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Contents
Preface / xiii
Chapter 1
General Overview / 1
Chapter 2
Descriptive Statistics / 5
2.1 Introduction / 5 2.9 Case Study 1: Effects of Lead Exposure on
Neurological and Psychological Function in
2.2 Measures of Location / 6
Children / 32
2.3 Some Properties of the Arithmetic
2.10 Case Study 2: Effects of Tobacco Use
Mean / 14
on Bone-Mineral Density in Middle-Aged
2.4 Measures of Spread / 16 Women / 32
2.5 Some Properties of the Variance 2.11 Obtaining Descriptive Statistics
and Standard Deviation / 20 on the Computer / 35
2.6 The Coefficient of Variation / 22 2.12 Summary / 35
2.7 Grouped Data / 24 Problems / 35
2.8 Graphic Methods / 27
vii
viii Contents
Chapter 3
Probability / 42
3.1 Introduction / 42 3.7 Bayes’ Rule and Screening Tests / 55
3.2 Definition of Probability / 43 3.8 Bayesian Inference / 60
3.3 Some Useful Probabilistic Notation / 44 3.9 ROC Curves / 61
3.4 The Multiplication Law of Probability / 46 3.10 Prevalence and Incidence / 63
3.5 The Addition Law of Probability / 48 3.11 Summary / 64
3.6 Conditional Probability / 50 Problems / 65
Chapter 4
Discrete Probability Distributions / 77

4.1 Introduction / 77 4.8 The Binomial Distribution / 90
4.2 Random Variables / 78 4.9 Expected Value and Variance
of the Binomial Distribution / 96
4.3 The Probability-Mass Function for
a Discrete Random Variable / 79 4.10 The Poisson Distribution / 98
4.4 The Expected Value of a Discrete 4.11 Computation of Poisson Probabilities / 101
Random Variable / 81
4.12 Expected Value and Variance
4.5 The Variance of a Discrete of the Poisson Distribution / 102
Random Variable / 82
4.13 Poisson Approximation to the
4.6 The Cumulative-Distribution Function Binomial Distribution / 104
of a Discrete Random Variable / 84
4.14 Summary / 106
4.7 Permutations and Combinations / 85
Problems / 107
Chapter 5
Continuous Probability Distributions / 115

5.1 Introduction / 115 5.6 Linear Combinations of Random
Variables / 132
5.2 General Concepts / 115
5.7 Normal Approximation to the Binomial
5.3 The Normal Distribution / 118
Distribution / 133
5.4 Properties of the Standard Normal
5.8 Normal Approximation to the Poisson
Distribution / 121
Distribution / 139
5.5 Conversion from an N ( μ,σ2) Distribution
5.9 Summary / 141
to an N (0,1) Distribution / 127
Problems / 142
Contents ix
Chapter 6
Estimation / 154
6.1 Introduction / 154 6.7 Estimation of the Variance of a
Distribution / 181
6.2 The Relationship Between Population
and Sample / 155 6.8 Estimation for the Binomial Distribution / 187
6.3 Random-Number Tables / 157 6.9 Estimation for the Poisson Distribution / 193
6.4 Randomized Clinical Trials / 161 6.10 One-Sided Confidence Intervals / 197
6.5 Estimation of the Mean of a Distribution / 165 6.11 The Bootstrap / 199
6.6 Case Study: Effects of Tobacco Use on 6.12 Summary / 202
Bone-Mineral Density (BMD) in Middle-Aged
Problems / 203
Women / 180
Chapter 7
Hypothesis Testing: One-Sample Inference / 211

7.1 Introduction / 211 7.8 One-Sample χ2 Test for the Variance
of a Normal Distribution / 245
7.2 General Concepts / 211
7.9 One-Sample Inference for the Binomial
7.3 One-Sample Test for the Mean of a Normal
Distribution / 249
Distribution: One-Sided Alternatives / 214
7.10 One-Sample Inference for the Poisson
7.4 One-Sample Test for the Mean of a Normal
Distribution / 259
Distribution: Two-Sided Alternatives / 222
7.11 Case Study: Effects of Tobacco Use on Bone-
7.5 The Relationship Between Hypothesis
Mineral Density in Middle-Aged Women / 265
Testing and Confidence Intervals / 229
7.12 Derivation of Selected Formulas / 265
7.6 The Power of a Test / 232
7.13 Summary / 267
7.7 Sample-Size Determination / 239
Problems / 269
Chapter 8
Hypothesis Testing: Two-Sample Inference / 279

8.1 Introduction / 279 8.5 Interval Estimation for the Comparison of
Means from Two Independent Samples
8.2 The Paired t Test / 281
(Equal Variance Case) / 290
8.3 Interval Estimation for the Comparison of
8.6 Testing for the Equality of Two Variances / 292
Means from Two Paired Samples / 285
8.7 Two-Sample t Test for Independent Samples
8.4 Two-Sample t Test for Independent Samples
with Unequal Variances / 298
with Equal Variances / 286
x Contents
8.8 Case Study: Effects of Lead Exposure on 8.10 The Treatment of Outliers / 312
Neurologic and Psychological Function in
8.11 Derivation of Equation 8.13 / 319
Children / 305
8.12 Summary / 320
8.9 Estimation of Sample Size and Power for
Comparing Two Means / 307 Problems / 320
Chapter 9
Nonparametric Methods / 338

9.1 Introduction / 338 9.5 Case Study: Effects of Lead Exposure on
Neurological and Psychological Function in
9.2 The Sign Test / 340
Children / 358
9.3 The Wilcoxon Signed-Rank
9.6 Permutation Tests / 359
Test / 345
9.7 Summary / 364
9.4 The Wilcoxon Rank-Sum Test / 352
Problems / 365
Chapter 10
Hypothesis Testing: Categorical Data / 372

10.1 Introduction / 372 10.6 R × C Contingency Tables / 413
10.2 Two-Sample Test for Binomial 10.7 Chi-Square Goodness-of-Fit Test / 425
Proportions / 373
10.8 The Kappa Statistic / 431
10.3 Fisher’s Exact Test / 387
10.4 Two-Sample Test for Binomial Proportions for
10.10 Summary / 437
Matched-Pair Data (McNemar’s Test) / 395
Problems / 439
10.5 Estimation of Sample Size and Power for
Comparing Two Binomial Proportions / 403
Chapter 11
Regression and Correlation Methods / 457

11.1 Introduction / 457 11.7 The Correlation Coefficient / 485
11.2 General Concepts / 458 11.8 Statistical Inference for Correlation
Coefficients / 490
11.3 Fitting Regression Lines—The Method of
Least Squares / 461 11.9 Multiple Regression / 502
11.4 Inferences About Parameters from 11.10 Case Study: Effects of Lead Exposure on
Regression Lines / 465 Neurologic and Psychological Function in
Children / 519
11.5 Interval Estimation for Linear
Regression / 475 11.11 Partial and Multiple Correlation / 526
11.6 Assessing the Goodness of Fit of 11.12 Rank Correlation / 529
Regression Lines / 481
Contents xi
11.13 Interval Estimation for Rank-Correlation 11.15 Summary / 539

