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CHAPTER 41 Chest Imaging in the Pediatric Patient 1189
160. Taylor GA, Atalabi OM, Estroff JA: Imaging of congenital 172. Weinberg PM: Aortic arch anomalies. J Cardiovasc Magn Reson
diaphragmatic hernias. Pediatr Radiol 39(1):1–16, 2009. 8(4):633–643, 2006.
161. Terheggen-Lagro SW, Arets HG, van der Laag J, et al: Radiological and 173. Weisbrod GL, Chamberlain DW, Tao LC: Pulmonary blastoma, report
functional changes over 3 years in young children with cystic fibrosis. of three cases and a review of the literature. Can Assoc Radiol J
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162. Terheggen-Lagro S, Truijens N, van Poppel N, et al: Correlation of six 174. Wells TR, Gwinn JL, Landing BH, et al: Reconsideration of the anatomy
different cystic fibrosis chest radiograph scoring systems with clinical of sling left pulmonary artery: The association of one form with
parameters. Pediatr Pulmonol 35(6):441–445, 2003. bridging bronchus and imperforate anus. Anatomic and diagnostic
163. Tiddens HA: Chest computed tomography scans should be considered aspects. J Pediatr Surg 23(10):892–898, 1988.
as a routine investigation in cystic fibrosis. Paediatr Respir Rev 175. White RI, Pollak JS: Pulmonary arteriovenous malformations:
7(3):202–208, 2006. Diagnosis with three-dimensional helical CT—A breakthrough without
164. Van Dyke JA, Sagel SS: Calcified pulmonary sequestration: CT contrast media. Radiology 191(3):613–614, 1994.
demonstration. J Comput Assist Tomogr 9(2):372–374, 1985. 176. Wick MR, Ritter JH, Humphrey PA: Sarcomatoid carcinomas of the
165. Van Meurs KP, Newman KD, Anderson KD, et al: Effect of lung: A clinicopathologic review. Am J Clin Pathol 108(1):40–53,
extracorporeal membrane oxygenation on survival of infants with 1997.
congenital diaphragmatic hernia. J Pediatr 117(6):954–960, 1990. 177. Wielpütz MO, Eichinger M, Puderbach M: Magnetic resonance imaging
166. Veenma DC, de Klein A, Tibboel D: Developmental and genetic aspects of cysti fibrosis lung disease. J Thorac Imaging 28(3):151–159, 2013.
of congenital diaphragmatic hernia. Pediatr Pulmonol 47(6):534–545, 178. Williams AJ, Schuster SR: Bronchial atresia associated with a
2012. bronchogenic cyst. Evidence of early appearance of atretic segments.
167. Vu L, Tsao K, Lee H, et al: Characteristics of congenital cystic Chest 87(3):396–398, 1985.
adenomatoid malformations associated with nonimmune hydrops and 179. Wilson RD, Hedrick HL, Liechty KW, et al: Cystic adenomatoid
outcome. J Pediatr Surg 42(8):1351–1356, 2007. malformation of the lung: Review of genetics, prenatal diagnosis, and
168. Vult von Steyern K, Björkman-Burtscher IM, Geijer M: Radiography, in utero treatment. Am J Med Genet A 140(2):151–155, 2006.
tomosynthesis, CT and MRI in the evaluation of pulmonary cystic 180. Winters WD, Effmann EL: Congenital masses of the lung: Prenatal and
fibrosis: An untangling review of the multitude of scoring systems. postnatal imaging evaluation. J Thorac Imaging 16(4):196–206, 2001.
Insights Imaging 4(6):787–798, 2013. 181. Wootton-Gorges SL, Stein-Wexler R, Walton JW, et al: Comparison of
169. Wagner AL, Szabunio M, Hazlett KS, et al: Radiologic manifestations of computed tomography and chest radiography in the detection of rib
round pneumonia in adults. AJR Am J Roentgenol 170(3):723–726, fractures in abused infants. Child Abuse Negl 32(6):659–663, 2008.
1998. 182. Yano Y, Mori M, Kagami S, et al: Inflammatory pseudotumor of the
170. Wan YL, Kuo HP, Tsai YH, et al: Eight cases of severe acute respiratory lung with rapid growth. Intern Med 48(15):1279–1282, 2009.
syndrome presenting as round pneumonia. AJR Am J Roentgenol 183. Yasufuku M, Maeda K, Takano Y: Thymopharyngeal duct cyst: An
182(6):1567–1570, 2004. unusual cause of respiratory compromise. Pediatr Surg Int 25(9):807–
171. Weber SA, Ferrari GF: Incidence and evolution of nasal polyps in 809, 2009.
children and adolescents with cystic fibrosis. Braz J Otorhinolaryngol 184. Yi E, Aubry MC: Pulmonary pseudoneoplasms. Arch Pathol Lab Med
74(1):16–20, 2008. 134(3):417–426, 2010.
1198 PART II CT and MR Imaging of the Whole Body
necessary to visualize calcified stones because postcontrast CT masks

them264 (Fig. 42-17). Some stones with mixed composition are isoat-
tenuating to bile or adjacent soft tissue and are therefore difficult to
detect on CT (Fig. 42-18). Pure cholesterol stones are rare but exhibit
low attenuation resembling that of soft tissue (Fig. 42-19) or bile (Fig.
42-20). Stones containing fat or air can be detected because of the
difference in attenuation from bile (Fig. 42-21).
For more accurate detection of intrahepatic ductal stones, thin
section with narrow collimation (<2.5 mm) is necessary. The presence
of bile around a stone results in a ring (bull’s-eye or target sign) or a
crescent of water attenuation between the stone and the bile duct
wall11,14 (Fig. 42-22). A concentrically thickened bile duct wall with
enhancement may be seen around a stone, representing inflamma-
tion and fibrosis due to irritation by the stone. On cholangiograms or
MR cholangiograms, stones are depicted as single or multiple filling
defects (Fig. 42-23). Muddy stones, small fragments of stones, and
FIG 42-14 Gallstone pancreatitis. The pancreas is enlarged and there
is a peripancreatic fluid collection. The common bile duct (arrow) is gravel are difficult to visualize on CT (see Fig. 42-20), MR, or even
dilated and the wall is thick. Note the tiny stones in the gallbladder and cholangiography.
the thickened gallbladder wall. Bile ducts may not be dilated despite the presence of stones in the
common duct in 24% to 36% of cases12,65 (Fig. 42-24). In acute obstruc-
tion due to stone impaction, the bile duct does not become dilated
until some time has passed. Bile ducts remain dilated after passage of
FIG 42-15 Suppurative cholangitis caused by gallbladder stone migra-

