Comprehensive Radiographic

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Mary Jo Bergman, MEd, MS, RN,
RT(R)
Program Director
Sanford Medical Center/Sanford
Health
Fargo, North Dakota
Melanie Billmeier, MSRS, RT(R)
Radiology Program Coordinator
North Central Texas College
Gainesville, Texas
Delores Boland, BSRS, R M
Clinic Coordinator
Radiologic Technology Program
Southwest Tennessee Community
College
Memphis, Tennessee
Deanna Butcher, MA, RT(R)
Program Director
School of Diagnostic Imaging
St. Cloud Hospital
St. Cloud, Minnesota
Diane T. Castor, BS, RT(R)
Program Director
Radiologic Science Program
College of Coastal Georgia
Brunswick, Georgia
Cynthia M. Cobb, RT(R)(CT),
CCRP
Imaging Quality Assurance and
Research Coordinator
Diagnostic Imaging Department
Rhode Island Hospital
Providence, Rhode Island
Robin Cornett, MAEd, RT(R)(CV)
Clinical Coordinator, Faculty
Caldwell Community College &
Technical Institute
Hudson, North Carolina
Tammy Curtis, MSRS, RT(R)
(CT)(CHES)
Associate Professor
Northwestern State University
Shreveport, Louisiana
Catherine DeBallie, MSEd, RT(R)
Assistant Professor
Trinity College of Nursing and
Health Sciences
Rock Island, Illinois
Susan L. Grimm, RT(R)
Assistant Professor, Radiography
Richland Community College
One College Park
Decatur, Illinois
Kelli Haynes, MSRS, RT(R)
Director of Undergraduate Studies/
Associate Professor/Graduate
Faculty
Radiologic Sciences Department
Northwestern State University
Shreveport, Louisiana
Kathleen Kath, MS, RT(R)(M)
Program Director
Radiologic Technology &
Radiologist Assistant Studies
Wayne State University
Henry Ford Hospital
Detroit, Michigan
Tricia Leggett, DHed, RT(R)(QM)
RAD Program Director/Associate
Professor
Zane State College
Zanesville, Ohio
David L. McLaughlin, MAEd, RT(R)
Program Director/Co-Chair/
Professor
Mt. San Antonio College
Walnut, California
Wendy Mickelsen, MHE, RT(R)(M)
Assistant Professor
Idaho State University
Pocatello, Idaho
Galen Miller, BS, RT(R)
Radiography Clinical Coordinator
Mid Michigan Community
College
Harrison Michigan
Reviewers
Kristi Moore, MS, RT(R)(CT)
Assistant Professor
Radiologic Sciences Program
The University of Mississippi
Medical Center
Jackson, Mississippi
Charles W. Newell, EdD, RT(R)
(MR)(CT)(CV)
Chairperson/Associate Professor
University of South Alabama
Mobile, Alabama
Paula Pate-Schloder, MS, RT(R)
(CV)(CT)(VI)
Associate Professor
Medical Imaging
Misericordia University
Dallas, Pennsylvania
Mimi Polczynski, MSEd, RT(R)
(M)(CT)
Radiology Director
Kaskaskia Community College
Centralia, Illinois
Roger A. Preston, MSRS, RT(R)
Program Director
Reid Hospital & Health Care
Services
School of Radiologic Technology
Richmond, Indiana
James Pronovost, MS, RT(R)
Professor/Director
Radiologic Technology
Naugatuck Valley Community College
Waterbury, Connecticut
Angela Sapp, MHA, BS, RT(R)
Program Chair
Mercy College of Health Sciences
Des Moines, Iowa
Andrew Shappell, MEd, RT(R)
(MR)(CT)(QM)
Assistant Professor/Clinical
Coordinator
Rhodes State College
Lima, Ohio
vii
viii Reviewers
Deena Slockett, MBA, RT(R)(M)
Assistant Chair/Associate Professor
Department of Radiologic Sciences
Florida Hospital College of Health
Sciences
Orlando, Florida
Karie Solembrino, MS, RT(R)(CT)
Department Head /Associate Professor
Radiologic Technology Department
Wor-Wic Community College
Salisbury, Maryland
Tiffani Walker, MSRS, RT(R)
Clinical Coordinator
North Central Texas College
Gainesville, Texas

Understanding the basic principles of pathology is an
essential part of the radiologic technologist's ­education.
Knowing how disease processes work and ­recognizing
the radiographic appearance of specific diseases aids
the technologist in selecting proper modalities and
­determining the need for repeat radiographs in different
­situations. This kind of knowledge enables the radiologic
­technologist to become a more competent professional
and a contributing member of the diagnostic team.
Organization
Fully illustrated and well organized, Comprehensive
Radiographic Pathology meets the needs of today's stu-
dent and practicing radiographers. The book opens with
a chapter on disease processes that introduces the patho-
logic terms used throughout the text. Chapter 2 describes
the advantages and limitations of seven widely used
modalities: ultrasound, computed tomography, magnetic
resonance imaging, nuclear medicine, single-photon emis-
sion computed tomography (SPECT), positron-emission
tomography (PET), and fusion imaging.
Each of the remaining chapters is a systematic approach
to the diseases involving a specific organ system. These
chapters begin with an overview of physiology. For each
of the most common pathologic conditions associated
with the system, there is a brief description of the disease
and its clinical manifestations, followed by imaging find-
ings and treatment. Summary tables follow each major
discussion, reiterating the location, radiographic appear-
ance, and treatment of the diseases just presented.
Distinctive Features
• Comprehensive coverage provides the most thorough
explanations of any radiographic pathology text of
those pathologies that can be diagnosed with medical
imaging.
• Navigating the chapters is easy with the standardized
heading scheme and chapter outlines for the systems
chapters.
• Radiographers Notes in every chapter instruct the stu-
dents on how to deal effectively with varying patient
needs and provide perspective on why learning pathol-
ogy is important for radiography practice.
• Systems approach makes it easy to locate information
and to study one area at a time, assimilating details in
a logical sequence. It provides the best framework for
building understanding of pathology.
Preface
• Summary tables list the radiographic appearance and
treatment of each disease and have been updated to
include pathologic conditions included in the text.
• Coverage of the alternative imaging modalities that
supplement radiographic imaging for diagnosis of
some pathology conditions orients readers to other
modalities that may be needed to ensure proper diag-
nosis of certain pathologies.
• Treatment sections provide useful background treat-
ment and prognosis.
• The student Workbook provides extra opportunities
for review and self-assessment.
New to This Edition
• Updates and additions of the following: morbidity/
mortality/epidemiology; scoliosis; chest tubes and
lines; MRSA (methicillin-resistant Staphylococcus
aureus infection); systemic/highly-infectious disease;
fusion imaging; SPECT, PET, CT, MR, and their cor-
relation with general radiography.
• New CT/MR images for correlation with radiographs
where appropriate.
• Updated Radiographer Notes to incorporate film and
digital information.
Pedagogical Features
• Each chapter opens with an outline and a key terms
list to aid the student in navigating the content.
• Radiographer Notes offer helpful suggestions for
­producing optimal radiographs of the organ system
­featured in each chapter. Information especially rel-
evant to radiologic technologists is included, such
as positioning and exposure factor adjustments for
patients with specific conditions and special patient
handling requirements. If multiple imaging modalities
can be used, the most appropriate initial procedure
is indicated, as well as the sequence in which various
imaging studies should be performed.
• The body system chapters are organized as follows:
physiology, identification of anatomic structures on
anatomy figures and radiographs, pathologic condi-
tions, radiographic appearance, and treatment.
• Each section of related pathologies is summarized
in a table at the end of the section. The tables name
the ­disorder and then list the location, radiographic
appearance, and treatment for easy review and
enhanced retention.
ix
x Preface
• Finally, each chapter ends with a series of review ques-
tions to help readers assess their comprehension of
the material. An answer key is found at the back of
the book, along with several appendices, an extensive
glossary, and a list of major prefixes, roots, and suf-
fixes to help readers determine the meaning of unfa-
miliar words.
Ancillaries
For the Instructor
• Instructor Resources on Evolve include lesson plans, a test
bank with approximately 500 questions, PowerPoint slides,
and an image collection with approximately 900 images.
For the Student
• The Workbook contains a variety of exercises for
each of the twelve chapters in the book. Examples
include matching terms with their definitions; label-
ing diagrams; fill-in-the-blank, short answer, and mul-
tiple choice questions; pathology case studies; and
a posttest. Completing the workbook activities will
ensure understanding of disease processes, their radio-
graphic appearance, and their likely treatment. The
answers for the exercises are located in the back of the
workbook.
By understanding the disease processes, their radio-
graphic appearance, and their treatment, the technologist
will be prepared to contribute to the diagnostic team.

