Obstetrics & Gynecology (Diagnostic

Medical Sonography Series) Fourth

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T he restructured fourth edition of Diagnostic Medical So-
nography: Obstetrics and GynecolDgy follows input from
instructors who use the textbook. Separation of chapters in
the Obstetrics section to follow fetal systems offers continu-
ity by presenting embryonic development and normal and
abnormal anatomy divided by system. This edition continues
to give information recognizing the diverse backgrounds and
experiences of readers. This textbook continues to be useful as
an introduction to the profession or as a continuing reference.
The content lays the foundation for a better understanding
of anatomy, physiology, pathophysiology, and complemen-
tary imaging for the sonographer practitioner, sonographer,
sonologist. or student when caring for the patient.
The textbook has two major sections, with the first being
gynecology and the second obstetrics. The first chapters in
each section, "Principles of Scanning Technique in Gyne-
cologic lfltrasound" and "Principles of Scanning Technique
in Obstetric lfltrasound," have information on patient care
and the process of beginning the gynecologic or obstetric
exam. The first chapter describes picture archiving and com-
munication systems (PACSs) and interconnected computer
systems within a clinic or hospital that have revolutionized
our profession and daily workflows. Both introductory chap-
ters offer methods to care for the patient while performing
the ultrasound exam.
PREFACE
Throughout the chapters, we have tried to incorporate
instrumentation and complementary imaging modalities
when appropriate. This allows for integration of sonographic
physics as well as other imaging modality findings that
sonographers often encounter.
We made every attempt to produce an up-to-date and
factual textbook, at the same time presenting the material in
an interesting 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 sonographic representation of these anatomic
and pathologic entities. illustrations, summary tables, and
images include valuable case study information.
Our goal is to present as complete a text as possible,
recognizing that current journal readings must supple-
ment the content. With every technologic advance made
in equipment, the sonographer's imagination must stretch
to use new applications. With the comprehensive founda-
tion available in this text, the sonographer can meet that
challenge.
Susan R. Stephenson, MS. MAEcL ROMS, RVT, CliP
Julia Dmitrieva. DBA, ROMS (OB)(AB) (BR).
RDCS,RVf
vii
CONTRIBUTORS

Karen Ambrowitz, RDCS Arri Hall-Terracciano

Technical Director Dixie Regional Medical Center
Pediatric Echocardiography Laboratory St. George, Utah
UCLA Mattel Children's Hospital
Los Angeles, California Faith Hutson, BAS, RT, RDMS
OMS Clinical Coordinator
Lisa Allen, BS, RDMS, RDCS, RVT, FAIUM Diagnostic Medial Sonography
Ultrasound Coordinator Dona Ana Community College
The Regional Perinatal Center Las Cruces, New Mexico
State University of New York
Upstate Medical University Catheeja Ismail, RDMS, EdD
Syracuse, New York Staff Sonographer
Assistant Professor of Radiology,
Liana Amarillas, BS, RDMS (ABD)(OB), RVT, RDCS The George Washington Uni ,ersity Hospital
Diagnostic Medical Sonographer Washington, District of ('.; lum6ia
Divisions of Ultrasound and Prenatal Diagnosis
University of Colorado Hospital Sanja Ku
Aurora, Colorado Clinical 1cs & Gynecology
and
Amanda Auckland, RDMS, RDCS, RVT
Depar al Education
Sonographer Pa 1 L ol of Medicine
Department of Ultrasound
University of Colorado Hospital
Aurora, Colorado
Bridgette Lunsford, MAEd, RDMS, RVT
Clinical Applications Specialist
Sue Benzonelli-Blanchard, BS, RDMS, RDCS
GE Healthcare - Ultrasound
Ultrasound Consultant
Arlington, Virginia
Issaquah, WA
Darla Mathew, BAS, RT, RDMS
Danielle M. Bolger, RT, RDMS, RVT, RDC
Department of Ultrasound OMS Program Director
University of Colorado Hospital Diagnostic Medical Sonography
Aurora, Colorado Dona Ana Community College
Las Cruces, New Mexico
Molina Dayal, MD, MPH, FACOG
Medical Director Amber Matuzal<, BS, RDMS, RVT, RDCS
Sher Institute of Reproductive Medicine Division of Ultrasound
St. Louis, Missouri University of Colorado Hospital
Diagnostic Medical Sonographer
Greggory DeVore, MD Aurora, Colorado
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology Kassandra Quigley, BS, RDMS, RVT, RDCS
David Geffen School of Medicine at UCLA Lead Sonographer
Los Angeles, California University of Colorado Hospital
Fetal Diagnostic Centers Aurora, Colorado
Pasadena, Tarzana, and Lancaster, California
Cindy Rapp, BS, RDMS, FAIUM, FSDMS
Julia Dmitrieva, DBA, RDMS (OB)(AB)(BR), RDCS, RVT Senior Clinical Marketing Manager
Philips Healthcare Toshiba America Medical Systems
Bothell, Washington Tustin, California

viii
 REVl E'VVERS ix

Gary Satou, MD, FASE, FAHA Cheryl Vance, MA, RDMS, RVT, RT
Director Women's Health & Specialty Education
Pediatric Echocardiography Program Manager
Co-Director GE Healthcare- Ultrasound
Fetal Cardiology Program San Antonio, Texas
UCLA Mattei Children's Hospital
Ronald Reagan Medical Center & UCLA Health Michelle Wilson, MS, RDMS
Clinical Professor Kaiser Permanente Medical Center at Vallejo
David Geffen School of Medicine UCLA Sonography Sessions IJ.C
Los Angeles, California Napa, California

Tammy Steams, MSAS, BSRT, RDMS, RVT Paula Woletz, MPH, RDMS, RDCS
CoxHealth School of Diagnostic Medical Sonography Clinical Coordinator
Springfield, Missouri Howard Community College
Columbia, Maryland
Susan R. Stephenson, MS. MAEd, RDMS. RVT, CliP
Siemens Medical Solutions USA, Inc.
Salt Lake City, Utah

REVIEWERS

Michelle Cordio Tiffany Johnson

University of Wisconsin Hospital and Clinics School of Saint Luke's School of Diagnostic Medical Sonography
Diagnostic Medical Sonography Kansas City, Missouri
Madison, Wisconsin
Tanya Nolan
Beth Edson Weber State University
Community College of Allegheny County Ogden, Utah
Monroeville, Pennsylvania
Latha Parameswaran
'Thcl Fox JFK Muhlenberg Harold B. & Dorothy A. Snyder Schools
Thomas Jefferson University Plainfield, New Jersey
Philadelphia, Pennsylvania
Cherie Pohlmann
Kathryn Gill University of South Alabama
Institute of mtrasound Diagnostics Mobile, Alabama
Mobile, Alabama
USING THIS SERIES

he books in the Diagnostic Medical Sorwgraphy series help you develop an under-
will
T standing of specialty sonography topics. Key
textbook
resources and tools throughout the
learning
to increase your understanding of the topics provided and better prepare you for
aim
your professional career. This User•s Guide will help you
familiarize yourself with these exciting features designed
to enhance your learning experience.

Chapter Objectives Embryonic Development

Measurable objectives listed at the beginning of each o f the Female Genital System
chapter help you understand the intended outcomes for
the chapter, as well as recognize and study important
concepts within each chapter.
OBJECTIVS I<£Y Tl!t>1S
• o-o.....,. _..........
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Key terms are listed at the beginning of each chapter • f .......... QCirl~:l~~-~·.4'ft"'liD'"w.
~Ntr.acw"'"'atlh
and are clearly defined. then highlighted in bold type

- .
GLOSSAAY ~d«n

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throughout the chapter to help you to learn and recall ...._oh Sid4• ~d.-....,... t1lf IK»bor ew-t!ocn..O*""'**.... lN
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important terminology. l.tt,.., ll&.,..n&. f...UOI.-rfluoev\11'111! \Qif..,.,._..,...,.,ll'e~

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Each chapter includes tables of relevant pathologies. ""'~ ... 10~

which you can use as a quick reference for reviewing ~k \.11 wc:o1«21c:r!•· t1r"""YtU»~~
~-- lMJ., ~ ~l"ftb"'....o.&..,...4#tock.a1~

the material. ~cfium C. """t'''OCilll'W'm"h~lt'CfN~

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•4 PATHOLOGY BOX 12 · 1 III U·

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Perineal
Pain EPS
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Chronic Bacterial tl- + +
Chronic Pelvic Pain
lnnommotory tl- + 0
Non-lnnammatory tl- 0 0
Asymptomatic 0 + 0
lnil:unmatory

Critical Thinking Questions CRITICAL THINK I NG QUEST ION

Throughout the chapter are critical thinking ques-
tions to test your knowledge and help you develop
analytic skills that you will need in your profession.
I. A 25-year-old pat i~nt presems to her clinician with
the inabil ity to become pregnant aft(')' a yea.r of try-
ing. The initia I sonogram revealed what appears to be
a bicornua te uterus. Explain the development or this
malromlation and how this discovery would change
your imaging procedure.

Resources Poinf
You will also find additional resources and exercises on thePoint, including a glossary with pro-
nunciations. 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

PART ONE GYNECOLOGIC SONOGRAPHY

Principles of Scanning Technique in Gynecologic Ultrasound
SUS!\N R. STEPHENSON

2 Embryonic Development of the Female Genital System 15

SUS!\N R. STEPHENSON

l Congenital Anomalies of the Female Genital System 25

FAITH HUTSON

4 The Female Cycle 45

SUE BENZONEW-BL.ANCHARD

5 Normal Anatomy of the Female Pelvis 75

SANJA KUPESIC

6 Doppler Evaluation of the Pelvis 127

MICHELL£ Vv1l.SON

7 Pediatric Pelvis 145

SUS!\N R. STEPHENSON

8 Benign Disease of the Female Pelvis 161

SUSAN R. STEPHENSON

9 Malignant Disease of the Uterus and Cervix 197

FAITH HUTSON

10 Malignant Diseases of the Ovary 221

DANIElli M. BOLGER

II Pelvic Inflammatory Disease and Endometriosis 241

SUSAN R. STEPHENSON

12 Assisted Reproductive Technologies, Contraception, and Elective Abortion 261

CATHEEJA ISMAIL I MOLINA DAYAL

I] Complementary Imaging of the Female Reproductive System 295

ARRJ HALL-TERRACCIANO

PARTlWO OBSTETRIC SONOGRAPHY

14 Principles of Scanning Technique in Obstetric Ultrasound 323
SUSAN R. STEPHENSON

IS The Use of Ultrasound in the First Trimester 333

PAULA WOLETZ

16 Sonographic Evaluation of First-Trimester Complications 353

PAULA WOLETZ

xi
xii CONTENTS

17 Sonographic Assessment of the Ectopic Pregnancy 371

AMANDA AUCKLAND

18 Assessment of Fetal Age and Size in the Second and Third Trimester 391
SUSAN R. STEPHENSON

19 Normal Placenta and Umbilical Cord 421

JULIA DMITRI EVA

20 Abnormalities of the Placenta and Umbilical Cord 431

LISA ALLEN

21 Sonographic Assessment of the Fetal Head 467

JULIA DMITRI EVA

22 Sonographic Assessment of the Fetal Neck and Spine 495

JULIA DMITRI EVA

23 Fetal Echocardiography 509

GARY SATOU I GREGGORY DEVORE I KI\REN AMBROWI1Z

24 Sonographic Assessment of the Fetal Chest 541

CHERYL VANCE

25 Sonographic Assessment of the Fetal Abdomen (Includes Abdominal Wall) 575

CHERYL VANCE

26 Sonographic Assessment of the Fetal Genitourinary System and Fetal Pelvis 607
LIANAAMARILLAS

27 Normal and Abnormal Fetal Limbs 639

JULIA DMITRI EVA

28 The Biophysical Profile 659

SUSAN R. STEPHENSON

29 Multiple Gestations 673

AMBER MATUZAK

30 Intrauterine Growth Restriction 699

KASSANDRA QUIGLEY

3I Patterns of Fetal Anomalies 719

CINDY RAPP I DARLA MATHEW

32 Effects of Maternal Disease on Pregnancy 749

TAMMY STEARNS

33 The Postpartum Uterus 773

JULIA DMITRI EVA

34 lnterventional Ultrasound 779

SANJA KUPESIC

35 3D and 4D Imaging in Obstetrics and Gynecology 805

BRIDGETTE LUNSFORD

Index 837
 GYNECOLOGIC SONOGRAPHY
-
....
_:~,
I
... • I

Principles of Scanning Technique

in Gynecologic Ultrasound

SUSAN R. STEPHENSON

OBJECTIVES KEY TERMS

■ Describe preparation of the patient for a gynecologic sonogram patient preparation