tion into the common bile duct. Coronal CT shows slightly dilated bile
ducts with severe thickening of the walls of the extrahepatic duct and
gallbladder. FIG 42-16 Calcified stone (arrow) in the distal common bile duct.
A B
FIG 42-17 A, Heavily calcified left intrahepatic stones (arrows) are seen on precontrast CT. B, The stones
are not clearly delineated on postcontrast CT because the adjacent liver parenchyma enhances.
CHAPTER 42 Biliary Tract and Gallbladder 1199
A
A
B
B
FIG 42-18 Innumerable small intrahepatic stones in a patient with
recurrent pyogenic cholangitis. Because attenuation of the stones and FIG 42-20 Common bile duct stone (arrow) with water attenuation on
liver is similar, CT (A) shows several weakly calcified intrahepatic stones CT (A) and cholangiogram (B).
(arrows), whereas many stones are visible on cholangiogram (B).
FIG 42-19 Common bile duct stone with soft tissue attenuation
(arrow). FIG 42-21 Common bile duct stone (arrow) containing air presenting
with the “Mercedes-Benz” sign.
a stone through the papilla of Vater because the duodenal papillary Sometimes a stone that is not detected by one imaging modality is
orifice becomes tight owing to papillitis and papillary edema (see demonstrated by another (Fig. 42-25; see Fig. 42-24). Thus two or
Fig. 42-13). more imaging methods may be necessary for the diagnosis of bile duct
Small stones and gravel repeatedly passing through the duodenal stones.
papillary orifice can cause papillitis and eventually papillary steno-
sis.92,359 CT or MRI demonstrates a dilated and thickened bile duct and Cholangitis
an enlarged duodenal papilla164,275 (see Fig. 42-13) but no actual stone Suppurative Cholangitis. Acute suppurative cholangitis is a bacte-
in the bile duct. rial infection of the bile ducts occurring mostly in patients with biliary
The ability to detect a biliary stone by imaging varies depending on obstruction caused by either stones or a tumor. Most stones originate
the size, location, and components of the stone.90,142,164,209,275,282 Each from the gallbladder (Fig. 42-26). The tumor may be a carcinoma of
modality has advantages and disadvantages. With CT, detection the bile ducts, head of the pancreas, or ampulla of Vater or (uncom-
depends on the stone’s calcium content and bile duct dilatation. Detec- monly) a benign tumor.
tion of stones by MRI is hampered by artifacts caused by pulsation of The bile ducts may be normal or dilated, depending on the cause,
the adjacent vessels. During cholangiography, the technique of can- duration, and degree of obstruction. In acute obstruction caused by a
nulation and bile duct opacification must be optimal for visualization stone, the bile ducts may not be dilated for some time, whereas in
of small stones. obstruction caused by cancer, the bile ducts are usually dilated.
FIG 42-23 Small stone (arrows) in the common bile duct on MR

FIG 42-22 Common bile duct stone with rim calcification (arrow) mim- cholangiogram.
icking a bull’s-eye.
A B
FIG 42-24 Small stone in the common bile duct. Intraductal sonogram discloses a stone (A), but there is
no stone visible on cholangiogram (B).
A B
FIG 42-25 Small stones in the common bile duct (arrows) are visualized on MR cholangiogram (A) but not
on cholangiogram (B).
FIG 42-26 Acute suppurative cholangitis caused by a stone originating FIG 42-27 Suppurative cholangitis with a common bile duct stone in
from the gallbladder. The common bile duct is slightly dilated, and the a patient with recurrent pyogenic cholangitis. Note concentric thicken-
wall is thick and enhanced as a concentric ring (arrow). The gallbladder ing of the bile duct wall with enhancement.
contains a small stone and its wall is thick and enhanced owing to acute
cholecystitis.
Other than bile duct dilatation, imaging finding are usually
normal.14 The presence of purulent bile may result in increased attenu-
Obstruction of the bile ducts causes bile stasis and a predisposition to ation of bile (greater than that of water) on CT, but it is usually not
infection. Gram-negative organisms such as E. coli are usually respon- clearly depicted. Depending on the calcium content, stones may be
sible. It is believed that bacteria within the intestinal tract ascend clearly depicted as calcified high-attenuating foci or as noncalcified
through the ampulla of Vater; for this reason the disease is also called intraluminal material (see Figs. 42-19 and 42-20).
ascending cholangitis. Bacterial colonization may also occur through The wall of the bile ducts may be thickened concentrically and dif-
portal venous bacteremia. The combination of obstruction and colo- fusely, with dense contrast enhancement (Fig. 42-27; see Fig. 42-26);
nization leads to cholangitis, but neither obstruction nor colonization this is well delineated with thin-section CT.14 In contrast to periductal-
by itself is sufficient to cause disease.223 Patients present with acute infiltrating bile duct cancer, the thickness of the bile ducts is uniform
abdominal pain, fever, chills, and sometimes jaundice. In some patients and less than 1 mm. In patients with suppurative cholangitis caused
with bile duct stones or carcinoma along the bile ducts, the initial by a cancer along the bile ducts, a nodular mass or periductal-
symptoms and signs may be similar to those of acute suppurative infiltrating cholangiocarcinoma is depicted on US, CT (Fig. 42-28),
cholangitis. and MRI.
A B
FIG 42-28 A and B, Acute suppurative cholangitis caused by carcinoma of the common hepatic duct (arrow
in B). Note the dilated bile ducts and concentric thickening of the wall in A.
One complication of suppurative cholangitis is the occurrence of

multiple intrahepatic abscesses, and there may be communication with
the biliary tree. In a fulminating infection of gas-forming organisms,
pneumobilia can be seen on CT.
Recurrent Pyogenic Cholangitis

Incidence. Recurrent pyogenic cholangitis, also known as Orien-
tal cholangitis, Oriental cholangiohepatitis, or intrahepatic pigment
stone disease, is characterized by recurrent attacks of acute bacterial
cholangitis presenting with abdominal pain, fever, chills, and jaun-
dice.33,64,89,269,299 A bile duct stone is an integral part of the disease, and
the symptom complex repeats once or twice a year. The disease is
prevalent in the Far East and Southeast Asia (thus its alternative
names); it occurs infrequently in non-Asians.
The stones in patients with recurrent pyogenic cholangitis are
mainly bilirubinate pigment stones formed in the bile ducts, whereas
the most common stones in Caucasian people are cholesterol stones
in the CBD that originated from the gallbladder.297 Many patients with
recurrent pyogenic cholangitis also have muddy stones or tiny gravel.89
Chronic infection of the biliary tree by C. sinensis or O. viverrini
or inadvertent biliary Ascaris infection is a possible cause of the
disease.209,297 A long-standing partial obstruction due to parasites in the
bile ducts, bile stasis, increased secretion of mucin, or eggs or excreta
of parasites predisposes the patient to form bile duct stones, with the
eggs or debris being the stone’s nidus.209 Alternatively, portal septice-
mia due to poor eating habits and poor nutrition has been proposed
as a cause of bile duct infection and stone formation.57,239 FIG 42-29 Recurrent pyogenic cholangitis. ERCP shows markedly
Pathology and imaging findings. Because of repeated inflamma- dilated intrahepatic bile ducts with rigidity, decreased arborization, right-
tion, the bile duct walls are thickened diffusely owing to inflammatory angle branching, acute tapering, and the “arrowhead” sign. The extra-
cell infiltration and fibrosis. Fibrosis causes the bile ducts to become hepatic duct is also dilated, with proximal narrowing due to segmental
rigid and straight, lacking gentle dichotomous branching (Fig. 42-29). fibrous stricture (arrows). Note the large stones (arrowheads) in the
distal common bile duct.
In severe infection, adjacent hepatic parenchyma is involved, resulting
in cholangiohepatitis.57,64,89,269 Sometimes this inflammation becomes
suppurative and the bile ducts fill with pus. Larger IHDs and extrahe-
patic ducts become dilated because of a stricture of the duodenal peripheral branches164,195,209,220,339 (Fig. 42-30; see Fig. 42-29). Owing to
papilla caused by mechanical irritation and inflammation due to the long-standing inflammation and fibrosis, peripheral bile ducts appear
repeated passage of stones or sharp gravel.209 However, the small IHDs rigid and taper abruptly, producing an “arrowhead” appearance (see
are not dilated because of ductal fibrosis. Thus the biliary tree has a Fig. 42-29).275
“pruned tree” appearance because of the notable dilatation of the Imaging findings include stones, a dilated bile duct, wall thickening,
larger bile ducts, decreased arborization, and nonvisualization of the and duodenal papillary stenosis. Stones are visualized in 70% to 80%
FIG 42-31 ERCP in a patient with common bile duct obstruction

FIG 42-30 Recurrent pyogenic cholangitis. The extrahepatic ducts and
caused by a passed stone originating from the gallbladder shows simple
lobar and segmental bile ducts are dilated, but the peripheral ducts are
dilatation.
obliterated rapidly. Note multiple small stones in the extrahepatic ducts.
The gallbladder was resected.
of patients in the intrahepatic or extrahepatic ducts or both (see Fig.