Coefficients / 533
Problems / 540
11.14 Derivation of Equation 11.26 / 537
Chapter 12
Multisample Inference / 551

12.1 Introduction to the One-Way Analysis of 12.6 Two-Way ANOVA / 589
Variance / 551
12.7 The Kruskal-Wallis Test / 596
12.2 One-Way ANOVA—Fixed-Effects
12.8 One-Way ANOVA—The Random-Effects
Model / 552
Model / 604
12.3 Hypothesis Testing in One-Way ANOVA—
12.9 The Intraclass Correlation Coefficient / 609
Fixed-Effects Model / 553
12.10 Mixed Models / 614
12.4 Comparisons of Specific Groups in One-
Way ANOVA / 559 12.11 Derivation of Equation 12.30 / 619
12.5 Case Study: Effects of Lead Exposure on 12.12 Summary / 620
Neurologic and Psychological Function in
Problems / 621
Children / 579
Chapter 13
Design and Analysis Techniques for Epidemiologic Studies / 633

13.1 Introduction / 633 13.10 Meta-Analysis / 705
13.2 Study Design / 634 13.11 Equivalence Studies / 710
13.3 Measures of Effect for Categorical Data / 637 13.12 The Cross-Over Design / 713
13.4 Attributable Risk / 647 13.13 Clustered Binary Data / 721
13.5 Confounding and Standardization / 653 13.14 Longitudinal Data Analysis / 733
13.6 Methods of Inference for Stratified Categorical 13.15 Measurement-Error Methods / 743
Data—The Mantel-Haenszel Test / 659
13.16 Missing Data / 753
13.7 Multiple Logistic Regression / 673
13.17 Derivation of 100% × (1 – α) CI for the Risk
13.8 Extensions to Logistic Regression / 694 Difference / 758
13.9 Sample Size Estimation for Logistic 13.18 Summary / 761
Regression / 703
Problems / 762
Chapter 14
Hypothesis Testing: Person-Time Data / 777

14.1 Measure of Effect for Person-Time 14.3 Two-Sample Inference for
Data / 777 Incidence-Rate Data / 782
14.2 One-Sample Inference for 14.4 Power and Sample-Size Estimation
Incidence-Rate Data / 779 for Person-Time Data / 790
xii Contents
14.5 Inference for Stratified Person-Time Data / 793 14.12 Power and Sample-Size Estimation under
the Proportional-Hazards Model / 835
14.6 Power and Sample-Size Estimation for
Stratified Person-Time Data / 800 14.13 Parametric Survival Analysis / 839
14.7 Testing for Trend: Incidence-Rate Data / 805 14.14 Parametric Regression Models for Survival
Data / 847
14.8 Introduction to Survival Analysis / 808
14.9 Estimation of Survival Curves:
The Kaplan-Meier Estimator / 811 14.16 Summary / 856
14.10 The Log-Rank Test / 819 Problems / 856
14.11 The Proportional-Hazards Model / 825
APPENDIX
Tables / 867
1 Exact binomial probabilities Pr(X = k) = pkqn–k / 867
2 Exact Poisson probabilities / 871

3 The normal distribution / 874
4 Table of 1000 random digits / 878
5 Percentage points of the t distribution (td,u)a / 879
6 Percentage points of the chi-square distribution (χ2d,u)a / 880
7 Confidence limits for the expectation of a Poisson variable (µ) / 881
8 Percentage points of the F distribution (Fd1,d 2,p ) / 882
9 Critical values for the ESD (Extreme Studentized Deviate)
outlier statistic (ESDn,1–α , α = .05, .01) / 884
10 Two-tailed critical values for the Wilcoxon signed-rank test / 884
11 Two-tailed critical values for the Wilcoxon rank-sum test / 885
12 Fisher’s z transformation / 887
13 Two-tailed upper critical values for the Spearman rank-correlation coefficient (rs) / 888
14 Critical values for the Kruskal-Wallis test statistic (H ) for selected sample sizes for k = 3 / 889
15 Critical values for the studentized range statistic q*, α = .05 / 890
Answers to Selected Problems / 891
Flowchart: Methods of Statistical Inference / 895
Index of Data Sets / 901
Index of Statistical Software / 903
Subject Index / 909
Index of Applications / 936
Preface
T his introductory-level biostatistics text is designed for upper-level undergraduate

or graduate students interested in medicine or other health-related areas. It requires
no previous background in statistics, and its mathematical level assumes only a
knowledge of algebra.
Fundamentals of Biostatistics evolved from notes that I have used in a biostatistics
course taught to Harvard University undergraduates, Harvard Medical School, and
Harvard School of Public Health students over the past 30 years. I wrote this book
to help motivate students to master the statistical methods that are most often used
in the medical literature. From the student’s viewpoint, it is important that the
example material used to develop these methods is representative of what actually
exists in the literature. Therefore, most of the examples and exercises in this book
are based either on actual articles from the medical literature or on actual medi-
cal research problems I have encountered during my consulting experience at the
Harvard Medical School.
The Approach
Most introductory statistics texts either use a completely nonmathematical, cookbook
approach or develop the material in a rigorous, sophisticated mathematical frame-
work. In this book, however, I follow an intermediate course, minimizing the amount
of mathematical formulation but giving complete explanations of all important
concepts. Every new concept in this book is developed systematically through com-
pletely worked-out examples from current medical research problems. In addition, I
introduce computer output where appropriate to illustrate these concepts.
I initially wrote this text for the introductory biostatistics course. However, the
field has changed dramatically over the past 30 years; because of the increased power
of newer statistical packages, we can now perform more sophisticated data analyses
than ever before. Therefore, a second goal of this text is to present these new tech-
niques at an introductory level so that students can become familiar with them without
having to wade through specialized (and, usually, more advanced) statistical texts.
To differentiate these two goals more clearly, I included most of the content for
the introductory course in the first 12 chapters. More advanced statistical techniques
used in recent epidemiologic studies are covered in Chapter 13, “Design and Analysis
Techniques for Epidemiologic Studies,” and Chapter 14, “Hypothesis Testing:
Person-Time Data.”
xiii
xiv Preface
Changes in the Eighth Edition