■ Identify the appropriate transducer for an examination transabdominal
■ List the certification options available to a practicing sonographer endovaginal
■ Explain the need for laboratory accreditation ALARA
certification
GLOSSARY registry

Adnexa Area around an organ

Ascites Fluid within the abdominal or pelvic cavity
Bioeffects Biophysical results of the interaction of souod
Electronic medical record (EMR) Electronic database <mntaining all the patient
information
Endocavity Inside a cavity such as the abdome~ fDelvis
Fundus Top portion of the uterus
Hospital information system Paper-based or computerized system designed to
manage hospital data, such as billing and Ratient records
Lithotomy position Positio of the patient with the feet in stirrups often used during
delivery
Modality worklist (MWL) Electronic list of patients entered into a modality, such as
ultrasound, which helps reduce data entry errors
Nongravid Nonpregnant
Perivascular Around the vessels
Picture archiving and communication system (PACS) Database that stores ra-
diologic images
Radiology information system (RIS) Physical or electronic system designed to man-
age radiology data, such as billing, reports, and images
Scanning protocol List of images required for a complete examination
Transabdominal Imaging through the abdomen
Transducer footprint Area of the transducer that comes in contact with the patient
and emits ultrasound
Transvaginal/endovaginal Within the vagina
2 PART ONE GYNECOLOGIC SONOGAAPHY
T he goal of any sonographic examination is to produce
a diagnostic study using proper technique and patient
preparation. Optimization of the examination reduces costs,
adheres to the ALARA1 principle, and decreases patient dis-
comfort. A protocol-driven approach helps ensure complete
imaging of the pelvic organs and pathology. This systematic
imaging includes two-dimensional {2D) real-time, spectral,
color or power Doppler, and increasingly, three-dimensional
{3D) and four-dimensional (4D) imaging.
Many manufactures provide automated image adjustment
of technical factors such as overall gain, persistence, and
output power. Obtaining the required images for a study
requires not only lcnowledge of the physics of ultrasound
but also a thorough knowledge of normal and abnormal
anatomy, and the imaged disease processes.
In this chapter, you will find descriptions of basic tech-
niques and protocols for scanning in gynecology along with
emerging imaging technologies. Subsequent chapters detail
protocols specific to the topics discussed.
PATIENT PREPARATION
Getting Set Up
The first step in a patient's journey through her ultra-
sound exam is entering her data into the hospital informa-
tion system. A patient number assignment identifies the
patient's electronic medical record (EMR), which contains
all laboratory, pathology, and imaging studies. Each visit
generates a separate number to help identify procedures.
Upon entry into the radiology information system (RIS), the
sonographer is able to search the modality worklist (MWL),
and the patient study information automatically populates
on the ultrasound machine. Although this sounds quite
TABLE 1-1 Patient Identifier~
• Ask patient his or her name
• Have the patient slate his or her date d birth (DOB)
• b<amtype
• Ordering dinician
• Armband
To ensure the proper patient, use two different identifiers.ll
complicated, the connected hospital makes our lives much
easier through the elimination of errors and the use of film.1
The sonographer should introduce himself or herself
when meeting the patient. 1b confirm the patient's identi-
fication, use two identifiers such as the name and the date
of birth. Some facilities attach an armband to the patient
for identification purposes. At this time,. confirm the correct
order and her perception of the upcoming examination with
the patient (Table 1-1). Upon completion of patient identity
and exam confirmation. explain the procedure, the lengtb.
of the examination, what she may expect to feel, and the
movement and placement of the transducer.
All pertinent clinical information should be included on
the ultrasound report. This includes patient age, date of the
last menstrual period (LMP; also, whether it is normal},
gravidity, parity, symptoms such as pain or bleeding, his-
tory of pelvic procedures, and any other pertinent medical
or surgical history. The patient can provide their history
if it is not on the examination request. Many systems pro-
vide an introductory screen to enter patient information,
which then transfers to the electronic report (Fig. 1-1). It
is desirable to obtain this information before beginning the
ex.amination to minimize the chance that the patient will
FIGURE 1·1 The patient dam entry
(PDE) screen a! laws entry of the acces-
sion number or the patient visit number;
LMP. and patient pregnancy informaiion.
Ifyou work in a facility that does not
have a connected INOrkftow, the patient
infonnation may be manually entefed on
1hissaeen.
 I PRINCIPLES OF SCANNING TECHNIQUE IN GYNECOLOGIC ULTRASOUND
conclude the questions relate to something the sonographer
sees on the screen.
Knowing the patient's reproductive history gives the
sonographer information with which to design and in-
terpret the sonographic examination. For example, if the
patient has a large uterus, it may be due to the number of
pregnancies rather than a pathologic condition. Although
variations of the obstetric coding system may be used, the
following is the most common: Gravidity (G) refers to the
number of previous pregnancies and includes the CUITe.nt
gestation. A pregnant woman who had a nonviable ectopic
pregnancy and later gave birth to twins would be G3. Use
the nomenclature G4 if the patient is cummtly nongravid
but has had four previous pregnancies. Parity (P) refers to
the number of pregnancies the patient has canied to term;
thus, record an ectopic pregnancy as PO and a twin gesta-
tion would be Pl. The numbers used after Prefer, in order,
to the number of term pregnancies, abortions (spontane-
ous or induced}, and living children. Thus, the currently
pregnant patient would be classified as a G3P1Al T2, which
would mean the woman has had three pregnancies, one
full-term pregnancy, one abortion (the ectopic pregnancy
in this case), and two full-term births {in this case, a set of
twins).~ If the patient is not CUITently pregnant, she would
be a G2PlA1T2 (Table 1-2).
After obtaining all pertinent clinical infoimation, as-
sist the patient onto the examination table, making her as
comfortable as possible. A pillow or two under the patient's
knees relieves back strain. For a transabdominal examina-
tion, apply gel liberally to the lower abdomen to provide
an effective medium for sound transmission. Tb minimize
patient discomfort, warm the gel to body temperature. Most
laboratories have commercial gel warmers; however, plac-
ing a bottle of gel in a sink filled with warm water serves
the same purpose. Do not use a microwave, because the
gel heats unevenly and may explode. If an endovaginal
examination is to be performed, give the patient privacy
while she undresses from the waist down and drapes herself
with a sheet.
Every laboratory should develop scanning protocols for
each type of examination and include these in a printed
reference manual. Suggested protocols have been devel-
oped for gynecologic scanning by the American Institute
of Ultrasound in Medicine (AlUM; Displays 1-1 and 1-2).5.6
The Society of Diagnostic Medical Sonography (SDMS)
Guidelines for Obstetrics and Gynecology Review include
a section on scanning techniques,7 as do the American
College of Radiology (ACR) guidelines. A sonographer
developing his or her own protocols should keep in mind
TABLE 1-2 Gravida/Parity Definitions
'RIIrm/Abbrevladon Delnldon
Gravida(G) Number of pregnancies
Para(P) Number of pregnancies over 36 wk
{tenn)
Abortion {A) Number of failed pregnancies
Term(T) Number of live births
3
DISPLAY 1-1
Guidelines for dte Performance of the
Antepartum Obstetric: Ultrasound Examination
Guidelines for Ffrst-1Hmester Sonography
lnclicaliom: Confinn intrauterine pregnanc:r, evaluate for
suspec:ted ec:topie pregnancy; determine the cause of VICinal
bleeding or pelvic pain; estimate gestational ace: diagnose or
evaluate multiple precnancles; confirm viability, adJunct to
chorionic villus sampling. embryo transfer. and localization
and removal of an intrauterine device (IUD); assess for fetal
anomalies such as anencephaly; evaluate maternal uterine
anomalies and/or pelvic masses; measure the nuchal translu-
cency (NT); and eYaluate for suspected hydatidiform mole.
ONrGII Comment. Scanning In tt.e first 1rlmester may be
perfonnecl abdominally, wefnally. or using both mett.ods. If
an abdominal eumlnatlon falls to proYicle dllcnostlc Infor-
mation, perfonn a vacinal or transperitoneal examination.
Similarty, if a vacinal scan fails to imap all areas needed for
diagnosis, an abdominal scan should be performed.
I. Evaluate the uterus and adnexa for the presence of age.
tadonal sac. DoaJment any visualized gestational sacs and
determine the location. Note the presence or ablence of
an embryo and record the c~rump length (CRL).
Comment. (I) CRL Is a more accurate Indicator of pat.
tional ap ttlan gestmional sac diameter. If ttle embryo is not
identified, evaluate the gestational sac for die presence of a
yolk sac. The estimate of...-ionaJ ap would be based on
either 1he mean diameter of tt.e gestational sac or the m~
phology and contents of tt.e pltatlonaf sac. (2) ldendflcatlon
of a yolk sac or an embryo Is deftnltiYa evidence of a gest.
tional sac. Uae caution in making a definitive dia&nOiis of ages-
tational sac: prior to ttle development of dlese struc.bJres. The
lack of a yolk sac and embryo rUles . .picion of an i~
lne luld collection, which often CIOeDdsts wid! die pleUCiogesca-
tlonal sac: associated with an ectopic prepancy. (3) During tt.e
late first 1rlmester. biparietal diameter (BPD) and odler fetal
measurements also may be used to establish fetal age.
l. Record the presenee or absence of cardiac activity with
M~ode or Cineloop.
Comment. (I) Real-time obserwtion is critical for this
diagnosis. (2) With vaainal scans, an embryo with a CRL of 5
mm or greater should demonstrate cardiac motion. If an e~
bryo less than 5 mm In length Is seen wiCh no cardiac activity.
a follow~p scan may be needed to ewluate for fetal life.
3. Document fetal number.
Comment. Report multiple pregnancies only when Imag-
Ing multiple embryos. Incomplete amnion and chorion fusion,
or elevation of die chorionic membrane by intrauterine hem·
orrhiF, often mimics a second sac in the first trimester; lead-
ing to an incorrect diagnosis of a multiple pregnancy.
4. Evaluate the uterus, adnexal structures, and cul-de-sac.
Comment. (I) This allows recognition of incidenbll fi~
ings of potential dinical significance. Record die presence,
location, and size of myomas and adnexal masses. Scan the
cul~e-ac for presence or absence of luld. If tt.ere lsluld
In the a~l~sac. Image the flanks and subhepatic space for
inn1bclominal fluid. (l) Correlate serum honnonal levels
with ultrasound findings to help in differentiation of a normal,
abnormal, or ectopic preJnancy.
S. Evaluate the nuchal region In the presence of a llwl fetus.
Comment. (I) The NT measurement Is a very specific
measurement obtained at laboratory-determined lnterYafs.
(2) U1a1he NT measurement In conJunction wiCh 1en.1m
(continued)
 PART ONE GYNECOLOGIC SONOGAAPHY
biochemilb'y to determine the patient risk for trisomy 13 or
18, or other defects such as heart or spine malformations. (3)
NT certification ensures consistent quality and examlnadon
performance between sonographers.
Guidelin111 for Secencl- and Third-Trimester Son0Jlf'8Phr
lncliccrlions: Ewluation of gestadonal age and felaJ growth;
determlnadon of ttte cause of vaginal bleeding. pelvic pain, or
cei'Yicallnsufllclency; determination of fetal presentation; di-
agnosis or eYaluatlon of multiple pregnancies; conlrmatlon of
viability, adjunct to amnioc:~entesis; determination of cause of
uterine size and clinical date discrepandes; assessment for f.
tal anomalies; evaluation of maternal uterine anomalies, pelvic
muses, or suspected ectopic pregnancy; evaluation of fetal
wel~belng; determination of amniotic fluid le~~els, suspected
placental abruptlon, placement of cervical cerclage, adJunct to
extemal eephalic version, premature rupture of membranes,
abnormal biochemical markers; follow~p to a fetal anomaly
and plaeentallocation, history of a conpnital anomaly: evalu-
ation of fetal condition in patients witt! late prenatal care; •
sessment of flndlnp 1hat lncreue the risk of aneuploidy: and
evaluation for IUSpected hydatldform mole.
1. Document fetal life, number, presentation, and activity.
C........c. (I) Report an abnormal heart rate ancllor
rhythm. (2) Multiple pregnancies require the documentation of
additional information: number of pstltional sacs, number of
placlentls, presence or absence of a dividiriJ membrane, fetal
genitalia (If' visible), comparison of fetal sizles, and comparison
of armlodc: luld volume (AFV) on each side of the membrane.
2. Report an estimalle ofNV (Increased, decreased, normal).
Comment. When determining ttte appropriateness of
AFV. consider the physiologic variation 1hat occurs with each
stage of pregnancy.
3. Record the placental location and appearance, as well as
Its relationship to d'telnternal cei'Yical os. Document the
umbilical cord insertion sites into both the plaeenta and
fetus. Include a CTOSS-SeC:don of the free-floadr~~ cord for
three-vessel confirmadon as well as color Doppler images
of ttte umbilical vessels coursing lateral to the fetal bladder.
COII'NIIeflt. (I) It Is recognized that apparent placental
poeltlon early In pregnancy may not corTelate well with Its