42-30).41,208,209 For patients with intrahepatic stones, the lateral segment
of the left hepatic lobe and posterior segment of the right hepatic lobe
are frequent sites of stone lodging.89,209
The characteristic bile duct involvement patterns persist even when
the stone passes into the duodenum. This is true because repeated
passage of stones causes papillitis, fibrosis, and papillary stenosis.
In some cases, bile duct dilatation is limited to the hepatic segmen-
tal or lobar bile ducts. This dilatation occurs as intrahepatic stones
lodge at the branching points of large-caliber bile ducts, causing
mechanical irritation, chronic inflammation, and fibrosis and a resul-
tant stricture209,275 (Fig. 42-31). Frequent sites of focal stricture are the
branching points of the medial and lateral segments of the left hepatic
lobe (Fig. 42-32), posterior segmental duct of the right hepatic lobe,
and bifurcation of the right and left hepatic lobes (see Fig. 42-29).164,209
With acute and chronic inflammation, the wall of the bile duct
becomes thickened. On high-resolution contrast CT, the thickened wall FIG 42-32 Stones in the lateral segmental bile ducts with severe dilata-
is clearly visualized and enhanced (Fig. 42-33). The thickening of the tion due to stricture (arrow).
bile duct in patients with recurrent pyogenic cholangitis is more severe
than in those with acute suppurative cholangitis but less severe than
in patients with periductal-infiltrating cholangiocarcinoma. demonstrate on sonography, CT, cholangiography, and MR cholangi-
During the stage of acute exacerbation, the periductal hepatic ography because the structure of the ampulla-papilla is small, and
parenchyma is enhanced on contrast-enhanced CT, reflecting peri papillary stenosis caused by fibrosis cannot be visualized on imaging40
ductal hepatic parenchymal inflammation (cholangiohepatitis) (Fig. (Fig. 42-37).
42-34). Sometimes the hepatic lobe or segments are enhanced in the Complications. Biliary cirrhosis is a possible complication and
arterial phase, probably owing to severe cholangiohepatitis and arterial usually follows long-standing severe, repeated disease.89 Stones at
hyperemia.209 Hepatic abscesses occur as a complication (Fig. 42-35). the lower end of the CBD may cause acute pancreatitis89,204,294 and a
In patients with stricture of the lobar or segmental bile ducts, the cor- choledochoduodenal fistula.89 Intrahepatic cholangiocarcinoma may
responding hepatic lobe or segment becomes atrophic because of long- develop in a stone-harboring bile duct because of long-standing
standing obstruction of the bile ducts.209 Periportal inflammation and inflammation, hyperplasia, and dysplasia.167,186,261 The reported preva-
portal venous encroachment may play an additional role. lence ranges from 1.5% to 11%.167
Duodenal papillitis and papillary stenosis are an integral part of
recurrent pyogenic cholangitis. Impaction of stones and repeated Primary Sclerosing Cholangitis
passage of small stones or sharp gravel through the papillary orifice Incidence. Primary sclerosing cholangitis (PSC) is a chronic cho-
cause irritation, inflammation, edema, fibrosis, and a resultant papil- lestatic liver disease of unknown cause characterized by diffuse inflam-
lary stricture.91,254,272 mation and fibrosis of the biliary tree. PSC is a progressive disease that
A swollen duodenal papilla can be demonstrated on CT (Fig. can lead to obliteration of the bile ducts and subsequently biliary
42-36) and MR cholangiography. Papillary stenosis is difficult to cirrhosis; it may eventually progress to end-stage liver disease and
A B
FIG 42-33 Recurrent pyogenic cholangitis. A, Cholangiogram shows severe dilatation and acute peripheral
tapering of the intrahepatic bile ducts with the “arrowhead” sign. There are multiple large stones in the
extrahepatic duct. B, CT shows a dilated common bile duct and stones within it. Note the thickened wall of
the common bile duct (arrows).
Pathology. The pathology of sclerosing cholangitis is character-

ized by a fibrosing inflammation of the biliary tree resulting in diffuse
thickening of the bile duct wall, which if severe enough leads to
obstruction of the lumen.32,236,345 There are alternating areas of focal
narrowing and ductal dilatation.94,197,227 On microscopic examination
there is dense fibrosis, sparse mixed inflammatory cell infiltration, and
a relatively intact epithelium. These findings are nonspecific, and the
diagnosis cannot be based solely on a biopsy specimen.197 Because of
periductal fibrosis, ductal dilatation is not prominent even with high-
degree obstruction. PSC involves the intrahepatic and extrahepatic
ducts. In 20% of patients, the disease is confined to the intrahepatic
and hilar ducts. The gallbladder is involved in 40% of patients.
Imaging findings. Cholangiogram has long been the gold stan-
dard for the diagnosis of PSC. Multiple segmental strictures involving
the intra- and extrahepatic bile ducts are hallmarks of the disease and
characteristic findings (Fig. 42-38). The abnormality is not uniform
along the bile ducts. A normal or less-involved segment alternating
FIG 42-34 Recurrent pyogenic cholangiohepatitis. CT obtained during with strictures produces the classic “beaded” appearance (Fig. 42-39).
the arterial phase shows thickening and enhancement of the bile
The length of a stricture can range from 1 to 2 mm to several centi-
ducts (arrows) and stones in the common bile duct. Note the hetero-
meters. When the peripheral bile ducts are obliterated, the bile ducts
geneous enhancement of the hepatic parenchyma and periductal
enhancement. have a pruned-tree appearance (see Fig. 42-38). The bile duct wall is
irregular, from a fine brush border to a coarse, shaggy, or nodular
appearance (see Fig. 42-39). Sometimes there are small diverticula.
Thus the combination of short focal strictures and dilatations, beading,
cholangiocarcinoma. Liver transplantation is the only effective life- pruning, and mural irregularities are typical for PSC.
extending treatment for advanced PSC. The disease is much more MRCP has merit in depicting bile duct involvement patterns of
common in northern Europe and the United States than elsewhere, alternating strictures and dilatations of the entire biliary tree (see
with the age-adjusted incidence in the United States being 1.25 per Fig. 42-39).105,145 In addition to the advantage of noninvasiveness, MR
100,000 men and 0.54 per 100,000 women10; it is exceedingly rare in cholangiography can demonstrate abnormal bile ducts proximal to
Asian populations. Approximately 70% of the patients are male, and the completely obstructed segment that cannot be demonstrated by
70% have ulcerative colitis. cholangiography.
A B
FIG 42-35 A, Multiple liver abscesses (arrows) in a patient with recurrent pyogenic cholangitis. B, In addition
to the liver abscesses (arrows), note the small stone in the dilated segmental bile duct (arrowhead).
A B
FIG 42-36 Axial (A) and coronal (B) CT shows a markedly enlarged ampulla of Vater containing a stone that
is bulged into the duodenum (arrow in B).
Sonography and contrast-enhanced CT and MRI may show noma.231 Cholangiocarcinoma usually causes more complete obstruc-
thickening (Fig. 42-40) and contrast enhancement (Fig. 42-41) of the tion than PSC (dominant stricture), and there may be markedly dilated
bile duct wall. The thickness varies from 1 to 3 mm. Thus these bile ducts proximal to the bile duct segment involved by the cholan-
imaging techniques are helpful to determine the severity and extent of giocarcinoma. A rapidly progressing segmental stricture and proximal
disease. In some instances, cholangiographic “beading” can be seen on dilatation on serial images associated with clinical deterioration favor
contrast-enhanced CT (see Fig. 42-39). Like MRCP, CT has the advan- the presence of cholangiocarcinoma. In this regard, thin-section CT
tage of being able to visualize an obstructed segment that cannot be and MRI are helpful to assess the clinical course.
demonstrated on cholangiography.
Other imaging findings include alterations of the hepatic paren- AIDS Cholangitis. Inflammation of the bile ducts can occur in
chyma such as biliary cirrhosis, hepatic segmental atrophy and hyper- patients with acquired immunodeficiency syndrome (AIDS), owing to
trophy, portal hypertension, a dominant biliary stricture resulting in an opportunistic infection by cytomegalovirus, Mycobacterium avium-
obstructive jaundice, calculi in the gallbladder and CBD (25%-30%), intracellulare, Candida albicans, Cryptosporidium species, and Klebsi-
and a complicating cholangiocarcinoma (8%-15%).310 ella pneumoniae.35,289 Inflammation may involve the intrahepatic and
Clinical course. There is an increased incidence of cholangiocar- extrahepatic ducts as well as the duodenal papillae, resulting in papil-
cinoma in patients with PSC.310 In a series of patients undergoing liver lary stenosis. Cholangiogram shows irregularities and stricture of the
transplantation for PSC, 10% were found to have cholangiocarcinoma intrahepatic and extrahepatic bile ducts with associated bile duct dila-
in their native livers.129 When the two diseases coexist, the ductal tation. Papillary stenosis often occurs in conjunction with proximal
abnormality of PSC can easily mask the presence of cholangiocarci- duct stricture. Tiny polypoid intraductal defects due to granulation
A B
FIG 42-37 Papillary stenosis due to repeated passage of stones. A, ERCP shows dilatation of the extrahe-
patic ducts. There is normal contraction of the sphincter of Oddi at the end of the common bile duct (arrow).
B, CT shows a normal-sized duodenal papilla (arrow).
A B
FIG 42-38 Primary sclerosing cholangitis. A, ERCP shows multisegmental or diffuse narrowing and proximal
dilatation of the intra- and extrahepatic bile ducts. Peripheral ducts have a “pruned tree” appearance.
B, Contrast-enhanced CT shows diffuse thickening of the wall of the intra- and extrahepatic bile ducts
(arrows). Also note thickening of the gallbladder wall.
B C
FIG 42-39 Primary sclerosing cholangitis. A, MR cholangiogram shows innumerable foci of focal or seg-
mental narrowing or dilatation of the intrahepatic bile ducts, with a “beaded” appearance and obliteration of
the extrahepatic duct (arrow). B and C, CT shows peripheral bile duct narrowing and dilatation, with scattered
segments of peripheral duct dilatation. Note obliteration of the lumen of the extrahepatic duct due to severe
thickening of the wall (arrow in C).
tissue can also be observed.62,241 CT and sonography may demonstrate