For this edition, I have added three new sections and added new content to three
other sections. Features new to this edition include the following:
■ The data sets are now available on the book’s Companion Website at www
.cengage.com/statistics/rosner in an expanded set of formats, including Excel,
Minitab®, SPSS, JMP, SAS, Stata, R, and ASCII formats.
■ Data and medical research findings in Examples have been updated.
■ New or expanded coverage of the followings topics has been added:
■ The Bootstrap (Section 6.11)
■ One-sample inference for the Binomial Distribution (Section 7.9)
■ Permutation Tests (Section 9.6)
■ Sample size estimation for logistic regression (Section 13.9)
■ Estimation of survival curves: The Kaplan-Meier Estimator (Section 14.9)
■ Derivation of selected formulas (Sections 7.12, 8.11, 10.9, 11.14, 12.11,
13.17, 14.15)
The new sections and the expanded sections for this edition have been indicated by
an asterisk in the table of contents.
Exercises
This edition contains 1,490 exercises; 171 of these exercises are new. Data and medical
research findings in the problems have been updated where appropriate. All problems
based on the data sets are included. Problems marked by an asterisk (*) at the end of
each chapter have corresponding brief solutions in the answer section at the back of
the book. Based on requests from students for more completely solved problems, ap-
proximately 600 additional problems and complete solutions are presented in the
Study Guide available on the Companion Website accompanying this text. In addition,
approximately 100 of these problems are included in a Miscellaneous Problems section
and are randomly ordered so that they are not tied to a specific chapter in the book.
This gives the student additional practice in determining what method to use in what
situation. Complete instructor solutions to all exercises are available at the instructor
companion website at cengage.com/statistics/rosner.
Computation Method
The method of handling computations is similar to that used in the seventh edi-
tion. All intermediate results are carried to full precision (10+ significant digits),
even though they are presented with fewer significant digits (usually 2 or 3) in the
text. Thus, intermediate results may seem inconsistent with final results in some
instances; this, however, is not the case.
Organization
Fundamentals of Biostatistics, Eighth Edition, is organized as follows.
Chapter 1 is an introductory chapter that contains an outline of the develop-
ment of an actual medical study with which I was involved. It provides a unique
sense of the role of biostatistics in medical research.
Chapter 2 concerns descriptive statistics and presents all the major numeric and
graphic tools used for displaying medical data. This chapter is especially important
Preface xv
for both consumers and producers of medical literature because much information
is actually communicated via descriptive material.
Chapters 3 through 5 discuss probability. The basic principles of probability are
developed, and the most common probability distributions—such as the binomial
and normal distributions—are introduced. These distributions are used extensively
in later chapters of the book. The concepts of prior probability and posterior prob-
ability are also introduced.
Chapters 6 through 10 cover some of the basic methods of statistical inference.
Chapter 6 introduces the concept of drawing random samples from popula-
tions. The difficult notion of a sampling distribution is developed and includes an
introduction to the most common sampling distributions, such as the t and chi-
square distributions. The basic methods of estimation, including an extensive discus-
sion of confidence intervals, are also presented. In addition, the bootstrap method for
obtaining confidence limits is introduced for the first time.
Chapters 7 and 8 contain the basic principles of hypothesis testing. The most
elementary hypothesis tests for normally distributed data, such as the t test, are also
fully discussed for one- and two-sample problems.
Chapter 9 covers the basic principles of nonparametric statistics. The assump-
tions of normality are relaxed, and distribution-free analogues are developed for the
tests in Chapters 7 and 8. The technique of permutation testing, which is widely used in
genetic studies, is introduced for the first time.
Chapter 10 contains the basic concepts of hypothesis testing as applied to cat-
egorical data, including some of the most widely used statistical procedures, such as
the chi-square test and Fisher’s exact test.
Chapter 11 develops the principles of regression analysis. The case of simple lin-
ear regression is thoroughly covered, and extensions are provided for the multiple-
regression case. Important sections on goodness-of-fit of regression models are also
included. Also, rank correlation is introduced, including methods for obtaining
confidence intervals for rank correlation.
Chapter 12 introduces the basic principles of the analysis of variance (ANOVA).
The one-way analysis of variance fixed- and random-effects models are discussed.
In addition, two-way ANOVA, the analysis of covariance, and mixed effects mod-
els are covered. Finally, we discuss nonparametric approaches to one-way ANOVA.
Multiple comparison methods including material on the false discovery rate are also
provided.
Chapter 13 discusses methods of design and analysis for epidemiologic studies.
The most important study designs, including the prospective study, the case-control
study, the cross-sectional study, and the cross-over design are introduced. The con-
cept of a confounding variable—that is, a variable related to both the disease and
the exposure variable—is introduced, and methods for controlling for confound-
ing, which include the Mantel-Haenszel test and multiple-logistic regression, are
discussed in detail. Extensions to logistic regression models, including conditional
logistic regression, polytomous logistic regression, and ordinal logistic regression, are
discussed. Methods of estimation of sample size for logistic regression models are provided
for the first time. This discussion is followed by the exploration of topics of current
interest in epidemiologic data analysis, including meta-analysis (the combination
of results from more than one study); correlated binary data techniques (techniques
that can be applied when replicate measures, such as data from multiple teeth from
the same person, are available for an individual); measurement error methods (use-
ful when there is substantial measurement error in the exposure data collected);
equivalence studies (whose objective it is to establish bioequivalence between two
xvi Preface
treatment modalities rather than that one treatment is superior to the other); and
missing-data methods for how to handle missing data in epidemiologic studies.
Longitudinal data analysis and generalized estimating equation (GEE) methods are
also briefly discussed.
Chapter 14 introduces methods of analysis for person-time data. The methods
covered in this chapter include those for incidence-rate data, as well as several meth-
ods of survival analysis: the Kaplan-Meier survival curve estimator, the log-rank test,
and the proportional-hazards model. Methods for testing the assumptions of the
proportional-hazards model have also been included. Parametric survival analysis
methods are also discussed.
Throughout the text—particularly in Chapter 13—I discuss the elements of
study designs, including the concepts of matching; cohort studies; case-control
studies; retrospective studies; prospective studies; and the sensitivity, specificity,
and predictive value of screening tests. These designs are presented in the context
of actual samples. In addition, Chapters 7, 8, 10, 11, 13, and 14 contain specific
sections on sample-size estimation for different statistical situations.
There have been two important organizational changes in the presentation of
material in the text. First, the derivation of more complex formulas have either been
moved after the statement of an equation or to separate derivation sections at the
end of the chapter, to enable students to access the main results in the equations
more immediately. Second, there are numerous subsections entitled “Using the
Computer to Perform a Specific Test” to more clearly highlight use of the computer
to implement many of the methods in the text.
A flowchart of appropriate methods of statistical inference (see pages 895–900)
is a handy reference guide to the methods developed in this book. Page references
for each major method presented in the text are also provided. In Chapters 7 and 8
and Chapters 10–14, I refer students to this flowchart to give them some perspective
on how the methods discussed in a given chapter fit with all the other statistical
methods introduced in this book.
In addition, I have provided an index of applications, grouped by medical spe-
cialty, summarizing all the examples and problems this book covers.
Finally, we provide for the first time, an index of computer software to more clearly
identify the computer commands in specific computer packages that are featured in the text.
Acknowledgments
I am indebted to Debra Sheldon, the late Marie Sheehan, and Harry Taplin for their
invaluable help typing the manuscript, to Dale Rinkel for invaluable help in typing
problem solutions, and to Marion McPhee for helping to prepare the data sets on
the Companion Website. I am also indebted to Roland Matsouaka for updating solu-
tions to problems for this edition, and to Virginia Piaseczny for typing the Index of
Applications. In addition, I wish to thank the manuscript reviewers, among them:
Shouhao Zhou, Daniela Szatmari-Voicu, Jianying Gu, Raid Amin, Claus Wilke, Glen
Johnson, Kara Zografos, and Hui Zhao. I would also like to thank my colleagues
Nancy Cook, who was instrumental in helping me develop the part of Section 12.4
on the false-discovery rate, and Robert Glynn, who was invaluable in developing
Section 13.16 on missing data and Section 14.11 on testing the assumptions of the
proportional-hazards model.
In addition, I wish to thank Spencer Arritt and Jay Campbell, whose input was
critical in providing editorial advice and in preparing the manuscript.
Preface xvii
I am also indebted to my colleagues at the Channing Laboratory—most notably,

