Netters clinical anatomy with online access netter basic science 3rd edition

Netteru2019s Clinical Anatomy: with Online Access (Netter Basic Science) 3rd Edition Visit to download the full and correct content document: https://ebookmass.com/product/netters-clinical-anatomy-with-online-access-netter-ba sic-science-3rd-edition/

About the Artists

Frank H. Netter, MD Frank H. Netter was born in 1906, in New York City. He studied art at the Art Students’ League and the National Academy of Design before entering medical school at New York University, where he received his medical degree in 1931. During his student years, Dr. Netter’s notebook sketches attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating articles and textbooks. He continued illustrating as a sideline after establishing a surgical practice in 1933, but he ultimately opted to give up his practice in favor of a full-time commitment to art. After service in the United States Army during World War II, Dr. Netter began his long collaboration with the CIBA Pharmaceutical Company (now Novartis Pharmaceuticals). This 45-year partnership resulted in the production of the extraordinary collection of medical art so familiar to physicians and other medical professionals worldwide.

In 2005, Elsevier, Inc., purchased the Netter Collection and all publications from Icon Learning Systems. More than 50 publications featuring the art of Dr. Netter are available through Elsevier, Inc. (in the US: www.us.elsevierhealth.com/Netter and outside the US: www.elsevierhealth.com).

Dr. Netter’s works are among the finest examples of the use of illustration in the teaching of medical concepts. The 13-book Netter Collection of Medical Illustrations, which includes the greater part of the more than 20,000 paintings created by Dr. Netter, became and remains one of the most famous medical works ever published. The Netter Atlas of Human Anatomy, first published in 1989, presents the anatomic paintings from the Netter Collection. Now translated into 16 languages, it is the anatomy atlas of choice among medical and health professions students the world over.

The Netter illustrations are appreciated not only for their aesthetic qualities, but, more important, for their intellectual content. As Dr. Netter wrote in 1949, “. . . clarification of a subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may be, it is of little value as a medical illustration if it does not serve to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are what inform his paintings and what make them so intellectually valuable.

Frank H. Netter, MD, physician and artist, died in 1991.

Learn more about the physician-artist whose work has inspired the Netter Reference collection: http://www.netterimages.com/artist/netter.htm.

Carlos Machado, MD Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main artist who contributes to the Netter collection of medical illustrations.

Self-taught in medical illustration, cardiologist Carlos Machado has contributed meticulous updates to some of Dr. Netter’s original plates and has created many paintings of his own in the style of Netter as an extension of the Netter collection.

Dr. Machado’s photorealistic expertise and his keen insight into the physician/patient relationship informs his vivid and unforgettable visual style. His dedication to researching each topic and subject he paints places him among the premier medical illustrators at work today.

Learn more about his background and see more of his art at: http://www.netterimages.com/ artist/machado.htm.

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About the Author

John T. Hansen, PhD, is Professor of Neurobiology and Anatomy, and Associate Dean for Admissions at the University of Rochester School of Medicine and Dentistry. Dr. Hansen served as Chair of the Department of Neurobiology and Anatomy before becoming Associate Dean. Dr. Hansen is the recipient of numerous teaching awards from students at three different medical schools. In 1999, he was the recipient of the Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award given annually by the Association of American Medical Colleges to

nationally recognized medical educators. Dr. Hansen’s investigative career encompassed the study of the peripheral and central dopaminergic systems, neural plasticity, and neural inflammation. In addition to about 100 research publications, he is co-author of Netter’s Atlas of Human Physiology; the lead consulting editor of Netter’s Atlas of Human Anatomy; author of Netter’s Anatomy Flash Cards, Essential Anatomy Dissector, and Netter’s Anatomy Coloring Book; and co-author of the TNM Staging Atlas with Oncoanatomy.

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Acknowledgments

Compiling the illustrations for, researching, and writing Netter’s Clinical Anatomy, third edition, has been both enjoyable and educational, confirming again the importance of lifelong learning in the health professions.

Netter’s Clinical Anatomy is for all my students, and I am indebted to all of them who, like many others, yearn for a better view to help them learn the relevant essential anatomy that informs the practice of medicine. Anatomy is a visual science, and Netter’s illustrations are the gold standard of medical illustration.

