First Aid For The Usmle Step 1 2020 Thirtieth Edition

First Aid for the USMLE Step 1 2020,
Thirtieth edition
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Contributing Authors
MAJED H. ALGHAMDI, MBBS KAITLYN MELNICK, MD

Resident, Joint Program of Preventive Medicine Resident, Department of Neurological Surgery
Jeddah, Saudi Arabia University of Florida College of Medicine, Gainesville
LILIT ASLANYAN MARY KATHERINE MONTES de OCA, MD

New York Institute of Technology College of Osteopathic Medicine Resident, Department of Obstetrics and Gynecology
Class of 2020 Duke University Hospital
HUMOOD BOQAMBAR, MB BCh BAO SCOTT MOORE, DO

Assistant Registrar, Department of Orthopaedic Surgery Assistant Professor of Medical Laboratory Sciences
Farwaniya Hospital Weber State University
WEELIC CHONG VASILY OVECHKO, MD

Sidney Kimmel Medical College at Thomas Jefferson University Resident, Department of Surgery
MD/PhD Candidate Russian Medical Academy of Continuous Professional Education
KRISTINA DAMISCH VIVEK PODDER

University of Iowa Carver College of Medicine MBBS Student
Class of 2020 Tairunnessa Memorial Medical College and Hospital, Bangladesh
YUMI KOVIC, MD CONNIE QIU

Resident, Department of Psychiatry Lewis Katz School of Medicine at Temple University
University of Massachusetts Medical School MD/PhD Candidate
Image and Illustration Team
CAROLINE COLEMAN VICTOR JOSE MARTINEZ LEON, MD

Emory University School of Medicine Central University of Venezuela
Class of 2020
ALIREZA ZANDIFAR, MD
MATTHEW HO ZHI GUANG Research Fellow
University College Dublin (MD), DFCI (PhD) Isfahan University of Medical Sciences, Iran
MD/PhD Candidate
vii
FAS1_2019_00_Frontmatter.indd 7 11/14/19 4:35 PM

Associate Authors
HUZAIFA AHMAD, MD SARINA KOILPILLAI

Resident, Department of Medicine St. George’s University School of Medicine
Georgetown University Hospital/MedStar Washington Hospital Center Class of 2020
ALEXANDER R. ASLESEN LAUREN N. LESSOR, MPH, MD

Kirksville College of Osteopathic Medicine Resident, Department of Pediatrics
Class of 2020 Mercy Health – St. Vincent Medical Center
ANUP K. BHATTACHARYA, MD ROHAN BIR SINGH, MD

Resident, Mallinckrodt Institute of Radiology Fellow, Department of Ophthalmology
Washington University School of Medicine Massachusetts Eye and Ear
Harvard Medical School
ANUP CHALISE, MBBS
Resident, Department of General Surgery
Nepal Medical College and Teaching Hospital
ASHTEN R. DUNCAN, MPH

University of Oklahoma-Tulsa School of Community Medicine
Class of 2021
Image and Illustration Team
YAMNA JADOON, MD MITCHELL A. KATONA

Research Associate University of Texas Health Science Center, Long School of Medicine
Aga Khan University Class of 2020
DANA M. JORGENSON TAYLOR MANEY, MD

Chicago College of Osteopathic Medicine Resident, Department of Anesthesiology
Class of 2020 Brigham and Women’s Hospital
viii

Faculty Advisors
DIANA ALBA, MD ANTHONY L. DeFRANCO, PhD

Clinical Instructor Professor, Department of Microbiology and Immunology
University of California, San Francisco School of Medicine University of California, San Francisco School of Medicine
MARK A.W. ANDREWS, PhD CHARLES S. DELA CRUZ, MD, PhD

Professor of Physiology Associate Professor, Department of Pulmonary and Critical Care Medicine
Lake Erie College of Osteopathic Medicine at Seton Hill Yale School of Medicine
MARIA ANTONELLI, MD SAKINA FARHAT, MD

Assistant Professor, Division of Rheumatology Consulting Gastroenterologist
MetroHealth Medical Center, Case Western Reserve University State University of New York Downstate Medical Center
HERMAN SINGH BAGGA, MD CONRAD FISCHER, MD

Urologist, Allegheny Health Network Associate Professor, Medicine, Physiology, and Pharmacology
University of Pittsburgh Medical Center Passavant Touro College of Medicine
SHIN C. BEH, MD RAYUDU GOPALAKRISHNA, PhD

Assistant Professor, Department of Neurology & Neurotherapeutics Associate Professor, Department of Integrative Anatomical Sciences
UT Southwestern Medical Center at Dallas Keck School of Medicine of University of Southern California
JOHN R. BUTTERLY, MD RYAN C.W. HALL, MD

Professor of Medicine Assistant Professor, Department of Psychiatry
Dartmouth Geisel School of Medicine University of South Florida School of Medicine
SHELDON CAMPBELL, MD, PhD LOUISE HAWLEY, PhD

Professor of Laboratory Medicine Immediate Past Professor and Chair, Department of Microbiology
Yale School of Medicine Ross University School of Medicine
BROOKS D. CASH, MD JEFFREY W. HOFMANN, MD, PhD

Professor of Medicine, Division of Gastroenterology Resident, Department of Pathology
University of South Alabama School of Medicine University of California, San Francisco School of Medicine
SHIVANI VERMA CHMURA, MD CLARK KEBODEAUX, PharmD

Adjunct Clinical Faculty, Department of Psychiatry Clinical Assistant Professor, Pharmacy Practice and Science
Stanford University School of Medicine University of Kentucky College of Pharmacy
BRADLEY COLE, MD KRISTINE KRAFTS, MD

Assistant Professor of Basic Sciences Assistant Professor, Department of Basic Sciences
Loma Linda University School of Medicine University of Minnesota School of Medicine
LINDA S. COSTANZO, PhD MATTHEW KRAYBILL, PhD

Professor, Physiology & Biophysics Clinical Neuropsychologist
Virginia Commonwealth University School of Medicine Cottage Health, Santa Barbara, California
MANAS DAS, MD, MS GERALD LEE, MD

Assistant Professor, Departments of Pediatrics and Medicine
ix

KACHIU C. LEE, MD, MPH NATHAN W. SKELLEY, MD
Assistant Clinical Professor, Department of Dermatology Assistant Professor, Department of Orthopaedic Surgery
The Warren Alpert Medical School of Brown University University of Missouri, The Missouri Orthopaedic Institute
WARREN LEVINSON, MD, PhD HOWARD M. STEINMAN, PhD

Professor, Department of Microbiology and Immunology Assistant Dean, Biomedical Science Education
University of California, San Francisco School of Medicine Albert Einstein College of Medicine
JAMES LYONS, MD SUPORN SUKPRAPRUT-BRAATEN, PhD

Professor of Pathology and Family Medicine Director of Research, Graduate Medical Education
Alabama College of Osteopathic Medicine Unity Health, Searcy, Arkansas
PETER MARKS, MD, PhD RICHARD P. USATINE, MD

Center for Biologics Evaluation and Research Professor, Dermatology and Cutaneous Surgery
US Food and Drug Administration University of Texas Health Science Center San Antonio
DOUGLAS A. MATA, MD, MPH J. MATTHEW VELKEY, PhD

Brigham Education Institute and Brigham and Women’s Hospital Assistant Dean, Basic Science Education
Harvard Medical School Duke University School of Medicine
VICKI M. PARK, PhD, MS TISHA WANG, MD

Assistant Dean Associate Clinical Professor, Department of Medicine
University of Tennessee College of Medicine David Geffen School of Medicine at UCLA
SOROUSH RAIS-BAHRAMI, MD SYLVIA WASSERTHEIL-SMOLLER, PhD

Assistant Professor, Departments of Urology and Radiology Professor Emerita, Department of Epidemiology and Population Health
University of Alabama at Birmingham School of Medicine Albert Einstein College of Medicine
SASAN SAKIANI, MD ADAM WEINSTEIN, MD