1 Introduction to Pathology, 1
Disease, 1
Inflammation, 3
Edema, 4
Ischemia and Infarction, 5
Hemorrhage, 5
Alterations of Cell Growth, 6
Neoplasia, 7
Hereditary Diseases, 9
Disorders of Immunity, 11
Infectious Disease Exposure, 11
Acquired Immunodeficiency Syndrome, 12
2 Specialized Imaging Techniques, 15
Diagnostic Imaging Modalities, 15
Mammography, 16
Ultrasound, 16
Computed Tomography, 19
Magnetic Resonance Imaging, 23
Nuclear Medicine, 27
Single-Photon Emission Computed
Tomography, 28
Positron Emission Tomography, 29
Fusion Imaging, 31
3 Respiratory System, 34
Physiology of the Respiratory System, 36
Internal Devices, 38
Endotracheal Tube, 38
Central Venous Catheters, 38
Swan-Ganz Catheter, 39
Transvenous Cardiac Pacemakers, 40
Congenital/Hereditary Diseases, 41
Cystic Fibrosis, 41
Hyaline Membrane Disease, 42
Inflammatory Disorders of the Upper
Respiratory System, 43
Croup, 43
Epiglottitis, 43
Inflammatory Disorders of the Lower
Respiratory System, 44
Pneumonia, 44
Anthrax, 46
Lung Abscess, 46
Tuberculosis, 47
Contents
Pulmonary Mycosis, 50
Respiratory Syncytial Virus, 51
Severe Acute Respiratory Syndrome, 52
Diffuse Lung Disease, 53
Chronic Obstructive Pulmonary Disease, 53
Sarcoidosis, 56
Pneumoconiosis, 58
Neoplasms, 61
Solitary Pulmonary Nodule, 61
Bronchial Adenoma, 62
Bronchogenic Carcinoma, 62
Treatment of Pulmonary Neoplastic
Diseases, 65
Pulmonary Metastases, 65
Vascular Diseases, 66
Pulmonary Embolism, 66
Septic Embolism, 71
Pulmonary Arteriovenous Fistula, 71
Miscellaneous Lung Disorders, 72
Atelectasis, 72
Adult Respiratory Distress Syndrome, 73
Intrabronchial Foreign Bodies, 74
Mediastinal Emphysema
(Pneumomediastinum), 74
Subcutaneous Emphysema, 75
Treatment of Mediastinal and Subcutaneous
Emphysema, 75
Disorders of the Pleura, 76
Pneumothorax, 76
Pleural Effusion, 77
Empyema, 78
Mediastinal Masses, 79
Disorders of the Diaphragm, 80
Diaphragmatic Paralysis, 81
Eventration of the Diaphragm, 82
Other Causes of Elevation of the
Diaphragm, 83
4 Skeletal System, 85
Physiology of the Skeletal System, 87
Congenital/Hereditary Diseases of Bone, 88
Vertebral Anomalies, 88
Spina Bifida, 89
Osteopetrosis, 90
Osteogenesis Imperfecta, 91
Achondroplasia, 91
Congenital Hip Dysplasia (Dislocation), 92
xi
xii Contents Contents
Inflammatory and Infectious Disorders, 93
Rheumatoid Arthritis, 93
Rheumatoid Variants: Ankylosing
Spondylitis, Reiter's Syndrome, and
Psoriatic Arthritis, 94
Osteoarthritis (Degenerative Joint
Disease), 97
Infectious Arthritis, 98
Treatment of Arthritis, 99
Bursitis, 100
Rotator Cuff Tears, 102
Tears of the Menisci of the Knee, 102
Bacterial Osteomyelitis, 103
Tuberculous Osteomyelitis, 106
Metabolic Bone Disease, 108
Osteoporosis, 108
Osteomalacia, 109
Rickets, 109
Treatment for Osteomalacia and
Rickets, 111
Gout, 111
Paget's Disease, 113
Lead Poisoning, 114
Fibrous Dysplasia, 116
Ischemic Necrosis of Bone, 116
Benign Bone Tumors, 118
Treatment of Benign Bone Tumors, 122
Malignant Bone Tumors, 123
Treatment of Malignant Bone
Tumors, 127
Bone Metastases, 127
Fractures, 131
Types of Fractures, 131
Fracture Healing, 134
Pathologic Fractures, 136
Stress Fractures, 136
Battered-Child Syndrome, 137
Common Fractures and
Dislocations, 138
Fractures and Dislocations of the
Spine, 142
Herniation of Intervertebral Disks, 146
Scoliosis, 146
Spondylolysis and Spondylolisthesis, 149
5 Gastrointestinal System, 153
Physiology of the Digestive System, 154
Esophagus, 157
Tracheoesophageal Fistula, 157
Esophagitis, 159
Ingestion of Corrosive Agents, 162
Esophageal Cancer, 163
Esophageal Diverticula, 164
Esophageal Varices, 165
Hiatal Hernia, 166
Achalasia, 166
Foreign Bodies, 167
Perforation of the Esophagus, 168
Stomach, 171
Gastritis, 171
Pyloric Stenosis, 171
Peptic Ulcer Disease, 172
Cancer of the Stomach, 175
Small Bowel, 176
Crohn's Disease (Regional
Enteritis), 176
Small Bowel Obstruction, 179
Adynamic Ileus, 182
Intussusception, 183
Malabsorption Disorders, 184
Colon, 185
Appendicitis, 185
Diverticulosis, 187
Diverticulitis, 187
Ulcerative Colitis, 188
Crohn's Colitis, 191
Ischemic Colitis, 192
Irritable Bowel Syndrome, 193
Cancer of the Colon, 193
Large Bowel Obstruction, 195
Volvulus of the Colon, 195
Hemorrhoids, 196
Gallbladder, 199
Gallstones (Cholelithiasis), 199
Acute Cholecystitis, 200
Emphysematous Cholecystitis, 201
Treatment for Cholecystitis, 201
Porcelain Gallbladder, 202
Liver, 202
Hepatitis, 202
Cirrhosis of the Liver, 204
Hepatocellular Carcinoma, 205
Hepatic Metastases, 207
Pancreas, 208
Acute Pancreatitis, 208
Chronic Pancreatitis, 209
Treatment of Acute and Chronic
Pancreatitis, 210
Pancreatic Pseudocyst, 210
Cancer of the Pancreas, 211
Pneumoperitoneum, 213
Spleen, 215
Enlargement, 215
Rupture, 215
Treatment of Splenic Disorders, 216
 Contents xiii

6 Urinary System, 219 Mitral Insufficiency, 280

Physiology of the Urinary System, 219
Congenital/Hereditary Diseases, 222
Anomalies of Number and Size, 222
Anomalies of Rotation, Position, and
Fusion, 222
Anomalies of Renal Pelvis and Ureter, 224
Treatment of Congenital/Hereditary
Anomalies, 225
Ureterocele, 225
Posterior Urethral Valves, 225
Inflammatory Disorders, 225
Glomerulonephritis, 225
Pyelonephritis, 227
Tuberculosis, 229
Papillary Necrosis, 230
Cystitis, 230
Urinary Calculi, 232
Urinary Tract Obstruction, 236
Cysts and Tumors, 238
Renal Cyst, 238
Polycystic Kidney Disease, 239
Renal Carcinoma, 241
Wilms' Tumor (Nephroblastoma), 244
Carcinoma of the Bladder, 245
Renal Vein Thrombosis, 246
Acute Renal Failure, 248
Chronic Renal Failure, 249
7 Cardiovascular System, 251
Physiology of the Cardiovascular System, 251
Congenital Heart Disease, 255
Left-to-Right Shunts, 255
Tetralogy of Fallot, 256
Coarctation of the Aorta, 257
Acquired Vascular Disease, 259
Coronary Artery Disease, 259
Congestive Heart Failure, 263
Pulmonary Edema, 264
Treatment of Congestive Heart Failure and
Pulmonary Edema, 265
Hypertension, 266
Hypertensive Heart Disease, 268
Aneurysm, 269
Traumatic Rupture of the Aorta, 270
Dissection of the Aorta, 272
Atherosclerosis, 273
Thrombosis and Embolism, 275
Valvular Disease, 278
Rheumatic Heart Disease, 278
Mitral Stenosis, 279
Treatment of Mitral Stenosis and Mitral
Insufficiency, 281
Aortic Stenosis, 281
Aortic Insufficiency, 281
Treatment of Aortic Stenosis and Aortic
Insufficiency, 281
Infective Endocarditis, 282
Pericardial Effusion, 283
Venous Disease, 285
Deep Venous Thrombosis, 285
Varicose Veins, 285
8 Nervous System, 290
Physiology of the Nervous System, 291
Infections of the Central Nervous System, 294
Meningitis, 294
Encephalitis, 295
Brain Abscess, 296
Subdural Empyema, 297
Epidural Empyema, 297
Treatment of Subdural and Epidural
Empyemas, 298
Osteomyelitis of the Skull, 298
Tumors of the Central Nervous System, 299
Glioma, 300
Meningioma, 303
Acoustic Neuroma, 303
Pituitary Adenoma, 304
Craniopharyngioma, 308
Pineal Tumors, 309
Chordoma, 310
Metastatic Carcinoma, 311
Traumatic Processes of the Brain and Skull, 313
Skull Fracture, 313
Epidural Hematoma, 315
Subdural Hematoma, 315
Cerebral Contusion, 316
Intracerebral Hematoma, 317
Subarachnoid Hemorrhage, 317
Carotid Artery Injury, 317
Facial Fractures, 318
Vascular Disease of the Central Nervous
System, 321
Stroke Syndrome, 322
Transient Ischemic Attacks, 323
Intraparenchymal Hemorrhage, 324
Subarachnoid Hemorrhage, 327
Multiple Sclerosis, 329
Epilepsy and Convulsive Disorders, 331
Degenerative Diseases, 332
Normal Aging, 332
xiv Contents Contents
Alzheimer's Disease, 332 Benign Prostatic Hyperplasia, 393
Huntington's Disease, 332 Carcinoma of the Prostate Gland, 394
Parkinson's Disease, 334 Staging, 395
Cerebellar Atrophy, 334 Undescended Testis (Cryptorchidism), 396
Amyotrophic Lateral Sclerosis Testicular Torsion and Epididymitis, 398
(Lou Gehrig's Disease), 335 Testicular Tumors, 399
Hydrocephalus, 335 Female Reproductive System, 401
Sinusitis, 337 Physiology of the Female Reproductive
System, 401
9 Hematopoietic System, 341 Pelvic Inflammatory Disease, 402
Cysts and Tumors, 404
Physiology of the Blood, 341 Ovarian Cysts and Tumors, 404
Diseases of Red Blood Cells, 342 Dermoid Cyst (Teratoma), 406
Anemia, 342 Uterine Fibroids, 407
Polycythemia, 347 Endometrial Carcinoma, 409
Treatment of Polycythemias, 347 Endometriosis, 410
Diseases of White Blood Cells, 348 Carcinoma of the Cervix, 411
Leukemia, 348 Breast Lesions, 413
Lymphoma, 349 Breast Cancer, 413
Infectious Mononucleosis, 354 Benign Breast Disease, 417
Diseases of Platelets (Bleeding Disorders), 354 Imaging in Pregnancy, 419
Hemophilia, 355 Ectopic Pregnancy, 423
Purpura (Thrombocytopenia), 356 Trophoblastic Disease, 423
Female Infertility, 424
10 Endocrine System, 359
Physiology of the Endocrine System, 359
12 Miscellaneous Diseases, 426
Adrenal Glands, 360 Nutritional Diseases, 426
Physiology of the Adrenal Glands, 360 Vitamin Deficiencies, 426
Diseases of the Adrenal Cortex, 360 Hypervitaminosis, 428
Diseases of the Adrenal Medulla, 364 Protein-Calorie Malnutrition
Pituitary Gland, 369 (Kwashiorkor), 429
Physiology of the Pituitary Gland, 369 Obesity, 429
Diseases of the Pituitary Gland, 370 Systemic Lupus Erythematosus, 430
Thyroid Gland, 373 Melanoma, 431
Physiology of the Thyroid Gland, 373 Muscular Dystrophy, 433
Diseases of the Thyroid Gland, 373 Hereditary Diseases, 433
Parathyroid Glands, 379 Chromosomal Aberrations, 433
Physiology of the Parathyroid Glands, 379 Genetic Amino Acid Disorders, 435
Diseases of the Parathyroid Glands, 379
Diabetes Mellitus, 384

11 Reproductive System, 389

Infectious Diseases of Both Genders, 389
Syphilis, 389
Gonorrhea, 391
Male Reproductive System, 392
Physiology of the Male Reproductive System, 392
 Chapter

1
Introduction to Pathology

Outline
Disease Alterations of Cell Growth Acquired Immunodeficiency
Inflammation Neoplasia Syndrome
Edema Hereditary Diseases Radiographic Appearance
Ischemia and Infarction Disorders of Immunity Treatment
Hemorrhage Infectious Disease Exposure

Key terms
abscess elephantiasis mortality
acquired immunodeficiency epidemiology mutations
syndrome (AIDS) grading neoplasia
active immunity granulation tissue nosocomial
anaphylactic hematogenous spread oncology
anaplastic hematoma permeable
anasarca hemorrhage personal protective
antibodies hereditary diseases equipment
antigens hyperplasia pyogenic
atrophy iatrogenic recessive
autosomes idiopathic sarcomas
bacteremia immune signs
benign infarct staging
cancers inflammation standard precautions
carcinomas ischemia symptoms
community acquired lymphatic spread toxoid
dominant malignant transmission-based precautions
dysplasia metastasize undifferentiated
edema morbidity vaccine

Objectives
After reading this chapter, the reader will be able to:
1. Classify the more common diseases in terms of their
attenuation of x-rays
2. Explain the changes in technical factors required
for obtaining optimal quality radiographic images
in patients with various underlying pathologic
conditions
3. Define and describe all bold-faced terms in this chapter
4. Differentiate inflammation, edema, infarction,
hemorrhage, and neoplasia
5. Characterize the various alterations of cell growth
6. Describe the various immune reactions of the body
7. Describe AIDS and the precautions necessary when
taking a radiograph of patients with AIDS or any
patient with whom contact with any body fluid is
possible (Standard Precautions)