Thanks and appreciation belong to my colleagues and reviewers who provided encouragement and constructive comments that clarified many aspects of the book. Especially, I wish to acknowledge David Lambert, MD, Senior Associate Dean for Undergraduate Medical Education at Rochester, who co-authored the first edition of this book with me and remains a treasured colleague and friend.

At Elsevier, it has been a distinct pleasure to work with dedicated, professional people who massaged, molded, and ultimately nourished the dream beyond even my wildest imagination. I owe much to the efforts of Marybeth Thiel, Senior

Content Development Editor, and John Casey, Senior Project Manager, both of whom kept me organized, focused, and on time. Without them, little would have been accomplished. Thanks and appreciation also to Lou Forgione, Design Direction and Karen Giacomucci, Illustration Manager.

A special thank you to Madelene Hyde, Publishing Director, and Elyse O’Grady, Senior Content Strategist, for believing in the idea and always supporting my efforts. This competent team defines the word “professionalism,” and it has been an honor to work with all of them.

Special thanks to Carlos Machado, MD, for his beautiful artistic renderings that superbly com­plemented, updated, and extended the Netter anatomy collection. Also, I wish to express my thanks to my faculty colleagues at Rochester for their generous and constructive feedback.

Finally, I remain indebted to Frank H. Netter, MD, whose creative genius lives on in generations of biomedical professionals who have learned clinical anatomy from his rich collection of medical illustrations.

To all of these remarkable people, and others, “Thank you.”

JOHN T. HANSEN, PHD

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Preface

Human anatomy is the foundation upon which the education of our medical, dental, and allied health science students is built. However, today’s biomedical science curriculum must cover an ever-increasing body of scientific knowledge, often in fewer hours, as competing disciplines and new technologies emerge. Many of these same technologies, especially those in the imaging science fields, have made understanding the anatomy even more important and have moved our discipline firmly into the realm of clinical medicine. It is fair to say that competent clinicians and allied health professionals can no longer simply view their anatomical training in isolation from the clinical implications related to that anatomy.

In this context, I am proud to introduce the third edition of Netter’s Clinical Anatomy. Generations of students have used Dr. Frank H. Netter’s elegant anatomical illustrations to learn anatomy, and this book combines his beautiful anatomical and embryological renderings with numerous clinical illustrations to help students bridge the gap between normal anatomy and its clinical application across each region of the human body.

This third edition provides succinct text, key bulleted points, and ample summary tables, which offer students a concise textbook description of normal human anatomy, as well as a quick reference and review guide for clinical practitioners.

Additionally, some of the more commonly encountered clinical conditions seen in medical practice are integrated within the textbook as Clinical Focus boxes. These clinical correlations are drawn from a wide variety of medical fields including emergency medicine, radiology, orthopedics, and surgery, but also include relevant clinical anatomy related to the fields of cardiology, endocrinology, infectious diseases, neurology, oncology, reproductive biology, and urology. By design, the text and clinical correlations are not exhaustive but are meant to help students focus on the essential

elements of anatomy and begin to appreciate some of the clinical manifestations related to that anatomy. Other features of this edition include:

• • • •

An introductory chapter designed to orient students to the body’s organ systems A set of end-of-chapter clinically oriented multiple choice review questions to help reinforce student learning of key concepts Basic embryology of each system that provides a contextual framework for human postnatal anatomy and several common congenital defects Online access with additional Clinical Focus boxes

My intent in writing this updated third edition of Netter’s Clinical Anatomy was to provide a concise and focused introduction to clinical anatomy as a viable alternative to the more comprehensive anatomy textbooks, which few students read and often find difficult to navigate when looking for essential anatomical details.

Moreover, this textbook serves as an excellent essential review text for students beginning their clinical clerkships or elective programs, and as a reference text that clinicians will find useful for review and patient education.