wall thickening of the bile duct and gallbladder. A small nodule may
be seen at the distal end of the CBD, reflecting inflammation and
edema of the papilla of Vater.73
Parasitic Diseases
Biliary parasitic diseases include clonorchiasis, opisthorchiasis, fascio-
liasis, and ascariasis. These diseases are prevalent in East and Southeast
Asia but rare in the United States and Western Europe. C. sinensis and
O. viverrini are human liver flukes acquired through ingestion of raw
freshwater fish harboring metacercariae; Fasciola hepatica is a sheep
liver fluke and humans are infected accidentally. Adult flukes live in the
bile ducts and produce a mechanical obstruction, mucosal inflamma-
tion, adenomatous hyperplasia, and periductal fibrosis (Fig. 42-42).
Infection with C. sinensis and O. viverrini produces diffuse and
uniform dilatation of the peripheral IHD, with no or minimal dilata-
FIG 42-40 Primary sclerosing cholangitis. Sonogram shows the thick- tion of the extrahepatic ducts and without a focal obstructing lesion
ened wall of the extrahepatic bile ducts (arrows). along the bile ducts208,215 (Fig. 42-43). This occurs because the flukes
A B
FIG 42-41 A and B, Primary sclerosing cholangitis involving segmental intrahepatic bile ducts and extrahe-
patic ducts, with thickening of the bile duct wall and intense enhancement (arrow in B). The gallbladder wall
is also thickened and enhanced.
stone formation are frequent complications of clonorchiasis. Intra-

ductal inflammation, increased mucin, and mechanical obstruction by
the flukes and their eggs cause bile stasis, which provides a favorable
environment for bacterial infection. The eggs and bacteria serve as nidi
for pigment stone formation.208 A carcinoma may arise from the intra-
hepatic and extrahepatic bile ducts as a complication of long-standing
fluke infection (Figs. 42-46 and 42-47). Chronic inflammatory changes
and adenomatous hyperplasia of the biliary mucosal epithelium may
transform into dysplasia and cholangiocarcinoma.46,53,319
F. hepatica is a trematode that infects cattle and sheep; humans
are accidental hosts. Infection is caused by ingestion of raw aquatic
plants contaminated with metacercariae, which later penetrate the
intestinal wall and migrate through the peritoneal cavity to the liver.
After penetrating Glisson’s capsule, the flukes migrate randomly
through the liver parenchyma (hepatic stage) and enter the bile ducts,
where they mature and release eggs (biliary stage). Hepatic fascioliasis
manifests as clusters of microabscesses, usually in the subcapsular
FIG 42-42 Clonorchis sinensis in the bile duct. Photomicrograph from regions, arranged in a characteristic serpentine fashion resembling
a rabbit liver experimentally infected with C. sinensis shows adult flukes “tunnels and caves”36,121,270,156,281 (Fig. 42-48). A large cystlike necrotic
in the bile duct. Note adenomatous hyperplasia of the mucosa (short lesion may also be observed. Imaging findings of biliary fascioliasis
arrows) and periductal fibrosis (long arrows). (Hematoxylin-eosin; ×40.)
are more or less the same as for clonorchiasis, with bile duct dilata-
tion and intraductal flukes appearing as echogenic foci on ultrasono-
grams and as filling defects on cholangiograms (Fig. 42-49) and MR
reside in the small IHDs. This characteristic pattern of the biliary cholangiograms.
tree—apparent on cholangiography, CT, and MR cholangiography— The intestinal roundworm Ascaris lumbricoides is 15 to 30 cm long
is not encountered in other bile duct diseases such as cholangitis, and 3 to 5 mm thick and resides in the human small intestine. Occa-
bile duct stone, or tumor.48,49,55,71,72,208,215 Adult flukes in the bile ducts sionally worms migrate through the papilla of Vater into the biliary
can be demonstrated on cholangiography (Fig. 42-44) and MR chol- tree, resulting in bile duct obstruction, cholangitis, and pancreatitis.
angiography (Fig. 42-45) as small, linear, elliptical or leaflike filling The long worm is seen as a filling defect on cholangiograms or MR
defects measuring 2 to 10 mm long.208,215 The worms and their aggre- cholangiograms137,191 (Fig. 42-50).
gates in the bile duct lumen, in association with the inflammatory
reaction,55,72,208,215 impede contrast opacification of the peripheral ducts Bile Duct Strictures
(see Fig. 42-44). A benign bile duct stricture may affect the intrahepatic or extrahepatic
Because of long-standing inflammation and fibrosis, the bile duct ducts or both. Common causes of benign strictures are inflammatory
wall is thickened. CT may show the enhancing wall of the bile ducts. and iatrogenic. PSC and recurrent pyogenic cholangitis are the most
The gallbladder may be distended. In heavy infection the branch ducts common causes of an inflammatory stricture. An iatrogenic bile duct
of the tail of the pancreas are dilated, as in the liver.216 injury is most often caused by surgery such as a cholecystectomy, CBD
Once infection occurs the flukes can live in the biliary tree for exploration, T-tube indwelling in the CBD, endoscopic papillotomy, or
decades. Peripheral intrahepatic dilatation persists for a long time, even liver transplantation.150 A laparoscopic cholecystectomy predisposes to
after the flukes are eradicated spontaneously or by the administration bile duct injury because the CBD may be mistaken for the cystic duct.
of anthelmintic drugs. Recurrent pyogenic cholangitis and bile duct Thermal injury to the bile duct can occur during radiofrequency
A B
FIG 42-43 Mild clonorchiasis infection. A and B, CT shows mild dilatation of the peripheral intrahepatic bile
ducts, without dilatation of the central duct (arrow in B).
FIG 42-44 Clonorchiasis. Endoscopic retrograde cholangiogram shows