Disease from or variation of normal conditions. Diseases may

Pathology is the study of diseases that can cause abnor- be hereditary or may result from a broad spectrum of
malities in the structure or function of various organ traumatic, infectious, vascular, or metabolic processes
systems. In essence, a disease is the pattern of the body's manifesting as a set of characteristics known as signs
response to some form of injury that causes a deviation and symptoms. Signs represent the measurable or
Copyright © 2012, Elsevier Inc. 1
2 Chapter 1 Introduction to Pathology
Bo x 1- 1 Relative Attenuation of X-Rays in Advanced Stages of Diseases
Skeletal System
Additive (increased attenuation)
Acromegaly
Acute kyphosis
Callus
Charcot's joint
Chronic osteomyelitis (healed)
Exostosis
Hydrocephalus
Marble bone
Metastasis (osteosclerotic)
Osteochondroma
Osteoma
Paget's disease
Proliferative arthritis
Sclerosis
Destructive (decreased attenuation)
Active osteomyelitis
Active tuberculosis
Aseptic necrosis
­ bjective manifestations of the disease process. The
o (iatrogenic). Incidences of the development of infec-
experiences the patient feels and describes are the
symptoms, those (subjective) manifestations that are
not measurable or observable. They may reflect altera-
tions of cell growth, as in neoplasia (tumors), or they
may even be caused by physicians and their treatment
Radiographer Notes
Radiography of patients with underlying pathologic conditions can pres-
ent problems for even the most experienced radiographers. Adjustments
in patient position may be necessary to prevent excessive pain caused by
the body's response to trauma or certain disease processes. A change in
routine projections may be indicated to visualize subtle alterations in the
normal radiographic appearance. Many disease processes also alter the
density of the structures being radiographed and therefore require changes
in technique. For example, extensive edema may require an increased tech-
nique, whereas severe atrophy may require a decreased technique. Unless
the radiographer has access to previous images with recorded exposure
factors, a standard technique chart should be used to determine the initial
exposures. Any necessary adjustments can then be made on subsequent
images.
Box 1-1 lists the relative attenuation of x-rays that can be expected
in advanced stages of various disease processes. In chest radiography,
110 to 125 kilovolts peak (kVp) is optimal; therefore, milliampere-second
(mAs) factors should be adjusted to control density. In skeletal radiog-
raphy, when bone quality changes are expected, the best exposure fac-
tor to change is the kilovolt peak (beam quality change for structural
change). When bone quantity changes, the mAs value is the exposure fac-
tor to change to control density (beam quantity increases to ensure that
enough radiation reaches the image receptor without changing the con-
trast). For example, in osteoporosis there is a decrease in bone quantity
and quality; however, a decrease in kilovolts produces a higher-quality
Atrophy (disease or disuse)
Blastomycosis
Carcinoma
Coccidioidomycosis
Degenerative arthritis
Ewing's tumor (in children)
Fibrosarcoma
Giant cell tumor
Gout
Hemangioma
Hodgkin's disease
Hyperparathyroidism
Leprosy
Metastasis (osteolytic)
Multiple myeloma
Neuroblastoma
New bone (fibrosis)
Osteitis fibrosa cystica
Osteoporosis/osteomalacia
Radiation necrosis
Solitary myeloma
tions at the acute care facility are called nosocomial,
whereas infections that develop outside the healthcare
facility are known as community acquired. In some
cases the underlying cause is unknown, and the disease
is termed idiopathic.
image. The normal kilovolt peak easily penetrates the diseased bone,
producing a low-contrast image with loss of visibility of detail. As imag-
ing progresses into the digital ­imaging arena, the same theories apply;
however, the processing algorithm will control brightness (density) and
contrast. The exposure index (number) will represent the over- or under-
exposure of the image.
Certain diseases suppress the normal immune response. Immunocom­
promised patients (such as those with advanced leukemia) may require
special care to prevent their acquiring a disease from the radiographer.
Personal protective equipment (PPE) aids in preventing the spread of
microorganisms to the patient and to the healthcare worker. The patient
may have to be placed in protective isolation (or “reverse” isolation),
and the radiographer may be required to put on a mask, gown, and
gloves before approaching the patient. Diseases such as AIDS and hepa-
titis require that the radiographer wear rubber or latex gloves to be
protected against exposure to blood and body fluids, which could con-
taminate any area near the patient. When examining a patient with
AIDS who has a productive cough, the radiographer must wear a mask
and possibly protective eye goggles if there is a need to be very close
to the patient's face. It is important to remember that many patients
undergoing radiographic procedures have not been diagnosed and thus
all patients should be treated as though they may have a communicable
disease. Therefore, whenever exposure to any type of body secretion or
blood may occur, the healthcare worker should wear appropriate PPE.
 Chapter 1 Introduction to Pathology 3

B o x 1- 1 Relative Attenuation of X-Rays in Advanced Stages of Diseases—cont'd

Respiratory System Pneumonia

Additive (increased attenuation) Syphilis
Actinomycosis Thoracoplasty
Arrested tuberculosis (calcification) Destructive (decreased attenuation)
Atelectasis Early lung abscess
Bronchiectasis Emphysema
Edema Pneumothorax
Empyema
Circulatory System
Encapsulated abscess
Additive (increased attenuation)
Hydropneumothorax
Aortic aneurysm
Malignancy
Ascites
Miliary tuberculosis
Cirrhosis of the liver
Pleural effusion
Enlarged heart
Pneumoconiosis:
Anthracosis Soft Tissue
Asbestosis Additive (increased attenuation)
Calcinosis Edema
Siderosis Destructive (decreased attenuation)
Silicosis Emaciation
Even though disease processes increase or decrease the attenuation of the x-rays, it is important to produce a quality image to demonstrate the change in
­attenuation. Excessive variation of the technical exposure factors may obscure the pathophysiologic changes due to the disease process.
From Thompson TT: Cahoon's formulating x-ray techniques, ed 9, Durham, NC, 1979, Duke University Press.

This chapter discusses several basic reactions of the

body that characterize the underlying mechanisms for
the radiographic manifestations of most pathologic con-
ditions. These processes are inflammation, edema, isch-
emia and infarction, hemorrhage, and alterations of
cell growth leading to the development of neoplasms
(tumors). In addition, this chapter deals with hereditary
diseases and immune reactions, such as acquired immu-
nodeficiency syndrome (AIDS).
Su m m a r y o f T e rm s f o r Di s e a s e
Box 1-2 Events that Occur in Inflammatory
Response
1. Alterations in blood flow and vascular permeability
2. Migration of circulating white blood cells to the interstitium
of the injured tissue
3. Phagocytosis and enzymatic digestion of dead cells and tissue
elements
4. Repair of injury by regeneration of normal parenchymal cells or
proliferation of granulation tissue and eventual scar formation

Term Definition hyperemia produces the heat and redness associated with
Signs Measurable or objective manifestations inflammation. As hyperemia develops, the venules and cap-
Symptoms Feelings that the patient describes— illaries become abnormally permeable, allowing passage of
subjective manifestations protein-rich plasma across vessel walls into the interstitium.
Iatrogenic Disease caused by physician or treatment
This inflammatory exudate in the tissues results in the swell-
Nosocomial Infections contracted in the acute care
ing associated with inflammation, which produces pressure
infections facility
Community-acquired Infections contracted in a public setting on sensitive nerve endings and causes pain. The protein-
infections outside of the acute care facility rich exudate of inflammation must be differentiated from
Idiopathic Underlying cause is unknown a transudate, a ­low-protein fluid such as that seen in the
pulmonary edema that develops in congestive heart failure.
Very early in the inflammatory response, leukocytes
Inflammation (white blood cells, especially neutrophils and mac-
Acute inflammation is the initial response of body tissues rophages) of the circulating blood migrate to the area of
to local injury. The various types of injury include those injury. These white blood cells cross the capillary walls
caused by blunt or penetrating trauma, infectious organ- into the injured tissues, where they engulf and enzymat-
isms, and irritating chemical substances. Regardless of the ically digest infecting organisms and cellular debris, a
underlying cause, the inflammatory response consists of process called phagocytosis.
four overlapping events that occur sequentially (Box 1-2). The removal of necrotic debris and any injurious
The earliest bodily response to local injury is dilation of agents, such as bacteria, makes possible the repair of
arterioles, capillaries, and venules, leading to a dramatic the injury that triggered the inflammatory response.
increase in blood flow in and around the injury site. This In many tissues, such as the lung after pneumococcal
4 Chapter 1 Introduction to Pathology
pneumonia, regeneration of parenchymal cells permits
­reconstitution of normal anatomic structure and func-
tion. However, some tissues, such as the heart after
myocardial infarction, cannot heal by regeneration. A
fibrous scar replaces the area of destroyed tissue with
granulation tissue. Granulation tissue refers to a combi-
nation of young developing capillaries and actively pro-
liferating fibroblasts, which produce connective tissue
fibers (collagen) that replace the dead tissue. Eventually
the strong connective tissue contracts to produce a fibrous
scar. In the abdomen, such fibrous adhesions can narrow
loops of intestine and result in an obstruction. The accu-
mulation of excessive amounts of collagen (more com-
mon in African Americans) may produce a protruding,
tumor-like scar known as a keloid. Unfortunately, sur-
gery to remove a keloid is usually ineffective because the
subsequent incision tends to heal in the same way.
Many injuries heal by a combination of regeneration
and scar tissue formation. An example is the response of the
liver to repeated and persistent alcoholic injury; the result
is cirrhosis, in which irregular lobules of regenerated liver
cells are crisscrossed and surrounded by bands of scar tissue.
Scar tissue formation consists of fibrous connective tissue,
which can be divided into primary union (surgical incision)
and secondary union (nonsurgical; gunshot wound).
The five clinical signs of acute inflammation are rubor
(redness), calor (heat), tumor (swelling), dolor (pain),
and loss of function. The localized heat and redness
result from increased blood flow in the microcirculation
at the site of injury. The swelling occurs because the exu-
date increases the amount of interstitial fluid, resulting in
pressure on nerve endings and thus pain, which results in
a loss of function.
Acute inflammation can also lead to systemic mani-
festations. Fever is especially common in inflammatory
conditions associated with the spread of organisms into
the bloodstream. The number of circulating white blood
cells also increases (leukocytosis).
Some bacterial organisms (such as staphylococci and
streptococci) produce toxins that damage the tissues and
incite an inflammatory response. The presence of pyo-
genic bacteria leads to the production of a thick, yel-
low fluid called pus, which contains dead white blood
cells, inflammatory exudate, and bacteria. A suppurative
inflammation is one that is associated with pus formation.
When a pyogenic infection occurs beneath the skin or in
a solid organ, it produces an abscess, a localized, usually
encapsulated, collection of pus. All pyogens, wherever
they become implanted, have the ability to invade blood
vessels to produce bacteremia, with the potential involve-
ment of other organs and tissues in the body.
A granulomatous inflammation manifests as a distinct
pattern seen in relatively few diseases, including tubercu-
losis, syphilis, and sarcoidosis. A granuloma is a localized
area of chronic inflammation, often with central necrosis.
It is characterized by the accumulation of macrophages,
some of which fuse to form multinucleated giant cells.
Summary of Terms for Inflammatory Process
Term Definition
Inflammation Initial response of the tissue to local
injury
Permeable membrane Allows fluids/cells to pass from one
tissue to another tissue or location
Granulation tissue Fibrous scar replaces destroyed tissue
Pyogenic bacteria Thick, yellow fluid called pus (dead
white cells)
Abscess Localized, usually encapsulated,
collection of fluid
Bacteremia Potential involvement of other organs
and tissues in the body by organisms
invading the blood vessels
Edema
Edema is the accumulation of abnormal amounts of
fluid in the intercellular tissue spaces or body cavities.
Localized edema results from an inflammatory reaction,
whereas generalized edema occurs with pronounced
swelling of subcutaneous tissues throughout the body
(anasarca). Localized edema may result from inflamma-
tion, with the escape of protein-rich intravascular fluid
into the extravascular tissue. It may also result from a
local obstruction to lymphatic drainage; for example,
in filariasis, a parasitic worm causes lymphatic obstruc-
tion, and the resulting localized edema is termed ele-
phantiasis. Generalized edema occurs most frequently
in patients with congestive heart failure, cirrhosis of
the liver, and certain forms of renal disease. Because of
the effect of gravity, generalized edema is usually most
prominent in dependent portions of the body. Thus
ambulatory patients tend to accumulate fluid in tissues
around the ankles and lower legs, whereas in hospi-
talized patients who are nonambulatory or sedentary,
the edema fluid collects most prominently in the lower
back, sacral areas, and lung.
Extravascular fluid can also accumulate in serous
cavities to produce pleural and pericardial effusions
and peritoneal ascites. Edema may produce minimal
clinical symptoms or be potentially fatal. If localized
to the subcutaneous tissues, large amounts of edema
may cause minimal functional impairment. In contrast,
pulmonary edema, pericardial effusion, or edematous
swelling of the brain may have dire consequences.
Su mmar y of Ter ms f or Edema
Term Definition
Edema Accumulation of abnormal amounts of fluid in
the intercellular tissue spaces or body cavities
Anasarca Generalized edema that occurs with pronounced
swelling of subcutaneous tissues throughout
the body
Elephantiasis Localized lymphatic obstruction resulting in
localized edema