The text is by no means comprehensive but does provide the essential anatomy needed by the generalist physician-in-training that is commonly encountered in the first year of medical school. I have intentionally focused on the anatomy that a first-year student might be expected to grasp and carry forward into his or her clerkship training, especially in this day and age when anatomy courses are often streamlined and dissection exercises abbreviated. Those students, who by choice, choose to enter specialties where advanced anatomical training is required (e.g., surgical specialties, radiology, physical therapy, etc.) may encounter a need for additional anatomical expertise that will be provided by their graduate medical xiii

xiv or allied health education. By meeting the needs of the beginning student and providing ample detail for subsequent review or handy reference, my hope is that Netter’s Clinical Anatomy will be the anatomy textbook of choice that will actually be read and used by students throughout their undergraduate medical or allied health careers.

Preface I hope that you, the health science studentin-training or the physician-in-practice, will find Netter’s Clinical Anatomy, third edition, the valuable link you’ve searched for to enhance your understanding of clinical anatomy as only Frank Netter can present it.

JOHN T. HANSEN, PHD

Contents

chapter 1

Introduction to the Human Body 1

chapter 2

Back

chapter 3

Thorax

chapter 4

Abdomen

chapter 5

Pelvis and Perineum 217

chapter 6

Lower Limb 271

chapter 7

Upper Limb 345

chapter 8

Head and Neck 411

49 87 145

Index 525

xv

Clinical Focus Boxes

chapter 1

Introduction to the Human Body 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8

Psoriasis, 5 Burns, 6 Langer’s Lines, 6 Fractures, 12 Degenerative Joint Disease, 13 Atherogenesis, 18 Asthma, 22 Potential Spaces, 38

Available Online 1-9

chapter 2

Myasthenia Gravis

Back 2-1 2-2 2-3 2-4 2-5 2-6 2-7 2-8 2-9 2-10 2-11 2-12

Scoliosis, 51 Cervical Fractures, 53 Osteoarthritis, 55 Osteoporosis, 58 Spondylolysis and Spondylolisthesis, 59 Intervertebral Disc Herniation, 59 Back Pain Associated with the Zygapophysial (Facet) Joints, 61 Low Back Pain, 62 Whiplash Injury, 64 Herpes Zoster, 75 Lumbar Puncture and Epidural Anesthesia, 77 Spina Bifida, 83

Available Online 2-13 Myofascial Pain 2-14 Acute Spinal Syndromes

chapter 3

Thorax 3-1 3-2

xvi

Thoracic Cage Injuries, 92 Fibrocystic Breast Disease, 96

Clinical Focus Boxes 3-3 3-4 3-5 3-6 3-7 3-8 3-9 3-10 3-11 3-12 3-13 3-14 3-15 3-16 3-17 3-18 3-19 3-20 3-21 3-22 3-23 3-24 3-25

xvii Breast Cancer, 97 Partial Mastectomy, 98 Modified Radical Mastectomy, 99 Chest Drainage Tubes, 103 Pulmonary Embolism, 105 Lung Cancer, 106 Chronic Obstructive Pulmonary Disease, 107 Idiopathic Pulmonary Fibrosis, 107 Cardiac Tamponade, 110 Dominant Coronary Circulation, 112 Angina Pectoris (the Referred Pain of Myocardial Ischemia), 115 Coronary Bypass, 115 Coronary Angiogenesis, 116 Myocardial Infarction, 118 Cardiac Auscultation, 119 Valvular Heart Disease, 120 Cardiac Pacemakers, 122 Cardiac Defibrillators, 123 Mediastinal Masses, 127 Ventricular Septal Defect, 136 Atrial Septal Defect, 137 Patent Ductus Arteriosus, 138 Repair of Tetralogy of Fallot, 139

Available Online 3-26 3-27 3-28 3-29 3-30 3-31 3-32 3-33 3-34 3-35

chapter 4

Hemothorax Chronic Cough Pneumonia Cardiovascular Disease Saphenous Vein Graft Disease Infective Endocarditis Mitral Valve Prolapse Ventricular Tachycardia Chylothorax Coarctation of the Aorta