the late Edward Kass, Frank Speizer, Charles Hennekens, the late Frank Polk, Ira
Tager, Jerome Klein, James Taylor, Stephen Zinner, Scott Weiss, Frank Sacks, Walter
Willett, Alvaro Munoz, Graham Colditz, and Susan Hankinson—and to my other
colleagues at the Harvard Medical School, most notably, the late Frederick Mosteller,
Eliot Berson, Robert Ackerman, Mark Abelson, Arthur Garvey, Leo Chylack, Eugene
Braunwald, and Arthur Dempster, who inspired me to write this book. I also wish to
express appreciation to John Hopper and Philip Landrigan for providing the data for
our case studies.
Finally, I would like to acknowledge Leslie Miller, Andrea Wagner, Ithamar
Jotkowitz, Loren Fishman, and Frank Santopietro, without whose clinical help the
current edition of this book would not have been possible.
Bernard Rosner
About the Author
Bernard Rosner is Professor of Medicine (Biostatistics)

at Harvard Medical School and Professor of Biosta-
tistics in the Harvard School of Public Health. He
received a B.A. in Mathematics from Columbia Uni-
versity in 1967, an M.S. in Statistics from Stanford
University in 1968, and a Ph.D. in Statistics from Har-
vard University in 1971.
He has more than 30 years of biostatistical con-
sulting experience with other investigators at the Har-
vard Medical School. Special areas of interest include
cardiovascular disease, hypertension, breast cancer,
and ophthalmology. Many of the examples and exer-
Photo courtesy of the Museum of Science, Boston

cises used in the text reflect data collected from actual
studies in conjunction with his consulting experience.
In addition, he has developed new biostatistical meth-
ods, mainly in the areas of longitudinal data analysis,
analysis of clustered data (such as data collected in
families or from paired organ systems in the same
person), measurement error methods, and outlier de-
tection methods. You will see some of these methods
introduced in this book at an elementary level. He was
married in 1972 to his wife, Cynthia, and they have
three children, Sarah, David, and Laura, each of whom
has contributed examples to this book.
xix
General Overview
1
Statistics is the science whereby inferences are made about specific random phe-
nomena on the basis of relatively limited sample material. The field of statistics
has two main areas: mathematical statistics and applied statistics. Mathematical
statistics concerns the development of new methods of statistical inference and
requires detailed knowledge of abstract mathematics for its implementation.
Applied statistics involves applying the methods of mathematical statistics to spe-
cific subject areas, such as economics, psychology, and public health. Biostatistics
is the branch of applied statistics that applies statistical methods to medical and bio-
logical problems. Of course, these areas of statistics overlap somewhat. For example,
in some instances, given a certain biostatistical application, standard methods do
not apply and must be modified. In this circumstance, biostatisticians are involved
in developing new methods.
A good way to learn about biostatistics and its role in the research process is to
follow the flow of a research study from its inception at the planning stage to its com-
pletion, which usually occurs when a manuscript reporting the results of the study
is published. As an example, I will describe one such study in which I participated.
A friend called one morning and in the course of our conversation mentioned
that he had recently used a new, automated blood-pressure measuring device of the
type seen in many banks, hotels, and department stores. The machine had measured
his average diastolic blood pressure on several occasions as 115 mm Hg; the highest
reading was 130 mm Hg. I was very worried, because if these readings were accurate,
my friend might be in imminent danger of having a stroke or developing some other
serious cardiovascular disease. I referred him to a clinical colleague of mine who,
using a standard blood-pressure cuff, measured my friend’s diastolic blood pressure
as 90 mm Hg. The contrast in readings aroused my interest, and I began to jot down
readings from the digital display every time I passed the machine at my local bank.
I got the distinct impression that a large percentage of the reported readings were in
the hypertensive range. Although one would expect hypertensive individuals to be
more likely to use such a machine, I still believed that blood-pressure readings from
the machine might not be comparable with those obtained using standard methods
2 C H A P T E R 1 General Overview
of blood-pressure measurement. I spoke with Dr. B. Frank Polk, a physician at Harvard