location at the time of deiiYery. (2) An overdlstendecl mater-
nal urinary bladder or a lower uterine contraction can give ttte
examiner a false impression of plac.enta previa. (3) Abdominal,
transperineal, or wginal views may be helpful in visualizing ttte
lntemal cervical os and Its relationship to ttte placenta.
4. Obtain fetal measurements to assess gescatlonal ace using
a combination of cranial measurement such as ttte BPD or
head circumference (HC), and limb measurement such as
the femur~ (FL).
CommeM. (I) Third-trimester measurements may not
accundely reflect pstational IF because of morpholo&ic dif-
ferences in individuals (I.e., short, tall). Base d'te cum!nt exam
dates on the earliest examination because ttte CRL. BPD,
HC, and FL have a greater accuracy earlier In ttte pregnancy.
To determine the current fetal age, use an 08 wheel, enter
data Into the equipment, or .,.. the following calculation:
CRL. BPO, HC, and/or the Fl by the equation: current fetal
aae = estimated aae at time of initial study+ number of
weeks elapsed since first study.
4A The standard raferenCle level for measurement of ttte
BPD Is an axlallmaee that Includes the thalamus.
Comment. If the fetal head Is dolichocephalic or brachy-
cephalic, the BPD measurement may be mllleadlrw. Occa-
sionally. computation of the cephalic Index, a ratio of the BPD
AmeriCAil lnstihrte of Ultrasound in Medicine. GuideJines for A!r(Ormance ofthe
to the fronto-occipitll diameter, is needed to make tttis de-
terminadon. In suet. situadons, other measurements of head
size, such as ttte HC, may be necessary.
48. Measure the HC at ttte same level as the PBD, around
the outer perimeter of ttte calwrlum at ttte le~~el of ttte
thalamus.
4C. Routinely measure and record ttte Fl afterttte l~h
week of gestation.
Commenc. Aa with head measurements, there is consid-
enlble biolo&ic varidion in normal Fls late in pregnancy.
5. Obtain a fetal Wl!ight estimate in the late second and in d'te
d'tird trimesters. This measurement requires an abdominal
diameter or clrc.umference.
Commen&. (I) Check appropriateness of growth from
previous studies at least 2 to 4 weelca previous. (2) Fetal
weight estimations may be as much as ± 15% from actual
delivery wei&fa. This may be due to the patient population,
sonographer measuring techniques, and technical factors.
SA. Measure the abdominal circumference (AC) on a true
transw:rw view, prefenbly at d'te level of the junction of
the left and right portal veins and fetal stomach.
Commenc. AnN:. mea~~.~rement helps estimalle fetal weight
and may allow derac1ion ofgrowd'l recardadon and maci"'OIO''''Ia.
58. Estimate Interval growth from previous fetal blomecrlc
studies.
6. Ewluate the uterus (Including the cervix) and adneocal
structures.
Commen&. This allows recognition of Incidental ftndlnp
of potential clinical sJ&nlflcance. Record ttte presence, loca-
tion, and size of myomas and adnexal masses. It is frequently
not possible to irn~~p d'te maternal ovaries durirw the second
and d'tird trimesters. VIcinal or transperineal scanning may be
helpful In evaluating ttte cervix when the fetal head prevents
visualization of the cervix from transabdominal scanning.
7. The study should Include, but not necessarily be limited
to, assessment of the following fetal anatomy: eerebral
w:ntricles, posterior fossa (lnduding cerebellar hemi-
spheres and cistema magna), choroid plexus, latenll
cerebral ventricles, midline falx, c:awm sepd pellucldl,
upper lip, views of ttte heart to Include ttte four chambers
(Including Its position within the thorax), left ventricular
outflow and right ventricular outflow along with aortic
arch and ductal arch images, spine, stomach, kidneys. uri-
nary bladder, color Doppler or power Doppler imaaes of
ttte umbilical vessels latenll to ttte bladder, fetal umbilical
cord Insertion site, and Intactness of ttte anterior abdomi-
nal wall and placenta. Also Include lmaaes of the limbs,
along with ttte presence or absence of ttte long bone and
the fetal sex determination. Although not considered part
of the minimum required examination, when fetal position
permits, it is desirable to examine all areas of the anatomy.
Commen&. (I) It is rtiClO&nized that not all malformations
of ttte previously mentioned orpn systems can be detected
Ullng ultrasonography. (l) Consider tttese racommendadons as
a minimum guideline for ttte fetal anatomic surwy. Occaslo~
ally, some of these structures may not be well vlsulllzed, as
OCICUrs when fetal position, low amniotic volume, or maternal
body habitus limit d'te sonographic examination. When this oc-
curs, ttte report of the ultrasound examination should indude
a notation dellneadng scructures tttac were not well seen. (3)
Suspected abnormalities may require a tarpted evaluation of
ttte area(s) of concern. (4) In ttte patient with an Increased risk
of aneuploidy. perform a nuchal fold measurement.
Artr.epartum Obstetrical Ultrasoond Examination. Laurel: AlUM; 2007.
 I PRINCIPLES OF SCANNING TECHNIQUE IN GYNECOLOGIC ULTRASOUND
DISPLAY 1-2
Guidelines for Performance of the Ultrasound
Examination of the Female Pelvis
ln6:atloftl: Pain; P*tful ~ (dysme!IDI'rilea); lack of
~ (arnenont-); t!Xcessivoe menstrual bleeclng (menor-
rN&fa); ...,...... uterine bleed!,. (rnecrorrhlgta); ~
lrre&Uiar bleedfrw (menometront.gla); follow~ of pnwl-
ous cletKt:ed enormlltty; IMiuldon, II'IOrl>'toriFW. ancl/or
treatment of Infertility peientl; delayed menses, precocious
puberty, or vaclnal bleedil"ll in a prepubertal child; post-
menopausal bleedinz abnormal or b!chnically limited manual
examination: s1Jns and symptoms of a peMc Infection; funtler
lrnagl!lr of an anomaly found during another Imaging study;
corwenltal anon'181y evaluation; excesslw bleeding; pain or
s p of Infection abr pelvis surgery, deliwry or abortion;
localimion of an IUD, mllliJnancy screening for hiJh-risk
patienm; urinary Incontinence or pelvic orpn prolaple; and
guidance for lntwvendonal or surgical proc:edures.
The followi"lauklelines de~eribe examination perfor-
mance for ..ch organ and anatomic region In the female
peiYia• .All Nlevant atructuru should be Identified by die
.txlomlrwl andlorwclnal8pproach.lf an abdominal examina-
tion is performed lnd f•ls to provide the necessary diagnostic
information, a VICinal .Kan snould be done when possible.
Similrly, if a vaclnlll ~an is performed and fails to image all
area needed for dlaenosls, an abdominal tcan should be per-
formed. In tome cuea, both an abdomnal and a vaginal IlCari
n-ay be needed.
Genen!Nwlc Prep.radan
For a pelvic ~., performed throuch the abclornilllll
wal, the l*lenC'• urlrwy bladder lhould, In ..,..a!. be
distended ldequ8tely to displace die small bowel and Its con-
tained ps from die fl..d of view (FOV). Ocasionlllly. eMir-
distention of the bl.dde,. may compromise ewluation. When
this acx:un, ima&1111 should be repeated after the patient
partially emptl• the bladder.
For a vaatnll tonqvam, die urinary bladder Is preferably
empty. Thllvaclnal transducer may be Introduced by the
patient, the aonoJJ'8pher; or the dlnlclan. A female member
of the physician's or hospital's staff should be present, when
possible, u a chaperone in the examining room during vaginal
sonOI"IPhy.
Uterus
The W&IIW Md utwus pi"''YYde anatomic lanc:lnwrks that can
be used as reference points when evaluating the pelvic struc-
tures. In evaluatJ111 the Llb!rus, document the following: (I)
uterine size, sh.pe, and orientation; (2) the endometrium; (3)
the myometrium: lnd (-4) die cervix.
Evaluac. the uterine length on a long-axis view as the dis-
tance from the fundus to the C8I"Ybt. The depth <:1 the uta'ul
(~ clmenslon) Is~ on the same lone-
all Wlw fr'om ttl anc.rtor to posterlol walls, perpelldicUar
to its lone Dis. Meas&.n! the width on the axial or coronal
'View. Exdude the cervix when perf'ormkiJ volume rneasu.
ments of' the uterus.
hnerican Institute of Ult1'1150'.1ld in Medidne. Guidelines (or Ft!rf'ormire of the
Document abnonnalitiel of the uterus to include contour
chanps, echopnlclty. masses, and cysts. Measure flndlnp on
5
lit IMSt two dimensions, IICknowledJing that it is not neces-
Al"/ m ITIIIUUnl 1111 fibroids.
hWyD t he endomebium for thic:kneu, focal abnormality,
and the pre~~~nce dllrf fluid or masses In die endometrial
cavity. MeuuN the e~ldomecrtum on a midline aglttlllnvp,
induclrw anterior 11\d posterior portions of the baSil endo-
metrium and exduclins the adjacent hypoechoic: reyornetrium
.00 any llndometriaJ fluid. Assessment of the aldol rletrium
should a1ow for normal variaticns in the appearance of the
endometrium IDCp8Ct8CI wtch phases of the menstrual qt:le
and with hormonllsupplementatlon. Sonohysterognphy
helpsevllu8te the ~lent with abnormal dysfunctlorwl uter-
ine bleed inc or with an abnormally thickened endometrium.
Document an IUD and the location within the uterus. When
available, obtain a lD wlume for coronal reconstn.Jction of
the an:.rus.
AdiiMIIIa (Ovarl• lind F..lopirln Tubes)
When evalt.ati"l the adnexa, an attempt should be made to
identify the ovaries first becwse they can sene as a major
point of reference for assessing the presence of adnexal pa-
thology. Althoush their location Is variable, die CMries are
moat ott.n situated anterior' to the Internal Iliac (hypopstrlc)
wuels, 1an1 to the uterus. and superficial to the obtura-
tor' intemus musde. Measure the ovaries and document any
ovarian abnormalities. Determine the ovarian size by measur-
i"l the CNarf In three dimensions (width, length, and depth)
on viiiWI obtained In two or'thogonal planes. To ensure mea-
sunment of*- ortt.ogon.l planes, udlze the dual~
formlt. It II ~ that the war1es may not be ldentll-
able In some women. This oca.n most hquendy after
~or In prldentll with a larp ~ utenJs.
Thr! noma! fallopbn tubes are not visualized In mast
ptll:iena. Surwty the pan4drrexlll n~~ions for' abnormalities,
f*"ticularty flu id-filled or distended tubular structures that
may Npt"eeent dllad fal lopian tubes.
R.M...nc• any ldnmcal m. . . to 1t1 relationship to the
IDnls. Document the lpsllatanl ovary. Determine the owry
size and echo patt.m (cystic, solid, or mixed; presence of
septat.ions). Doppler uknsound may be useful in select cases
to identify the vucular nature of pelvic structures.
Cul-d•Sac
The cul-de-ac Md bowel posterior to the uterus n-ay not
be clearly viiUallzed. This area should be evalwted for the
pn~~~~tnc:e of free fluid Or' mass. When free fluid is detected,
its ec:hopnlclty should be :u-ed. If a m:us is detected, its
size, poaltlon, 11-epe, echo pattem (cystic, solid, or complex),
and ltl relatlonlhlp to the ovarial and uterus should be docu-
mem:.d. Pwisc.llls helps to differentiate bowel from a peMc
maa. In the ablence of peristalsis, differentiation of no1'11'al
Or' abnormal loops of bowel from a rnas may, at times, be
diffiaJit. An endovap1aJ acamination may be helpful in dis-
tl"l'*'*'c aiU:Ip8Ctled mas from fluid and feces wtthln the
normal~· An ultrasound water enema study or
a ,..,- ..,.,ll"'lltton attar a claanslng enema n-ay also l'l8lp
disti,.ulsh a a.pectec1 rnas from bowel.
Ulttmtlund Exominatlan a( the Female PeNis. Laurel: AlUM; 2009.
6 PART ONE GYNECOLOGIC SONOGAAPHY
A B
c (open anaw).
that the sonographic examination must clearly demonstrate
the normality or abnormality of each anatomic structure
through a series of representative images.
Gynecologic Examinations
A full urinary bladder is the hallmark of gynecologic scan-
ning (Fig. 1-2). Taylor exam preparation instructions to the
patient. the examination objectives, and the transducer
type. A premenopausal woman who is to be examined for
a possible ovarian cyst can be instructed to eat normally.
void, and then finish drinking four 8-oz glasses of water
1 hour before the examination and not void until after the
examination. These directions should ensure proper prepara-
tion for the transabdominal pelvic sonogram. A postmeno-
pausal woman in her 60s or 70s with a history of uterine
bleeding may have decreased bladder capacity or suffer
from incontinence. Modify the directions for this patient
by asking her to drink only three 8-oz glasses of water. An
endovaginal examination requires an empty bladder unless
the abdominal scan occurs during the same examination.
An adequately filled bladder extends slightly beyond
the fundus of a nongravid uterus. Clear delineation of the
uterus and adnexa indicates a properly filled bladder. If not.
instruct the patient to drink more water or wait for her blad-
der to fill. Patient positioning techniques may be particularly
helpful with a less than optimally filled bladder. Ask the
FIGURE 1·1 A: Tnis sagittal transabdominal scan 1hroogn an empty bladder
pnilSel1ls a suboptimal image of the uterus (UT). The adnexa does not vis~
ize. B: This image demonslrates a partially filled bladder (8L). Although the UT
visualizes better. 1he bladder is net filled enough 10 allow complete evaluation
of the fundall"efJon (arrow). C: Wrth 1he bladder adequately filled, 1he 1\r.dus
(arrow) can be evaluated, as can the edlogenicity of the myometrium and
endometrium. A small amount of free fluid images in the posrerior cul-de-sac
patient to lie in a left or right posterior oblique position so
that the bladder drapes over the structure of interest. such
as the lateral section of the uterus, the adnexa, or a mass.
Overdistention of the bladder compresses and displaces
the pelvic viscera, and often the patient cannot tolerate
the examination. In this case, have her partially empty by
giving her a cup and telling her how many cups she may
void. Many patients are skeptical of their ability to stop the
fl.ow of wine. but most are successful.
In many cases, it is possible to evaluate most of the
low-lying pelvic structures with an empty urinary bladder
by using an endovaginal transducer. Use a transabdominal