Fellow, Transplant Hepatology Assistant Professor, Pediatric Nephrology and Medical Education
Cleveland Clinic Geisel School of Medicine at Dartmouth
MELANIE SCHORR, MD ABHISHEK YADAV, MBBS, MSc

Assistant in Medicine Associate Professor of Anatomy
Massachusetts General Hospital Geisinger Commonwealth School of Medicine
SHIREEN MADANI SIMS, MD KRISTAL YOUNG, MD

Chief, Division of Gynecology, Gynecologic Surgery, and Obstetrics Clinical Instructor, Department of Cardiology
University of Florida School of Medicine Huntington Hospital, Pasadena, California

Thirtieth Anniversary Foreword
Our exam experiences remain vivid in our minds to this day as we reflect on 30 years of First Aid. In 1989, our
big idea was to cobble together a “quick and dirty” study guide so that we would never again have to deal with the
USMLE Step 1. We passed, but in a Faustian twist, we now relive the exam yearly while preparing each new edition.
Like all students before us, we noticed that certain topics tended to appear frequently on examinations. So we
compulsively bought and rated review books and pored through a mind-numbing number of “recall” questions,
distilling each into short facts. We had a love-hate relationship with mnemonics. They went against our purist desires
for conceptual knowledge, but remained the best way to absorb the vocabulary and near-random associations that
unlocked questions and eponyms.
To pull it all together, we used a then “state-of-the-art” computer database (Paradox/MS DOS 4) that fortuitously
limited our entries to 256 characters. That length constraint (which predated Twitter by nearly two decades) imposed
extreme brevity. The three-column layout created structure—and this was the blueprint upon which First Aid was
founded.
The printed, three-column database was first distributed in 1989 at the University of California, San Francisco.
The next year, the official first edition was self-published under the title High-Yield Basic Science Boards Review: A
Student-to-Student Guide. The following year, our new publisher dismissed the High-Yield title as too confusing and
came up with First Aid for the Boards. We thought the name was a bit cheesy, but it proved memorable. Interestingly,
our “High-Yield” name resurfaced years later as the title of a competing board review series.
We lived in San Francisco and Los Angeles during medical school and residency. It was before the Web, and
before med students could afford cell phones and laptops, so we relied on AOL e-mail and bulky desktops. One of
us would drive down to the other person’s place for multiple weekends of frenetic revisions fueled by triple-Swiss
white chocolate lattes from the Coffee Bean & Tea Leaf, with R.E.M. and the Nusrat Fateh Ali Khan playing in the
background. Everything was marked up on 11- by 17-inch “tearsheets,” and at the end of the marathon weekend
we would converge at the local 24-hour Kinko’s followed by the FedEx box near LAX (10 years before these two
great institutions merged). These days we work with our online collaborative platform A.nnotate, GoToMeeting, and
ubiquitous broadband Internet, and sadly, we rarely get to see each other.
What hasn’t changed, however, is the collaborative nature of the book. Thousands of authors, editors, and
contributors have enriched our lives and made this book possible. Most helped for a year or two and moved on, but
a few, like Ted Hon, Chirag Amin, and Andi Fellows, made lasting contributions. Like the very first edition, the team
is always led by student authors who live and breathe (and fear) the exam, not professors years away from that reality.
We’re proud of the precedent that First Aid set for the many excellent student-to-student publications that followed.
More importantly, First Aid itself owes its success to the global community of medical students and international
medical graduates (IMGs) who each year contribute ideas, suggestions, and new content. In the early days, we
used book coupons and tear-out business reply mail forms. These days, we get many thousands of comments and
suggestions each year via our blog FirstAidTeam.com and A.nnotate.
xi

At the end of the day, we don’t take any of this for granted. Students are expected to synthesize an ever increasing
amount of information, and we have a bigger challenge ahead of us to try to keep First Aid indispensable to students
and IMGs. We want and need your participation in the First Aid community. (See How to Contribute, p. xvii.) With
your help, we hope editing First Aid will continue to be just as fun and rewarding as the past 30 years have been.
Louisville Tao Le
Boracay Vikas Bhushan
First Aid for the USMLE Step 1 Through the Years
xii

Preface
With the 30th edition of First Aid for the USMLE Step 1, we continue our commitment to providing students with
the most useful and up-to-date preparation guide for the USMLE Step 1. This edition represents an outstanding
revision in many ways, including:
50 entirely new or heavily revised high-yield topics reflecting evolving trends in the USMLE Step 1.
Reorganization of high-yield topics in Pharmacology, Endocrine, and Reproductive chapters for improved study.
Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of more than 30
medical student and resident physician authors who excelled on their Step 1 examinations and verified by a team
of expert faculty advisors and nationally recognized USMLE instructors.
Updated with 178 new and revised diagrams and illustrations as part of our ongoing collaboration with
USMLE-Rx and ScholarRx (MedIQ Learning, LLC).
Updated with 75 new and revised photos to help visualize various disorders, descriptive findings, and basic
science concepts. Additionally, revised imaging photos have been labeled and optimized to show both normal
anatomy and pathologic findings.
Updated study tips on the opening page of each chapter.
Improved integration of clinical images and illustrations to better reinforce and learn key anatomic concepts.
Improved organization and integration of text, illustrations, clinical images, and tables throughout for focused
review of high-yield topics.
Revised and expanded ratings of current, high-yield review resources, with clear explanations of their relevance
to USMLE review.
Real-time Step 1 updates and corrections can be found exclusively on our blog, www.firstaidteam.com.
We invite students and faculty to share their thoughts and ideas to help us continually improve First Aid for the
USMLE Step 1 through our blog and collaborative editorial platform. (See How to Contribute, p. xvii.)
Louisville Tao Le
St. Louis Matthew Sochat
Phoenix Vaishnavi Vaidyanathan
Bristol Sarah Schimansky
New York City Jordan Abrams
San Francisco Kimberly Kallianos
xiii

Special Acknowledgments
This has been a collaborative project from the start. We gratefully acknowledge the thousands of thoughtful
comments, corrections, and advice of the many medical students, international medical graduates, and faculty who
have supported the authors in our continuing development of First Aid for the USMLE Step 1.
For support and encouragement throughout the process, we are grateful to Thao Pham, Jinky Flang, and Jonathan
Kirsch, Esq. Thanks to Louise Petersen for organizing and supporting the project. Thanks to our publisher, McGraw-
Hill, for the valuable assistance of its staff, including Bob Boehringer, Jeffrey Herzich, and Christina Thomas.
We are also very grateful to Dr. Fred Howell and Dr. Robert Cannon of Textensor Ltd for providing us extensive
customization and support for their powerful Annotate.co collaborative editing platform (www.annotate.co), which
allows us to efficiently manage thousands of contributions. Thanks to Dr. Richard Usatine and Dr. Kristine Krafts
for their outstanding image contributions. Thanks also to Jean-Christophe Fournet (www.humpath.com), Dr. Ed
Uthman, and Dr. Frank Gaillard (www.radiopaedia.org) for generously allowing us to access some of their striking
photographs.
For exceptional editorial leadership, enormous thanks to Kathleen Naylor, Christine Diedrich and Emma
Underdown. Thank you to our USMLE-Rx/ScholarRx team of editors, Jessie Schanzle, Ruth Kaufman, Janene
Matragrano, Susan Mazik, Isabel Nogueira, Sharon Prevost, Jen Shimony, and Hannah Warnshuis. Special thanks to
our indexer Dr. Anne Fifer. We are also grateful to our medical illustrator, Hans Neuhart, for his creative work on the
new and updated illustrations. Lastly, tremendous thanks to Graphic World, especially Anne Banning, Sandy Brown,
Gary Clark, and Cindy Geiss.
Louisville Tao Le
St. Louis Matthew Sochat
Phoenix Vaishnavi Vaidyanathan
Bristol Sarah Schimansky
New York City Jordan Abrams
San Francisco Kimberly Kallianos
xiv