Ischemia and Infarction
Ischemia refers to an interference with the blood supply to
an organ or part of an organ, depriving the organ's cells and
tissues of oxygen and nutrients. Ischemia may be caused
by a narrowing of arterial structures, as in atherosclero-
sis, or by thrombotic or embolic occlusion (Figure 1-1).
Depending on several factors, occlusion of an artery or vein
may have little or no effect on the involved tissue, or it may
cause death of the tissue and even of the individual. A major
determinant is the availability of an alternative or newly
acquired route of blood supply (collateral vessels). Other
factors include the rate of development of the occlusion,
the vulnerability of the tissue to hypoxia, and the oxygen-
­carrying capacity of the blood. Slowly developing occlusions
A
B branes, or serosal surfaces are called ­petechiae; slightly
Figure 1-1 Computed tomography (CT) scan of pulmonary
embolism. (A) Filling defect on both the right and left pulmonary
arteries (saddle type), and (B) a blockage (filling defect) nearly com-
plete on the right.
Chapter 1 Introduction to Pathology 5
are less likely to cause tissue death (necrosis) because they
provide an opportunity for the development of alternative
pathways of flow. Ganglion cells of the nervous system
and myocardial muscle cells undergo irreversible damage if
deprived of their blood supply for 3 to 5 minutes. Anemic
or cyanotic patients tolerate arterial insufficiency less well
than normal individuals do, and thus occlusion of even a
small vessel in such a patient may lead to death of tissue.
An infarct is a localized area of ischemic necrosis
within a tissue or organ produced by occlusion of either
its arterial supply or its venous drainage. The two most
common clinical forms of infarction are myocardial and
pulmonary. Almost all infarcts result from thrombotic or
embolic occlusion. Infrequent causes include twisting
of an organ (volvulus), compression of the blood sup-
ply of a loop of bowel in a hernia sac, or trapping of a
viscus under a peritoneal adhesion.
In cases in which ischemia continues to progress, result-
ing in an infarction, necrosis may occur as a result of lack
of blood flow. This progressive situation can lead to a con-
dition called gangrene. Severe arterial disease of the lower
extremities may result in necrosis of several toes or a large
segment of the foot, causing gangrene. A frequent present-
ing symptom in diabetic patients is ischemia of the foot,
which may progress to infarction and result in gangrene.
Infarctions tend to be especially severe because they occur
more often in the patients least able to withstand them. Thus,
infarcts tend to occur in elderly individuals with advanced
atherosclerosis or impaired cardiac ­function and are move
likely to occur after surgery or delivery.
Hemorrhage
The term hemorrhage implies rupture of a blood vessel.
Rupture of a large artery or vein is almost always caused
by some form of injury, such as trauma, atherosclero-
sis, or inflammatory or neoplastic erosion of the vessel
wall. Hemorrhage may be external, or the blood may be
trapped within body tissues, resulting in an accumulation
termed a hematoma (Figure 1-2). The accumulation of
blood in a body cavity results in hemothorax, hemoperi-
cardium, hemoperitoneum, or hemarthrosis (blood in a
joint). Minimal hemorrhages into the skin, mucous mem-
Su mmar y of Ter ms f or Blood Vessels
Term Definition
Ischemia Interference of blood supply to an organ;
deprives cells and tissues of oxygen and
nutrients
Infarct Localized area of ischemic necrosis; produced
by occlusion of either arterial supply or
venous drainage
Hemorrhage Implies rupture of a blood vessel
Hematoma Accumulation of blood trapped within body
tissues
6 Chapter 1 Introduction to Pathology

the cast also removes the stress and strain from the
enclosed bone that normally stimulates new bone forma-
tion, normal bone resorption continues unchecked and
the loss of calcified bone can be detected on radiographs.
In this situation, there is rapid recovery from the atro-
phic appearance when the cast is removed and normal
function is resumed.
Pathologic, irreversible atrophy may be caused by loss
of innervation, by hormonal stimulation, or by decreased
blood supply. For example, stenosis of a renal artery may
cause atrophy of the kidney with shrinkage of individual
nephrons and loss of interstitial tissue.
Hypertrophy refers to an increase in the size of the
cells of a tissue or organ in response to a demand for
increased function. This must be distinguished from
hyperplasia, an increase in the number of cells in a tissue
or organ (Figure 1-3). Hypertrophy occurs most often in
cells that cannot multiply, especially those in myocardial
and peripheral striated muscle. Myocardial hypertrophy
is necessary to maintain cardiac output despite increased
peripheral resistance in patients with arterial hyperten-
sion or aortic valve disease. After the loss of a normal
kidney, hypertrophy of the other kidney occurs in an
attempt to continue adequate renal function.
Figure 1-2 Subdural hematoma (concave appearance of increase
attenuation) on the left causing midline shift of the ventricles.

larger hemorrhages are termed purpura. A large (greater

than 1 to 2 cm) subcutaneous hematoma, or bruise, is
called an ecchymosis.
The significance of hemorrhage depends on the volume
of blood loss, the rate of loss, and the site of the hemor-
rhage. Sudden losses of up to 20% of the blood volume or
slow losses of even larger amounts may have little clini-
A
cal significance. The site of the hemorrhage is critical. For
example, an amount of bleeding that would have little
clinical significance in the subcutaneous tissues may cause
death when located in a vital portion of the brain. Large
amounts of external bleeding lead to the chronic loss of
iron from the body and anemia. In contrast, internal hem-
orrhages into body cavities, joints, or tissues permit the
iron to be recaptured for the synthesis of hemoglobin and
the development of normal red blood cells.

Alterations of Cell Growth

Changes in the number and size of cells, their differentia-
tion, and their arrangement may develop in response to B
physiologic stimuli. Atrophy refers to a reduction in the
size or number of cells in an organ or tissue, with a cor-
responding decrease in function. It must be distinguished
from hypoplasia and aplasia, in which failure of normal
development accounts for small size.
An example is the disuse atrophy that occurs with Figure 1-3 Infantile cortical hyperostosis (Caffey's disease).
immobilization of a limb by a plaster cast. The muscle Affected bones demonstrate cortical thickening with new periosteal
mass of the encased limb reduces dramatically. Because bone formation bilaterally on the femurs (A) and tibias (B) (arrows).