Abdomen 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8

Abdominal Wall Hernias, 152 Inguinal Hernias, 157 Hydrocele and Varicocele, 158 Acute Appendicitis, 163 Gastroesophageal Refl ux Disease (GERD), 164 Hiatal Hernia, 165 Peptic Ulcer Disease, 166 Bariatric Surgery, 167

xviii

Clinical Focus Boxes 4-9 4-10 4-11 4-12 4-13 4-14 4-15 4-16 4-17 4-18 4-19 4-20 4-21 4-22 4-23 4-24 4-25 4-26 4-27 4-28

Crohn Disease, 168 Ulcerative Colitis, 169 Diverticulosis, 170 Colorectal Cancer, 171 Volvulus, 172 Intussusception, 175 Gallstones (Cholelithiasis), 176 Pancreatic Cancer, 178 Rupture of the Spleen, 179 Cirrhosis of the Liver, 185 Portal Hypertension, 186 Renal Stones (Calculi), 194 Obstructive Uropathy, 195 Malignant Tumors of the Kidney, 196 Surgical Management of Abdominal Aortic Aneurysm, 198 Congenital Megacolon, 206 Meckel’s Diverticulum, 208 Congenital Malrotation of the Colon, 210 Renal Fusion, 211 Pheochromocytoma, 212

Available Online 4-29 4-30 4-31 4-32

chapter 5

Acute Abdomen: Visceral Etiology Irritable Bowel Syndrome Acute Pyelonephritis Causes and Consequences of Portal Hypertension

Pelvis and Perineum 5-1 5-2 5-3 5-4 5-5 5-6 5-7 5-8 5-9 5-10 5-11 5-12 5-13 5-14 5-15 5-16 5-17

Pelvic Fractures, 219 Urinary Tract Infections, 225 Stress Incontinence in Women, 228 Uterine Prolapse, 229 Cervical Carcinoma, 229 Uterine Leiomyomas (Fibroids), 230 Endometriosis, 230 Uterine Endometrial Carcinoma, 231 Chronic Pelvic Inflammatory Disease, 231 Dysfunctional Uterine Bleeding, 232 Ectopic Pregnancy, 233 Assisted Reproduction, 233 Ovarian Cancer, 234 Vasectomy, 237 Testicular Cancer, 238 Hydrocele and Varicocele, 238 Transurethral Resection of the Prostate, 239

Clinical Focus Boxes 5-18 5-19 5-20 5-21 5-22 5-23 5-24 5-25 5-26

xix Prostatic Carcinoma, 240 Hemorrhoids, 253 Episiotomy, 254 Sexually Transmitted Diseases, 255 Urethral Trauma in the Male, 259 Urine Extravasation in the Male, 259 Erectile Dysfunction, 260 Hypospadias and Epispadias, 264 Uterine Anomalies, 265

Available Online 5-27 Ovarian Tumors

chapter 6

Lower Limb 6-1 6-2 6-3 6-4 6-5 6-6 6-7 6-8 6-9 6-10 6-11 6-12 6-13 6-14 6-15 6-16 6-17 6-18 6-19 6-20 6-21 6-22 6-23 6-24 6-25 6-26 6-27 6-28 6-29 6-30 6-31

Deep Venous Thrombosis, 273 Congenital Hip Dislocation, 276 Pelvic Fractures, 277 Intracapsular Femoral Neck Fracture, 278 Pressure (Decubitus) Ulcers, 282 Iliotibial Tract (Band) Syndrome, 283 Fractures of the Shaft and Distal Femur, 284 Thigh Muscle Injuries, 287 Diagnosis of Hip, Buttock, and Back Pain, 289 Revascularization of the Lower Limb, 291 Femoral Pulse and Vascular Access, 292 Multiple Myeloma, 298 Tibial Fractures, 299 Deep Tendon Reflexes, 299 Patellar Injuries, 300 Rupture of the Anterior Cruciate Ligament, 300 Sprains of the Knee Ligaments, 301 Tears of the Meniscus, 301 Osgood-Schlatter Disease, 302 Osteoarthritis of the Knee, 302 Septic Bursitis and Arthritis, 303 Shin Splints, 305 Osteosarcoma of the Tibia, 305 Genu Varum and Valgum, 310 Exertional Compartment Syndromes, 310 Achilles Tendinitis and Bursitis, 311 Footdrop, 316 Lateral Ankle Sprain, 316 Ankle Fractures, 317 Rotational Fractures, 319 Fractures of the Calcaneus, 320