General Acknowledgments
Each year we are fortunate to receive the input of thousands of medical students and graduates who provide new
material, clarifications, and potential corrections through our website and our collaborative editing platform.
This has been a tremendous help in clarifying difficult concepts, correcting errata from the previous edition, and
minimizing new errata during the revision of the current edition. This reflects our long-standing vision of a true,
student-to-student publication. We have done our best to thank each person individually below, but we recognize
that errors and omissions are likely. Therefore, we will post an updated list of acknowledgments at our website, www.
firstaidteam.com/bonus/. We will gladly make corrections if they are brought to our attention.
For submitting contributions and corrections, many thanks to Raed Ababneh, Antara Afrin, Rasim Agaev, Vanya
Aggarwal, Ataa Ahmed, Hasan Alarouri, Basim Ali, Muhammad Faizan Ali, Moatasem Al-Janabi, Mohamed
Almahmodi, Chima Amadi, Arman Amin, Jacqueline Aredo, Ranya Baddourah, Daniel Badin, Nida Bajwa, Dileni
Bandarage, Jerrin Bawa, Esra Bayram, Craig Beavers, Jacqueline Bekhit, Matthias Bergmann, Stephanie Biecker,
Aaron Birnbaum, Prateek Bommu, Nathaniel Borochov, Susan Brands, Olivia W. Brooks, Meghan Brown, Stanley
Budzinski, Kevin Budziszewski, Pavel Burski, Elisa M. Cairns, Sergio Camba, Katie Carsky, Esteban Casasola,
Marielys Castro, Jesse Chait, Bliss Chang, Santosh Cherian, Heewon Choi, Charilaos Chourpiliadis, Maruf
Chowdhury, Matthew J. Christensen, Matthew Yat Hon Chung, Alexander Ciaramella, Dillon Clancy, Sofija Conic,
M. Marwan Dabbagh, Parag Das, Ketan Dayma, Elmer De Camps, Charles de Leeuw, Xavier De Pena, Christopher
DeAngelo, Elliott Delgado, Anthony DeMarinis, Stacy Diaz, Evan Dishion, Nicola Helen Duzak, Emily Edwards,
Alec Egan, Mohamed Elashwal, Osama El-Gabalawy, Matthew Eli, Awab Elnaeem, Sally El Sammak, Dylan Erwin,
Stephanie Estevez-Marin, Gray Evans, Najat Fadlallah, Aria Fariborzi, Richard Ferro, Adam Fletcher, Kimberly A.
Foley, Kyle Fratta, Samantha Friday, Nikhila Gandrakota, Siva Garapati, Nicolas Curi Gawlinski, Joanna Georgakas,
Beth Anne George, Ashley Ghaemi, E. Sophia Gonzalez, Justin Graff, Gabriel Graham, Donovan Griggs, David
Gruen, Gursewak Hadday, Jacqueline Hairston, Hunter Harrison, Gull Shahmir Hasnat, Maximillan Hawkins,
Grecia Haymee, Briana Hernandez, Robin Hilder, Tammy Hua, Derrek Humphries, Audrey Hunt, Nanki Hura,
Danny Ibrahim, Jyothik Varun Inampudi, Hnin Ingyin, Maham Irfan, Mina Iskandar, Kritika Iyer, Christina Jacobs,
Arpit Jain, Neil K. Jain, Ala Jamal, Natalie Jansen, Jordan Jay, Mohammad Jmasi, Colton Junod, Talia Kamdjou,
Filip Kaniski, Lydia Kaoutzani, Panagiotis Kaparaliotis, Srikrishna Karnatapu, Patrick Keller, Olivia Keller-Baruch,
Cameron Kerl, Ahmed Ali Khan, Sara Khan, Shaima Khandaker, Samir Khouzam, Sonya Klein, Elana Kleinman,
Andrew Ko, Soheil Kooraki, Anna Kukharchuk, Dennis Vu Kulp, Anil A. Kumar, Julie Kurek, Chloe Lahoud,
Mike Lawandy, Ramy Lawandy, Jessica Lazar, Andrea Leal-Lopez, Lynda Lee, Chime Lhatso, Christine Lin,
Benjamin Lodge, Soon Khai Low, Estefanía Henríquez Luthje, Lisa-Qiao MacDonald, Divya Madhavarapu, Mahir
Mameledzija, Keerer Mann, Rajver Mann, Nadeen Mansour, Yusra Mansour, Bridget Martinez, Ahmad Mashlah,
Rick Mathews, Amy McGregor, Alexandra & Joshua Medeiros & Fowler, Viviana Medina, Areeka Memon, Pedro
G. R. Menicucci, Ben Meyers, Stephan A. Miller, Fatima Mirza, Murli Mishra, Elana Molcho, Guarina Molina,
John Moon, Nayla Mroueh, Neha Mylarapu, Behnam Nabavizadeh, Moeko Nagatsuka, Ghazal Naghibzadeh, Alice
Nassar, Nadya Nee, Lucas Nelson, Zach Nelson, Monica Nemat, Kenneth Nguyen, Michael Nguyen, Christian
xv

Nieves, Nyia Njamfa, Ahmed Noor, Kyle Nyugen, Ahamd Obeidat, Gerald Olayan, Anndres Olson, Hasaan Omar,
Daniel Ortiz, Michael O’Shea, Zonghao Pan, Vasilis Sebastian Paraschos, Christopher Parrino, Janak Patel, Vanisha
Patel, Cyril Patra, Rita Paulis, Dmytro Pavlenko, Nancy A. Pina, Alexander Polyak, Jackeline Porto, Shannon D.
Powell, Jacob Pruett, Laith Rahabneh, Kamleshun Ramphul, Janhvi Rana, Nidaa Rasheed, Abdul Sattar Raslan,
Tomas Ream, Rashelle Ripa, Amanda Michelle Ritchie, Helio Manuel Grullón Rodríguez, Sarah Rohrig, Gessel
Romero, Alexander Rose, Rachel Rose, Erica Rubin, Areesha Saati, Jeffrey Sackey, Raza H. Sagarwala, Chhavi Saini,
Sergii Sakhno, Allie Sakowicz, Shadia Saleh, Roshun Sangani, Dhruv Sarwal, Abeer Sarwar, M. Sathyanarayanan,
Neetu Scariya, Tonio Felix Schaffert, Melissa Schechter, Kathryn Scheinberg, Emma Schnuckle, Emma Schulte,
Taylor Schweigert, Lee Seifert, Sheila Serin, Deeksha Seth, Omid Shafaat, Nirav Shah, Samir K. Shah, Wasif
Nauman Shah, Muhanad Shaib, Ahmed Shakir, Purnima Sharma, Tina Sharma, Kayla Sheehan, Dr. Priya
Shenwai, Sami Shoura, Kris Sifeldeen, Akhand Singh, Manik Inder Singh, Ramzi Y. Skaik, Samantha A. Smith,
Timothy Smith, Emilie Song, Hang Song, Shichen Song, Luke Sorensen, Charles Starling, Jonathan Andrew
Stone, Nathan Stumpf, Johnny Su, Bahaa Eddine Succar, Saranya Sundaram, Steven Svoboda, Clara Sze, Olive
Tang, Brian Tanksley, Omar Tayh, Joshua Taylor, Valerie Teano, Warren Teltser, Steffanie Camilo Tertulien, Roger
Torres, Michael Trainer, Andrew Trinh, Aalap K. Trivedi, Georgeanna Tsoumas, Elizabeth Tsui, Cem Turam,
Methma Udawatta, Daramfon Udofia, Adaku Ume, Rio Varghese, Judith Vásquez, Earl Vialpando, Sagar Vinayak,
Phuong Vo, Habiba Wada, Jason Wang, Tiffany Wang, Zoe Warczak, Mitchell Waters, Rachel Watson, Elizabeth
Douglas Weigel, Rabbi Michael Weingarten, Kaystin Weisenberger, Aidan Woodthorpe, Mattia Wruble, Angela Wu,
Catherine Xie, Rebecca Xu, Nicholas Yeisley, Sammy Yeroushalmi, Melissas Yuan, Sahil Zaveri, and Yolanda Zhang.
xvi