Examples of hyperplasia include (1) proliferation of
granulation tissue in the repair of injury and (2) the
increased cellularity of bone marrow in patients with
hemolytic anemia or after hemorrhage. Hyperplasia of
the adrenal cortex is a response to increased adrenocor-
ticotropic hormone (ACTH) secretion; hyperplasia of the
thyroid gland occurs with increased thyrotropic hormone
secretion by the pituitary gland.
Dysplasia is a loss in the uniformity of individual cells
and their architectural orientation; it is typically associ-
ated with prolonged chronic irritation or inflammation.
Removal of the irritant may result in a return to normal,
but often the tissue change persists, and it may evolve
into a totally abnormal growth pattern. Thus dysplasia is
generally considered at least potentially premalignant—a
borderline lesion that may heal or progress to cancer.
Neoplasia
Neoplasia, from the Latin word for “new growth,” refers
to an abnormal proliferation of cells that are no lon-
ger controlled by the factors that govern the growth of
­normal cells. Neoplastic cells act as parasites, competing
with normal cells and tissues for their metabolic needs.
Thus tumor cells may flourish and the patient becomes
weak and emaciated, a condition termed cachexia.
Neoplasms are commonly referred to as tumors;
indeed the study of neoplasms is called oncology, derived
from the Greek word oncos, meaning “tumor.” Although
the word tumor originally referred to any swelling,
which could also be produced by edema or hemorrhage
in tissue, the word now refers almost exclusively to a
neoplasm.
Neoplasms are divided into benign and malignant
categories on the basis of their potential clinical behav-
ior. Benign tumors closely resemble their cells of ori-
gin in structure and function. They remain localized,
without spreading to other sites, and thus can usually
be surgically removed with resultant survival of the
patient.
Nevertheless, some benign tumors can have severe
consequences because of their position or hormonal
secretion. For example, a benign pituitary tumor can
cause pressure atrophy and destruction of the surround-
ing gland, and a benign tumor of the islets of Langerhans
in the pancreas can produce excessive amounts of ­insulin,
resulting in possibly fatal low levels of blood glucose.
Other potentially dangerous benign tumors include those
arising in the brain or spinal cord, which may influence
central nervous system function. Tumors of the trachea
or esophagus may occlude the air supply or make it
impossible to swallow.
Malignant neoplasms invade and destroy adjacent
structures and spread to distant sites (metastasize), causing
death. Malignancies tend to be poorly differentiated so that
it may be impossible to determine the organ from which
they originate. Malignant tumors are collectively referred
Chapter 1 Introduction to Pathology 7
to as cancers. This term is derived from the Latin word
for “crab,” possibly because the fingerlike projections that
extend into underlying tissue resemble crablike claws.
All tumors, both benign and malignant, have two
basic components: (1) the parenchyma (organ tissue),
made up of proliferating neoplastic cells, and (2) the sup-
porting stroma (supporting tissue), made up of connec-
tive tissue, blood vessels, and possibly lymphatic vessels.
The parenchyma of the neoplasm largely determines its
biologic behavior and is the component that determines
how the tumor is named.
Most benign tumors consist of parenchymal cells that
closely resemble the tissue of origin. Their names come
from adding the suffix -oma to the cell type from which
the tumor arose. For example, benign tumors of fibrous
tissue are termed fibromas, whereas benign cartilaginous
tumors are chondromas (Figure 1-4). The term adenoma
is applied to benign epithelial neoplasms that grow in
glandlike patterns. Benign tumors that form large cys-
tic masses are called cystadenomas. Lipomas consist
of soft fatty tissue, myomas are tumors of muscle, and
angiomas are tumors composed of blood vessels. An epi-
thelial tumor that grows as a projecting mass on the skin
or from an inner mucous membrane (such as the gastro-
intestinal tract) is termed a papilloma or a polyp.
Malignant neoplasms of epithelial cell origin are called
carcinomas, from the Greek word karkinos, meaning
“crab.” Carcinomas affect epithelial tissues, skin, and
mucous membranes lining body cavities. Adenocarcinoma
refers to malignancies of glandular tissues, such as the
breast, liver, and pancreas, and of the cells lining the gas-
trointestinal tract. Squamous cell carcinoma denotes a can-
cer in which the tumor cells resemble stratified squamous
epithelium, as in the lung and head and neck regions. At
times, the tumor grows in such a bizarre pattern that it is
termed undifferentiated or anaplastic (without form).
Sarcomas are highly malignant tumors arising from
connective tissues, such as bone, muscle, and cartilage.
Although they are less common than carcinomas, sarco-
mas tend to spread more rapidly.
Figure 1-4 Enchondroma, a lobulated area with increased bone
density in the supra-acetabular region on the right side (arrow).
8 Chapter 1 Introduction to Pathology
Substantial evidence exists indicating that most
tumors arise from a single cell (monoclonal origin).
The rate of growth generally correlates inversely with
the level of parenchymal differentiation. Thus well-
differentiated tumors tend to grow slowly, whereas
bizarre, undifferentiated neoplasms have a rapid
growth rate.
Although the cause of cancer is still unknown, many
possible causative factors (carcinogens) have been
implicated. Chemical carcinogens may cause structural
alteration of the deoxyribonucleic acid (DNA) mole-
cule (mutation), which may lead to the development of
a neoplasm. Examples of chemical carcinogens include
air and water pollution, cigarette smoke, asbestos, and
a variety of other substances used in industry, food,
cosmetics, and plastics. The development of specific
types of cancer in certain families suggests a possible
genetic predisposition. Excessive exposure to ultra-
violet radiation (sunshine) may lead to the develop-
ment of skin cancer. Survivors of the atom bomb who
received huge doses of radiation have demonstrated a
high incidence of leukemia. A greater-than-expected
rate of leukemia was also seen in persons working with
x-radiation before the need for proper protection was
appreciated.
The study of experimental animal tumors has offered
convincing evidence that DNA and ribonucleic acid
(RNA) viruses can induce neoplastic transformation.
Viruses that invade normal cells may alter their genetic
material, leading to the abnormal cell divisions and rapid
growth observed in malignant tumors.
The clinical symptoms of cancer vary with the site
of malignancy. A blood-tinged stool, a change in bowel
activity (e.g., intermittent constipation and diarrhea),
or intestinal obstruction is suggestive of gastrointesti-
nal malignancy. Difficulty in swallowing (dysphagia)
or loss of appetite (anorexia), especially if accompa-
nied by rapid weight loss, suggests a neoplasm in the
esophagus or stomach. Hematuria may indicate kid-
ney or bladder cancer, whereas difficulties in urination
(e.g., urgency, a burning sensation, or an inability to
start the stream of urine) in an elderly man may be
a sign of prostate tumor. Hemoptysis (coughing up
blood), a persistent cough, or hoarseness may suggest
a neoplasm in the respiratory tract. Severe anemia may
develop from internal bleeding or from malfunction
of the bone marrow caused by growth of a malignant
lesion in the skeleton.
It should be stressed that these clinical symptoms may
also be caused by benign disease. Nevertheless, because
they may signal an underlying malignancy, they should
be carefully investigated to exclude the presence of
cancer.
Pain is frequently not an early sign of cancer. Unfor­
tunately, pain may be appreciated only when the malig-
nancy has spread too extensively to be curable. Secondary
infections are common and an increasing cause of death.
Most cancer patients are immunologically compromised,
either because of their original disease or as a result of
irradiation or chemotherapy. In addition to having typi-
cal bacterial and viral infections, immunocompromised
patients with malignancy are especially susceptible to
unusual opportunistic infections, such as Pneumocystis
jirovecii (formerly Pneumocystis carinii) pneumonia and
cytomegalovirus.
Some cancers that are still at a curable stage can
be detected by screening procedures. Routine mam-
mography may identify nonpalpable breast cancer; a
Papanicolaou (Pap) smear may show otherwise unsus-
pected cancer of the cervix. Surgical removal of these
small tumors without metastatic spread offers an excel-
lent prognosis.
Malignant neoplasms disseminate to distant sites
by one of three pathways: (1) seeding within body
cavities, (2) lymphatic spread, and (3) hematogenous
spread.
Seeding (diffuse spread) of cancers occurs when neo-
plasms invade a natural body cavity. For example, a
tumor of the gastrointestinal tract may penetrate the wall
of the gut (visceral peritoneum), permitting metastases to
enter the peritoneal cavity and implant at distant sites.
A similar sequence may occur with lung cancers in the
pleural cavity. Neoplasms of the central nervous system
(medulloblastoma, ependymoma) may spread from the
cerebral ventricles by means of the cerebrospinal fluid to
reimplant on the meningeal surfaces within the brain or
in the spinal cord.
Lymphatic spread is the major metastatic route of car-
cinomas, especially those of the lung and breast. The pat-
tern of lymph node involvement depends on the site of
the primary neoplasm and the natural lymphatic path-
ways of drainage of that region. Carcinomas of the
lung metastasize first to the regional bronchial lymph
nodes and then to the tracheobronchial and hilar nodes.
Carcinoma of the breast usually arises in the upper outer
quadrant and first spreads to the axillary nodes. Medial
breast lesions may drain through the chest wall to nodes
along the internal mammary artery.
The hematogenous spread of cancer is a complex
process involving several steps. Tumor cells invade and
­penetrate blood vessels, traveling as neoplastic emboli in
the circulation. These emboli of tumor cells are trapped
in small vascular channels of distant organs, where
they invade the wall of the arresting vessel and infil-
trate and multiply in the adjacent tissue. The localiza-
tion of hematogenous metastases tends to be determined
by the vascular connections and anatomic relationships
between the primary neoplasm and the metastatic sites.
For example, carcinomas arising in abdominal organs,
such as the gastrointestinal tract, tend to metastasize to
the liver because of the flow of portal vein blood to that
organ. Cancers arising in midline organs close to the
vertebral column (e.g., prostate, thyroid) tend to embo-
lize through the paravertebral venous plexus to seed the

vertebral column. Neoplasms in organs drained by the
inferior and superior vena cava, such as the kidney, tend
to metastasize to the lung. However, several well-defined
patterns of metastatic spread cannot be easily explained
by vascular-anatomic relationships. Some examples are
the tendency for carcinoma of the lung to involve the
adrenal glands, simultaneous metastatic deposits in the
brain and adrenal glands, and pituitary metastases occur-
ring from breast carcinomas.
The grading of a malignant tumor assesses aggres-
siveness, or degree of malignancy. The grade of a tumor
usually indicates its biologic behavior and may allow
prediction of its responsiveness to certain therapeutic
agents. Staging refers to the extensiveness of a tumor at
its primary site and the presence or absence of metas-
tases to lymph nodes and distant organs, such as the
liver, lungs, and skeleton. The staging of a tumor aids in
determining the most appropriate therapy. Well-localized
tumors without evidence of metastases may be surgically
removed. Fast-growing, undifferentiated tumors, such
as those found in patients with Hodgkin's disease, may
respond best to radiation therapy. Cancer of the prostate
responds to hormonal therapy, which consists of either
the removal of the sources of male gonadal hormones
that stimulate tumor growth or the administration of
the female gonadal hormone (estrogen) that inhibits it.
Chemotherapy uses one or a combination of cytotoxic
substances that kill neoplastic cells, but these drugs
may injure many normal cells and result in significant
complications.
Upon determination of the type of neoplastic
involvement, a study of determinants is compiled for
the specific disease in a given population, which is
called epidemiology. Using epidemiology and the grad-
ing of the neoplasms then becomes part of establish-
ing morbidity. Morbidity is the rate that an illness or
abnormality occurs. Depending on the stage of the
tumor, mortality is calculated by reviewing the popu-
lation involved to statistically calculate the expected
death rate. These factors will be taken into consider-
ation when the best course of treatment for the patient
is being determined.
Hereditary diseases
Hereditary diseases pass from one generation to the next
through the genetic information contained in the nucleus
of each cell. They reflect an abnormality in the DNA,
which provides the blueprint for protein synthesis in
the cell. In many hereditary diseases, an error in a sin-
gle protein molecule leads to enzyme defects; membrane
receptor and transport system defects; alterations in the
structure, function, or quantity of nonenzyme proteins;
and unusual drug reactions.
The most common hereditary abnormality is an
enzyme deficiency. This leads to a metabolic block that
results either in a decreased amount of a substance needed
Chapter 1 Introduction to Pathology 9
Su mmar y of Ter ms f or Alt er at ion s
of Cell Gr ow t h
Term Definition
Atrophy Reduction in the size or number of cells in
an organ or tissue, with a corresponding
decrease in function
Hypertrophy Increase in the size of the cells of a tissue
or organ in response to a demand for
increased function
Hyperplasia Increase in the number of cells in a tissue
or organ
Dysplasia Loss of uniformity of individual cells and their
architectural orientation
Neoplasia Ungoverned abnormal proliferation of cells
Oncology Study of neoplasms (tumors)
Benign Growth that closely resembles the cells of
origin in structure and function
Malignant Neoplastic growth that invades and destroys
adjacent structures
Metastasize Malignant neoplasms that travel to distant
sites
Carcinoma Malignant neoplasm of epithelial cell origin
Anaplastic Undifferentiated cell growth— without form
(bizarre)
Sarcoma Highly malignant tumor originating from
connective tissue
Lymphatic spread Major route by which carcinoma metastasizes
Hematogenous Malignant tumors that have invaded the
spread circulatory system and travel as neoplastic
emboli
Grading Assessment of aggressiveness or degree
of malignancy
Staging (1) Extensiveness of tumor at the primary site
(2) Presence or absence of metastases to
lymph nodes and distant organs
Epidemiology Study of determinants of disease events in
given populations
Morbidity Rate that an illness or abnormality occurs
Mortality Reflects the number of deaths by disease per
population
for normal function or in an accumulation of a metabolic
intermediate that may cause injury. An example of the
first mechanism is albinism, the absence of pigmentation
resulting from an enzymatic deficiency that prevents the
synthesis of the pigment melanin. An example of the sec-
ond mechanism is phenylketonuria, in which the absence
of an enzyme leads to the accumulation of toxic levels of
the amino acid phenylalanine.
A defect in the structure of the globin molecule leads
to the development of the hemoglobinopathies, such as
sickle cell disease and thalassemia. An example of a genet-
ically determined adverse reaction to drugs is glucose
6-phosphate dehydrogenase deficiency, in which an insuf-
ficient amount of the enzyme results in a severe hemolytic
anemia in patients receiving a common antimalarial drug.
Despite our extensive knowledge of the biochemical
basis of many genetic disorders, there are a large number
of conditions for which the underlying mechanism is still
10 Chapter 1 Introduction to Pathology