Medical School with an interest in hypertension, about my suspicion and succeeded
in interesting him in a small-scale evaluation of such machines. We decided to send
a human observer, who was well trained in blood-pressure measurement techniques,
to several of these machines. He would offer to pay participants 50¢ for the cost of
using the machine if they would agree to fill out a short questionnaire and have
their blood pressure measured by both a human observer and the machine.
At this stage we had to make several important decisions, each of which proved
vital to the success of the study. These decisions were based on the following
questions:
(1) How many machines should we test?
(2) How many participants should we test at each machine?
(3) In what order should we take the measurements? That is, should the human
observer or the machine take the first measurement? Under ideal circumstances
we would have taken both the human and machine readings simultaneously,
but this was logistically impossible.
(4) What data should we collect on the questionnaire that might influence the
comparison between methods?
(5) How should we record the data to facilitate computerization later?
(6) How should we check the accuracy of the computerized data?
We resolved these problems as follows:
(1) and (2) Because we were not sure whether all blood-pressure machines were
comparable in quality, we decided to test four of them. However, we wanted to
sample enough subjects from each machine so as to obtain an accurate comparison
of the standard and automated methods for each machine. We tried to predict how
large a discrepancy there might be between the two methods. Using the methods of
sample-size determination discussed in this book, we calculated that we would need
100 participants at each site to make an accurate comparison.
(3) We then had to decide in what order to take the measurements for each
person. According to some reports, one problem with obtaining repeated blood-
pressure measurements is that people tense up during the initial measurement, yield-
ing higher blood-pressure readings. Thus we would not always want to use either the
automated or manual method first, because the effect of the method would get con-
fused with the order-of-measurement effect. A conventional technique we used here
was to randomize the order in which the measurements were taken, so that for any
person it was equally likely that the machine or the human observer would take the
first measurement. This random pattern could be implemented by flipping a coin or,
more likely, by using a table of random numbers similar to Table 4 of the Appendix.
(4) We believed that the major extraneous factor that might influence the results
would be body size (we might have more difficulty getting accurate readings from
people with fatter arms than from those with leaner arms). We also wanted to get
some idea of the type of people who use these machines. Thus we asked questions
about age, gender, and previous hypertension history.
(5) To record the data, we developed a coding form that could be filled out on
site and from which data could be easily entered into a computer for subsequent
analysis. Each person in the study was assigned a unique identification (ID) number
by which the computer could identify that person. The data on the coding forms
were then keyed and verified. That is, the same form was entered twice and the two
General Overview 3
records compared to make sure they were the same. If the records did not match, the
form was re-entered.
(6) Checking each item on each form was impossible because of the large
amount of data involved. Instead, after data entry we ran some editing programs
to ensure that the data were accurate. These programs checked that the values for
individual variables fell within specified ranges and printed out aberrant values for
manual checking. For example, we checked that all blood-pressure readings were at
least 50 mm Hg and no higher than 300 mm Hg, and we printed out all readings
that fell outside this range. We also ran programs to detect outliers as discussed later
in this book.
After completing the data-collection, data-entry, and data-editing phases, we

were ready to look at the results of the study. The first step in this process is to get
an impression of the data by summarizing the information in the form of several
descriptive statistics. This descriptive material can be numeric or graphic. If numeric,
it can be in the form of a few summary statistics, which can be presented in tabular
form or, alternatively, in the form of a frequency distribution, which lists each value
in the data and how frequently it occurs. If graphic, the data are summarized pictori-
ally and can be presented in one or more figures. The appropriate type of descriptive
material to use varies with the type of distribution considered. If the distribution is
continuous—that is, if there is essentially an infinite number of possible values, as
would be the case for blood pressure—then means and standard deviations may be
the appropriate descriptive statistics. However, if the distribution is discrete—that
is, if there are only a few possible values, as would be the case for gender—then
percentages of people taking on each value are the appropriate descriptive measure.
In some cases both types of descriptive statistics are used for continuous distribu-
tions by condensing the range of possible values into a few groups and giving the
percentage of people that fall into each group (e.g., the percentages of people who
have blood pressures between 120 and 129 mm Hg, between 130 and 139 mm Hg,
and so on).
In this study we decided first to look at mean blood pressure for each method at
each of the four sites. Table 1.1 summarizes this information [1].
You may notice from this table that we did not obtain meaningful data from
all 100 people interviewed at each site. This was because we could not obtain valid
readings from the machine for many of the people. This problem of missing data is
very common in biostatistics and should be anticipated at the planning stage when
deciding on sample size (which was not done in this study).
Ta b le 1 . 1 Mean blood pressures and differences between machine

and human readings at four locations
Systolic blood pressure (mm Hg)
Machine Human Difference
Number Standard Standard Standard

Location of people Mean deviation Mean deviation Mean deviation
A 98 142.5 21.0 142.0 18.1 0.5 11.2

B 84 134.1 22.5 133.6 23.2 0.5 12.1
C 98 147.9 20.3 133.9 18.3 14.0 11.7
D 62 135.4 16.7 128.5 19.0 6.9 13.6
Source: Based on the American Heart Association, Inc.
4 C H A P T E R 1 General Overview
Our next step in the study was to determine whether the apparent differences in
blood pressure between machine and human measurements at two of the locations
(C, D) were “real” in some sense or were “due to chance.” This type of question falls
into the area of inferential statistics. We realized that although there was a differ-
ence of 14 mm Hg in mean systolic blood pressure between the two methods for
the 98 people we interviewed at location C, this difference might not hold up if we
interviewed 98 other people at this location at a different time, and we wanted to
have some idea as to the error in the estimate of 14 mm Hg. In statistical jargon,
this group of 98 people represents a sample from the population of all people who
might use that machine. We were interested in the population, and we wanted to
use the sample to help us learn something about the population. In particular, we
wanted to know how different the estimated mean difference of 14 mm Hg in our
sample was likely to be from the true mean difference in the population of all peo-
ple who might use this machine. More specifically, we wanted to know if it was still
possible that there was no underlying difference between the two methods and that
our results were due to chance. The 14-mm Hg difference in our group of 98 people
is referred to as an estimate of the true mean difference (d) in the population. The
problem of inferring characteristics of a population from a sample is the central con-
cern of statistical inference and is a major topic in this text. To accomplish this aim,
we needed to develop a probability model, which would tell us how likely it is that
we would obtain a 14-mm Hg difference between the two methods in a sample of
98 people if there were no real difference between the two methods over the entire
population of users of the machine. If this probability were small enough, then we
would begin to believe a real difference existed between the two methods. In this
particular case, using a probability model based on the t distribution, we concluded
this probability was less than 1 in 1000 for each of the machines at locations C and D.
This probability was sufficiently small for us to conclude there was a real difference
between the automatic and manual methods of measuring blood pressure for two of
the four machines tested.
We used a statistical package to perform the preceding data analyses. A package
is a collection of statistical programs that describe data and perform various statisti-
cal tests on the data. Currently the most widely used statistical packages are SAS,
SPSS, Stata, R, MINITAB, and Excel.
The final step in this study, after completing the data analysis, was to compile
the results in a publishable manuscript. Inevitably, because of space considerations,
we weeded out much of the material developed during the data-analysis phase and
presented only the essential items for publication.
This review of our blood-pressure study should give you some idea of what
medical research is about and the role of biostatistics in this process. The material in
this text parallels the description of the data-analysis phase of the study. Chapter 2
summarizes different types of descriptive statistics. Chapters 3 through 5 present
some basic principles of probability and various probability models for use in later
discussions of inferential statistics. Chapters 6 through 14 discuss the major topics
of inferential statistics as used in biomedical practice. Issues of study design or data
collection are brought up only as they relate to other topics discussed in the text.
Reference
[1] Polk, B. F., Rosner, B., Feudo, R., & Vandenburgh, M.
(1980). An evaluation of the Vita-Stat automatic blood pres-
sure measuring device. Hypertension, 2(2), 221−227.
Descriptive Statistics
2.1 Introduction
2
The first step in looking at data is to describe the data at
hand in some concise way. In smaller studies this step can be
accomplished by listing each data point. In general, however,
this procedure is tedious or impossible and, even if it were
possible, would not give an overall picture of what the data
look like.
E xamp le 2 . 1 Cancer, Nutrition Some investigators have proposed that consumption of vitamin A
prevents cancer. To test this theory, a dietary questionnaire might be used to collect
data on vitamin-A consumption among 200 hospitalized cancer patients (cases) and
200 controls. The controls would be matched with regard to age and gender with the
cancer cases and would be in the hospital at the same time for an unrelated disease.
What should be done with these data after they are collected?
Before any formal attempt to answer this question can be made, the vitamin-A
consumption among cases and controls must be described. Consider Figure 2.1. The
bar graphs show that the controls consume more vitamin A than the cases do, par-
ticularly at consumption levels exceeding the Recommended Daily Allowance (RDA).
E xamp le 2 . 2 Pulmonary Disease Medical researchers have often suspected that passive smokers—
people who themselves do not smoke but who live or work in an environment in
which others smoke—might have impaired pulmonary function as a result. In 1980
a research group in San Diego published results indicating that passive smokers did
indeed have significantly lower pulmonary function than comparable nonsmokers
who did not work in smoky environments [1]. As supporting evidence, the authors
measured the carbon-monoxide (CO) concentrations in the working environments
of passive smokers and of nonsmokers whose companies did not permit smoking in
the workplace to see if the relative CO concentration changed over the course of the
day. These results are displayed as a scatter plot in Figure 2.2.
Figure 2.2 clearly shows that the CO concentrations in the two working environ-
ments are about the same early in the day but diverge widely in the middle of the
day and then converge again after the workday is over at 7 p.m.
Graphic displays illustrate the important role of descriptive statistics, which
is to quickly display data to give the researcher a clue as to the principal trends in
the data and suggest hints as to where a more detailed look at the data, using the
6 C H A P T E R 2 Descriptive Statistics
Fi gu re 2. 1 Daily vitamin-A consumption among cancer cases and controls
50
Percentage of cases
40
30
20
10
≤ ½ RDA* > ½, ≤ 1 > 1, ≤ 2 > 2, ≤ 5
50
Percentage of controls
40
30
20
10
≤ ½ RDA* > ½, ≤ 1 > 1, ≤2 > 2, ≤5