How to Contribute
This version of First Aid for the USMLE Step 1 incorporates thousands of contributions and improvements suggested
by student and faculty advisors. We invite you to participate in this process. Please send us your suggestions for:
Study and test-taking strategies for the USMLE Step 1
New facts, mnemonics, diagrams, and clinical images
High-yield topics that may appear on future Step 1 exams
Personal ratings and comments on review books, question banks, apps, videos, and courses
For each new entry incorporated into the next edition, you will receive up to a $20 Amazon.com gift card as well as
personal acknowledgment in the next edition. Significant contributions will be compensated at the discretion of the
authors. Also, let us know about material in this edition that you feel is low yield and should be deleted.
All submissions including potential errata should ideally be supported with hyperlinks to a dynamically updated Web
resource such as UpToDate, AccessMedicine, and ClinicalKey.
We welcome potential errata on grammar and style if the change improves readability. Please note that First Aid style
is somewhat unique; for example, we have fully adopted the AMA Manual of Style recommendations on eponyms
(“We recommend that the possessive form be omitted in eponymous terms”) and on abbreviations (no periods with
eg, ie, etc). We also avoid periods in tables unless required for full sentences. Kindly refrain from submitting “style
errata” unless you find specific inconsistencies with the AMA Manual of Style.
The preferred way to submit new entries, clarifications, mnemonics, or potential corrections with a valid,
authoritative reference is via our website: www.firstaidteam.com.
This website will be continuously updated with validated errata, new high-yield content, and a new online platform
to contribute suggestions, mnemonics, diagrams, clinical images, and potential errata.
Alternatively, you can email us at: firstaid@scholarrx.com.
Contributions submitted by May 15, 2020, receive priority consideration for the 2021 edition of First Aid for the
USMLE Step 1. We thank you for taking the time to share your experience and apologize in advance that we cannot
individually respond to all contributors as we receive thousands of contributions each year.
xvii

NOTE TO CONTRIBUTORS
``
All contributions become property of the authors and are subject to editing and reviewing. Please verify all data and
spellings carefully. Contributions should be supported by at least two high-quality references.
Check our website first to avoid duplicate submissions. In the event that similar or duplicate entries are received,
only the first complete entry received with valid, authoritative references will be credited. Please follow the style,
punctuation, and format of this edition as much as possible.
JOIN THE FIRST AID TEAM

``
The First Aid author team is pleased to offer part-time and full-time paid internships in medical education and
publishing to motivated medical students and physicians. Internships range from a few months (eg, a summer) up
to a full year. Participants will have an opportunity to author, edit, and earn academic credit on a wide variety of
projects, including the popular First Aid series.
For 2020, we are actively seeking passionate medical students and graduates with a specific interest in improving our
medical illustrations, expanding our database of medical photographs, and developing the software that supports our
crowdsourcing platform. We welcome people with prior experience and talent in these areas. Relevant skills include
clinical imaging, digital photography, digital asset management, information design, medical illustration, graphic
design, tutoring, and software development.
Please email us at firstaid@scholarrx.com with a CV and summary of your interest or sample work.
xviii

How to Use This Book
CONGRATULATIONS: You now possess the book that has guided nearly two million students to USMLE success
for 30 years. With appropriate care, the binding should last the useful life of the book. Keep in mind that putting
excessive flattening pressure on any binding will accelerate its failure. If you purchased a book that you believe
is defective, please immediately return it to the place of purchase. If you encounter ongoing issues, you can also
contact Customer Service at our publisher, McGraw-Hill Education, at https://www.mheducation.com/contact.html.
START EARLY: Use this book as early as possible while learning the basic medical sciences. The first semester of
your first year is not too early! Devise a study plan by reading Section I: Guide to Efficient Exam Preparation, and
make an early decision on resources to use by checking Section IV: Top-Rated Review Resources. Note that First Aid
is neither a textbook nor a comprehensive review book, and it is not a panacea for inadequate preparation.
CONSIDER FIRST AID YOUR ANNOTATION HUB: Annotate material from other resources, such as class
notes or comprehensive textbooks, into your book. This will keep all the high-yield information you need in one
place. Other tips on keeping yourself organized:
For best results, use fine-tipped ballpoint pens (eg, BIC Pro+, Uni-Ball Jetstream Sports, Pilot Drawing Pen,
Zebra F-301). If you like gel pens, try Pentel Slicci, and for markers that dry almost immediately, consider
Staedtler Triplus Fineliner, Pilot Drawing Pen, and Sharpies.
Consider using pens with different colors of ink to indicate different sources of information (eg, blue for
USMLE-Rx Step 1 Qmax, green for UWorld Step 1 Qbank).
Choose highlighters that are bright and dry quickly to minimize smudging and bleeding through the page
(eg, Tombow Kei Coat, Sharpie Gel).
Many students de-spine their book and get it 3-hole-punched. This will allow you to insert materials from other
sources, including curricular materials.
INTEGRATE STUDY WITH CASES, FLASH CARDS, AND QUESTIONS: To broaden your learning strategy,
consider integrating your First Aid study with case-based reviews (eg, First Aid Cases for the USMLE Step 1), flash
cards (eg, First Aid Flash Facts), and practice questions (eg, the USMLE-Rx Step 1 Qmax). Read the chapter in the
book, then test your comprehension by using cases, flash cards, and questions that cover the same topics. Maintain
access to more comprehensive resources (eg, First Aid for the Basic Sciences: General Principles and Organ Systems
and First Aid Express videos) for deeper review as needed.
PRIME YOUR MEMORY: Return to your annotated Sections II and III several days before taking the USMLE
Step 1. The book can serve as a useful way of retaining key associations and keeping high-yield facts fresh in your
memory just prior to the exam. The Rapid Review section includes high-yield topics to help guide your studying.
CONTRIBUTE TO FIRST AID: Reviewing the book immediately after your exam can help us improve the next
edition. Decide what was truly high and low yield and send us your comments. Feel free to send us scanned images
all examinees are under
xix

Selected USMLE Laboratory Values
* = Included in the Biochemical Profile (SMA-12)
Blood, Plasma, Serum Reference Range SI Reference Intervals
*Alanine aminotransferase (ALT, GPT at 30°C) 8–20 U/L 8–20 U/L

Amylase, serum 25–125 U/L 25–125 U/L
*Aspartate aminotransferase (AST, GOT at 30°C) 8–20 U/L 8–20 U/L
Bilirubin, serum (adult)
Total // Direct 0.1–1.0 mg/dL // 0.0–0.3 mg/dL 2–17 µmol/L // 0–5 µmol/L
*Calcium, serum (Total) 8.4–10.2 mg/dL 2.1–2.8 mmol/L
*Cholesterol, serum (Total) Rec: < 200 mg/dL < 5.2 mmol/L
*Creatinine, serum (Total) 0.6–1.2 mg/dL 53–106 µmol/L
Electrolytes, serum
Sodium (Na+) 136–145 mEq/L 136–145 mmol/L
Chloride (Cl–) 95–105 mEq/L 95–105 mmol/L
* Potassium (K ) 3.5–5.0 mEq/L 3.5–5.0 mmol/L
+
Bicarbonate (HCO3–) 22–28 mEq/L 22–28 mmol/L