unknown. This list includes neurofibromatosis, retino-

blastoma, and familial colonic polyposis (Chapter 5).
Each human cell contains 46 chromosomes divided into
23 pairs. The chromosomes in turn contain thousands of
genes, each of which is responsible for the synthesis of a
single protein. Forty-four of the chromosomes are called
autosomes; the other two are the X and Y chromosomes,
which determine the sex of the person. A combination of
XY chromosomes results in a male, whereas an XX con-
figuration results in a female.
Each person inherits half of his or her chromosomes
from each parent. If the genes inherited from each parent
are the same for a particular trait, the person is homozy-
gous for that trait. If the genes differ (e.g., one for brown
eyes and one for blue eyes), the person is heterozygous
for that trait. Dominant genes always produce an effect
regardless of whether the person is homozygous or
heterozygous; recessive genes manifest themselves only
when the person is homozygous for the trait. In deter-
mining eye color, brown is dominant, whereas blue is
recessive. It must be remembered that although a reces-
sive trait must have been contributed by both parents,
the possibility exists that neither parent demonstrates
that trait. For example, two parents, each with one gene
for brown eyes and one gene for blue eyes, would show
the dominant brown coloration, although they could
each contribute a blue-eye gene to their offspring, who
would manifest the recessive blue-eye trait. Figure 1-5 Right foot image with seven metatarsals and eight
For some traits, the genes are codominant, so that digits, demonstrating polydactyly.
both are expressed. An example is the AB blood type, in
which the gene for factor A is inherited from one parent not usually affect the parents, although siblings may
and that for factor B is inherited from the other. show the disease. On average, siblings have a one-in-four
Mutations are alterations in the DNA structure that chance of being affected; two out of four will be carri-
may become permanent hereditary changes if they affect ers of the gene, and one will be normal. Recessive genes
the gonadal cells. Mutations may result from radiation, appear more frequently in a family, and close intermar-
chemicals, or viruses. They may have minimal effect and riage (as between first cousins) increases the risk of the
be virtually undetectable or may be so serious that they particular disease. Unlike in autosomal dominant dis-
are incompatible with life, causing the death of a fetus eases, the expression of the defect tends to be uniform
and spontaneous abortion. in autosomal recessive diseases and the age of onset is
Autosomal dominant disorders are transmitted from frequently early in life. Examples of autosomal reces-
one generation to the next. These disorders affect females sive disorders are phenylketonuria (Chapter 12) cystic
and males, and both can transmit the condition. When ­fibrosis (Chapter 3), galactosemia, glycogen and lipid
an affected person marries an unaffected person, half the storage diseases (Chapter 12), Tay-Sachs disease, and
children (on the average) will have the disease. The clini- sickle cell anemia (Chapter 9).
cal manifestations of autosomal dominant disorders can Sex-linked disorders generally result from defective
be modified by reduced penetrance and variable expres- genes on the X chromosome because the Y chromosome
sivity. Reduced penetrance means that not everyone who is small and carries very few genes. Most of these condi-
has the gene will demonstrate the trait; variable expres- tions are transmitted by heterozygous female carriers vir-
sivity refers to the fact that a dominant gene may manifest tually only to sons, who have only the single, affected X
somewhat differently in different individuals (Figure 1-5) chromosome. Sons of a heterozygous woman have a one-
(e.g., polydactyly may be expressed in the toes or in the fin- in-two chance of receiving the mutant gene. An affected
gers as one or more extra digits). Examples of autosomal man does not transmit the disorder to his sons, but all his
dominant disorders include achondroplasia (Chapter 4), daughters carry the genetic trait. In rare cases a female
neurofibromatosis, Marfan's syndrome (Chapter 12), may have the sex-linked disease if she is homozygous for
and familial hypercholesterolemia. the recessive gene. Virtually all sex-linked disorders are
Autosomal recessive disorders result only when a per- recessive. The most common example of a sex-linked
son is homozygous for the defective gene. The trait does disorder is color blindness. Other conditions are ­glucose

6-phosphate dehydrogenase deficiency, and some types
of hemophilia (Chapter 9) and muscular dystrophy
(Chapter 12).
Summary of Terms for Hereditary Diseases
Term Definition
Hereditary Genetic information contained in the nucleus
process of each cell passed to the next generation
Autosomes 44 chromosomes other than X and Y
Dominant gene Always produces an effect
Recessive gene Manifests when a person is homozygous for
the trait
Mutation Alteration in the DNA structures that may
become permanent hereditary change
Disorders of Immunity
The immune reaction of the body provides a powerful
defense against invading organisms by allowing it to recog-
nize foreign substances (antigens), such as bacteria, viruses,
fungi, and toxins, and to produce antibodies to counter-
act them. The antibody binds together with the antigen
to make the antigen harmless. Once antibodies have been
produced, a person becomes immune to the antigen.
Antibodies, or immunoglobulins, form in lymphoid
tissue, primarily in the lymph nodes, thymus gland, and
spleen. Although an infant has some immunity at birth,
most immunity is acquired either naturally by expo-
sure to a disease or artificially by immunization. There
are two types of artificial immunity: active and pas-
sive. In active immunity, a person forms antibodies to
counteract an antigen in the form of a vaccine or a tox-
oid. A vaccine consists of a low dose of dead or deac-
tivated bacteria or viruses. Although these organisms
cannot cause disease, they are foreign proteins contain-
ing antigens that stimulate the body to produce anti-
bodies against them. A toxoid is a chemically altered
toxin, the poisonous material produced by a pathogenic
organism. As with a vaccine, the toxin cannot cause
disease but does trigger the development of antibodies.
Examples of active immunity are the vaccines given to
prevent smallpox, polio, measles, tetanus, and diphthe-
ria. Active immunity persists for a long time, although
a relatively long time is required to build up immunity,
and a booster shot frequently gives a stronger effect.
Passive immunity refers to the administration of a
dose of preformed antibodies from the immune serum
of an animal, usually a horse. This type of immunity acts
immediately but lasts for a relatively short time. It is used
in situations in which a person is exposed to a serious
disease (hepatitis, rabies, tetanus) but has no immunity
against it and thus requires an immediate supply of anti-
bodies to prevent a possibly fatal infection.
Several fundamental mechanisms of immunologic
responses to antigens exist. The first type is a rapidly
occurring reaction in which antigens are attacked by
antibodies previously bound to the surface of mast
Chapter 1 Introduction to Pathology 11
cells. The mast cells release histamine, which causes
a local increase in vascular permeability and smooth
muscle contraction. Disorders resulting from localized
reactions of this type (which probably have a genet-
ically determined predisposition) include hay fever,
asthma, and gastrointestinal allergies. Generalized, or
systemic, anaphylactic reactions are characterized by
hypotension and vascular collapse (shock) with urti-
caria (hives), bronchiolar spasm, and laryngeal edema.
This reaction causes sudden death in patients who are
hypersensitive (“allergic”) to the sting of bees, wasps,
and other insects and to medications, such as penicillin
and the iodinated contrast materials used in radiology.
In the second type of immune reaction, called a cyto-
toxic reaction, either the antigen is a component of a cell or
it attaches to the wall of red blood cells, white blood cells,
platelets, or vascular endothelial cells. The reaction with
an antibody leads to cell destruction by lysis or phagocy-
tosis. Examples of a cytotoxic immune reaction include
the transfusion reaction occurring after the administration
of ABO-incompatible blood, and erythroblastosis fetalis,
the hemolytic anemia of the Rh-positive newborn whose
Rh-negative mother has produced anti-Rh antibodies.
The third type of immune reaction, a delayed reaction,
occurs in an individual previously sensitized to an anti-
gen. As an example, the first time a person touches poison
ivy no reaction occurs. However, on the next exposure to
poison ivy, antibodies are present to attack the antigen,
and the patient develops the typical rash and irritation.
A similar process produces a reaction to tuberculosis,
leprosy, many fungal diseases, and other infections. This
process also represents the principal component of rejec-
tion in organ transplants.
Infectious disease exposure
Working in the healthcare environment means that expo-
sure to infectious microorganisms will occur. To minimize
exposure, all healthcare workers should ­follow the Center
for Disease Control and Prevention's (CDC) Standard
Precautions. Exposure to blood-borne ­pathogens such
as human immunodeficiency virus (HIV) and hepatitis
B virus (HBV) can be minimized for all persons involved
with the use of the appropriate personal protective equip-
ment (PPE). The CDC recommends that all such persons be
considered potentially infected and that standard precau-
tions be applied when they are delivering health services
to every patient. In cases of highly transmissible patho-
gens, additional precautions are necessary; Transmission-
Based Precautions should be utilized for persons with
pathogens transmissible by contact, droplet, or through
air (airborne). Each healthcare facility is responsible for
administering the precautions, educating, training, and
monitoring its employees, and providing a protective
environment. Every healthcare worker must take personal
responsibility to help contain the infectious process in the
work environment by following CDC standards.
12 Chapter 1 Introduction to Pathology

Acquired immunodeficiency
syndrome
Acquired immunodeficiency syndrome (AIDS), which
most commonly affects young homosexual men and
intravenous drug abusers, is characterized by a pro-
found and sustained impairment of cellular immunity
that results in recurrent or sequential opportunistic
infections and a particularly aggressive form of Kaposi's
sarcoma. AIDS has also been reported in a substantial
number of hemophiliac patients, in recipients of trans-
fusions, and increasingly in heterosexual partners of
affected individuals. AIDS is attributable to infection
with retroviruses (RNA viruses) known as human immu-
nodeficiency viruses (HIV). This immune deficiency pre-
dominantly involves the lungs, gastrointestinal tract,
and central ­nervous system. Pulmonary infections are
extremely common in patients with AIDS and are fre-
quently caused by organisms that only rarely produce
disease in individuals with normal immune systems. Figure 1-6 Kaposi's sarcoma. Small bowel study shows multiple
intramural nodules (predominantly involving the jejunum) that dis-
About 60% of AIDS victims experience one or more tort the mucosal pattern and produce contour defects and intralu-
attacks of P. jirovecii pneumonia, which is character- minal lucencies.
ized by a sudden onset, a rapid progression to diffuse
lung involvement, and a considerable delay in resolu-
tion. The fungus cannot be cultured, and the disease is
usually fatal if untreated. An open-lung biopsy is often
necessary to make the diagnosis if a sputum examina-
tion reveals no organisms in a patient in whom this dis-
ease is suspected.
Gastrointestinal manifestations of AIDS include a
variety of sexually transmitted diseases involving the
rectum and colon, infectious processes (such as shigello-
sis, amebiasis, candidiasis, and giardiasis), and alimen-
tary tract dissemination (spread) of Kaposi's sarcoma.
Kaposi's sarcoma, a systemic disease, characteristi-
cally affects the skin and causes an ulcerated hemor-
rhagic dermatitis. Metastases to the small bowel, which
are relatively ­common, consist of multiple reddish or
bluish red nodules that intrude into the lumen of the
bowel (Figure 1-6). Similar lesions can develop through-
out the gastrointestinal tract. Central ulceration of the
­metastases causes ­gastrointestinal bleeding and a charac-
Figure 1-7 Pneumocystis jirovecii pneumonia. Diffuse bilateral
teristic radiographic appearance of multiple “bull's-eye” air-space consolidation is suggestive of severe bacterial pneumonia or
lesions simulating metastatic melanoma. pulmonary edema.
About 40% of all AIDS victims have neurologic symp-
toms, most commonly progressive dementia. Patients
with mass lesions of the brain commonly have focal neu- Magnetic resonance imaging (MRI) best demon-
rologic symptoms and signs. strates the multiple manifestations of AIDS in the cen-
Radiographic Appearance. The typical early radio- tral nervous system, where areas of increased signal
graphic finding of P. jirovecii pneumonia is a hazy, peri- intensity can be seen on T2-weighted images. Atypical
hilar, granular infiltrate that spreads to the periphery and brain abscesses and meningeal infection often occur,
appears predominantly interstitial. In later stages the pat- most commonly related to toxoplasmosis, cryptococ-
tern progresses to patchy areas of air-space consolidation cosis, cytomegalovirus, and herpesvirus (Figure 1-8).
with air bronchograms, indicating the alveolar nature of Increasing evidence indicates that cerebral infections
the process (Figure 1-7). The radiographic appearance may manifest from the HIV itself. Patients with AIDS
may closely resemble that of pulmonary edema or bacte- also have a high incidence of lymphoma involving the
rial pneumonia. central nervous system.
 Chapter 1 Introduction to Pathology 13

A B

Figure 1-8 Neurologic manifestations of AIDS. A, Computed tomography (CT) scan shows multiple ring-enhancing lesions caused by
cryptococcal brain abscesses. B, MRI, after intravenous administration of contrast medium, demonstrates multiple enhancing abscesses caused
by toxoplasmosis.