Consumption of Vitamin A
*RDA = Recommended Daily Allowance.
methods of inferential statistics, might be worthwhile. Descriptive statistics are also

crucially important in conveying the final results of studies in written publications.
Unless it is one of their primary interests, most readers will not have time to criti-
cally evaluate the work of others but will be influenced mainly by the descriptive
statistics presented.
What makes a good graphic or numeric display? The main guideline is that
the material should be as self-contained as possible and should be understandable
without reading the text. These attributes require clear labeling. The captions, units,
and axes on graphs should be clearly labeled, and the statistical terms used in tables
and figures should be well defined. The quantity of material presented is equally
important. If bar graphs are constructed, then care must be taken to display neither
too many nor too few groups. The same is true of tabular material.
Many methods are available for summarizing data in both numeric and graphic
form. In this chapter these methods are summarized and their strengths and weak-
nesses noted.
2.2 Me a s u r e s o f L o c a t i o n
The basic problem of statistics can be stated as follows: Consider a sample of data
x1, . . . , xn, where x1 corresponds to the first sample point and xn corresponds to the
2.2 Measures of Location 7
Fi gu r e 2 . 2 Mean carbon-monoxide concentration (± standard error) by time of day as measured

in the working environment of passive smokers and in nonsmokers who work in a
nonsmoking environment
13.0
12.0
11.0
(parts per million, mean ± standard error)

10.0
CO concentration 9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
7 8 9 10 11 12 1 2 3 4 5 6 7
A.M. Noon P.M.
Passive smokers
Nonsmokers who work
in nonsmoking environment
Source: Based on The New England Journal of Medicine, 302, 720–723, 1980.
nth sample point. Presuming that the sample is drawn from some population P,
what inferences or conclusions can be made about P from the sample?
Before this question can be answered, the data must be summarized as succinctly
as possible; this is because the number of sample points is often large, and it is easy
to lose track of the overall picture when looking at individual sample points. One
type of measure useful for summarizing data defines the center, or middle, of the
sample. This type of measure is a measure of location.
The Arithmetic Mean

How to define the middle of a sample may seem obvious, but the more you think
about it, the less obvious it becomes. Suppose the sample consists of the birth-
weights of all live-born infants born at a private hospital in San Diego, California,
during a 1-week period. This sample is shown in Table 2.1.
One measure of location for this sample is the arithmetic mean (colloqui-
ally called the average). The arithmetic mean (or mean or sample mean) is usually
denoted by x.
Table 2 . 1 Sample of birthweights (g) of live-born infants born at a private hospital in San Diego,
California, during a 1-week period
i xi i xi i xi i xi
1 3265 6 3323 11 2581 16 2759

2 3260 7 3649 12 2841 17 3248
3 3245 8 3200 13 3609 18 3314
4 3484 9 3031 14 2838 19 3101
5 4146 10 2069 15 3541 20 2834
De fi n i t i on 2. 1 The arithmetic mean is the sum of all the observations divided by the number of
observations. It is written in statistical terms as
1 n
x = ∑ xi
n i =1
The sign Σ (sigma) in Definition 2.1 is a summation sign. The expression

n
∑ xi
i =1
is simply a short way of writing the quantity ( x1 + x2 + L + xn ).
If a and b are integers, where a < b, then

b
∑ xi

i =a
means xa + xa+1 + L + xb.
If a = b, then ∑ i = a xi = xa . One property of summation signs is that if each term in

b
the summation is a multiple of the same constant c, then c can be factored out from
the summation; that is,
n  n 
∑ cxi = c  ∑ xi
i =1 i =1
E xam p le 2 . 3 If x1 = 2 x2 = 5 x3 = -4
3 3 3 3
find ∑ xi ∑ xi ∑ xi2 ∑ 2 xi
i =1 i =2 i =1 i =1
Solution:
3 3
∑3 xi = 2 + 5 − 4 = 3 ∑3 xi = 5 − 4 = 1
∑
i =1
3 i
x = 2 + 5 − 4 = 3 i∑ =2
xi = 5 − 4 = 1
3 3
i =1 2 i =2
∑3 xi = 4 + 25 + 16 = 45 ∑3 2 xi = 2∑3 xi = 6
∑ xi = 4 + 25 + 16 = 45 ∑
i =1 2 i =1
2 xi = 2 ∑
i =1
xi = 6
i =1 i =1 i =1
It is important to become familiar with summation signs because they are used
extensively throughout the remainder of the text.
E xamp le 2 . 4 What is the arithmetic mean for the sample of birthweights in Table 2.1?
x = (3265 + 3260 + L + 2834) 20 = 3166.9 g