Magnesium (Mg2+) 1.5–2 mEq/L 0.75–1.0 mmol/L
Gases, arterial blood (room air)
PO 2
75–105 mm Hg 10.0–14.0 kPa
PCO 2
33–45 mm Hg 4.4–5.9 kPa
pH 7.35–7.45 [H+] 36–44 nmol/L
*Glucose, serum Fasting: 70–110 mg/dL 3.8–6.1 mmol/L
2-h postprandial: < 120 mg/dL < 6.6 mmol/L
Growth hormone − arginine stimulation Fasting: < 5 ng/mL < 5 µg/L
provocative stimuli: > 7 ng/mL > 7 µg/L
Osmolality, serum 275–295 mOsm/kg 275–295 mOsm/kg
*Phosphatase (alkaline), serum (p-NPP at 30°C) 20–70 U/L 20–70 U/L
*Phosphorus (inorganic), serum 3.0–4.5 mg/dL 1.0–1.5 mmol/L
Prolactin, serum (hPRL) < 20 ng/mL < 20 µg/L
*Proteins, serum
Total (recumbent) 6.0–7.8 g/dL 60–78 g/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Globulins 2.3–3.5 g/dL 23–35 g/L
Thyroid-stimulating hormone, serum or plasma 0.5–5.0 µU/mL 0.5–5.0 mU/L
*Urea nitrogen, serum (BUN) 7–18 mg/dL 1.2–3.0 mmol/L
0.18–0.48 mmol/L
(continues)
xx

Cerebrospinal Fluid Reference Range SI Reference Intervals
Glucose 40–70 mg/dL 2.2–3.9 mmol/L

Hematologic
Erythrocyte count Male: 4.3–5.9 million/mm3 4.3–5.9 × 1012/L

Female: 3.5–5.5 million/mm3 3.5–5.5 × 1012/L
Erythrocyte sedimentation rate (Westergen) Male: 0–15 mm/h 0–15 mm/h
Female: 0–20 mm/h 0–20 mm/h
Hematocrit Male: 41–53% 0.41–0.53
Female: 36–46% 0.36–0.46
Hemoglobin, blood Male: 13.5–17.5 g/dL 2.09–2.71 mmol/L
Female: 12.0–16.0 g/dL 1.86–2.48 mmol/L
Hemoglobin, plasma 1–4 mg/dL 0.16–0.62 µmol/L
Leukocyte count and differential
Leukocyte count 4,500–11,000/mm3 4.5–11.0 × 109/L
Segmented neutrophils 54–62% 0.54–0.62
Band forms 3–5% 0.03–0.05
Eosinophils 1–3% 0.01–0.03
Basophils 0–0.75% 0–0.0075
Lymphocytes 25–33% 0.25–0.33
Monocytes 3–7% 0.03–0.07
Mean corpuscular hemoglobin 25.4–34.6 pg/cell 0.39–0.54 fmol/cell
Mean corpuscular volume 80–100 μm 3
80–100 fL
Partial thromboplastin time (activated) 25–40 seconds 25–40 seconds
Platelet count 150,000–400,000/mm 3
150–400 × 109/L
Prothrombin time 11–15 seconds 11–15 seconds
Reticulocyte count 0.5–1.5% of red cells 0.005–0.015
Sweat
Chloride 0–35 mmol/L 0–35 mmol/L

Urine
Creatinine clearance Male: 97–137 mL/min

Female: 88–128 mL/min
Osmolality 50–1,400 mOsmol/kg H2O
Proteins, total < 150 mg/24 h < 0.15 g/24 h
xxi

First Aid
First Aid Checklist Checklist
for the USMLEfor
Stepthe
1 USMLE Step 1
This is an example of how you might use the information in Section I to prepare for the USMLE Step 1.
This
Referistoan example oftopics
corresponding how you might Iuse
in Section for the
moreinformation
details. in Section I to prepare for the USMLE
Step 1. Refer to corresponding topics in Section I for more details.
Years Prior Use top-rated review resources for first-year medical school courses.
Ask for advice from those who have recently taken the USMLE Step 1.
Months Prior Review computer test format and registration information.

Register six months in advance.
Carefully verify name and address printed on scheduling permit. Make sure
the name on scheduling permit matches the name printed on your photo ID.
Go online for test date ASAP.
Define your exam goals (pass comfortably, beat the mean, ace the test)
Set up a realistic timeline for study. Cover less crammable subjects first.
Evaluate and choose study materials (review books, question banks).
Use a question bank to simulate the USMLE Step 1 to pinpoint strengths and
weaknesses in knowledge and test-taking skills.
Weeks Prior Do another test simulation in a question bank.

Assess how close you are to your goal.
Pinpoint remaining weaknesses. Stay healthy (exercise, sleep).
Verify information on admission ticket (eg, location, date).
One Week Prior Remember comfort measures (loose clothing, earplugs, etc).
Work out test site logistics (eg, location, transportation, parking, lunch).
Print or download your Scheduling Permit and Scheduling Confirmation
to your phone.
One Day Prior Relax.

Lightly review short-term material if necessary. Skim high-yield facts.
Get a good night’s sleep.
Day of Exam Relax.

Eat breakfast.
Minimize bathroom breaks during exam by avoiding excessive morning
caffeine.
After Exam Celebrate, regardless of how well you feel you did.
Send feedback to us on our website at www.firstaidteam.com.
xxii

SECTION I
Guide to Efficient
Exam Preparation
“I don’t love studying. I hate studying. I like learning. Learning is `Ìntroduction2

beautiful.”
—Natalie Portman `ÙSMLE Step 1—The
Basics2
“Finally, from so little sleeping and so much reading, his brain dried up
and he went completely out of his mind.” ``Defining Your Goal 12
—Miguel de Cervantes Saavedra, Don Quixote
``Learning Strategies 13
“Sometimes the questions are complicated and the answers are simple.”
—Dr. Seuss ``Timeline for Study 16
“He who knows all the answers has not been asked all the questions.” ``Study Materials 20
—Confucius
``Test-Taking
“The expert in anything was once a beginner.”
Strategies22
—Helen Hayes
“It always seems impossible until it’s done.” ``Clinical Vignette

Strategies23
—Nelson Mandela
`Ìf You Think You

Failed24
``Testing Agencies 24
``References25
FAS1_2019_00_Section_I.indd 1 11/7/19 2:48 PM

2 SECTION I Guide to Efficient Exam Preparation
INTRODUCTION
``
Relax.
This section is intended to make your exam preparation easier, not harder.
Our goal is to reduce your level of anxiety and help you make the most
of your efforts by helping you understand more about the United States
Medical Licensing Examination, Step 1 (USMLE Step 1). As a medical
student, you are no doubt familiar with taking standardized examinations
and quickly absorbing large amounts of material. When you first confront
the USMLE Step 1, however, you may find it all too easy to become
sidetracked from your goal of studying with maximal effectiveness. Common
mistakes that students make when studying for Step 1 include the following:
Starting to study (including First Aid) too late

Starting to study intensely too early and burning out
Starting to prepare for boards before creating a knowledge foundation
Using inefficient or inappropriate study methods
Buying the wrong resources or buying too many resources
Buying only one publisher’s review series for all subjects
Not using practice examinations to maximum benefit
Not understanding how scoring is performed or what the score means
`` The test at a glance: Not using review books along with your classes
8-hour exam Not analyzing and improving your test-taking strategies
Up to a total of 280 multiple choice items Getting bogged down by reviewing difficult topics excessively
7 test blocks (60 min/block) Studying material that is rarely tested on the USMLE Step 1
Up to 40 test items per block Failing to master certain high-yield subjects owing to overconfidence
45 minutes of break time, plus another 15 Using First Aid as your sole study resource
if you skip the tutorial Trying to prepare for it all alone
In this section, we offer advice to help you avoid these pitfalls and be more
productive in your studies.
USMLE STEP 1—THE BASICS

``
The USMLE Step 1 is the first of three examinations that you must pass in
order to become a licensed physician in the United States. The USMLE
is a joint endeavor of the National Board of Medical Examiners (NBME)
and the Federation of State Medical Boards (FSMB). The USMLE serves
as the single examination system for US medical students and international
medical graduates (IMGs) seeking medical licensure in the United States.