innumerable small elliptical filling defects in the bile ducts, representing
adult Clonorchis sinensis. Filling of the peripheral duct is impeded by
flukes (arrowheads). The intrahepatic ducts are dilated, but the extra-
hepatic bile ducts are not.
FIG 42-46 Clonorchiasis and cholangiocarcinoma of the common
hepatic duct. Endoscopic retrograde cholangiogram shows markedly
dilated intrahepatic bile ducts containing multiple elliptical filling defects
due to adult flukes of Clonorchis sinensis. Arrows point to the segment
of cholangiocarcinoma.
FIG 42-45 Severe clonorchiasis. MRI shows severe dilatation of the

intrahepatic bile ducts up to the periphery of the liver. Adult flukes are
visible in the bile ducts (arrows).
FIG 42-47 Peripheral cholangiocarcinoma (arrow) in a patient with clo-

norchiasis, which has caused dilatation of the peripheral bile ducts.
A
B
FIG 42-50 Biliary ascariasis. Endoscopic retrograde cholangiogram
FIG 42-48 Hepatic fascioliasis. CT shows multiple small, clustered, (A) and MRCP (B) show a long convoluted filling defect in the extrahe-
necrotic lesions in the subcapsular area arranged as “tunnels and patic ducts representing adult Ascaris lumbricoides. (Courtesy So Yeon
caves.” Kim, MD, Ulsan University Medical School, Seoul, Republic of Korea.)
ablation for hepatic tumors173 (Fig. 42-51). Blunt abdominal trauma

may result in injury to the duodenum and extrahepatic bile ducts.
For a biliary stricture with a benign cause, the stenotic segment
shows minimal wall thickening, making it difficult to see on CT or MRI
(Fig. 42-52). The stenotic segment is abrupt and short, measuring less
than 1 cm. In contrast, for periductal-infiltrating cholangiocarcinoma,
the involved bile duct wall is thicker than 2 mm and enhances intensely
after contrast administration.
In PSC, there are multiple sites of stricture and normal or dilated
segments, resulting in a beaded appearance. In recurrent pyogenic
cholangitis, branching points of lobar and segmental bile ducts are
the common sites of stricture; this is where the stones tend to lodge,
causing irritation and inflammation at the branching points, resulting
in fibrosis and stricture. Common sites are the lateral segmental bile
duct of the left hepatic lobe (Fig. 42-53), posterior segmental bile duct
of the right hepatic lobe (Fig. 42-54), and bifurcation of the right and
FIG 42-49 Biliary fascioliasis. Endoscopic retrograde cholangiogram left hepatic ducts (see Figs. 42-11 and 42-29).
shows two elliptical filling defects in the common bile duct representing A focal stricture of the CBD occurs in approximately 0.5% of cho-
adult Fasciola hepatica. (Courtesy Cheol Min Park, MD, Korea University lecystectomy patients.128 This complication occurs when the cystic duct
Medical School, Seoul, Republic of Korea.) is clamped and ligated and the CBD is inadvertently incorporated into
the ligatures, causing injury.66 Clinical manifestations including jaun- the more proximal duct. A delayed common duct stricture has been
dice may appear within a week, months, or years, depending on the reported after blunt abdominal trauma. The injury results in a short
severity of the bile duct damage. CT reveals severely dilated IHDs, with segmental tight stricture with concentric or eccentric involvement and
the degree of dilatation depending on the severity of the bile duct proximal dilatation.
obstruction. At the hepatic hilum there is an abrupt transition from
the dilated bile ducts to the normal extrahepatic ducts, where there is Neoplasms of the Biliary System
a short segmental tight stricture (Fig. 42-55). A coronal reconstruction Benign Tumors of the Bile Ducts
image better shows the stenotic segment. A biliary stricture caused by Bile duct hamartoma. Bile duct hamartoma, also known as von
injury to the anastomotic site during liver transplantation typically Meyenburg’s complex, is a focal disorderly collection of bile ducts and
occurs at the proximal part of the extrahepatic duct. The degree of ductules surrounded by abundant fibrous stroma.60,131 There is usually
stenosis varies from mild stenosis without bile flow impairment a centrally located small cystic lesion lined by a single layer of biliary
(Fig. 42-56) to a tight stricture and complete obstruction of bile flow epithelium that does not communicate with the biliary tree.256 The
(Fig. 42-57). lesions are 0.1 to 1.5 cm in diameter and are scattered diffusely in the
A biliary stricture caused by blunt abdominal trauma occurs in liver parenchyma.
the suprapancreatic portion of the CBD.352 The CBD is susceptible to CT shows multiple or innumerable hypoattenuating cystlike
disruption from deceleration injuries, usually at the level of the pan- hepatic nodules, typically less than 1.5 cm in diameter, occurring
creaticoduodenal junction, where it is relatively fixed compared with throughout both lobes of the liver256 (Fig. 42-58). MRI shows tiny
FIG 42-51 Bile duct stricture caused by thermal injury during radiofre- FIG 42-53 Tight stricture (arrow) at the left hepatic duct in a patient
quency ablation for hepatocellular carcinoma. CT shows severe dilata- with recurrent pyogenic cholangitis. Note stones in the left hepatic duct
tion of the posterior segmental bile ducts abutting the necrotic nodule. proximal to the stricture site.
A B
FIG 42-52 Bile duct stricture due to recurrent pyogenic cholangitis and fibrosis. A, Cholangiogram shows
a tight stricture at the bifurcation (arrow). Note several stones in the extrahepatic duct. B, CT shows tight
narrowing and wall thickening at the bifurcation (arrow).
hypointense lesions on T1-weighted images and strongly hyperintense varying length, it produces a large amount of mucus, resulting in
lesions on T2-weighted images (Fig. 42-59). Contrast-enhanced CT or nonobstructive dilatation of the entire biliary tree.7 This tumor has
MRI may show homogeneous enhancement of the lesions256,300,309 (see great potential for malignant transformation (see Fig. 42-61).261
Fig. 42-59). Biliary cystadenoma and cystadenocarcinoma. Benign and
Bile duct adenoma. A solitary adenoma appears as a well- malignant cystic tumors of bile duct origin can occur in the IHDs of
circumscribed wedgelike mass less than 1 cm in diameter. The gallblad- the liver or rarely in the extrahepatic ducts. These tumors occur in
der is the most frequent site; these tumors are rare along the bile ducts. adults, with a strong middle-aged female predominance. The usually
A villous adenoma can occur at the duodenal papilla (Fig. 42-60). single tumor is covered by a fibrous capsule and is unilocular or
Biliary papillomatosis. Biliary papillomatosis is a papillary or multilocular, containing mucinous or serous fluid.18 A cystadenoma is
villous tumor in the intrahepatic or extrahepatic bile ducts showing lined by a single layer of cuboidal or tall columnar mucin-producing
cytologic and histologic atypia, though not enough for a diagnosis of cells, and a cystadenocarcinoma is lined by intestinal-type mucosa
malignancy.268 Papillary fragile tumors are seen on the inner surface of (including goblet cells and Paneth cells) associated with varying
the biliary tree; there may be multiple tumors or they may spread dif- degrees of atypia and mitotic activity.18 Benign and malignant compo-
fusely along the biliary tree261 (Figs. 42-61 and 42-62). The tumor does nents may coexist. There is usually no communication between the
not cause biliary obstruction; although it spreads superficially for a cystic tumor and the bile ducts.
A biliary cystadenoma appears as a solitary cystic mass possessing
a well-defined fibrous capsule containing clear fluid. The fibrous
capsule may not be evident when the mass is covered by the liver
FIG 42-54 Stricture of bile duct in recurrent pyogenic cholangitis. The