xx

Clinical Focus Boxes 6-32 6-33 6-34 6-35 6-36 6-37 6-38 6-39 6-40

Congenital Clubfoot, 323 Metatarsal and Phalangeal Injuries, 324 Plantar Fasciitis, 325 Deformities of the Toes, 325 Fractures of the Talar Neck, 326 Common Foot Infections, 327 Diabetic Foot Lesions, 328 Arterial Occlusive Disease, 329 Gout, 329

Available Online 6-41 Healing of Fractures

chapter 7

Upper Limb 7-1 7-2 7-3 7-4 7-5 7-6 7-7 7-8 7-9 7-10 7-11 7-12 7-13 7-14 7-15 7-16 7-17 7-18 7-19 7-20 7-21 7-22 7-23 7-24 7-25 7-26

Glenohumeral Dislocations, 348 Fracture of the Proximal Humerus, 349 Clavicular Fractures, 350 Rotator Cuff Injury, 354 Shoulder Tendinitis and Bursitis, 355 Brachial Plexopathy, 358 Axillary Lipoma, 361 Deep Tendon Reflexes, 367 Fractures of the Humerus, 367 Biceps Brachii Rupture, 370 Elbow Dislocation, 371 Fracture of the Radial Head and Neck, 375 Biomechanics of Forearm Radial Fractures, 377 Fracture of the Ulna Shaft, 382 Distal Radial (Colles’) Fracture, 382 Median Nerve Compression and Carpal Tunnel Syndrome, 387 Fracture of the Scaphoid, 388 Allen’s Test, 388 De Quervain Tenosynovitis, 389 Proximal Interphalangeal Joint Dislocations, 390 Finger Injuries, 391 Radial Nerve Compression, 397 Proximal Median Nerve Compression, 400 Ulnar Tunnel Syndrome, 401 Clinical Evaluation of Compression Neuropathy, 402 Ulnar Nerve Compression in Cubital Tunnel, 403

Available Online 7-27 Trigger Finger 7-28 Rheumatoid Arthritis 7-29 Central Venous Access

Clinical Focus Boxes

chapter 8

xxi

Head and Neck 8-1 8-2 8-3 8-4 8-5 8-6 8-7 8-8 8-9 8-10 8-11 8-12 8-13 8-14 8-15 8-16 8-17 8-18 8-19 8-20 8-21 8-22 8-23 8-24 8-25 8-26 8-27 8-28 8-29 8-30 8-31 8-32 8-33 8-34 8-35 8-36 8-37 8-38 8-39 8-40 8-41 8-42 8-43 8-44

Skull Fractures, 415 Zygomatic Fractures, 415 Midface Fractures, 416 Hydrocephalus, 422 Meningitis, 423 Subarachnoid Hemorrhage, 425 Epidural Hematomas, 427 Subdural Hematomas, 428 Transient Ischemic Attack, 428 Stroke, 429 Carotid–Cavernous Sinus Fistula, 430 Collateral Circulation after Internal Carotid Artery Occlusion, 430 Vascular (Multi-infarct) Dementia, 431 Brain Tumors, 432 Metastatic Brain Tumors, 433 Trigeminal Neuralgia, 438 Herpes Zoster (Shingles), 438 Facial Nerve (Bell’s) Palsy, 439 Tetanus, 440 Orbital Blow-out Fracture, 443 Clinical Testing of the Extra-ocular Muscles, 445 Horner’s Syndrome, 446 Eyelid Infections and Conjunctival Disorders, 451 Papilledema, 451 Diabetic Retinopathy, 452 Glaucoma, 453 Ocular Refractive Disorders, 454 Cataract, 455 Pupillary Light Reflex, 456 Mandibular Dislocation, 457 Mandibular Fractures, 459 Rhinosinusitis, 461 Nosebleed, 466 Acute Otitis Externa and Otitis Media, 471 Weber and Rinne Tests, 473 Cochlear Implant, 473 Vertigo, 474 Removal of an Acoustic Neuroma, 475 Common Oral Lesions, 480 Cancer of the Oral Cavity, 481 Hyperthyroidism with Diffuse Goiter (Graves’ Disease), 490 Primary Hypothyroidism, 491 Manifestations of Primary Hyperparathyroidism, 492 Emergency Airway: Cricothyrotomy, 500