Guide to Efficient Exam Preparation SECTION I 3
The Step 1 exam includes test items that can be grouped by the organiza-
tional constructs outlined in Table 1 (in order of tested frequency).
T A B L E 1 . Frequency of Various Constructs Tested on the USMLE Step 1.*
Competency Range, % System Range, %
Medical knowledge: applying foundational 52–62 General principles 13–17
science concepts
Patient care: diagnosis 20–30 Behavioral health & nervous systems/special senses 9–13
Patient care: management 7–12 Respiratory & renal/urinary systems 9–13
Practice-based learning & improvement 5–7 Reproductive & endocrine systems 9–13
Communication/professionalism 2–5 Blood & lymphoreticular/immune systems 7–11
Discipline Range, % Multisystem processes & disorders 7–11
Pathology 45–52 Musculoskeletal, skin & subcutaneous tissue 6–10
Physiology 26–34 Cardiovascular system 6–10
Pharmacology 16–23 Gastrointestinal system 5–9
Biochemistry & nutrition 14–24 Biostatistics & epidemiology/population health 5–7
Microbiology & immunology 15–22 Social sciences: communication skills/ethics 3–5
Gross anatomy & embryology 11–15
Histology & cell biology 9–13
Behavioral sciences 8–12
Genetics 5–9
*Percentages are subject to change at any time. www.usmle.org
How Is the Computer-Based Test (CBT) Structured?
The CBT Step 1 exam consists of one “optional” tutorial/simulation block

and seven “real” question blocks of up to 40 questions per block with no
more than 280 questions in total, timed at 60 minutes per block. A short
11-question survey follows the last question block. The computer begins the
survey with a prompt to proceed to the next block of questions.
Once an examinee finishes a particular question block on the CBT, he or

she must click on a screen icon to continue to the next block. Examinees
cannot go back and change their answers to questions from any previously
completed block. However, changing answers is allowed within a block of
questions as long as the block has not been ended and if time permits.
What Is the CBT Like?
Given the unique environment of the CBT, it’s important that you become
familiar ahead of time with what your test-day conditions will be like. You
can access a 15-minute tutorial and practice blocks at http://orientation.
nbme.org/Launch/USMLE/STPF1. This tutorial interface is very similar to
the one you will use in the exam; learn it now and you can skip taking it
during the exam, giving you up to 15 extra minutes of break time. You can
practice session at a test center for a fee.

For security reasons, examinees are not allowed to bring any personal
electronic equipment into the testing area. This includes both digital and
analog watches, iPods, tablets, calculators, cell phones, and electronic paging
devices. Examinees are also prohibited from carrying in their books, notes,
pens/pencils, and scratch paper. Food and beverages are also prohibited
in the testing area. The testing centers are monitored by audio and video
surveillance equipment. However, most testing centers allot each examinee
a small locker outside the testing area in which he or she can store snacks,
beverages, and personal items.
`` Keyboard shortcuts:
Questions are typically presented in multiple choice format, with 4–5
A, B, etc—letter choices
possible answer options. There is a countdown timer on the lower left corner
Enter or spacebar—move to next
of the screen as well. There is also a button that allows the examinee to
question
mark a question for review. If a given question happens to be longer than
Esc—exit pop-up Calculator and Notes
the screen (which occurs very rarely), a scroll bar will appear on the right,
windows
allowing the examinee to see the rest of the question. Regardless of whether
the examinee clicks on an answer choice or leaves it blank, he or she must
click the “Next” button to advance to the next question.
The USMLE features a small number of media clips in the form of audio
`` Heart sounds are tested via media questions. and/or video. There may even be a question with a multimedia heart sound
Make sure you know how different heart simulation. In these questions, a digital image of a torso appears on the
diseases sound on auscultation. screen, and the examinee directs a digital stethoscope to various auscultation
points to listen for heart and breath sounds. The USMLE orientation
materials include several practice questions in these formats. During the
exam tutorial, examinees are given an opportunity to ensure that both the
`` Be sure to test your headphones during the
audio headphones and the volume are functioning properly. If you are
tutorial.
already familiar with the tutorial and planning on skipping it, first skip ahead
to the section where you can test your headphones. After you are sure the
headphones are working properly, proceed to the exam.
`` Familiarize yourself with the commonly

The examinee can call up a window displaying normal laboratory values.
tested lab values (eg, Hgb, WBC, platelets,
In order to do so, he or she must click the “Lab” icon on the top part of
Na+, K+).
the screen. Afterward, the examinee will have the option to choose between
“Blood,” “Cerebrospinal,” “Hematologic,” or “Sweat and Urine.” The
normal values screen may obscure the question if it is expanded. The
examinee may have to scroll down to search for the needed lab values. You
`` Illustrations on the test include: might want to memorize some common lab values so you spend less time on
Gross specimen photos questions that require you to analyze these.
Histology slides
The CBT interface provides a running list of questions on the left part of the
Medical imaging (eg, x-ray, CT, MRI)
screen at all times. The software also permits examinees to highlight or cross
Electron micrographs
out information by using their mouse. There is a “Notes” icon on the top
Line drawings
part of the screen that allows students to write notes to themselves for review
at a later time. Finally, the USMLE has recently added new functionality
including text magnification and reverse color (white text on black
`` Ctrl-Alt-Delete are the keys of death during background). Being familiar with these features can save time and may help
you better view and organize the information you need to answer a question.

For those who feel they might benefit, the USMLE offers an opportunity
to take a simulated test, or “CBT Practice Session” at a Prometric center.
Students are eligible to register for this three-and-one-half-hour practice
session after they have received their scheduling permit.
The same USMLE Step 1 sample test items (120 questions) available on `` You can take a shortened CBT practice test at
the USMLE website, www.usmle.org, are used at these sessions. No new a Prometric center.
items will be presented. The practice session is available at a cost of $75
(or more if taken outside of the US and Canada) and is divided into a short
tutorial and three 1-hour blocks of ~40 test items each. Students receive a
printed percent-correct score after completing the session. No explanations
of questions are provided.
You may register for a practice session online at www.usmle.org. A separate

scheduling permit is issued for the practice session. Students should allow
two weeks for receipt of this permit.
How Do I Register to Take the Exam?
Prometric test centers offer Step 1 on a year-round basis, except for the `` The Prometric website will display a calendar
first two weeks in January and major holidays. The exam is given every day with open test dates.
except Sunday at most centers. Some schools administer the exam on their
own campuses. Check with the test center you want to use before making
your exam plans.
US students can apply to take Step 1 at the NBME website. This application
allows you to select one of 12 overlapping three-month blocks in which to be
tested (eg, April–May–June, June–July–August). Choose your three-month
eligibility period wisely. If you need to reschedule outside your initial three-
month period, you can request a one-time extension of eligibility for the next
contiguous three-month period, and pay a rescheduling fee. The application
also includes a photo ID form that must be certified by an official at your
medical school to verify your enrollment. After the NBME processes your
application, it will send you a scheduling permit.
The scheduling permit you receive from the NBME will contain your USMLE
identification number, the eligibility period in which you may take the exam,
and two additional numbers. The first of these is known as your “scheduling
number.” You must have this number in order to make your exam appointment
with Prometric. The second number is known as the “candidate identification
number,” or CIN. Examinees must enter their CINs at the Prometric
workstation in order to access their exams. However, you will not be allowed
to bring your permit into the exam and will be asked to copy your CIN onto
your scratch paper. Prometric has no access to the codes. Make sure to bring
a paper or electronic copy of your permit with you to the exam! Also bring
an unexpired, government-issued photo ID that includes your signature (such
as a driver’s license or passport). Make sure the name on your photo ID exactly

`` The confirmation emails that Prometric Once you receive your scheduling permit, you may access the Prometric
and NBME send are not the same as the website or call Prometric’s toll-free number to arrange a time to take the
scheduling permit. exam. You may contact Prometric two weeks before the test date if you
want to confirm identification requirements. Although requests for taking
the exam may be completed more than six months before the test date,
examinees will not receive their scheduling permits earlier than six months
before the eligibility period. The eligibility period is the three-month period
you have chosen to take the exam. Most medical students choose the April–
June or June–August period. Because exams are scheduled on a “first-come,
`` Test scheduling is done on a “first-come,
first-served” basis, it is recommended that you book an exam date on the
first-served” basis. It’s important to schedule
Prometric website as soon as you receive your permit. Prometric will provide
an exam date as soon as you receive your
appointment confirmation on a print-out and by email. Be sure to read the
scheduling permit.
latest USMLE Bulletin of Information for further details.
What If I Need to Reschedule the Exam?
You can change your test date and/or center by contacting Prometric at
1-800-MED-EXAM (1-800-633-3926) or www.prometric.com. Make sure to
have your CIN when rescheduling. If you are rescheduling by phone, you
must speak with a Prometric representative; leaving a voicemail message will
not suffice. To avoid a rescheduling fee, you will need to request a change
at least 31 calendar days before your appointment. Please note that your
rescheduled test date must fall within your assigned three-month eligibility
period.
When Should I Register for the Exam?