The arithmetic mean is, in general, a very natural measure of location. One
of its main limitations, however, is that it is oversensitive to extreme values. In
this instance, it may not be representative of the location of the great majority
of sample points. For example, if the first infant in Table 2.1 happened to be a
premature infant weighing 500 g rather than 3265 g, then the arithmetic mean
of the sample would fall to 3028.7 g. In this instance, 7 of the birthweights would
be lower than the arithmetic mean, and 13 would be higher than the arithmetic
mean. It is possible in extreme cases for all but one of the sample points to be on
one side of the arithmetic mean. In these types of samples, the arithmetic mean
is a poor measure of central location because it does not reflect the center of the
sample. Nevertheless, the arithmetic mean is by far the most widely used measure
of central location.
The Median
An alternative measure of location, perhaps second in popularity to the arithmetic
mean, is the median or, more precisely, the sample median.
Suppose there are n observations in a sample. If these observations are ordered
from smallest to largest, then the median is defined as follows:
Def i ni ti o n 2 . 2 The sample median is

 n + 1
(1) The  th largest observation if n is odd
 2 
 n n 
(2) The average of the   th and  + 1 th largest observations if n is even
 2 2 
The rationale for these definitions is to ensure an equal number of sample points
on both sides of the sample median. The median is defined differently when n is
even and odd because it is impossible to achieve this goal with one uniform defini-
tion. Samples with an odd sample size have a unique central point; for example,
for samples of size 7, the fourth largest point is the central point in the sense that
3 points are smaller than it and 3 points are larger. Samples with an even sample size
have no unique central point, and the middle two values must be averaged. Thus,
for samples of size 8 the fourth and fifth largest points would be averaged to obtain
the median, because neither is the central point.
E xamp le 2 . 5 Compute the sample median for the sample in Table 2.1.
Solution: First, arrange the sample in ascending order:
069, 2581, 2759, 2834, 2838, 2841, 3031, 3101, 3200, 3245, 3248, 3260, 3265,
2
3314, 3323, 3484, 3541, 3609, 3649, 4146
Because n is even,
Sample median = average of the 10th and 11th largest observations

= (3245 + 3248)/2 = 3246.5 g
We can also use a computer package to compute the mean and median. We
have used the computer package R for this purpose. We first enter the data from
Table 2.1 into a spreadsheet and save it as a text file with the names of the variables
(in this case two variables called id and birthwt) in the first row. We then read the
data into R using the read.xlsx command and assign the data set the name bwt.
We then use the attach command to refer to the variables in the data set by name.
We also use the names command to determine what the names are in the data set.
Finally, we use the mean and median commands to compute the arithmetic mean
and the median, respectively. The results are given in Table 2.2.
Table 2 . 2 Use of R to compute the mean and median for the birthweight data in Table 2.1
> bwt<-read.xlsx(“E:/Rosner/DataCh2/fob.8thedition.
table2.1.xlsx”,2, header=TRUE)
> attach(bwt)
> names(bwt)
[1] “id” “birthwt”
> birthwt
[1] 3265 3260 3245 3484 4146 3323 3649 3200 3031 2069 2581 2841
3609 2838 3541
[16] 2759 3248 3314 3101 2834
> mean(birthwt)
[1] 3166.9
> median(birthwt)
[1] 3246.5
E xam p le 2. 6 Infectious Disease Consider the data set in Table 2.3, which consists of white-blood
counts taken upon admission of all patients entering a small hospital in Allentown,
Pennsylvania, on a given day. Compute the median white-blood count.
Tab le 2 . 3 Sample of admission white-blood counts

(× 1000) for all patients entering a hospital
in Allentown, Pennsylvania, on a given day
i xi i xi
1 7 6 3
2 35 7 10
3 5 8 12
4 9 9 8
5 8
Solution: First, order the sample as follows: 3, 5, 7, 8, 8, 9, 10, 12, 35. Because n is
odd, the sample median is given by the fifth largest point, which equals 8 or 8000
on the original scale.
The main strength of the sample median is that it is insensitive to very large
or very small values. In particular, if the second patient in Table 2.3 had a white
count of 65,000 rather than 35,000, the sample median would remain unchanged,
because the fifth largest value is still 8000. Conversely, the arithmetic mean would
increase dramatically from 10,778 in the original sample to 14,111 in the new sample.
The main weakness of the sample median is that it is determined mainly by the
middle points in a sample and is less sensitive to the actual numeric values of the
remaining data points.
Comparison of the Arithmetic Mean and the Median

If a distribution is symmetric, then the relative position of the points on each side
of the sample median is the same. An example of a distribution that is expected to
be roughly symmetric is the distribution of systolic blood-pressure measurements
taken on all 30- to 39-year-old factory workers in a given workplace (Figure 2.3a).
If a distribution is positively skewed (skewed to the right), then points above
the median tend to be farther from the median in absolute value than points below
the median. An example of a positively skewed distribution is that of the number of
years of oral contraceptive (OC) use among a group of women ages 20 to 29 years
(Figure 2.3b). Similarly, if a distribution is negatively skewed (skewed to the left),
then points below the median tend to be farther from the median in absolute value
than points above the median. An example of a negatively skewed distribution is
that of relative humidities observed in a humid climate at the same time of day over
a number of days. In this case, most humidities are at or close to 100%, with a few
very low humidities on dry days (Figure 2.3c).
Fi gu re 2 .3 Graphic displays of (a) symmetric, (b) positively skewed, and (c) negatively skewed distributions
Number of factory workers
Number of women
0 90 100 110 120 130 140 150 160 0 1 2 3 4 5 6 7 8 9 10

Systolic blood pressure Years of OC use
(a) (b)
Number of days
0 40% 50% 60% 70% 80% 90% 100%