xxii

Clinical Focus Boxes 8-45 8-46 8-47 8-48 8-49

Manifestations of Hoarseness, 500 Nerve Lesions, 511 Craniosynostosis, 518 Congenital Anomalies of the Oral Cavity, 518 Pharyngeal Arch and Pouch Anomalies, 519

chapter

Introduction to the Human Body 1. TERMINOLOGY 2. SKIN 3. SKELETAL SYSTEM 4. MUSCULAR SYSTEM 5. CARDIOVASCULAR SYSTEM 6. LYMPHATIC SYSTEM

7. RESPIRATORY SYSTEM 8. NERVOUS SYSTEM 9. ENDOCRINE SYSTEM 10. GASTROINTESTINAL SYSTEM 11. URINARY SYSTEM 12. REPRODUCTIVE SYSTEM

1. TERMINOLOGY Anatomical Position The study of anatomy requires a clinical vocabulary that defines position, movements, relationships, and planes of reference, as well as the systems of the human body. The study of anatomy can be by body region or by body organ systems.

Generally, courses of anatomy in the United States approach anatomical study by regions, integrating all applicable body systems into the study of a particular region. This textbook therefore is arranged regionally, and for those studying anatomy for the first time, this initial chapter introduces you to the major body systems that you will encounter in your study of anatomy. You will find it extremely helpful to refer back to this introduction as you encounter various body systems in your study of regional anatomy.

By convention, anatomical descriptions of the human body are based on a person in the anatomical position (Fig. 1-1), as follows:

•• •

Standing erect and facing forward Arms hanging at the sides with palms facing forward Legs placed together with feet facing forward

Terms of Relationship and Body Planes Anatomical descriptions often are referenced to one or more of three distinct body planes (Fig. 1-2 and Table 1-1), as follows:

•

Sagittal plane: vertical plane that divides the body into equal right and left halves (median or midsagittal plane) or a plane

• •

1

13. BODY CAVITIES 14. OVERVIEW OF EARLY DEVELOPMENT 15. IMAGING THE INTERNAL ANATOMY CHALLENGE YOURSELF QUESTIONS

parallel to the median sagittal plane (parasagittal) that divides the body into unequal right and left portions.

Frontal (coronal) plane: vertical plane that divides the body into anterior and posterior portions (equal or unequal); this plane is at right angles to the median sagittal plane.

Transverse (axial) plane: horizontal plane that divides the body into superior and inferior portions (equal or unequal) and is at right angles to both the median sagittal and the frontal planes (sometimes called cross sections).

Key terms of relationship used in anatomy and the clinic are summarized in Table 1-1. A structure or feature closer to the front of the body is considered anterior (ventral), and one closer to the back is termed posterior (dorsal).

The terms medial and lateral are used to distinguish a structure or feature in relationship to the midline; the nose is medial to the ear, and in anatomical position, the nose also is anterior to the ear. Sometimes these terms of relationship are used in combination (e.g., superomedial, meaning closer to the head and nearer the median sagittal plane).

Movements Body movements usually occur at the joints where two or more bones or cartilages articulate with one another. Muscles act on joints to accomplish these movements and may be described as follows: “The biceps muscle flexes the forearm at the elbow.” Figure 1-3 summarizes the terms of movement.