approach to rule out pelvic masses that are beyond the
imaging range of the endovaginal transducer.
Perfonnlng the Gynecologic Examination
Regardless of clinical indication. a gynecologic examina-
tion should include the following images: sagittal midline
of the uterus, including the cervix and vagina; right and
left parasagittal views of the uterus and both adnexa; and
transverse views of the uterine fundus with cornua, the
uterine corpus, cervix, vagina. and each ovary. Demonstrate
and record characteristics of any suspected pathology in
addition to the standard views. Include several sagittal
and transverse views of any suspected abnormality in the
sonographic record. Documentation should include images
with and without measurements and a demonstration of
 I PRINCIPLES OF SCANNING TECHNIQUE IN GYNECOLOGIC ULTRASOUND
the echogenici.ty of the abnormal structure. Make every
attempt to delineate clearly any masses and their relation-
ship to surrounding organs and structures. If results of the
sonographic examination are negative, image the area of
interest to prove a lack of pathology.
The sonographer must also be aware of associated find-
ings of a particular disease. For instance, when imaging
a solid ovarian mass, the sonographer also will carefully
examine the cul-de-sac, Morison's pouch, the liver edge,
and the flanks for ascites. Also, examine the liver, kidneys,
and perivascular areas for evidence of metastases. Perform
every examination thoroughly; the additional time required
is minimal when using real-time scanners, and the findings
may be critical to the patient's well-being. Although sono-
graphic images of gynecologic masses often are frustratingly
nonspecific, with optimal technique, characteristics related
to particular masses can be visualized (Table 1-3). It is also
important to understand when spectral and color Doppler
may enhance diagnosis. Several chapters in this textbook
describe specific techniques for imaging pelvic masses.
A good understanding of the physical principles of ultra-
sound enables the sonographer to solve imaging problems.
Many excellent textbooks explain these principles.9•10
Every sonographer should make efforts to minimize so-
nographic artifacts produced during imaging. The following
basic scanning principles help achieve diagnostic images:
1. To optimize the superior axial resolution of the
transducer, keep the sonographic beam as close to
perpendicular as possible to the area of interest
TABLE 1-3 General Principles of Gynecologic
Scanning Techniques
C~rilltics Df M... 5CIInnill8 Technique
Size Measure three longest dimensions:
length, height, width
Mobility Tum patient, empty bladder, apply
transducer pressure
Tissue composition Change transducer: high to low
frequency
Compare to urine, which is fluid and
anedloic
Raise gain settings to see septations,
lower gain to see shadows from
c.alcifications
Look for edge shad<ming and
anterior reverberation artifacts in
fluid-filled structures
Check. for peristalsis in masses to
determine whether it is bowel
Extension Examine the bladder wall, which
should appear as a clean, echogenic
line measuring 3 to 6 mm
Examine the wl-<le-sac, flanks, and
Morison's pouch for ascites
Examine the liver for metastases
Examine the kidneys for
hydronephrosis and metlstases
Examine the perivascular area for
enlarged nodes
7
2. The best resolution occurs within the focal zone of
the transducer
3. Higher-frequency transducers provide better resolution
4. Lower-frequency transducers provide greater depth
of penetration
S. Fluid-filled structures enhance the transmission of
sound
6. Solid structures attenuate sound to varying degrees
TRANSDUCER SELECTION
Base your transducer choice on the patient habitus and
examination objectives. Each laboratory should have a se-
lection of transducers of varying frequencies with M-mode,
spectral Doppler, and color Doppler capabilities. Many
transducers are now duplex: a 2D image with a simultane-
ous M-mode or spectral Doppler display. 'D:iplex imaging is
the simultaneous display of 2D, color, and spectral Doppler.
Electronically focused transducers enable the sonographer
optimally image the structure of interest by changing the
depth of the focal point, and the number of focal points.
Broadband transducers allow the operator to change imaging
frequencies to optimize resolution at different depths.9•10
The small scanning surface or footprint of sector trans-
ducers makes them easily maneuverable and, therefore, is
effective in most gynecologic applications. Linear transduc-
ers in a variety of sizes and shapes provide various fields
of view related to their length and produce, making them
particularly useful for imaging the appendix in a patient
complaining of right lower quadrant pain. CUrved linear
may transducers combine the wider FOV of sector trans-
ducers with greater near-field visualization and increased
linear measurement accuracy.
Patient body habitus affects the choice of transducer
frequency. Large patients may require the use of a 2.5 MHz
transducer, whereas 5.0 MHz provides excellent resolution
on slender women and on children. Infants image well
with 7 .S MHz transducers. Improvement in image process-
ing has enhanced resolution, thereby allowing the use of
higher-frequency transducers than was previously feasible.
To optimize image quality, the sonographer should change
transducers depending on the depth of the imaged struc-
ture. For example, if imaging a young girl or thin woman's
pelvic organs, change to a higher-frequency transducer to
improve resolution. If a patient is obese, and therefore the
pelvic organs are far from the transducer face, change to a
lower-frequency transducer.
The utility of the endovaginal transducer and the supe-
rior imaging it provides in most gynecologic exams make
it an essential addition to the transducer arsenal of any
laboratory doing gynecologic ultrasound. Endovaginal
transducers range from 3.0 MHz to more typically a 6.0 to
7.5 MHz. The distance of an imaged structure {i.e., uterine
fundus) from the cervix determines the frequency needed
for optimal imaging. Endovaginal transducers produced by
different manufacturers vary in size, shape, orientation of
the imaging plane in relation to the shaft of the transducer,
whether the shaft has an angle to it, and the addition of
duplexed M-mode {simultaneous display of M-mode with
2D images}, spectral Doppler, color Doppler, and power
Doppler capabilities. Some machines and transducers also
have the capability of beam steering.9•10
8 PART ONE GYNECOLOGIC SONOGAAPHY
A B
FIGURE 1-l A:. M abdominal scan demonstrates a normal-appearing uterus (UT) posterior to a full bladder (Bl). The reverileration artifact is due to patient
obesity: however. a decrease of dynamic ronge or c:mrall gain helps rei1'C'Je some ~111e scattering artifact. B; The endovaginal scan allows better imaging of the
endometrium revealing an edlogenic (orrow) poi}'P and fluid (open C1ffl7W).
ENDOVAGINAL SCANNING
Commonly, endovaginal scans complement transabdominal
scans. The endovaginal transducer images anatomy within a
focal range of 2 to 7 em and cannot be inserted past the area
of the vaginal fornices, limiting visualization to the uterus
and adnexa in the nongravid patient without an enlarged
leiomyomatous uterus. An endovaginal. transducer provides
a smaller FOV than the transabdominal exam (Fig. 1-3). A
few gynecologic applications for endovaginal sonography
include evaluation of uterine, ovarian, and pelvic inflam-
matory disease; ovarian torsion; and monitoring ovulation.
Other uses include guidance for procedures such as ova
aspiration, and drainage or aspiration of pelvic fluid, and
treatment. The SDMS publication Sonography Examination
GuiJlelin.esn provides a good overview of the technique,
and the AlUM's tntrasound Practice Committee has issued
recommendations1l for cleaning endocavitary transducers.
TRANSPERINEAL SCANNING
In some cases, endovaginal scanning may be conttaindicated.
If there is a concern about introducing infection, for example,
in the case of ruptured membranes, or if the patient refuses
an endovaginal scan, the transperineal approach may en-
able the sonographer to obtain images of the cervix and the
lower uterine segment. The patient is positioned as for an
endovaginal scan. Perform the study using a conventional
ultrasound transducer that has been covered with a transducer
cover (as described in the section on endovaginal technique)
and scanning between the labia on the perineum. Occasion-
ally, the view may be obstructed by bowel gas. To improve
visualization, the patient's buttocks may be elevated onto a
pillow or towels, shifting the bowel and changing the angle
of the ultrasound beam relative to the cervix13•14 (Fig. 1-4).
Technique
Carefully explain the procedure to the patient before beginning
the examination procedure. In some institutions, the patient
signs an informed consent form before the examination.
1. Scan the patient with an empty bladder, as a distended
bladder may distort pelvic anatomy and push oq;ans
of interest out of the transducer range.
2. Use the lithotomy position or place a pillow under the
supine patient's buttocks. Positioning the patient's
upper body higher than the pelvis helps with pooling
of any fluid in the cul-de-sac.
3. Protect the transducer with a cover designed for this
purpose. The cover reduces the patient's risk of infec-
tion. If a transducer cover is not available, substitute
a condom or a digit of a surgical glove. Place a small
amount of gel on the face of the transducer before
covering to provide a fluid contact between the scan-
ning face and the cover. Take care to remove all air
bubbles between the transducer face and the cover
to optimize image quality.
4. Lubricate the transducer cover with K-Yjelly to mini-
mize patient discomfort. Do not use coupling gel with
the infertility patient because of its spermicidal effect;
instead, lubricate the transducer with saline.
5. Depending on institutional policy, the patient, clini-
cian, or sonographer inserts the transducer into the
vagina. It is advisable for a female chaperone to be
present during the examination.
6. The sonographer manipulates the transducer to image
sagittal, coronal, and transverse sections of the uterus
and adnexa. Pushing or pulling the transducer and
tilting or rotating the handle brings these views into
the FOV. Move the transducer while imaging to avoid
advancing the transducer too far. As with standard
scanning, enlarging the image enhances visualization.
7. Because the orientation of the images differs from
transabdominal scans, it is important to indicate the
location and directions on each scan. Orientation
and labeling have not been standardized; therefore.
referencing images by using anatomic landmarks is
recommended (e.g., demonstrating the ovaries in
relationship to the iliac vessels).
8. At the completion of the examination, remove the
cover carefully and disinfect the transducer as recom-
mended by the manufacturer.12
 I PRINCIPLES OF SCANNING TECHNIQUE IN GYNECOLOGIC ULTRASOUND
A B
FIGURE 1-4 A: Schematic diagram oftransperineal scannillJ plane for
the nongravid uterus B: Transperineal sonogram of normal uterus, (C) with
machine-gener<lted outline of structures. Qmages courtesy of Susan Scttultz.
RDMS, Ted1nical Coortlinator of Education, The Jefl'~ Ultrasound lnstib.rte,
Philadelphia. PA.)
Completion of the Examination
Obtaining the needed images for the examination is only
a portion of the required steps for the examination. The
measurements obtained during the exam are displayed on
an electronic report contained within the equipment (Fig.
1-S). These, along with the patient information screens, are
often included as images in the patient record. Some clinical
sites also print reports on a paper or a stand-alone printer.
If your equipment is set up to batch send, you may review
your images, deleting any that you repeated or felt were
technically inadequate. Images sent at acquisition require
deletion from the picture archiving and communication
system (PACS).
Although it sounds complicated, when you end the
examination, the images move to the PACS, for storage,
and then are attached to the patient's EMR. The electronic
report then appears on both the main record and the one
contained within the radiology department. This allows
access to the approved people, including the clinician,
to the images and reports contained within the patient
chart. The electronically dictated and sent report arrives
within a day or two, reducing the time a patient must
wait for results.
9
c
NEW DEVELOPMENTS IN DIAGNOSTIC
MEDICAL ULTRASOUND
Sonoelastography, often simply called elastography, provides
a quantitative or qualitative measurement of tissue stiff-
ness. 6 Based on the same principle as external palpation,
elastograpby uses some type of stress, either compression
or system generated, to determine the volume change of a
targeted area.10 During compression, measurements taken
determine how much, or little, the tissue maintains the
original shape. 10 Pathology such as fibroids, u.t~ polyps, 14
and cervical malignancies15 compresses less than sUITound-
ing tissue. Displacement of tissue by the stress mechanism
.results in tissue strain. 1b determine the strain, the ultra-
sound system quantitatively compares the change in tissue
shape between the target (or pathology) and normal tissue.
The elastogram data then overlie the grayscale image with
a selected color map (Figs. 1-6 and 1-7).
Sonohysterography is a technique in which infusion of
25 to 30 mL of sterile saline into the endometrial cavity
enhances visualization by either the transabdominal or
the endovaginal approach. A fine, flexible catheter placed
through the cervix allows for the saline infusion. Patient
10 PART ONE GYNECOLOGIC SONOGRAPHY

