoid is restored.
coracoclavicular ligaments are disrupted, and the distance
between the clavicle and coracoid is increased >1.2 cm. The Scapular fractures. The body of the scapula is rarely injured
clavicle is elevated. Type IV is a posterior dislocation of the in simple falls; most occur in motor vehicle collisions.
clavicle. The outer end of the clavicle pierces into or through Fractures can be identified on radiographs of the chest (Figure
the trapezius muscle. The clavicle may be elevated or, at times, 2-7A) but are much more clearly depicted by CT, particularly
depressed. Posterior displacement can be seen on the axillary CT of the chest (Figures 2-7B and C), which is nearly always
or Y views. In Type V the clavicle is markedly elevated and obtained in those who have sustained high impact trauma.
lies subcutaneously. The clavicle is at least partially detached The full extent of scapular fractures is best disclosed by CT
from its muscle attachments. Type VI is an inferior dislocation with 3-D reconstruction (Figures 2-7C and 2-8C).
wherein the outer end of the clavicle comes to rest beneath Scapular fractures involving the glenoid, acromion, and
the coracoid process posterior to the coracobrachialis tendon. coracoid process also occur in association with glenohumeral
and/or acromioclavicular dislocations (Figure 2-8). Fractures
Proximal humerus fractures. Avulsions of the greater of the acromion, coracoid process, and superior border of
tuberosity occur either in isolation or in association with scapula associated with a posterior dislocation of the gleno-
fractures of the surgical neck of the humerus (Figure 2-6A). humeral joint are shown in Case 1 (Figure 2-8A). Note the
Fractures of the surgical neck are particularly common in the humeral head is in internal rotation, and the distance between
elderly with or without (Figure 2-6B) associated avulsions of it and the anterior rim of the glenoid is widened indicating a
the greater tuberosity. posterior dislocation of the glenohumeral joint (Figure 2-8A).
With fractures of the humeral head and/or neck, the humeral In Case 2 (Figures 2-8B and C) an acromioclavicular disloca-
head may be displaced inferiorly giving the appearance of an tion and fracture of the superior border of the scapula and
coracoid are shown. Note AC dislocation and associated frac-
ture of acromion. The scapular fracture is barely visible on this
AP view of the shoulder (Figure 2-8B). However, this fracture
of the superior border of the scapula is nicely shown by CT
3-D reconstruction (Figure 2-8C).
Fractures of the glenoid rim are created by an impact of
the humeral head against the anterior inferior margin of the
glenoid during a transient or complete anterior dislocation
of the glenohumeral joint. The fracture fragment is displaced
inferior and medial. The fracture is usually better seen on the
post-reduction radiographs. Look closely at the anterior rim
of the glenoid on the AP projections (Figure 2-9A). Is the
ovoid rim density intact? Anterior glenoid rim fractures are
best seen on the Grashey projection (Figure 2-9B) or axillary
view. Obtain these views if you have not already done so. If
A B questionable, quit fooling around; get a CT.
Fracture of the anterior inferior glenoid rim associated
FIGURE 2-6 Proximal humerus fractures. A, Avulsions of the with an anterior dislocation of the glenohumeral joint is
greater tuberosity occur either in isolation or in association with frac-
tures of the surgical neck of the humerus. B, Fractures of the surgical shown in Figures 2-9C and D. The initial AP view clearly dem-
neck are particularly common in the elderly with or without associ- onstrates the subcoracoid anterior dislocation (Figure 2-9C).
ated avulsions of the greater tuberosity. Note: underlying the humeral head is a small bony fragment
A B C
FIGURE 2-7 Scapular fractures. A, Radiograph of the chest. B, (Axial) C, (3D reformat) CTs of the chest.
The Shoulder 9
adjacent to the glenoid at the 7 o’clock position. This is an head is displaced anterior, medial, and inferior, coming to rest
avulsion fracture of the glenoid rim. There is also a small bony beneath either the coracoid process (subcoracoid) (Figure
fragment just interior to the medial margin of the coracoid on 2-10A) or glenoid process (subglenoid) (Figure 2-10B).
this view. Note that this small glenoid rim fracture is better Subcoracoid is by far the most common. Fractures of the
seen on the postreduction AP view (Figure 2-9D). anterior inferior rim of the glenoid are frequent and often best
seen on the postreduction views (see Figure 2-9).
Glenohumeral dislocations. Dislocations are more common A characteristic impaction fracture of the humeral head
in the shoulder than at other major joints. Anterior dislocations may occur during an anterior dislocation as the humeral head
account for 95% of all glenohumeral dislocations. The humeral becomes impaled on the anterior inferior margin of the glenoid
A B C
FIGURE 2-8 A, B, C, Scapular fractures involving the glenoid, acromion, and coracoid process also occur in association with glenohumeral
and/or acromioclavicular dislocations.
A B C D
FIGURE 2-9 A, An anterior glenoid rim fracture on AP projection. B, Anterior glenoid rim fractures are best seen on the Grashey projection or
axillary view. C, D, Fracture of the anterior inferior glenoid rim associated with an anterior dislocation of the glenohumeral joint.
A B
FIGURE 2-10 Glenohumeral dislocations are more common in the shoulder than at other major joints. Anterior dislocations account for 95%
of all glenohumeral dislocations. The humeral head is displaced anterior, medial, and inferior, coming to rest beneath either the coracoid pro-
cess (subcoracoid) (A) or glenoid process (subglenoid) (B).
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
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.