Treatment. Although much research has been initiated, and illegal drugs is recommended. An HIV carrier should
no cure for AIDS has been found. Currently, treatment avoid infections if possible because they may accelerate
assists in maintaining quality of life and managing symp- the HIV process.
toms as they manifest. Antiviral drugs help suppress the
HIV infection. A healthy lifestyle free of stress, alcohol,
Review Questions
1. The accumulation of abnormal amounts of fluid in
the spaces between cells or in body cavities is termed
S u m m a r y o f T e rm s f o r I m m u ni t y Di sor der s _________________.
Term Definition 2. _________________ is the process by which white
Antigens Foreign substance that evokes an immune blood cells surround and digest infectious organisms.
response 3. A tumor-like scar is referred to as a(n)
Antibodies Immunoglobulins responding to the antigens _________________.
to make them harmless 4. Inflammation with pus formation is termed
Immune Protected against antigens; antibodies binding _________________.
with antigens to make them harmless 5. An interruption in the blood supply to an organ or
Active immunity Forming antibodies to counteract an antigen body part is referred to as _________________.
by way of vaccine or toxoid 6. A localized area of ischemic necrosis in an organ or
Vaccine Contact with dead or deactivated tissue is termed a(n) _________________.
microorganisms to form antibodies
7. A swelling caused by bleeding into an enclosed area
Toxoid Treated toxin with antigenic power to produce
is termed _________________.
immunity by creating antibodies
Anaphylactic Hypersensitive reaction resulting in a 8. A decrease in function of an organ or tissue because
reaction histamine release of a reduction in the size or number of cells is termed
Standard Protection utilized when delivering healthcare ________________.
Precautions services to any person 9. The term _________________ means new growth.
Personal PPE— gowns, gloves, masks, shoe covers, and 10. The term for benign epithelial neoplasms that have a
Protective eye protection used to prevent transmission glandlike pattern is _________________.
Equipment of potential infectious agents 11. The study of determinants of disease events in given
Transmission- Additional protective equipment to prevent the populations is ________________.
Based spread of highly infectious pathogens through 12. Statistically, ________________ reflects the number
Precautions contact, droplet, or airborne transmission
of deaths by disease per population.
14 Chapter 1 Introduction to Pathology
13. The rate that an illness or abnormality occurs is
called ________________.
14. Gowns, gloves, masks, shoe covers, and eye protec-
tion used to prevent transmission of potential infec-
tious agents are ________________.
15. ________________ determines the additional pro-
tective equipment needed to prevent the spread of
highly infectious pathogens through contact, drop-
let, or airborne transmission.
 Chapter

2
Specialized Imaging Techniques

Outline
Diagnostic Imaging Modalities Magnetic Resonance Imaging Positron Emission Tomography
Mammography Nuclear Medicine Fusion Imaging
Ultrasound Single-Photon Emission
Computed Tomography Computed Tomography

Key terms
anechoic helical radiofrequency (RF) pulse
annihilation hyperechoic radiopharmaceutical
collimator hypoechoic single-photon emission computed
computed tomography (CT) integrated imaging tomography (SPECT)
CT number isoechoic T1-weighted images
diffusion imaging magnetic resonance imaging (MRI) T2-weighted images
direct fusion mammography ultrasound
fat suppression nuclear medicine virtual reality
functional MRI (fMRI) perfusion imaging volume-rendered imaging
gamma camera positron emission tomography (PET)

Objectives
After reading this chapter, the reader will be able to:
1. Differentiate screening and diagnostic mammography
imaging protocols and how the protocols are used to
demonstrate pathology
2. Describe the theory of image production with
ultrasound and why this modality becomes the optimal
choice to demonstrate pathologic conditions
3. Describe the theory of image production with computed
tomography (CT) and the body structures best
demonstrated
4. Briefly describe the theory of image production with
magnetic resonance imaging (MRI) and the different
sequences used to demonstrate specific tissue
5. Describe the theory of image production with nuclear
medicine, single-photon emission computed tomography
(SPECT), and positron emission tomography (PET)
6. Identify the fusion imaging techniques required to
produce optimal quality images in patients with various
underlying pathologic conditions
7. Define and describe all bold-faced terms in this chapter

Diagnostic imaging modalities
As the world of technology advances, medical imaging
modalities have become more technical. This change requires
the radiographer to have a broader and more specific skill
set to produce quality images. An example of this trend in
diagnostic imaging is the expansion of the department with
the development of specific x-ray tubes to produce high-
quality mammographic images of the breast.
The first of these new modalities was ultrasound,
which was capable of producing images without the use
of ionizing radiation, providing a diagnostic tool to view
soft tissues, especially in the fetus. In the early to middle
1970s, computed axial tomography (now known as CT)
Copyright © 2012, Elsevier Inc.
­ rovided revolutionary new images of the brain that dem-
p
onstrated the bone structure, white and gray matter, and
the fluid-filled ventricles. Eventually, CT eliminated the
need for pneumoencephalography and replaced many
cerebral angiograms. Scientists integrated the use of strong
magnets and radiofrequencies to provide another mode of
producing images without the use of ionizing radiation—
nuclear magnetic resonance (now known as magnetic res-
onance imaging). MRI offers clinicians images with high
soft tissue resolution and the ability to visualize structural
and functional tissue. CT and MRI now provide diagnos-
ticians with three-­dimensional (3D) (axial, sagittal, and
coronal) images and offer a way to separate overlapping
15
16 Chapter 2 Specialized Imaging Techniques
Radiographer Notes
A medical radiographer is one of the patient's healthcare team, pro-
viding care, diagnosis, and treatment, especially in the diagnostic
imaging department. The role of the radiolographer as a team member
is to produce the best quality images for diagnosis. Not only radiolo-
gists and physicians view the images; technologists using other imag-
ing modalities—such as mammography, ultrasound, CT, MRI, nuclear
medicine, SPECT, and PET—view these images as a basis for produc-
ing studies in their respective modalities.
For the healthcare team, communication is especially important. To
communicate effectively, the radiographer may need to gather infor-
mation from the patient (patient history). Once the added informa-
tion is recorded, the technologist may confer with the radiologist to
anatomic structures. With continuing research, nuclear
medicine expanded its role by adding movement and a
computer that allowed more than anterior and posterior
projections, resulting in the develop­ment of single-photon
emission computed tomography. Additional research
developments in radiopharmaceuticals led to the creation
of a positron-emitting radionuclide, which resulted in the
newest modality—positron emission tomography. Now
the concept of multiplanar imaging and gamma camera
movement (tomography) has provided healthcare with
two new perspectives in molecular imaging.
Computerized technology has become prevalent in
imaging today. Imaging modalities with special software
can now be integrated to create a fused image (superim-
position of images from two different modalities). PET/
CT is the most prominent hybrid equipment available
today. As computed technology continues to become
more complex, the modalities of today's imaging depart-
ment will also become more complicated. However, these
positive changes result in images that are more precise
and have greater sensitivity. This offers the radiologist
opportunity to make a quicker, more accurate diagnosis
for the patient.
Mammography
Most modern imaging departments have a separate area
where breast imaging procedures are performed. The
most common imaging technique for diagnosing breast
cancer is full-field digital mammography (FFDM). Some
centers still use the conventional screen-film imaging,
which employs a specially designed x-ray screen that per-
mits the proper exposure of film by many fewer x-rays
than would otherwise be necessary. This procedure pro-
duces a conventional black-and-white image at a very low
radiation dose. Full-field digital mammography relies on
radiation captured by multiple cells that convert the radi-
ation energy to electrical energy to produce a numerical
value (i.e., a digitized image). The advantages of digital
mammography are faster image acquisition with lower
dose (shorter exposure), increased contrast resolution
with the ability to manipulate images to visualize ­specific
ensure that the correct examination has been ordered. In some cases,
even though the examination is correct, it also would be beneficial if
further history were gathered or additional image projections were
taken to provide supplementary information. The better radiographers
understand their role in imaging, the more adept they will be at pro-
ducing the correct images for the specific pathophysiologic condition
of the patient.
To best demonstrate the pathology, all imaging technologists
must do their part to provide added information. The imaging team is
responsible for providing the best images to complement one another.
The collection of images from all modalities aids the diagnostician in
making the most accurate diagnosis.
areas of interest, decreased need to repeat studies, and the
ease of sharing images with other professionals. Screening
mammography consists of two images of each breast, the
craniocaudal and mediolateral oblique projections. For a
woman with a palpable nodule, the first choice may be
a diagnostic mammogram, which includes an additional
90-degree mediolateral projection. When screening mam-
mography demonstrates a suspicious area or a definite
abnormality, additional images, such as coned-down or
magnification projections, can be completed to compli-
ment the study. In some cases, ultrasound supplements
mammography images by demonstrating the lesion to be
fluid filled (cystic) or solid.
Ultrasound
Ultrasound (also called ultrasonography) is a widely
accepted cross-sectional imaging technique because of
its low cost, availability, and ability to differentiate cys-
tic (gallbladder), solid (liver), and complex (liver tumor)
tissue. A noninvasive imaging modality, ultrasound uses
high-frequency sound waves produced by electrical stim-
ulation of a specialized crystal (Figure 2-1). When the
high-frequency sound waves pass through the body, their
intensity is reduced by different amounts depending on
the acoustic properties of the tissues through which they
travel. The crystal mounted in a transducer sends the sig-
nal and also acts as a receiver to record echoes reflected
back from the body whenever the sound wave strikes an
interface between two tissues that have different acous-
tic properties. The transducer records the tiny changes
of the signal's pitch and direction. A water-tissue inter-
face can produce strong reflections (echoes), whereas a
solid tissue mass that contains small differences in com-
position can cause weak reflections. The display of the
ultrasound image on an imaging monitor shows both the
intensity level of the echoes and the position in the body
from which they were scanned. Ultrasound images may
be displayed as static gray-scale images or as multiple
(video) images that permit movement to be viewed in
real time. Color display on a sonogram is used to detect
motion (most specifically, blood flow). Depending on the
 Chapter 2 Specialized Imaging Techniques 17