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Doltto Coli

P~o 114 1 Prov Next Ropon Rttum

B
FIGURE 1·5 These two report pages for a gynecologic exam demonstrate uterine and ovarian measurements.
 I PRINCIPLES OF SCANNING TECHNIQUE IN GYNECOLOGIC ULTRASOUND II

Soft Force
11uua applied

Adenomyosis

Uterus

Fibroid

Hard
lluua
A B
FIGURE I~ Schematic diagram of use of real-1ime sonoelastDgraphy. k Transducer pressure applied 1D the uterus causes deformation of tissue. Deformation
caused by compression depends on 1issue stiffness, with mone deformation in soft tissue than in harder tissue. B: Cha~ in deformcdion is color-coded and is
5Uperimposed on the torTeSponding B-mode image. We mos11y used the "ascending colors' color map on 1he ultrasound macnine: darlc purple or blue indi<:ilte$
lwtlertissue; ~and yeliaN indicate moderately stiff1issue; and orange and red indicate soft1issue. (From Stoelinga B, Hehenkamp W. Brolmann H, etal. Real-
1ime elastcgraphy for assessment of urerine disorders. Ultrosound Obstet GpleCDJ. 20 14:43:21 B-226.)

A B
FIGURE 1-7 Ultrasound images of uterine leiom~rroma (A) and leiomyoma (B) with the graysale image next 1D the sonoelas!Dgram. Irregular distribu-
tion of blue, yellow, green, and red suggests a heterogeneous inner structure. Notable blue was present in high echoic spats shown on grayscale imaging. (From
Furukawa 5, Soeda 5, Wamnabe T, et al. The measurement of stiffhess of uterine smooth muscle tumor by elastography. SpringerP/us. 20 14;3 :294.)

preparation may include testing for Chlamydia. Ureaplasma,
and gonorrhea and the use of prophylactic antibiotics. As
in endovaginal examinations, the patient is in the dorsal
lithotomy position. A speculum inserted into the vagina
exposes the cervix; the clinician uses Betadine to clean the
external os, and then inserts the catheter.16 Patients tolerate
the procedure well, reporting little or no pain. The anechoic
saline delineates the endometrial cavity and often appears
echogenic because of contained microbubbles of air. Fluid
in the cul-de-sac indicates passage of the saline through the
fallopian tubes. The technique has proven superior to en-
dovaginal sonography alone in characterizing the thickened
endometrium for contained polyps, submucous myomas,
synechiae, endometrial hyperplasia, and signs of cancerous
masses and in investigating tubal patency. 16
Contrast agents such as saline used in gynecologic
scanning enhance visualization of the endomebial cavity
and fallopian tubes. Coupled with the acquisition of a 3D
data set, saline injected through a catheter inserted into
the vagina and cervical os has successfully demonstrated
patent and blocked tubes.l7·18 The use of saline in the
hysterosalpingogram has proven diagnostic validity. What
role the sonographer has depends on the setting in which
he or she practices. Usually, the sonographer acts as an
assistant to the physician instilling the saline. However, as
sonographers begin developing the role of the advanced
practitioner, that person might be considered qualified to
perform the entire examination.
3D ultrasound, an outgrowth of computer technology, is
one of the most dynamic new developments in sonographic
imaging. Several types of 30 ultrasound are being inves-
tigated, such as 20 serial scanning,10 volume imaging,19.2fl
and the use of a defocusing lens.9 Studies of the efficacy of
20 serial scanning (commonly referred to as 3D imaging)
in obstetric scanning, particularly in the evaluation of the
first-trimester embryo,21 fetal face, limbs, and digits, have
12 PART ONE GYNECOLOGIC SONOGRAPHY

shown it to add important detail to the study. Spatiotemporal
image correlation is a 3D imaging method to image the fetal
heart that results in the display of three orthogonal planes
of the heart in a multiplanar reconstruction format. u
Scanning technique for 3D or 40 imaging does not change
appreciably. The volume transducer mechanically obtains
sequential images, which are stored as volume data. At some
time after the scan, the data may be recalled and volumetric
reconstructions produced that may be rotated approximately
360 degrees. The clinician is able to evaluate entire organs
in a dynamic manner, rather than in static sections. The
technique enables the user to study an infinite variety of
orthogonal views through an area of interest at any time
after storage of the volume data.

TABLE 1-4 Code of Professional Conduct for Diagnostic Medical Sonographers

The goal of this coded ethic; is to promote excellence in patient care by fostering responsibility and accounlability among dia§lostic medical
sonogra~. In so doing, we maintain the integrity of the profession of diagnostic medicalsonography.