`` Register six months in advance for seating
and scheduling preference. You should plan to register as far in advance as possible ahead of your
desired test date (eg, six months), but, depending on your particular test
center, new dates and times may open closer to the date. Scheduling early
will guarantee that you will get either your test center of choice or one
within a 50-mile radius of your first choice. For most US medical students,
the desired testing window is in June, since most medical school curricula
for the second year end in May or June. Thus, US medical students should
plan to register before January in anticipation of a June test date. The timing
of the exam is more flexible for IMGs, as it is related only to when they
finish exam preparation. Talk with upperclassmen who have already taken
the test so you have real-life experience from students who went through a
similar curriculum, then formulate your own strategy.
Where Can I Take the Exam?
Your testing location is arranged with Prometric when you book your test
date (after you receive your scheduling permit). For a list of Prometric
locations nearest you, visit www.prometric.com.

How Long Will I Have to Wait Before I Get My Scores?
The USMLE reports scores in three to four weeks, unless there are delays
in score processing. Examinees will be notified via email when their scores
are available. By following the online instructions, examinees will be able to
view, download, and print their score report online for ~120 days after score
notification, after which scores can only be obtained through requesting an
official USMLE transcript. Additional information about score timetables
and accessibility is available on the official USMLE website.
What About Time?

`` Gain extra break time by skipping the tutorial
Time is of special interest on the CBT exam. Here’s a breakdown of the or finishing a block early.
exam schedule:
15 minutes Tutorial (skip if familiar with test format and features)

7 hours Seven 60-minute question blocks
45 minutes Break time (includes time for lunch)
The computer will keep track of how much time has elapsed on the exam.
However, the computer will show you only how much time you have
remaining in a given block. Therefore, it is up to you to determine if you
are pacing yourself properly (at a rate of approximately one question per 90
seconds).
The computer does not warn you if you are spending more than your
allotted time for a break. You should therefore budget your time so that
you can take a short break when you need one and have time to eat. You
must be especially careful not to spend too much time in between blocks
(you should keep track of how much time elapses from the time you finish a
block of questions to the time you start the next block). After you finish one
question block, you’ll need to click to proceed to the next block of questions.
If you do not click within 30 seconds, you will automatically be entered into
a break period.
Break time for the day is 45 minutes, but you are not required to use all of
it, nor are you required to use any of it. You can gain extra break time (but
not extra time for the question blocks) by skipping the tutorial or by finishing
`` Be careful to watch the clock on your break
a block ahead of the allotted time. Any time remaining on the clock when
time.
you finish a block gets added to your remaining break time. Once a new
question block has been started, you may not take a break until you have
reached the end of that block. If you do so, this will be recorded as an
“unauthorized break” and will be reported on your final score report.
Finally, be aware that it may take a few minutes of your break time to “check
out” of the secure resting room and then “check in” again to resume testing,
so plan accordingly. The “check-in” process may include fingerprints,
pocket checks, and metal detector scanning. Some students recommend

If I Freak Out and Leave, What Happens to My Score?
Your scheduling permit shows a CIN that you will need to enter to start
your exam. Entering the CIN is the same as breaking the seal on a test book,
and you are considered to have started the exam when you do so. However,
no score will be reported if you do not complete the exam. In fact, if you
leave at any time from the start of the test to the last block, no score will be
reported. The fact that you started but did not complete the exam, however,
will appear on your USMLE score transcript. Even though a score is not
posted for incomplete tests, examinees may still get an option to request that
their scores be calculated and reported if they desire; unanswered questions
will be scored as incorrect.
The exam ends when all question blocks have been completed or when
their time has expired. As you leave the testing center, you will receive a
printed test-completion notice to document your completion of the exam.
To receive an official score, you must finish the entire exam.
What Types of Questions Are Asked?
`` Nearly three fourths of Step 1 questions begin

All questions on the exam are one-best-answer multiple choice items.
with a description of a patient.
Most questions consist of a clinical scenario or a direct question followed
by a list of five or more options. You are required to select the single best
answer among the options given. There are no “except,” “not,” or matching
questions on the exam. A number of options may be partially correct, in
which case you must select the option that best answers the question or
completes the statement. Additionally, keep in mind that experimental
questions may appear on the exam, which do not affect your score.
How Is the Test Scored?
Each Step 1 examinee receives an electronic score report that includes the
examinee’s pass/fail status, a three-digit test score, a bar chart comparing the
examinee’s performance to that of other examinees’, and a graphic depiction
of the examinee’s performance by physician task, discipline and organ
system.
The USMLE score report highlights the examinee’s strength and weaknesses
by providing an overview of their performance by physician task, discipline
and organ system compared to their overall performance on the exam.
Each of the questions (minus experimental questions) is tagged according
to any or all relevant content areas. Yellow-colored boxes (lower, same,
higher) on your score report indicate your performance in each specific
content area relative to your overall performance on the exam. This is often
a direct consequence of the total number of questions for each physician
task, discipline or system, which is indicated by percentage range after each
specified content area on the score report (see Figure 1).

F I G U R E 1 . Samples from the USMLE Step 1 Performance Profile.
The NBME provides a three-digit test score based on the total number of
items answered correctly on the examination, which corresponds to a
particular percentile (see Figure 2). Your three-digit score will be qualified
by the mean and standard deviation of US and Canadian medical school
first-time examinees.
`` The mean Step 1 score for US medical
Since some questions may be experimental and are not counted, it is
students continues to rise, from 200 in 1991
possible to get different scores for the same number of correct answers. In
to 230 in 2018.
2018, the mean score was 230 with a standard deviation of 19.
The passing score for Step 1 is 194. The NBME does not report the
minimum number of correct responses needed to pass, but estimates that it
is roughly 60–70%. The NBME may adjust the minimum passing score in
the future, so please check the USMLE website or www.firstaidteam.com for
updates.
According to the USMLE, medical schools receive a listing of total scores

and pass/fail results plus group summaries by discipline and organ system.
Students can withhold their scores from their medical school if they wish.
Official USMLE transcripts, which can be sent on request to residency
programs, include only total scores, not performance profiles.