posterior segmental branch of the right hepatic duct is missing (“missing FIG 42-56 Mild bile duct stricture (arrow) at the site of anastomosis
duct” sign; long arrow). Note two stones in the anterior segmental bile after liver transplantation. There are many stones and debris in the bile
duct (short arrows). ducts proximal to the stricture.
A B
FIG 42-55 Iatrogenic stricture of the common hepatic duct after cholecystectomy. A, CT shows intrahepatic
bile duct dilatation and abrupt stricture at the confluence of the rigid hepatic duct (arrow). B, Cholangiogram
shows complete obstruction at the bifurcation (arrow).
A B
C
FIG 42-57 Bile duct stricture at the site of anastomosis in a liver transplant patient. A and B, CT shows
fibrous thickening of the anastomosis site (arrow) between the dilated intrahepatic ducts and the extrahepatic
duct. C, ERCP shows the tight stricture at the anastomosis site (arrow).
parenchyma. Usually the cystic tumor is multiloculated, divided by

thin uniform curvilinear septa, and measures 1 mm or less. Sometimes
it is barely visible30,31,52,98,101,189,256,259 (Fig. 42-63). There may be multiple
daughter cysts inside (Fig. 42-64). When the septa are very thin, sonog-
raphy is better than CT or MRI for depicting them. In some cystadeno-
mas, there is no septum or daughter cyst and differentiation from a
simple hepatic cyst is impossible (Fig. 42-65). There may be calcium
deposits in the fibrous capsule or septa. The contents of the cystic
tumor can be serous or mucinous fluid, thus attenuation on CT and
signal intensity on MRI may be different depending on the contents
of the individual loculations (see Fig. 42-64). Papillary areas or polyp-
oid mural nodules in the cyst wall or septa have been reported256 but
are rare with cystadenoma.
A biliary cystadenocarcinoma presents as a single cystic mass
covered by a thick capsule; it contains multiple thick septa, mural
nodules, and polypoid or fungating tumors attached to the cyst wall
FIG 42-58 Biliary hamartomas. CT shows many small cystic lesions or septa213 (Fig. 42-66). Coarse thick septal or capsular calcifications
scattered throughout the liver parenchyma. are more frequent in cystadenocarcinoma189 than in cystadenoma
A B
C
FIG 42-59 Biliary hamartomas (von Meyenburg’s complex). A, T2-weighted image shows innumerable tiny
high-signal-intensity nodules and cystic lesions in the liver. On T1-weighted (B) and gadolinium-enhanced (C)
images, the number of lesions is markedly decreased, suggesting that many of the nodules are enhanced
and isoattenuating to the liver parenchyma.
FIG 42-60 Adenoma of the ampulla of Vater. CT shows a 1-cm mass

(arrow) at the ampulla of Vater that has bulged into the duodenum.
FIG 42-61 Biliary papillomatosis. MRI shows innumerable tiny papillary

tumors in the surface of the dilated intrahepatic bile ducts (arrows). Foci
of carcinoma in situ were found on pathologic examination.
(Fig. 42-67). The septa and mural nodules are typically enhanced on Other benign tumors. A plexiform neurofibroma may involve the
contrast-enhanced CT or MRI. Thin or thick septa are clearly visible biliary tract, forming a branching mass along the intrahepatic and
on sonography. Various CT attenuation or MR signal intensities are extrahepatic bile ducts, surrounding the bile ducts and portal
seen on both T1- and T2-weighted images, depending on the presence veins, or sometimes forming an intraductal mass159,206 (Fig. 42-69).
of solid components, hemorrhage, and protein content.256 Hamartomas, granulosa cell tumors, heterotopic gastric or pancreatic
A cystadenoma arising from the extrahepatic ducts is rare, account- mucosal rests, and adenomyomas (Fig. 42-70) may appear as intralu-
ing for less than 10% of biliary cystadenomas. The most common minal or intramural masses.163 Traumatic neuroma of the bile duct is
presentation is biliary obstruction and jaundice. As with an intrahe- not a true neoplasm but a reactive proliferation of pericholangial
patic cystadenoma, an extrahepatic cystadenoma or cystadenocarci- nerve tissue caused by cholecystectomy (Fig. 42-71), liver transplanta-
noma appears as a uniloculated or multiloculated cystic mass with tion, or blunt trauma, resulting in bile duct stricture and proximal
internal septa and mural nodules in the extrahepatic ducts180,273 (Fig. dilatation.134,244,304
42-68). A choledochal cyst, especially a choledochal diverticulum or
choledochocele, can be differentiated based on the presence of septa Malignant Tumors of the Bile Ducts
or a multiloculated shape. There is no communication between the Cholangiocarcinoma. Cholangiocarcinoma is the most common
cystic tumor and the bile duct.273 malignant tumor arising from the epithelium of the bile ducts. It is
much less common than hepatocellular carcinoma, accounting for 5%
to 30% of all primary hepatic malignancies.290 The peak age is in the
sixth to seventh decades. Hilar cholangiocarcinoma is the most
common lesion, accounting for 53% to 67% of cases, with peripheral
intrahepatic cholangiocarcinoma accounting for 6% to 25% of cases
FIG 42-62 Biliary papillomatosis. Cholangiogram shows multiple small FIG 42-63 Biliary cystadenoma. CT shows a large oval cyst containing
flat papillary tumors along the proximal extrahepatic duct. barely visible septa and small daughter cysts.
A B
FIG 42-64 Biliary cystadenoma. A and B, CT shows curvilinear thin septa and daughter cysts. The attenu-
ation value of cysts differs depending on the hemorrhage and protein content.
and extrahepatic cholangiocarcinoma accounting for 22% to 27% of