Relative humidity
(c)
In many samples, the relationship between the arithmetic mean and the
sample median can be used to assess the symmetry of a distribution. In particular,
for symmetric distributions the arithmetic mean is approximately the same as the
median. For positively skewed distributions, the arithmetic mean tends to be larger
than the median; for negatively skewed distributions, the arithmetic mean tends to
be smaller than the median.
The Mode
Another widely used measure of location is the mode.
De fi n i t i on 2. 3 The mode is the most frequently occurring value among all the observations in a
sample.
E xam p le 2. 7 Gynecology Consider the sample of time intervals between successive menstrual
periods for a group of 500 college women age 18 to 21 years, shown in Table 2.4. The
frequency column gives the number of women who reported each of the respective
durations. The mode is 28 because it is the most frequently occurring value.
Table 2 .4 Sample of time intervals between successive menstrual periods (days)

in college-age women
Value Frequency Value Frequency Value Frequency
24 5 29 96 34 7
25 10 30 63 35 3
26 28 31 24 36 2
27 64 32 9 37 1
28 185 33 2 38 1
E xam p le 2 . 8 Compute the mode of the distribution in Table 2.3.
Solution: The mode is 8000 because it occurs more frequently than any other white-
blood count.
Some distributions have more than one mode. In fact, one useful method of
classifying distributions is by the number of modes present. A distribution with one
mode is called unimodal; two modes, bimodal; three modes, trimodal; and so
forth.
E xam p le 2 . 9 Compute the mode of the distribution in Table 2.1.
Solution: There is no mode, because all the values occur exactly once.
Example 2.9 illustrates a common problem with the mode: It is not a useful
measure of location if there is a large number of possible values, each of which
occurs infrequently. In such cases the mode will be either far from the center of the
sample or, in extreme cases, will not exist, as in Example 2.9.
The Geometric Mean

Many types of laboratory data, specifically data in the form of concentrations of
one substance in another, as assessed by serial dilution techniques, can be expressed
either as multiples of 2 or as a constant multiplied by a power of 2; that is, outcomes
can only be of the form 2kc, k = 0, 1, . . . , for some constant c. For example, the data
in Table 2.5 represent the minimum inhibitory concentration (MIC) of penicillin
G in the urine for N. gonorrhoeae in 74 patients [2]. The arithmetic mean is not
appropriate as a measure of location in this situation because the distribution is
very skewed.
However, the data do have a certain pattern because the only possible values
are of the form 2k(0.03125) for k = 0, 1, 2, . . . . One solution is to work with the
distribution of the logs of the concentrations. The log concentrations have the prop-
erty that successive possible concentrations differ by a constant; that is, log(2k+1c)
− log(2kc) = log(2k+1) + log c − log(2k) − log c = (k + 1) log 2 − k log 2 = log 2. Thus the
log concentrations are equally spaced from each other, and the resulting distribu-
tion is now not as skewed as the concentrations themselves. The arithmetic mean
can then be computed in the log scale; that is,
Ta b le 2. 5 Distribution of minimum inhibitory concentration (MIC)

of penicillin G for N. gonorrhoeae
Concentration ( µg/mL) Frequency Concentration ( µg/mL) Frequency
0.03125 = 20(0.03125) 21 0.250 = 23(0.03125) 19

0.0625 = 21(0.03125) 6 0.50 = 24(0.03125) 17
0.125 = 22(0.03125) 8 1.0 = 25(0.03125) 3
Source: Based on JAMA, 220, 205–208, 1972.
1 n
log x = ∑ log xi
n i =1
and used as a measure of location. However, it is usually preferable to work in the

original scale by taking the antilogarithm of log x to form the geometric mean,
which leads to the following definition:
De f in i ti o n 2 . 4 The geometric mean is the antilogarithm of log x, where

1 n
log x = ∑ log xi
n i =1
Any base can be used to compute logarithms for the geometric mean. The geometric
mean is the same regardless of which base is used. The only requirement is that the
logs and antilogs in Definition 2.4 should be in the same base. Bases often used in
practice are base 10 and base e.
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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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Discrete Probability Distributions / 77

Continuous Probability Distributions / 115

Hypothesis Testing: One-Sample Inference / 211

Hypothesis Testing: Two-Sample Inference / 279

Nonparametric Methods / 338

Hypothesis Testing: Categorical Data / 372

Regression and Correlation Methods / 457

11.13 Interval Estimation for Rank-Correlation 11.15 Summary / 539

Multisample Inference / 551

Design and Analysis Techniques for Epidemiologic Studies / 633

Hypothesis Testing: Person-Time Data / 777

2 Exact Poisson probabilities / 871

Answers to Selected Problems / 891

Flowchart: Methods of Statistical Inference / 895

Index of Data Sets / 901

Index of Statistical Software / 903

Subject Index / 909

Index of Applications / 936

T his introductory-level biostatistics text is designed for upper-level undergraduate

Changes in the Eighth Edition

I am also indebted to my colleagues at the Channing Laboratory—most notably,

Bernard Rosner is Professor of Medicine (Biostatistics)

Photo courtesy of the Museum of Science, Boston

of blood-pressure measurement. I spoke with Dr. B. Frank Polk, a physician at Harvard

We resolved these problems as follows:

After completing the data-collection, data-entry, and data-editing phases, we

Ta b le 1 . 1 Mean blood pressures and differences between machine

Number Standard Standard Standard

A 98 142.5 21.0 142.0 18.1 0.5 11.2

Source: Based on the American Heart Association, Inc.

Fi gu re 2. 1 Daily vitamin-A consumption among cancer cases and controls

≤ ½ RDA* > ½, ≤ 1 > 1, ≤ 2 > 2, ≤ 5

≤ ½ RDA* > ½, ≤ 1 > 1, ≤2 > 2, ≤5

methods of inferential statistics, might be worthwhile. Descriptive statistics are also

Fi gu r e 2 . 2 Mean carbon-monoxide concentration (± standard error) by time of day as measured

(parts per million, mean ± standard error)

The Arithmetic Mean

1 3265 6 3323 11 2581 16 2759

The sign Σ (sigma) in Definition 2.1 is a summation sign. The expression

is simply a short way of writing the quantity ( x1 + x2 + L + xn ).

If a and b are integers, where a < b, then

means xa + xa+1 + L + xb.

If a = b, then ∑ i = a xi = xa . One property of summation signs is that if each term in

Def i ni ti o n 2 . 2 The sample median is

Solution: First, arrange the sample in ascending order:

Sample median = average of the 10th and 11th largest observations

Tab le 2 . 3 Sample of admission white-blood counts

Comparison of the Arithmetic Mean and the Median

0 90 100 110 120 130 140 150 160 0 1 2 3 4 5 6 7 8 9 10

0 40% 50% 60% 70% 80% 90% 100%

Table 2 .4 Sample of time intervals between successive menstrual periods (days)

Value Frequency Value Frequency Value Frequency

E xam p le 2 . 8 Compute the mode of the distribution in Table 2.3.

E xam p le 2 . 9 Compute the mode of the distribution in Table 2.1.

The Geometric Mean

Ta b le 2. 5 Distribution of minimum inhibitory concentration (MIC)

Concentration ( µg/mL) Frequency Concentration ( µg/mL) Frequency

0.03125 = 20(0.03125) 21 0.250 = 23(0.03125) 19

Source: Based on JAMA, 220, 205–208, 1972.

and used as a measure of location. However, it is usually preferable to work in the

De f in i ti o n 2 . 4 The geometric mean is the antilogarithm of log x, where

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