F I G U R E 2 . Score and Percentile for First-time Step 1 Takers.
100
80
60
Percentile
40
Minimum
passing score
20
0
150 175 200 225 250 275 300
USMLE Step 1 Score

N=72,473 including US and Canadian medical school students testing between January 1, 2016–December 31, 2018.
www.usmle.org.
Consult the USMLE website or your medical school for the most current
and accurate information regarding the examination.
What Does My Score Mean?
The most important point with the Step 1 score is passing versus failing.
Passing essentially means, “Hey, you’re on your way to becoming a fully
licensed doc.” As Table 2 shows, the majority of students pass the exam, so
remember, we told you to relax.
T A B L E 2 . Passing Rates for the 2017–2018 USMLE Step 1.2

2017 2018
No. Tested % Passing No. Tested % Passing
Allopathic 1st takers 20,353 96% 20,670 96%
Repeaters 1,029 67% 941 67%
Allopathic total 21,382 94% 21,611 95%
Osteopathic 1st takers 3,786 95% 4,092 96%
Repeaters 49 76% 44 73%
Osteopathic total 3,835 95% 4,136 96%
Total US/Canadian 25,217 94% 25,747 94%
IMG 1st takers 14,900 78% 14,332 80%
44%
75%
Total Step 1 examinees 42,420 85% 42,190 86%

Beyond that, the main point of having a quantitative score is to give you T A B L E 3 . CBSE to USMLE Score
a sense of how well you’ve done on the exam and to help schools and Prediction.
residencies rank their students and applicants, respectively. CBSE Step 1
Score Equivalent
≥ 94 ≥ 260
Official NBME/USMLE Resources
92 255
The NBME offers a Comprehensive Basic Science Examination (CBSE) for 90 250
practice that is a shorter version of the Step 1. The CBSE contains four blocks
88 245
of 50 questions each and covers material that is typically learned during the
basic science years. Scores range from 45 to 95 and correlate with a Step 1 86 240
equivalent (see Table 3). The standard error of measurement is approximately 84 235
3 points, meaning a score of 80 would estimate the student’s proficiency is 82 230
somewhere between 77 and 83. In other words, the actual Step 1 score could be 80 225
predicted to be between 218 and 232. Of course, these values do not correlate 78 220
exactly, and they do not reflect different test preparation methods. Many schools
76 215
use this test to gauge whether a student is expected to pass Step 1. If this test
is offered by your school, it is usually conducted at the end of regular didactic 74 210
time before any dedicated Step 1 preparation. If you do not encounter the 72 205
CBSE before your dedicated study time, you need not worry about taking it. 70 200
Use the information to help set realistic goals and timetables for your success. 68 195
The NBME also offers six forms of Comprehensive Basic Science Self- 66 190
Assessment (CBSSA). Students who prepared for the exam using this web- 64 185
based tool reported that they found the format and content highly indicative 62 180
of questions tested on the actual exam. In addition, the CBSSA is a fair 60 175
predictor of USMLE performance (see Table 4). The test interface, however,
58 170
does not match the actual USMLE test interface, so practicing with these
forms alone is not advised. 56 165
54 160
The CBSSA exists in two formats: standard-paced and self-paced, both of 52 155
which consist of four sections of 50 questions each (for a total of 200 multiple
50 150
choice items). The standard-paced format allows the user up to 75 minutes
to complete each section, reflecting time limits similar to the actual exam. 48 145
By contrast, the self-paced format places a 5-hour time limit on answering 46 140
all multiple choice questions. Every few years, a new form is released and an ≤ 44 ≤ 135
older one is retired, reflecting changes in exam content. Therefore, the newer
exams tend to be more similar to the actual Step 1, and scores from these
exams tend to provide a better estimation of exam day performance.
Keep in mind that this bank of questions is available only on the web. The
NBME requires that users start and complete the exam within 90 days of
purchase. Once the assessment has begun, users are required to complete
the sections within 20 days. Following completion of the questions, the
CBSSA provides a performance profile indicating the user’s relative
strengths and weaknesses, much like the report profile for the USMLE Step
1 exam. The profile is scaled with an average score of 500 and a standard
` Practice questions may be easier than the

T A B L E 4 . CBSSA to USMLE Score

Explanations for the correct answer, however, will not be provided. The
Prediction. NBME charges $60 for assessments with expanded feedback. The fees are
CBSSA Approximate payable by credit card or money order. For more information regarding the
Score USMLE Step 1 Score CBSE and the CBSSA, visit the NBME’s website at www.nbme.org.
150 155
The NBME scoring system is weighted for each assessment exam. While
200 165 some exams seem more difficult than others, the score reported takes into
250 175 account these inter-test differences when predicting Step 1 performance.
300 186 Also, while many students report seeing Step 1 questions “word-for-word”
350 196 out of the assessments, the NBME makes special note that no live USMLE
questions are shown on any NBME assessment.
400 207
450 217 Lastly, the International Foundations of Medicine (IFOM) offers a Basic
500 228 Science Examination (BSE) practice exam at participating Prometric test
centers for $200. Students may also take the self-assessment test online for
550 238
$35 through the NBME’s website. The IFOM BSE is intended to determine
600 248
an examinee’s relative areas of strength and weakness in general areas of
650 259 basic science—not to predict performance on the USMLE Step 1 exam—
700 269 and the content covered by the two examinations is somewhat different.
750 280 However, because there is substantial overlap in content coverage and many
800 290 IFOM items were previously used on the USMLE Step 1, it is possible to
roughly project IFOM performance onto the USMLE Step 1 score scale.
More information is available at http://www.nbme.org/ifom/.
DEFINING YOUR GOAL

``
It is useful to define your own personal performance goal when approaching

the USMLE Step 1. Your style and intensity of preparation can then be
matched to your goal. Furthermore, your goal may depend on your school’s
requirements, your specialty choice, your grades to date, and your personal
assessment of the test’s importance. Do your best to define your goals early
so that you can prepare accordingly.
The value of the USMLE Step 1 score in selecting residency applicants

`` Some competitive residency programs place
remains controversial, and some have called for less emphasis to be placed
more weight on Step 1 scores when choosing
on the score when selecting or screening applicants.3 For the time being,
candidates to interview.
however, it continues to be an important part of the residency application, and
it is not uncommon for some specialties to implement filters that screen out
applicants who score below a certain cutoff. This is more likely to be seen in
competitive specialties (eg, orthopedic surgery, ophthalmology, dermatology,
`` Fourth-year medical students have the best otolaryngology). Independent of your career goals, you can maximize your
feel for how Step 1 scores factor into the future options by doing your best to obtain the highest score possible (see
residency application process. Figure 3). At the same time, your Step 1 score is only one of a number of
factors that are assessed when you apply for residency. In fact, many residency
programs value other criteria such as letters of recommendation, third-year
clerkship grades, honors, and research experience more than a high score
on Step 1. Fourth-year medical students who have recently completed the
residency application process can be a valuable resource in this regard.

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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

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First Aid for the USMLE Step 1 2020,

MAJED H. ALGHAMDI, MBBS KAITLYN MELNICK, MD

LILIT ASLANYAN MARY KATHERINE MONTES de OCA, MD

HUMOOD BOQAMBAR, MB BCh BAO SCOTT MOORE, DO

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YUMI KOVIC, MD CONNIE QIU

Image and Illustration Team

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HUZAIFA AHMAD, MD SARINA KOILPILLAI

ALEXANDER R. ASLESEN LAUREN N. LESSOR, MPH, MD

ANUP K. BHATTACHARYA, MD ROHAN BIR SINGH, MD

ASHTEN R. DUNCAN, MPH

Image and Illustration Team

YAMNA JADOON, MD MITCHELL A. KATONA

DANA M. JORGENSON TAYLOR MANEY, MD

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DIANA ALBA, MD ANTHONY L. DeFRANCO, PhD

MARK A.W. ANDREWS, PhD CHARLES S. DELA CRUZ, MD, PhD

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PETER MARKS, MD, PhD RICHARD P. USATINE, MD

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* = Included in the Biochemical Profile (SMA-12)

Blood, Plasma, Serum Reference Range SI Reference Intervals

*Alanine aminotransferase (ALT, GPT at 30°C) 8–20 U/L 8­–20 U/L

Bicarbonate (HCO3–) 22–28 mEq/L 22–28 mmol/L

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Glucose 40–70 mg/dL 2.2–3.9 mmol/L

Erythrocyte count Male: 4.3–5.9 million/mm3 4.3–5.9 × 1012/L

Study and test-taking strategies for the USMLE Step 1

New facts, mnemonics, diagrams, and clinical images

High-yield topics that may appear on future Step 1 exams

*Alanine aminotransferase (ALT, GPT at 30°C) 8–20 U/L 8–20 U/L

“I don’t love studying. I hate studying. I like learning. Learning is ``Introduction2

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