A GB B
h
CBD

V P

Figure 2-1 Ultrasound images of normal abdomens. A, Right atrium of the heart (RA), the inferior vena cava (marked for measure-
ment), and the hepatic vein joining the inferior vena cava. B, Gallbladder (GB), common bile duct (CBD), portal vein (P), hepatic vein (h), and
inferior vena cava (V).

equipment used, the interactions of the tissue with the

sound wave determine how the tissue or organ is visual-
ized and described.
In general, fluid-filled structures have intense
echoes at their borders, no internal echoes, and good
transmission of the sound waves. Anechoic tissue
or structures (which are echo free, or lacking a sig-
nal) transmit sound waves easily and appear as the A
dark region on the image; examples are the gallblad-
der and a distended urinary bladder. Solid structures
(e.g., liver, spleen) produce internal echoes of variable
intensity. The terms hyperechoic and hypoechoic are
used to make comparisons of echo intensities between
adjacent structures. For example, the normal liver can
be described as being hyperechoic to the normal renal
cortex because the hepatic parenchymal tissue appears
as a lighter shade of gray. Conversely, because the nor-
mal renal cortex appears as a darker shade of gray
than the normal liver parenchyma, it can be described
as being hypoechoic to the liver. The term isoechoic
is used to describe two structures that have the same
B
echogenicity even though the tissue may not be the
same; for example, liver tissue is often isoechoic to the
spleen. Complex tissue types have both anechoic and
echogenic areas (Figure 2-2).
The major advantage of ultrasound is its safety. There
has been no evidence of any adverse effect on human
tissues at the intensity level currently used for diag-
nostic procedures. Therefore, ultrasound is the modal- Figure 2-2 Ultrasound images of the abdomen. A, Transverse
ity of choice for examinations of children and pregnant right kidney demonstrates a hyperechoic area (white) within the
women in whom a potential danger exists from the radi- mass caused by renal cell carcinoma. B, Gallbladder (GB) and aorta
(AO) are hypoechoic compared with the pancreas. Focal masses
ation exposure involved with other imaging ­studies. (arrows) are isoechoic (i.e., similar in density) to the adjacent pan-
Ultrasound is by far the best technique for evaluating creatic tissue.
fetal age and placenta placement, congenital anomalies,
and complications of pregnancy (Figure 2-3). Abdominal of the prostate gland aid in the detection and accurate
ultrasound is used extensively to evaluate the intraperi- staging of neoplasms. Pelvic imaging is performed via a
toneal and retroperitoneal structures, to detect abdomi- transabdominal (through the abdominal wall), transvag-
nal and pelvic abscesses, and to diagnose obstruction of inal (through the vagina), or transrectal (through the rec-
the biliary and urinary tracts. Pelvic ultrasound images tum) approach.
18 Chapter 2 Specialized Imaging Techniques
B A
Figure 2-3 Sonogram of the abdomen of a woman with a
multiple pregnancy. Cranial architecture is normal in fetus A and
abnormal in fetus B, a finding that documented demise of fetus B
(and also fetus C, which is not imaged).
Vascular or color-flow Doppler studies assess the pat-
ency of major blood vessels, demonstrating obstructions
(stenoses), blood clots, plaques, and emboli. The color-
flow duplex system, in which conventional real-time
imaging is integrated with Doppler imaging (to produce
quantitative data) and with color, depicts motion and
the direction and velocity of blood flow. The color and
intensity represent the direction of flow and the velocity,
respectively (e.g., in the carotid artery).
Other uses of ultrasound include breast imaging
(to differentiate solid from cystic masses) (Figure 2-4),
­musculoskeletal imaging (to detect problems with ten-
dons, muscles, and joints, and soft tissue fluid collec-
tions or masses) (Figure 2-5), and as an imaging guide
for ­invasive procedures (biopsies, aspirations, and drain
placement) (Figure 2-6).
C tion in a hypersthenic patient so that patient size does
Figure 2-4 Ultrasound image of a focal area of breast tissue.
The sonogram shows an anechoic mass (C) with a well-defined back
wall and distal enhancement (arrows).
Figure 2-5 Ultrasound image of a wrist demonstrating
the musculoskeletal architecture. A cystic structure (15 × 5 mm)
can be seen near the dorsal aspect of base of the fourth and fifth
metacarpals.
Ultrasound is a quick, inexpensive procedure for evaluat-
ing postoperative complications, although it may be difficult
to perform in some patients because of overlying dressings,
retention sutures, drains, and open wounds, which may
prevent the transducer from being in direct contact with
the skin. In children with open fontanelles, ultrasound can
image the intracranial structures. ­High-resolution, real-
time ultrasound systems can assist surgeons during oper-
ative procedures. This technique has been applied to the
neurosurgical localization of brain and spine neoplasms, to
the evaluation of ­intraventricular shunt tube placement, to
the localization of renal calculi, and to surgical procedures
involving the hepatobiliary system and pancreas.
The role of ultrasound imaging has expanded as a
result of the availability of multifrequency transducers
(2 -15 MHz) and advances in software (signal-processing)
technology. The resultant higher-­resolution images are
used in musculoskeletal, breast, and small-parts imaging.
The latest technologies include harmonic imaging (which
involves a broad band of low frequencies and can sup-
press reflection from surrounding tissue) to reduce image
noise and artifact, real-time compound imaging (a com-
bination of multiple lines of sight that increases image
clarity and provides more diagnostic information), and
contrast agents ­(microbubble ­echo-enhancing agents)
that increase vasculature definition. Harmonic imaging
produces diminished noise images, increasing the resolu-
not prevent obtaining diagnostic images. Contrast agents,
injectable low-solubility gas bubbles (less than 5 µm) such
as perfluorochemicals (inert dense fluids), increase the
differentiation of tissues and enhance visibility of detail
in tumors, small and stenotic vessels, heart studies, and
ultrasound hysterosonograms.
Ultrasound imaging requires an expanded knowledge
of anatomy, physiology, and pathology to locate and
demonstrate the specific region of interest. The quality of
the scans is operator dependent, and extensive instruction
and guidance are required to produce optimal images.
 Chapter 2 Specialized Imaging Techniques 19

the air-filled bowel from the region of interest. More

information on ultrasound imaging can be found on the
following websites: www.aium.org, www.sdms.org and
www.ardms.org.

A Computed Tomography
Computed tomography (CT) produces cross-sectional
tomographic images by first scanning a slice of tis-
sue from multiple angles with a narrow x-ray beam,
then calculating a relative linear attenuation coefficient
(representing the amount of radiation absorbed in tis-
sue for the various tissue elements in the section), and
finally displaying the computed reconstruction as a gray-
scale image on a imaging monitor. Unlike other imaging
modalities (except for the more recent MRI), CT per-
mits the radiographic differentiation of a variety of soft
­tissues from each other (Figure 2-7). CT is extremely
sensitive to slight (1%) differences in tissue densities; for
comparison, detection by conventional screen-film radi-
ography requires differences in tissue density of at least
5%. Thus, in the head, CT can differentiate between
blood clots, white matter and gray matter, cerebrospinal
fluid, ­cerebral edema, and neoplastic processes.
The CT number (Hounsfield number) reflects the
attenuation of a specific tissue relative to that of water,
which is arbitrarily assigned a CT number of 0 and
B appears gray on the image. The highest CT number
(1000) represents bone, which appears white, and the
lowest CT number (−1000) denotes air, which appears
black. Fat has a CT number less than 0, whereas soft
tissues have CT numbers higher than 0. The use of the
computer allows the image to be manipulated by adjust-
ment of the window width (gray scale—contrast scale)
and window level (density or brightness). From the
radiographer's perspective, the window width deter-
mines the number of densities that can be visualized on
the monitor. The window level is the midpoint or cen-
ter of the total number of densities being viewed in a
selected window width. Predetermined window widths

Figure 2-6 Ultrasound-guided localization. A, Ultrasound nee-

dle localization for surgical biopsy of the breast. B, Mammography
image verifying needle localization.

G
IVC
The major limitation of ultrasound is the presence
of acoustic barriers, such as air, bone, and barium. For L A
example, air reflects essentially the entire ultrasound
S
beam, so that structures beneath cannot be imaged well.
This special problem interferes with imaging of the solid
abdominal organs (e.g., the pancreas) in a patient with
adynamic ileus, and it is the major factor precluding
ultrasound examination of the thorax. For an ultrasound
examination of the pelvis, the patient usually drinks a Figure 2-7 Normal CT scan of lower abdomen. a, Aorta; L, liver;
large amount of fluid to fill the bladder, thus ­displacing G, gallbladder; S, spine; IVC, inferior vena cava.
20 Chapter 2 Specialized Imaging Techniques
and window levels are used to demonstrate specific parts
of the ­anatomy (lung, liver, bone). Technical improve-
ments in CT instrumentation and tube heat unit capacity
have greatly reduced the time required to produce mul-
tiple slices (1 to 2 seconds), permitting the CT evaluation
of virtually any portion of the body. In most instances,
some type of preliminary image is obtained (either a
radiograph or a CT-generated image) for localization, the
detection of potentially interfering high-density material
(metallic clips, barium, electrodes), and correlation with
the CT images. An overlying grid with numeric mark-
ers permits close correlation between the subsequent CT
scans and the initial scout image (Figure 2-8).
The intravenous injection of iodinated contrast mate-
rial has become an integral part of many CT examinations.
Scanning during or immediately after the administra-
tion of contrast material permits the ­differentiation of
Figure 2-8 CT scout image with overlying grid representing
scan slices.
A B
Figure 2-9 High-resolution CT scan of the lung. A, A pneumothorax can be seen in the right side of the lung of an emphysematous
patient, and blebs (high-density areas) in the left lung. B, Visualization of catheter placement in the treatment for the pneumothorax.
v­ ascular from nonvascular solid structures. Differences
in the degree and the time course of contrast enhance-
ment may permit the detection of neoplastic or infec-
tious processes within normal parenchymal structures.
Because of its relatively low CT number, fat can serve
as a natural contrast material and can outline parenchy-
mal organs. In patients with malignant lesions, the loss
of adjacent fat planes strongly suggests tumor extension.
For abdominal studies, especially those of the pancreas
and retroperitoneum, dilute oral contrast material (1%
to 3% weight per volume barium sulfate) is frequently
given to demonstrate the lumen of the gastrointestinal
tract, and it permits the distinction between loops of
bowel and solid abdominal structures.
Conventional CT produces images using a section
thickness of 5 to 10 mm. In high-resolution CT, thin
sections (1.5- to 2.0-mm slices) are used to produce a
very detailed display of lung anatomy. High-resolution
CT is far more sensitive and specific than plain chest
radiographs (or conventional CT) for the diagnosis of
­parenchymal lung disease (Figure 2-9).
CT technology has moved to spiral (helical) scanning.
In this technique, continual CT scanning is performed as
the patient moves through the gantry (unlike the mul-
tiple single scans in conventional CT) (Figure 2-10).
This approach permits much faster scanning without
respiratory motion and provides data that can be ­easily
­reformatted in coronal and sagittal planes, and in the
standard axial plane. Helical scanners with subsecond
scanning abilities produce images of the chest (taking less
than 20 seconds to complete the scan protocol) that dem-
onstrate the pulmonary arteries without motion and can
detect pulmonary emboli. CT imaging protocols for some
procedures (e.g., obtaining images of the kidneys and
liver) may require three-phase scanning (arterial, capil-
lary, and venous phases, and an excretory phase) to dem-
onstrate all anatomic (tissue) structures (Figure 2-11).
The single-scan protocol changed with subsecond scan-
ning because the intravenous bolus ­injection appears very
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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