OBJEC11VES
To create and encourage an environment for discussion of professional and ethical issues.
To help the individual diagnoslic medical sonographer identify ethical issues.
To provide guidelines for individual diagnostic medial! sonographers regarding ethical behavior.
PRINCIPLES
Principle 1: In order to promote IHlfient well-beinr. the diapostic medicCit sonovo(Jher shall:
A Provide information to the patient about the purpose of the sonography procedure and respond to the patient's questions and concerns
B. Respect the pa:tient's autonomy and the right to refuse the procedure
C. Recognize the patient's individuality and pi'OIIicle care in a nonjudgmental and nondiscriminatory manner
D. Promote the privacy, dignity, and comfort of the patient by thoroughly explaining the examination and patient positioning and implementing proper
draping techniques
E. Maintlin confidentiality of acquired patient information and follow national patient privacy regulations as required by the Health Insurance
Portability and kcountability Act of 1996 (HIPAA)
F. Promote patient safety during lhe provision of sonography procedures and while the pcdient is in the care of the diagnostic medical sonographer
Principle II: To promote the highest level ofcon1f»etent pt«ti~. diognoltic medical JOnOgrophels shall:
A Obtain appropriate diagnostic medical sonography education and dinical skills to ensure competence
B. Achieve and maintain specialty specific sonography credentials. Sonography credentials must be awarded by a national sonography credentialing
body that is accredited by a national organization that accredit> credentialing bodies, that is, the Na1ional Commission for Certifying Agencies
(NCCA), http://wwiN.ncxa.org/ncca/ncca.htm; or the International Organization for Stlndardization (ISO), http://wwiN.iso.orgt'lso/en.IISOOnline
.frontpage.
C. Uphold professional standards by adhering to defined technical protocols and diagnostic criteria established by peer review
D. Acknowledge personal and legal limit>, practi~ wiltlin the defined scope of practice, and assume responsibility for his or her actions
E. Maintlin continued competence through lifelong leaming, which includes continuing education, acquisition of specialty specific credentials, and
recredentialing
F. Perform medically indiated ultrasound studies, ordered by a licensed physician or a designated health care provider
G. Protect patients and/or study subjects by adhering to oversight and approval of investigational procedures, including documented informed consent
H. Refrain from the use of any substlnces that may alter judgment or skill and thereby compromise pa:tient care
I. Be accounlable and participate in regular assessment and review of equipment, procedures, protocols, and results. Facility accreditation
acwmplishes this goal.
Principle Ill: To pr~ profeuionol integrity and ~>Ublic tn.lst., the diagnostic medicGI sonogropher shall:
A Be truthful and promote appropriate communications with patients and colleagues
B. Respect the rights of patients, colleagues, and yourself
C. Avoid conflicts of interest and si1lJations that exploit others or misrepresent information
D. Accurately represent his or her experience, education, and O'edentialing
E. Promote equitable access to care
F. Collaborate with professional colleagues to create an environment that promotes communication and respect
G. Communicate and collaborate with others to promote ethical practice
H. Engage in ethical billing practices
I. Engage only in legal arrangements in the medical industry
J. Report deviations from the Code of Ethic; to institutional leadership for internal sanctions, local intervention, and/or criminal prosecution. The
Code of Ethic; can serve as a valuable tool to develop local polides and procedures.
The Society of Diagnostic Medical Sonographers. Code ofPr~ CondLICt (or Diagnostic Medicd Sonotfaphers. Dallas: SDMS; 2006.
 I PRINCIPLES OF SCANNING TECHNIQUE IN GYNECOLOGIC ULTRASOUND
PROFESSIONAL RESPONSIBILITIES
OF THE SONOGRAPHER
In March 2002, the Bureau of Labor Stati.stics26 classified
sonography as a unique professional classification and it
became listed in the Occupational Outlook Handbook.z7 1t
is essential that sonographers be familiar with the Sonog-
rapher's Code of Professional Conducf8 (Table 1-4), Code
of Ethics,19 The Scope of Practice7; that they abide by the
Patients' Bill of Rights; and that they practice infection
control techniques to protect their patients and themselves.
Individuals choosing diagnostic ultrasound as a profession
should take certifying examinations. Passing a credenti.aling
examination attests that the sonographer has a practicing
level of knowledge in the specialties in which he or she is
registered. There are currently several testing bodies in the
United States, such as the American Registry of Radiologic
Technologists (ARRT); however, the gold standard is still the
test given by the American Registry of Diagnostic Medical
Sonographers (ARDMS). The ARRT test contains general
topics, whereas the ARDMS specifies specialty areas such
as obstetrics/gynecology. When deciding which test to take,
be sure of acceptance by your facilities' accrediting body.
Based on the National Competency Profile for Sonog-
raphy, the Canadian exam contains a core competency
section with a Generalist Sonographer designation. This
examination tests on multiple topics to include obstetrics,
gynecology, abdomen, and vascular topics. There are also
dedicated tests for the cardiac and vascular specialties. If
you wish to scan in a specific country, make sure to check
credenti.aling requirements because they vary.
Th maintain registry status, the sonographer must com-
plete continuing medical education (CME) credits depending
on the credential held and credentialing body. In a field as
SUMMARY
• The sonographic examination begins with entry of patient
data into the EMR, RIS, and, if available, the MWL on
the equipment.
• The performing sonographer introduces himself or her-
self, confirms patient identity through multiple methods
{name, date of birth, exam, armband), and takes a history.
• Each imaging laboratory must develop an imaging proto-
col to ensure completeness of the exam and consistency
between examinations.
• A transabdoiillnal examination of the female reproductive
organs begins with an adequately full bladder.
• 'Ihmsducer selection depends on the transducer footprint,
body habitus, examination, and stage of pregnancy.
• Endovaginal examinations require covering of the transducer.
• Professionalism is partially determined through obtain-
ing certification and maintaining registries through CME
completion.
CRITICAL THINKING QUESTIONS
1. You have been asked to be part of a hiring committee
for the sonography department. After reviewing the
13
dynamic as diagnostic ultrasound, keeping informed of in-
novations is imperative. Without CME maintenance, none
of the testing bodies list the registrant on the web page
directory search as an active member. Many credentialing
bodies require recertification at regular intervals.
In the United Sates, the AlUM accredits practices that im-
age obstetric, gynecologic, abdominal, and breast ultrasound
areas. 23 Another governing body, the ACR, also accredits
imaging laboratories. The AlUM requires the ARDMS registry
in the accrediting specialty areas; however, they do accept
the ARRT Breast certification.24 The ACR accepts either the
ARD.MS or the ARRT credential.25 Each requires the proper
education and credenti.aling of sonographers in the prac-
tice. Add to this the increasing requirements by third-party
payers, such as Medicare- that will only reimburse for
examinations performed in accredited labs with certified
sonographers-and it becomes clear that anyone perfonn-
ing the sonographic examination has to have credentialing.
The sonographer should become a member of a professional
society in his or her area of practice, in this case, General and
Women's Health Imaging. Examples of societies include the
SDMS, the AlUM, or even the International Society of mtra-
sound in Obstetrics and Gynecology (ISUOG). Membership
in a society brillgs with it the benefits of being part of a pro-
fessional organization whose mission is to keep its members
informed and competent. Among the resources the societies
include are educational guidelines, profiles of sonographer
characteristics (including salary levels), peer-reviewed journals
(The Journal of Diagnostic Medical Sorwgmphy, Journal of
Ultmsowul Medicine, Ultrasowul in Obstetrics and Gynecol-
ogy), and annual national and regional scientific meetings. It
also keeps its membership informed of legislation and current
societal trends that can affect the practice of ultrasound at
the local, national, and international level.
applicants' application material. you want to verify
CME, ARDMS, and ASRT registry status. What resources
would you use to perform this task?
2. As a newly appointed CMB coordinator in a hospital
located in the United States. it is your responsibility
to find and provide educational opportunities for your
feDow sonographers. What Ie80urce8 would you use
to set up your own program? How would you locate
bldependent study ac:dvfties at Utde or no cort?
3. An obstetridan's offke would like to become ~ted
to ensure quaUty sonographic examinations. Thia office
images from the first trimester to term, performing early
pregnancy screening for aneuploidy. What is the flm
step in becoming accredited within the United States?
MEDIA MENU
Student Resources available on Point' include:
• Audio glossary
• Interactive question bank
• Videos
• Internet resources
14 PART ONE GYNECOLOGIC SONOGRAPHY
REFERENCES
1. American Institute of Ultrasound in Medicine. Official Statement
As Low As Reasonably Achievable (ALARA) Principle. Laurel,
MD: AlUM; 2014.
2. Shortliff EH, Cimino JJ. Biomerlical. Infomwtics: Computer Ap-
plications in Health Care and Biomedicine. 4th ed. New York:
Springer; 2014.
3. Hacker NF, Moore JG. Essentials of Obstetrics and Gynecowgy.
Philadelphia: WB Saunders; 1986.
4. Hansman M, Hackeloer BJ, Staudach A. Ultrasound Diagnosis in
Obstetrics and Gynecowgy. Berlin: Springer-Verlag; 1985.
5. American Institute of Ultrasound in Medicine. Guidelines for Per·
formance of the Antepartum Obstetri.cal Ultrasound Examination.
Laurel: AlUM; 2007.
6. American Institute of Ultrasound in Medicine. Guidelines for
Performance of the Ultrasound Examination of the Female Pelvis.
Laurel: AlUM; 2009 .
7. Society of Diagnostic Medical Sonographers. The Scope of Practi.ce
for the DiagnDstic Medical Sonographer. Dallas: SDMS; 2009.
8. American Institute of Ultrasound in Medicine. Bioeffects committee
reviews RADrUS study. AlUM Report. 1994;10:2-4.
9. Kremkau F. Diagnostic lRtrnsound: Principles and Instruments.
9th ed. Philadelphia: Saunders Elsevier; 2011.
10. Hedrick WR. Thchrwlogy for DiagnDstic Sonography. St. Louis:
Elsevier Mosby; 2013.
11. Society of Diagnostic Medical Sonographers. Sonography Examina-
tion Guidelines. 2nd ed. Plano: SDMS; 2006.
12. American Institute of Ultrasound in Medicine. Guidelines for clean-
ing and preparing endocavitary ultrasound trnnsdu.cers between
patients. AlUM Official statement. Laurel: AlUM; 2014.
13. Stoelinga B, Hehenkamp W, Brolmann H, et al. Real-time elas-
tography for assessment of uterine disorders. Ultrasound Obstet
Gynecol. 2014:43:218-226.
14. Furukawa S, Soeda S, Watanabe T, et al. The measurement of
stiffness of uterine smooth muscle tumor by elastography. Sprtng-
erPlus. 2014;3:294.
15. Bakay 0, Golovko T. Use of elastography for cervical cancer diag-
nostics. F.xp Oncol. 2015;37(2):139-145.
16. Elsayes KM, Pandya A, Platt JF, et al. Thchnique and diagnostic
utility of saline Infusion sonohysterography. Int J Gyno.ecol Obstet.
2009;105(1):5-9.
17. Chan CC, Ng EH, lang OS, et al. Comparison of thre.e-dlmensional
hysterosalpingo-contrast-sonography and diagnostic laparoscopy
with chromopertubation in the assessment of tubal patency
for the investigation of subfertility. Acta Obstet Gynecol Scand.
2005;84(9):909-913.
18. De FeliceC, Porfiri LM, Savelli S, et al. Infertility in women combined
sonohysterography and hysterosalpingography in the evaluation
of the uterine cavity. Ultraschall Med. 2009;30(1) :52-57. Erratum
in: lRtraschaU Med. 2009;30(2) :195.
19. Andrist L, Katz v, Elijah R, et al. Developing a plan for routine
3-dimensional surface rendering in obstetrics. J Diagn Med Sonogr.
2001;17:16-21.
20. Ballard·Taraschi K, Roberts D, ThompsonS. Utilizing 3D ultrasound
to visualize trisomy 18 abnormalities in the first trimester. J Diagn
Med Sonogr. 2003;19:110-113.
21. Fauchon DE, Benzie R.J, Wye DA, et al. What information on
fetal anatomy can be provided by a single first-trimester trans-
abdominal three-dimensional sweep? Ultrasound Obstet Gynecol.
2008;31(3):266-274.
22. Hata T, Dai SY, Inubashiri E, et al. Real-time three-dimensional
color Doppler fetal echocardiographic features of congenital heart
disease. J Obstet Gyno.ecol Res. 2008;34(4, pt 2):670-673.
23. American Institute of Ultrasound in Medicine. Standards and
Guidelines for the Accreditation of UltrasolUld Practices. Laurel:
AlUM; 2005.
24. American Institute of Ultrasound in Medicine. Ultrasound Practice
Aa:red.it:ation: The Measure of Excellence. Laurel: AlUM; 2009.
25. American College of Radiology. Ultrasound Accreditation Program
Requirements. Reston: ACR; 2009.
26. Society of Diagnostic Medical Sonography. Press release http:/I
www.sdms.org/news/release03182002.asp. Accessed August 2017.
27. Occupational Outlook Handbook, 2008-2009 Edition. http://www
.bls.gov/oco/ocos273.htm. Accessed August 2017. .
28. Society of Diagnostic Medical Sonographers. Code of Professwnal
Conduct for Diagnostic Medical Sonographers. Plano: SDMS; 2006.
29. Society of Diagnostic Medical Sonographers. Code of Ethics for the
Profession of Diagnostic Medical Sonography. Plano: SDMS; 2006.
 .,-~, -
. ---,.,.