cases.262 The majority of cholangiocarcinomas are adenocarcinomas,
regardless of location.151,340 This tumor has a tendency to spread along
the bile duct walls,17 and periductal tissue invasion is common. Mucin
stains are nearly always positive, with mucin production often being
abundant.17,260,340 Predisposing conditions include PSC, biliary para-
sitic diseases such as long-standing C. sinensis or O. viverrini infection,
recurrent pyogenic cholangitis with intrahepatic stones, Thorotrast
exposure, and congenital biliary anomalies such as choledochal cyst
and Caroli’s disease.17,151
Based on growth characteristics, cholangiocarcinomas are classi-
fied as mass-forming, periductal-infiltrating, and intraductal-growing
types210,218,224 (Figs. 42-72 and 42-73). A mass-forming cholangiocarci-
noma arises from the mucosa of the bile ducts, grows into the lumen,
and invades and penetrates the bile duct wall; it thus grows three
dimensionally to a certain size. As the intraluminal tumor occludes the
lumen, the bile duct is obstructed.
FIG 42-65 Biliary cystadenoma. CT shows a unilocular cyst with com-
In contrast to the mass-forming type, a periductal-infiltrating chol-
pression of a segmental bile duct. angiocarcinoma tends to spread along the bile duct wall and periductal
A B
C D
FIG 42-66 Biliary cystadenocarcinoma. CT (A), MRIs (B and C), and a sonogram (D) show a large unilocular
cyst containing thick septa and multiple daughter cysts and solid components. Note the thick irregular
capsule.
A B
C
FIG 42-67 Biliary cystadenocarcinoma. Sonogram (A), CT (B), and MRI (C) show an oval unilocular cyst
containing a solid mass with an irregular surface. Note the punctate calcific focus and thick irregular wall
(arrows in B).
A B
C
FIG 42-68 Cystadenoma of the extrahepatic duct. Sonogram (A), MR cholangiogram (B), and cholangiogram
(C) show an ovoid cystic lesion producing balloon-like expansion of the extrahepatic duct. Note the thin wall
between the cyst and the bile duct (arrow in A); there is no communication between them. (Courtesy Dong
Ho Lee, MD, Kyung Hee University Medical School, Seoul, Republic of Korea.)
A B
FIG 42-69 Neurofibroma of the bile ducts in a patient with neurofibromatosis. CT (A) and MR cholangiogram
(B) show an intraductal mass (arrow) causing obstruction of the right and left hepatic ducts. (Courtesy Jun
Woo Lee, MD, Pusan National University Medical School, Pusan, Republic of Korea.)
A B
FIG 42-70 Adenomyoma of the distal common bile duct. A, CT shows a well-marginated mass in the ampul-
lary region (arrow). B, Cholangiogram shows a mass between the common bile duct and duodenum (arrows).
A B
FIG 42-71 Traumatic neuroma of the common bile duct after cholecystectomy. Coronal CT (A) and MR
cholangiogram (B) show an eccentric mass in the common bile duct at the site of resection of the cystic
duct (arrow). (Courtesy Yong Yeon Jeong, MD, Chonnam University Medical School, Guangju, Republic of
Korea.)
tissue.210,218,224,260,340 Occasionally a substantial tumor extends beneath by concentric thickening of the bile duct wall for a variable
the intact mucosal epithelium.340 Thus the tumor grows longitudi- length17,210,217,218,340; it does not produce a sizable mass.
nally and extends along the axis of the bile duct like the branch of a Intraductal-growing cholangiocarcinoma grows into the lumen
tree.217 The bile duct lumen is diffusely narrowed or completely obliter- then spreads superficially along the mucosal layer.122 Tumor cells
ated. An extrahepatic periductal-infiltrating tumor is characterized are confined to the mucosal layer and do not invade deep to the
submucosal layer. In contrast to mass-forming and periductal-
infiltrating cholangiocarcinomas, the bile duct lumen is not completely
CHOLANGIOCARCINOMA obstructed.210,218
The prognosis of mass-forming and periductal-infiltrating chol
angiocarcinomas is generally unfavorable; intraductal-growing
cholangiocarcinoma has a much better prognosis after surgical resec-
tion.140,210,295,349 Precise information about tumor location, extent,
growth pattern, and staging is mandatory for optimal treatment plan-
ning and for a prediction of prognosis. Surgical resection should be
individually tailored depending on the morphologic type and the stage
A of the tumor.
Peripheral intrahepatic and hilar cholangiocarcinomas.
Intrahepatic cholangiocarcinomas include peripheral and hilar chol-
angiocarcinomas. The vast majority of peripheral cholangiocarci
nomas are the mass-forming type, whereas the majority of hilar
cholangiocarcinomas are the periductal-infiltrating type.50 Clinically,
intrahepatic peripheral cholangiocarcinoma usually presents with
nonspecific abdominal symptoms, whereas hilar cholangiocarcinoma
B
presents with jaundice because of large bile duct obstruction.
Mass-forming type. A mass-forming intrahepatic cholangiocar-
cinoma is usually sizable, and the tumor does not cause clinical symp-
toms in its early stages. Grossly the tumor is firm and whitish gray
because of abundant fibrous stroma.17 The margin is well circum-
scribed and wavy or lobulated. There may be central necrosis.290 Satel-
lite tumors, especially around the main tumor, are common. These
C satellite tumors occur owing to the tumor’s propensity to invade the
FIG 42-72 Morphologic classification of cholangiocarcinoma. Tubules adjacent peripheral branches of the portal vein.17,210,217,224
represent bile ducts. Drawings show mass-forming (A), periductal- The most common appearance of a peripheral intrahepatic chol-
infiltrating (B), and intraductal-growing (C) cholangiocarcinomas. (From angiocarcinoma on imaging is a well-defined single hypovascular mass
Kimura K, et al: Association of gallbladder carcinoma and anomalous with wavy borders50,54,132,140,210,218,340 (Fig. 42-74). Owing to intrahepatic
pancreaticobiliary ductal union. Gastroenterology 89:1258–1265, 1985.) metastasis via the portal vein, satellite or daughter nodules are frequent
A B
C D
FIG 42-73 Mode of spread of cholangiocarcinoma. Drawings show mucosal (A), mass-forming (B), periductal-
infiltrating (C), and intraductal-growing (D) cholangiocarcinoma.
A B
FIG 42-74 Peripheral cholangiocarcinoma. A, CT during the arterial phase shows a lobulated mass with a
well-enhancing periphery and a heterogeneously enhancing center. Note a small satellite tumor (arrow).
B, CT during the delayed phase shows the same mass, but it appears much smaller because of gradual
enhancement from the periphery.
reflecting fibrosis; this is helpful in making the distinction from a

metastatic tumor.47,50,119 On dynamic MRI the enhancement pattern is
the same as on dynamic CT.
Hilar and peripheral mass-forming cholangiocarcinomas may
appear the same on imaging, except for the presence of IHD dilata-
tion.51,317 Most hilar cholangiocarcinomas result in obstruction of the
right and left hepatic ducts, and there may be a mass that overrides
and separates the bile ducts.51,123,317
Periductal-infiltrating type. Periductal-infiltrating cholangio-
carcinoma grows along the bile ducts and produces diffuse thickening
of them (Fig. 42-78); it is therefore difficult or impossible to depict the
discrete tumor mass.50,51,120,123,210,218,317 The involved bile duct becomes
narrow for a varying length, resulting in eventual obstruction. The
majority of hilar cholangiocarcinomas are of the periductal-infiltrating
type pathologically, but this type of lesion is not commonly seen in the
periphery of the liver.
On imaging, the involved bile ducts are obliterated or diffusely
narrow, whereas the bile ducts proximal to the cholangiocarcinoma
FIG 42-75 Multiple intrahepatic cholangiocarcinomas due to
are dilated210,218 (Fig. 42-79). Nonunion of the right and left hepatic
metastases.
ducts with or without a visibly thickened wall is a typical finding of
an infiltrating hilar cholangiocarcinoma (see Fig. 42-79).51,123,317 On
cholangiography the lumen may be completely obstructed or markedly
and vary in size165,210 (Fig. 42-75). On contrast-enhanced CT or MRI, narrowed. A stringlike severely narrowed bile duct may be visualized.120
thin or thick rimlike enhancement is frequently seen around the Hilar cholangiocarcinoma is often associated with lobar or segmental
periphery of the tumor on arterial-phase images, and there is gradual hepatic parenchymal atrophy, probably because of portal vein invasion
centripetal enhancement on delayed-phase images132,165,316 (Fig. 42-76; and occlusion and decreased portal flow or because of long-standing
see Figs. 42-74 and 42-75). The entire mass may be enhanced only on dilatation of the bile ducts and diversion of the portal flow.34,323 There
delayed-phase images some hours after contrast administration (Fig. are combined mass-forming and periductal-infiltrating cholangiocar-
42-77). These findings reflect the nature of the tumor, which is mainly cinomas353 (Fig. 42-80).
desmoplastic. Depending on the cellular and fibrous components, the Intraductal-growing type. Intraductal tumors are usually nod-
central part of the mass may be enhanced homogeneously or hetero- ular or castlike, often spreading superficially along the mucosal surface
geneously. Sometimes there is septum-like enhancement.165 Occasion- and resulting in multiple tumors (papillomatosis or papillary carcino-
ally the hepatic vein traverses the central part of the mass undisturbed.165 matosis) along varying segments of the bile ducts.122,174,200,210,218,219,261
Capsular retraction is relatively frequent (see Fig. 42-76).122,165 Bile duct The intraductal-growing type accounts for 8% to 18% of cholangio-
dilatation peripheral to the tumor is common. However, the bile ducts carcinomas.200 The majority of intraductal-growing cholangiocarcino-
may not be dilated even if the tumor arises from one of the IHDs.165,210 mas are papillary adenocarcinomas,174,200,219,353 comprising innumerable
On MRI the tumor is hypointense on T1-weighted images and frondlike infoldings of the proliferated columnar epithelial cells and
hyperintense on T2-weighted images (see Fig. 42-76), without a slender fibrovascular cores.219 Infrequently an intraductal tumor may
capsule. Central hypointensity may be seen on T2-weighted images, be papillotubular or purely tubular. The bile ducts are dilated
A B
C
FIG 42-76 MRI of peripheral cholangiocarcinoma. There is a well-defined lobulated mass with a dimple at
the surface (arrow). The mass is of low signal intensity on the T1-weighted image (A) and of high signal
intensity on the T2-weighted image (B). The central part is enhanced in the equilibrium phase (C), reflecting
the presence of massive fibrosis.
A B
C D
FIG 42-77 Contrast enhancement of peripheral cholangiocarcinoma. T1-weighted images before gadolinium
administration (A) and immediately (B), 5 minutes (C), and 3 hours (D) after gadolinium injection. In the arte-
rial phase the peripheral part is enhanced. In the delayed phase the central part is gradually enhanced and
eventually greatly enhanced.
secondary to incomplete obstruction by tumor, by sloughed tumor