• • I

,._ • I

Embryonic Development of the

Female Genital System

SUSAN R. STEPHENSON

OBJECTIVES KEY TERMS

■ Order the appearance of embryonic structures embryogenesis

■ Describe the first-trimester Carnegie staging urogenital
■ Relate embryonic structures to the resultant adult organs primordial germ cells
■ List the development stages of the female reproductive system mesonephros
■ Explain the interconnect1v1ty of the urinary and reproductive systems pronephros
inducer germ cells
GLOSSARY mesonephric ducts
~ ------- ·---------- ------------------------ -------~- -------- --------~~-------------- --- ·------- -- . -- --- . -- --
paramesonephric ducts
Allantois Sac-like vascular structure that lies below the ch · the
hindgut mullerian ducts
Atretic Blockage or absence of a structure external genitalia
Broad ligament Fold of peritoneum that connects the uterus t G the pelvis wolffian ducts
Embryogenesis Formation of an embryo
Cloaca Cavity that is part of the development of the l:l igest\,e and reproductive organs
Diploid Normal number of paired chromos0 mes
Gonadal ridges Structure that appears at appKQ~tely 5 weeks gestation and be-
comes either ovaries or testes • 'V""'
Hydrometrocolpos Accumulation of secreteEJ ~uid resulting in distention of the uterus
and vagina because of obstruction
Hydronephrosis Urine collection in the kidneys because of distal obstruction
Hydroureter Large, sometimes t0 rtuous , ureter because of distal blockage
Mesonephric ducts Connection between the mesonephros and the cloaca
Mesonephros Second stage of kidney development (aka wolffian body)
Mesovarium Section of the uterine broad ligament that covers the ovary
Mullerian ducts (paramesonephric ducts) Paired ducts that become the oviducts,
uterus, cervix, and upper vagina
Oocytes Female germ cells
Oogonia Immature oocytes
Paramesonephric ducts see mullerian ducts
Primordial germ cells Precursor of germ cells, become oocytes or spermatozoa in
the adult
Pronephros Primary or first kidney, which develops in the embryo
Wolffian ducts see Mesonephros
Urogenital Pertaining to the urinary and genital system

IS
16 PART ONE GYNECOLOGIC SONOGRAPHY
U nderstanding female reproductive anatomy begins
with a thorough knowledge of the pelvis structure
embryogenesis. Imaging of the uterus and ovaries becomes
complicated in the presence of developmental anomalies
because of changes in the normal sonographic anatomy.
Understanding the developmental relationship between the
urinary and reproductive systems requires knowledge of
normal and abnormal development of both organ systems.
Commonly, anomalies in either systems result in coexisting
malformations in the other. The urogenital system easily
images in utero and throughout a woman's life. This al-
lows for diagnosis of morphologic anomalies in all stages
of life from fetal, neonatal, pediatric, reproductive, and
postmenopausal.
carnegie stagi7t8, a method used to classify the embryo,
places the embryo into categories depending on age, size,
and morphologic characteristics. The embryo develops
structures in a specific order that remains constant. Because,
as with any organism, each develops at a different rate, the
segmentation of development allows for consideration of
morphologic development, regardless of dates. 1
Carnegie staging applies to the first 8 weeks of the
gestation and pertains to the organogenesis of the embryo.
The resulting 23 stages end after the eighth week when
the fetal period begins. Carnegie stages will be included
with each organ development chapter. This chapter cov-
ers the normal development of the female urogenital
structures, including the correlating Carnegie stages.
Abnormalities of development are further discussed in
the next chapter.
FETAL PERIOD
The genitourinary system encompasses two systems: re-
productive (genito-) and urinary. These systems develop
in tandem in the embryo and retain the close association
in the adult.
Most congenital anomalies discovered in fetuses in utero
occur in the genitourinary system, with urinary tract ab-
normalities accounting for about 50% of the total.2 These
anomalies represent a wide range, from complete agenesis
of the kidney and ureters to partial malformations, duplica-
tions, and obstructions with concomitant cyst formation.
Prenatal ultrasound may also detect congenital anomalies
in the ovaries, uterus, and vagina, especially when they
enlarge and produce a pelvic mass. Cloacal anomalies,
which can result in hydrometrocolpos, are the result of
obstruction of vaginal outflow in the female fetus. 3 This
hypoechoic mass posterior to the bladder compresses the
urinary tract, causing obstructive uropathy demonstrated
by hydronephrosis or hydroureter. 3
NEONATAL PERIOD
As in the fetal period, the most common mass lesions in
neonates are of renal origin4 ; however, ovarian cysts are
known to be the most common intra-abdominal lesion
in the neonate. 5 Identify the normal urinary bladder,
uterus, vagina, and (whenever possible) ovaries when
imaging the pelvis in a newborn girl to rule out masses
and obstructions.
PREMENARCHETHROUGH
ADULTHOOD
The onset of puberty results in menstrual irregularities and,
thus, a visit to the sonography lab. This often is the first
time any developmental abnormalities become apparent. For
example, in the patient with a duplicated uterus with one
septate vagina, obstruction to menstrual flow from one side
can present as unilateral hematocolpos. 6 In these patients,
imaging of the kidneys becomes important because there
are often associated anomalies. 6 Asymptomatic patients
may not be aware of the congenital anomalies unless other
conditions require sonographic imaging.
These anomalies occur early in embryonic life. The
following sections review the development of the female
internal and external genitalia.
EXPRESSION OF GENDER IN AN
EMBRYO
The Primordial Germ Cells
The chromosomal gender or sex is determined in the first
Carnegie stage at fertilization with the fusion of the sperm
and egg. 1 This stage is also called the pre-embryonic phnse,
which lasts into the third week. 1 The female gamete (the
ovum) always contains the X sex chromosome. The male
gamete (the spermatozoon) contributes either an X (female)
or Y (male). If the sperm contributes an X to the ovum's X,
the result is a female zygote (XX). If the male contributes a
Y chromosome, the result is a male zygote (XY) .6 Fertiliza-
tion results in a diploid chromosome count of 46 with two
sex chromosomes (XX or XY).
The primordial germ cells that express or produce female-
ness or maleness are first discernible in the embryo late in
the third week to early in the fourth week (approximately
the 17th day1 after conception. This stage, the embryonic
phase, begins in the fourth week and extends into the eighth. 1
The appearance of the primordial germ cells along with the
primitive groove, streak, and node indicate Carnegie stage
6. 1 These germ cells differentiate from cells in the caudal
part of the yolk sac, close to the allantois (a small diverticu-
lum of the yolk sac that extends into the connecting stalk)
(Fig. 2-lA). In the sixth week during Carnegie stage 17/
the primordial germ cells migrate from the yolk sac along
the allantois and into the gonadal cords.6•7 The genital or
gonadal ridges form simultaneously and are the precursors
to the female ovaries and to the male testes. These ridges are
located on the anteromedial sides of the mesonephros, the
embryonic regions where the kidneys develop (Fig. 2-1B). 7
The urinary system and the reproductive system are inti-
mately associated in origin, development, and certain final
relations. Both arise from mesoderm that initially takes the
form of a common ridge (mesonephros) located on both
sides of the median plane. This tissue appears during the
sixth Carnegie stage at about 13 days postovulation.2 Both
systems continue to develop in close proximity; they drain
into a common cloaca and slightly later into a urogenital
sinus, which is a subdivision of the cloaca. Some parts of
the urogenital system disappear after a transitory existence.8
For example, by the fifth developmental week, the first-stage
 2 EMBRYONIC DMLOPMENT OF THE FEMALE GENITAL SYSTEM 17

Foregut Hindgut Allantois

Genhal
ddge

Mesonephric
Aorta

Primordial~. •
genm cells ' . \
<1.~

Proliferating Paramesonephric
C body epithelium sex cords duct
FIGURE 2-1 Future spenn and egg cells galher in the genital ridge. Gametes arise in 1t1e gut tube endodenn (A) and migrate 1hrou&h 1he dorsal mesentery (8)
to receptive primitive sex cords tr.at are proliferating in 1tte genital ridge (C). (From Sadler TW.langmon's Medicc/ Embtyology. I Otk ed. Baltimore, MD: lippincott
Wiliams & Wilkins, 2006. Flllure 15.18a,b, p. 2-40; Figure 15.19, p. 249.)

kidney (pronephros} has differentiated and has already disap-
peared.9 The final set of kidneys forms at about days 31 to
38, during the 14th and 15th Carnegie stage.3 Certain com-
mon primordia transform differently in males and females.
INDUCER GERM CELLS
During the fifth week of development, the primordial germ
cells migrate by ameboid movement from their origin in
the yolk sac along the dorsal mesentery. In the sixth week.
they invade the gonadal ridges (Fig. 2·1). If by chance they
do not reach the ridges, the gonads cease to develop. Thus,
these primordial germ cells act as inducers of the gonads.
Note that at this time in development (the sixth week), the
mesonephros (previously named wolffian bodies) or second-
stage kidney and its mesonephric duct (previously named
wolffian ducts} have developed lateral to the gonadal ridges.7·1D
As the primordial cells are invading the ridges, an outer
layer of fetal tissue called coelomic epithelium grows into
the underlying mesenchymal tissue, or embryonic connec-
tive tissue. Active tissue growth here fonns a network. or
rete, called the primitive sex cords (Fig. 2·2). This rete forms
anastomoses with a portion of the mesonephric duct, thus
establishing the first urogenital connections in the embryo.

MQIIerlan duct

Wolffian tubule or duct

Neural tube

' - - - - - - Rete (primitive sex cords)