debris, or by an excessive amount of mucin.174,219 The lobar or segmen-
tal bile ducts are dilated diffusely, somewhat reminiscent of bronchi-
ectasis in the lung, or aneurysmally, depending on bile duct obstruction
and the amount of mucin production.122
On imaging, the bile ducts of the involved hepatic segment or lobe
are dilated.122 An intraductal tumor can appear as a polypoid mass in
the lumen of the dilated bile ducts (Fig. 42-81). Frequently intraductal
tumors fill multiple segmental or subsegmental bile ducts. The mass is
confined within the bile ducts, leaving the wall of the bile duct intact.
The outer margin of the thickened bile duct wall is smooth and clear.
The tumor may not be seen on imaging when it is small and isoattenu-
ating to the adjacent hepatic parenchyma or when the complex orien-
tation of the dilated bile ducts obscures the presence of the mass. On
ERCP or percutaneous transhepatic cholangiography, the involved
biliary tree is dilated secondary to partial obstruction and there are
filling defects due to the papillary tumors. There may be fine irregulari-
FIG 42-78 Periductal-infiltrating intrahepatic cholangiocarcinoma. ties, a velvety or serrated contour along the bile ducts, representing the
Cancer has spread along the intrahepatic bile ducts (arrows). papillary surface of the tumor.174,219
A B
FIG 42-79 A and B, Periductal-infiltrating cholangiocarcinoma involving the intra- and extrahepatic ducts.
Note the ill-defined mass involving the right and left hepatic ducts (arrows in A) and the encircling and
thickening of the extrahepatic ducts (arrows in B), obliterating the lumen of the bile duct.
A B
FIG 42-80 A and B, Combined mass-forming and periductal-infiltrating cholangiocarcinoma showing a
large ill-defined irregular mass (arrows) involving the hilum of the liver and wall thickening along the extra-
hepatic duct.
Extrahepatic cholangiocarcinoma. Cholangiocarcinoma can

develop in any part of the extrahepatic duct, with 50% to 75% of
reported cases occurring in the upper third of the duct, including the
hepatic hilum, 10% to 25% of cases occurring in the middle third of
the duct, and 10% to 20% of cases occurring in the lower third of the
duct.4,84 Approximately 95% of patients have extrahepatic bile duct
obstruction at the time of diagnosis.79 Involvement of the periductal
lymphatics, nerves, and perineural tissue is frequent.17 Infiltration to
the adjacent arteries and veins and lymph node metastasis are relatively
common.
Mass-forming or nodular type. The tumor forms a nodule that
is usually 1 to 2 cm in diameter210,217,218 (Fig. 42-82). The tumor
obstructs the bile duct lumen, penetrates the wall, and invades the
periductal tissue.340 The tumor mass is usually small at the time of
presentation because the bile ducts are occluded in the early stage of
the disease, and patients present with jaundice. Approximately 25%
of extrahepatic cholangiocarcinomas are of this type. A mass-forming
FIG 42-81 Intraductal-growing papillary neoplasm. CT shows an intra- extrahepatic cholangiocarcinoma can be easily detected on imaging
ductal polypoid mass (arrow) with bile duct dilatation. because the tumor occludes the bile duct, resulting in dilated proximal
A B
FIG 42-82 Nodular or mass-forming cholangiocarcinoma of the distal common bile duct (arrow) on CT
(A) and cholangiogram (B).
A B
FIG 42-83 Periductal-infiltrating cholangiocarcinoma. Axial (A) and coronal (B) CT images show concentric
thickening of the common hepatic duct (arrow in A) involving the upper half of the extrahepatic duct (arrow
in B).
bile ducts.13,123 However, because the mass is usually small, images opacified in cases of complete obstruction, or it may appear to be
should be carefully scrutinized. stringlike when the lumen is not completely obstructed210 (Fig. 42-84).
Periductal-infiltrating type. This type of tumor constitutes Differentiation from acute or recurrent pyogenic cholangitis may
more than 60% of extrahepatic cholangiocarcinomas. The tumor be problematic. The involved bile duct wall is thicker in cases of chol-
appears as a focal or segmental concentric thickening of the extrahe- angiocarcinoma (usually >1 mm), whereas in cholangitis the bile duct
patic ducts, with almost complete obstruction of the lumen.210,217,340 wall is thinner than 1 mm. Furthermore, the involved segment of the
The thickened wall (measuring up to 1 cm) is firm and grayish white.340 bile duct is narrowed or obliterated in cholangiocarcinoma but normal
The extent of the tumor varies, ranging from 0.5 to 6 cm in length; it or dilated in cholangitis.
may involve all the extrahepatic ducts and extend proximally as far as Intraductal-growing type. The intraductal tumor may be pol-
the IHDs. ypoid, sessile, or superficially spreading along the lumen.174,210,217,218
On CT or MRI, the thickened bile ducts can be visualized as an There may also be multiple discrete tumors (papillary cholangiocarci-
enhancing ring or spot (Fig. 42-83). It is often difficult to visualize the nomatosis) along the inner surface of the bile ducts. Usually the tumor
lesion on CT or MRI because of the absence of distinct tumor forma- is limited to the mucosa and invades the wall and surrounding tissue
tion; these imaging studies may show only focal or diffuse thickening in the very late phase.210,217,218 An intraductal papillary cholangiocarci-
of the bile duct.13,210,217,218 At the site of bile duct obstruction, the tumor noma is friable and sloughs easily by touching or rubbing at the time
border can be demonstrated as a symmetrically or asymmetrically of surgery, or it may slough spontaneously and occlude the bile ducts,
thickened bile duct wall, constituting a transition zone.298 On cholan- simulating a bile duct stone214 (Fig. 42-85). The bile ducts are dilated
giography or MR cholangiography, the involved segment may not be and incompletely obstructed by the tumor itself or by viscous mucin.
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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

CT and Mri of The Whole Body 2 Volume Set 6th Edition

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CT and MRI of the Whole Body,

2-Volume Set 6th Edition

necessary to visualize calcified stones because postcontrast CT masks

FIG 42-15 Suppurative cholangitis caused by gallbladder stone migra-

FIG 42-23 Small stone (arrows) in the common bile duct on MR

One complication of suppurative cholangitis is the occurrence of

Recurrent Pyogenic Cholangitis

FIG 42-31 ERCP in a patient with common bile duct obstruction

of patients in the intrahepatic or extrahepatic ducts or both (see Fig.

Pathology. The pathology of sclerosing cholangitis is character-

tissue can also be observed.62,241 CT and sonography may demonstrate

stone formation are frequent complications of clonorchiasis. Intra-

FIG 42-44 Clonorchiasis. Endoscopic retrograde cholangiogram shows

FIG 42-45 Severe clonorchiasis. MRI shows severe dilatation of the

FIG 42-47 Peripheral cholangiocarcinoma (arrow) in a patient with clo-

ablation for hepatic tumors173 (Fig. 42-51). Blunt abdominal trauma

FIG 42-54 Stricture of bile duct in recurrent pyogenic cholangitis. The

parenchyma. Usually the cystic tumor is multiloculated, divided by

FIG 42-60 Adenoma of the ampulla of Vater. CT shows a 1-cm mass

FIG 42-61 Biliary papillomatosis. MRI shows innumerable tiny papillary

and extrahepatic cholangiocarcinoma accounting for 22% to 27% of

reflecting fibrosis; this is helpful in making the distinction from a

secondary to incomplete obstruction by tumor, by sloughed tumor

Extrahepatic cholangiocarcinoma. Cholangiocarcinoma can

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

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

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

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