FIGURE 2-2 Development of embryo on one side. Indifferent gonad stage; formation of primitive sex cords.
18 PART ONE GYNECOLOGIC SONOGRAPHY
After the degeneration of the second-stage kidney, the
mesonephros-the male embryo-appropriates its meso-
nephric duct and converts it into genital canals. These stages
are similar between the two sexes, and it is impossible to
determine gender through morphology. This stage of de-
velopment is often termed the iJulifferent gonad stage.6•7•10
In the seventh week, if the embryo is a genetic male, the
primitive sex cords continue to proliferate and eventually
give rise to the rete testis. If the embryo is a genetic female,
the primitive sex cords break up into irregularly shaped cell
clusters, which evenrually disappear. They are replaced by
a vascular stroma, a supporting tissue, that later forms the
ovarian medulla (Fig. 2-3).6.7 In a female gonad (the ovary),
the outer layer of epithelium continues to proliferate. giving
rise to a second group of cords, which eventually occupy the
cortex of the ovary. These are the cortical cords, or Pluger's
tubules (Fig. 2-4). 10
In the fourth month, the cortical cords split into isolated
cell dU$ters, each surrounding one or more primitive germ
cells. Now, the primitive germ cells differentiate into oogonia,
which divide repeatedly by mitosis to reach a maximum
number of 7 million by the fifth month of prenatal life. Many
oogonia subsequently degenerate, so at birth, their number
is approximately 1 million (Fig. 2-S).'
The surviving oogonia differentiate into primary oocytes
during prenatal life and are surrounded by a single layer of
granulosa cells derived from the cortical cords. The primary
oocyte with its surrounding granulosa cells is called a primor-
dial follicle. Many undergo degeneration during childhood
and adolescence, so that by puberty, approximately 500,000
MOIIerlan duct Degenera11ng wolfflan tubule
Cortical oords
FIGURE 2-3 A: Transverse section of the
cm.ry at the seventh week. showifl: de-
generation of the primitive (medullary) sex
cords and fonnalion of the cortical cords.
B: Ovary and genital ducts in the ff1h
montn. Note degeneration of the medul-
lary cords. The exaetory 111e$01'1ephric
tl.lbules (efferentductl.lles) do not com-
municate wi1h the rete. The cortical zone
of the cm.ry contains groups af QO&Onia
surroonded by follio;lar cells.
remain. Between puberty and menopause, approximately
300 to 400 fertile ova are produced.7
Genital Ducts
It is necessary to backtrack in time to trace the develop-
ment of the ductal system that occurs simultaneously with
the development of the gonads (ovaries or testes). In the
indifferent gonad stage (until the seventh week), the genital
tracts of both male and female embryos have the same ap-
pearance and comprise two pairs of ducts. The mesonephric
ducts arise from the second-stage kidney, the mesonephros.
The milllerian ducts (or paramesonephric ducts) arise from
an invagination or pocket of coelomic epithelium lateral
to the cranial end of each mesonephric duct. Growth pro-
gresses caudad, eventually hollowing out to form an open
duct. 10 Development of the embryonic ductal system and
external genitalia occurs under the influence of circulating
hormones in the fetus. In males, fetal testes produce an
inducer substance that causes differentiation and growth of
the mesonephric ducts and inlnbition of the miillerian ducts.
In females, because the male inducer substance is absent,
the mesonephric ducts regress while the miillerian ductal
system, influenced by maternal and placental estrogens,
develops into the fallopian tubes and uterus. 10•11
The mfillerian ducts first extend downward parallel
to the mesonephric ducts, then turn medial in the lower
abdomen, crossing anterior to the mesonephric ducts and
fusing together in the midline to form a single duct, the
uterovaginal canal (Fig. 2-6). This fusion begins caudally
tube
FIGURE 2-4 Formation of the cortical cords.
 2 EMBRYONIC DMLOPMENT OF THE FEMALE GENITAL SYSTEM
Mullerian duct
Degenerating medullary cords
FIGURE 2·5 Differentiation rL primitive germ cells into oogonia in 1he fourth
monftl.
and progresses up to the site of the future fallopian tubes.
In normal development, the midline septum disappears
by the end of the third month and the uterine corpus and
cervix are formed. They are surrounded by a layer of mes-
enchyme, which eventually forms the muscular coat of the
uterus (the myometrium) and its peritoneal covering (the
perimetrium).7•10
Formation of the Fallopian Tubes
After the formation of the uterovaginal canal, the segment
of each milllerian duct positioned above the junction of
the inguinal ligament becomes a fallopian tube. The era·
nial orifice of the milllerian duct, which stays open to the
peritoneal cavity, becomes the fimbriae of the fallopian
tube. Initially, the fallopian tube lies in a vertical position.
As development proceeds, it moves to the interior of the
abdominal cavity to lie horizontally. This causes the ovary,
which is attached to the fallopian tube by the mesovarium,
to descend and finally to assume a position dorsal to the
fallopian tube (Thble 2-1, Fig. 2-7)/
Degenerating
wolffian tubules - -=-:._
Inguinal ligament - ----':
FIGURE 2-6 Formation rL uterovaginal
canal, eighth week. Inset: cm.ry at fourth
monftl. forming1tle oogonia.
19
Formation of the Broad Ligament
As the milllerian duct fuses medially and the ovary is suc-
cessfully located cranial and finally dorsal to the fallopian
tubes, the mesenteries follow these positional changes. 10 This
movement causes the folds of the peritoneum to be elevated
from the posterolateral wall, thus creating a large transverse
pelvic fold called the broad ligament, which extends from
the lateral sides of the fused milllerian ducts toward the
wall of the pelvis. The fallopian tube will be located on
its superior surface and on its posterior surface, the ovary
{Fig. 2-7). The ovary is suspended by several structures: (1)
the 1112sovari.um is a double-layered fold of peritoneum that
is continuous with the posterosuperior layer of the broad
ligament. (2) The proper ligament of the ovary is a band
of connective tissue that lies between the two layers of the
broad ligament and connects the lower pole of the ovary
with the lateral uterine wall. (3) The suspensory ligament
is a triangular fold of peritoneum that actually forms the
upper lateral comer of the broad ligament. This ligament
suspends both the ovary and the fallopian tube by its con·
fluence with the parietal peritoneum at the pelvic brim.11
Formation of the Vagina
The vagina has a dual origin: its upper region is derived from
the mesodermal tissue of the miillerian ducts and its lower
region is derived from the urogenital sinus. The urogenital
sinus is the ventral half of the primitive cloaca (hindgut)
after it has been divided by the urorectal septum. The upper
portion of the urogenital sinus becomes the urinary bladder,
and the lower portion is divided into two portions: the pars
pelvina, which is involved in the formation of the vagina,
and the pars phallica, which is related to the primordia
(developing organs) of the external genitalia. This can best
be understood by following the development of the vagina
step by step. First, the distal end of the uterovaginal canal
makes contact with the posterior wall of the urogenital
sinus {Fig. 2-SA}. As these structures fuse, a solid group of
cells called the vaginal plate is formed {Fig. 2·8B). From
~

TABLE 2-1 Embryonic Development Chart for Female Urogenital System1:1.7

w..~r~c:.rn.• .... Urlnuy s,n.m Gonads Ducts M-m.rl• Embryo SID
FIRST TRIMESTER
1st/6th Primordial germ cells appear NA
3ro/10th Pronephros differentiates Primordial cells seen in allantois 0.2-3.5cm
4th/13th Pronephros disappears and Formation of genital ridges 0.4-0.6mm
mesonephros differentiates
5th/14th-16th Metanephros (permanent Migr.ll:ion d primordial germ 0.5--0.1 I em
Gestrtional sac seen with kidney) starts to differentiate cells
ultrasound
6th/18th-19th - Primitive germ cells invade Two sets of ducts exist: 0.16--0.18 em
Embryo with heartbeat images gonadal ridges mesonephric (kidney) and
with ultrasound Genital tubercle appears mOIIerian (genital ridge)
Formation d primitive sex
coros: "indifferent stage•
7th/10th Primitive sex coros disappear 0.18-0.22 em
Testes or ovaries form
Cortical coros arise
8th/22n~23rd Mesonephros disappears, only External genitalia form but 0.27~.31 em
its duct (mesonephric) remains difficult to differentiate
SECOND TRIMESTER
8th-12th Mesonephric duct regresses Mullerian ducts fuse to form
almost completely utertMJginal canal and fallopian
tubes
121h Maletfemale genitalia Median sepb.lm disappears
characteristics become evident
Ovary descends
12th-5th month Metanephros-1hiro-stage Cortical coros split up and Formation d mesosalpinx.
kidney surround primitive germ cells mesovarium, broad ligament.
to produce 7,000,000 oogcnia proper ovarian ligament, and
suspensory ligament
 2 EMBRYONIC DMLOPMENT OF THE FEMALE GENITAL SYSTEM 21

Round ligament _ _ _ _ ____::

of uterus

GartM~~t ----------~
FIGURE 2·7 Fully developro female reprodudive organs.

the vaginal plate, two outgrowths {sinovaginal bulbs) sur-
round the uterovaginal canal and fuse on opposite sides
(Fig. 2-8C). If the sinovaginal bulbs do not fuse normally, a
vagina with two outlets, or a vagina with one normal outlet
and one atretic one, may result. 7•10
After normal development, the center core of cells hol-
lows out to form a lumen in the vagina. The vagina is now
separated from the urogenital sinus only by a thin tissue
plate, the hymen (Fig. 2-80). The vaginal fornices, which
surround the ends of the uterus (cervix), are thought to be
of miill.erian duct origin.
Extemal Genitalia Development
As discussed earlier, in the first few months of development,
the genitalia are undifferentiated. External development of
the genitalia is similar in both sexes until approximately the
ninth week.u Maternal estrogen is the promoting factor in

Urinary
bladder ----~-=-

Pubic
symphysis- -7--

Urinary
bladder

FIGURE 2-8 Formation of the vagina.

A:.lhe~nal canal makes contact wi1h
wall of urogenital sinus. B: Formation of
vaginal plate. C: SinCMtginal bulbs endrde
the vaginal plate and elongate. D: Canali-
zation ci Vili)nal plate to fonn U\e ~na;
sepanltion of var)na and urogenital sinus c D
by1he hymen.
22 PART ONE GYNECOLOGIC SONOGRAPHY

the development of the female external genitalia. External

TABLE 2-2 Embryonic Origin of Adult genitalia include the lower portion (vestibule} of the vagina,
Structures7At0.tt
vestibule, Bartholin and Skene glands, the clitoris, labia minora
Em..,_.lc Intermediate and majora, and the mons pubis.10•11 In the undifferentiated
Stnlctu.. Structu.. Adult Structu.. stage, the genital tubercle elongates while the labioscrotal
Indifferent gonad/ Geni1al/gonadal Ovary/testes swellings and urogenital folds develop lateral to the cloacal
primitive sex rords ridges membrane at 44 to 48 days during stage 18.1 In both sexes,
the genital tubercle becomes the primordial phallus. At this
Cortical cords/ Cortex of the avary/ point, the primordial phallus discontinues development to
Pluger's tubules primary oocytes
become the clitoris in the female, which is relatively large
Mesonephros Wolftian ducts Genital canals until the 18th week of gestation? Gonadal gender can be
detennined in the male embryo at approximately the 44th
Coelomic. epithelium MOIIerian duds Fallopian tubes,
uterus, myometrium,
day of gestation, which conelates with Carnegie stage 18.1
perimetrium
Gonadal gender for the female embryo appears later in
Carnegie stage 20, which conelates to approximately the
Upper urogenital Urinary bladder 49th day.1 The labioscrotal folds continue to grow, forming
sinus the labia minora through fusion of the posterior portion
Mullerian dudsJlov.ler \Ja&ina resulting in the frenulum. These folds fuse in the posterior
urogenital sinus area to form the posterior labial commissure, with anterior
fusion forming the anterior labial commissure and mons
Primordial phallus Glans of ditcris pubis. The labia majora are the result of nonfused labio-
Urogenital Urogenital 'I}'OOIIe/ Labia minora scrotal folds and correlate to the male scrotum (Table 2-2,
membrane folds Fig. 2-9).7• 10• 12• 1~ By stage 23 (56 days). the external genitalia
are completely formed. 1
labiosaotal $'Nelli~ Labia majora

Urethral fold ~ Genital

~
= .i\ _ tuberde
{ {·'
Lablosc~ :, ·~
swelling · . ·.. / Anus
u...,,., g - ~ Tall (Qit)

/ A Indifferent ~
/ (approximately 5 weeks) ~
Penis ~ CIIIDrls ~; . ·% '/ ~~nhal
Labioscrotal :I ,- A\ \\"'?"
------J+ \-l'., .I '
Labloscrotal Urethral folds swellings ~~ Urethralfolds

=~:) \ / \\l..:(;r=; .7 . Qabia majora)

Anus
.. ..- · ' . ~~;/ /
:~
· ... ... (labia minora)

Anus .. ·
../"'--
At10week8

l j
Glans penis.---___,

Cti""' ~
...........,~ Labia minora
Scrotum
Anus \ .. ~ ·.- -'_,..~ ·.
Anus - - -
"\_,··· ': ' ;' .

B Male development C Female development

FIGURE 2-9 Development of the external reproductive organs.
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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