1

2

Chapter 1 Forehead

Introduction to the Human Body

Cranium (skull) Cephalon (head) Cephalon (head) Face Cervicis (neck) Trunk

Cheek (buccal) Nasus (nose) Oris (mouth) Mentis (chin)

Otic (ear) Shoulder

Axilla (armpit)

Thoracis (thorax, chest) Mamma (breast)

Brachium (arm)

Abdomen

Loin

Antebrachium (forearm)

Umbilicus (navel)

Dorsum (back)

Olecranon (back of elbow)

Pelvis Carpus (wrist) Pollex (thumb) Digits (fingers)

Manus (hand)

Palm (palmar) Thigh

Groin Pubis

Patella (kneecap)

Upper limb

Gluteus (buttocks)

Lower limb

Popliteus (back of knee)

Crus (leg)

Calf

Tarsus (ankle) Digits (toes)

Calcaneus (heel of foot)

Pes (foot)

Plantus (sole of foot)

Hallux (great toe)

FIGURE 1-1 Anatomical Position and Terminology for Body Regions.

Superior Frontal plane

Right

Left

Cranial Medial

Lateral Proximal

Proximal

Transverse plane

Distal

Caudal

Dorsal or posterior Sagittal plane Distal Ventral or anterior

Inferior

FIGURE 1-2 Body Planes and Terms of Anatomical Relationship.

Chapter 1

Introduction to the Human Body

1

3

TABLE 1-1 General Terms of Anatomical Relationship TERM

DEFINITION

TERM

DEFINITION

Anterior (ventral) Posterior (dorsal) Superior (cranial) Inferior (caudal) Medial

Near the front Near the back Upward, or near the head Downward, or near the feet Toward the midline or median plane Farther from the midline or median plane Near a reference point Away from a reference point Closer to the surface Farther from the surface

Median plane

Divides body into equal right and left parts Median plane Divides body into unequal right and left parts Divides body into equal or unequal anterior and posterior parts Divides body into equal or unequal superior and inferior parts (cross sections)

Lateral Proximal Distal Superficial Deep

Midsagittal plane Sagittal plane Frontal (coronal) plane Transverse plane

Extension Abduction

Flexion

Lateral rotation Medial rotation

Adduction Abduction

Flexion

Elevation Depression

Extension

Lateral rotation

Adduction

Flexion

Medial rotation Extension

Pronation Extension

Flexion

Extension

Supination

Retrusion

Flexion

Protrusion

Flexion

Eversion

Extension

Inversion

Dorsiflexion

Circumduction

Plantarflexion

FIGURE 1-3 Terms of Movement.

4

Chapter 1

Introduction to the Human Body and often can be traced to their complex embryologic development; veins generally are more numerous than arteries, larger, and more variable.

Anatomical Variability The human body is remarkably complex and remarkably consistent anatomically, but normal variations do exist, often related to size, gender, age, number, shape, and attachment. Variations are particularly common in the following structures:

• • • • •

Bones: fine features of bones (processes, spines, articular surfaces) may be variable depending on the forces working on a bone.

Muscles: vary with size and fine details of their attachments (it is better to learn their actions and general attachments rather than focus on detailed exceptions).

Organs: the size and shape of some organs will vary depending on their normal physiology or pathophysiologic changes that have occurred previously.

Arteries: surprisingly consistent, although some variation is seen in the branching patterns, especially in the lower neck (subclavian branches) and in the pelvis (internal iliac branches).

Veins: consistent, although variations, especially in size and number of veins, can occur

2. SKIN The skin is the largest organ in the body, accounting for about 15% to 20% of the total body mass, and has the following functions:

• • • • •

Protection: against mechanical abrasion and in immune responses, as well as prevention of dehydration Temperature regulation: largely through vasodilation, vasoconstriction, fat storage, or activation of sweat glands Sensations: to touch by specialized mechanoreceptors such as pacinian and Meissner’s corpuscles; to pain by nociceptors; and to temperature by thermoreceptors Endocrine regulation: by secretion of hormones, cytokines, and growth factors, and by synthesis and storage of vitamin D Exocrine secretions: by secretion of sweat and oily sebum from sebaceous glands

The skin consists of two layers (Fig. 1-4):

Free n. endings Hair shaft Arrector pili m. of hair

Stratum spinosum

Epidermis

Meissner’s corpuscle Stratum corneum Stratum lucidum Stratum granulosum

Stratum basale

Dermal papilla (of papillary layer) Dermis

Sebaceous gland Reticular layer

Subcutaneous tissue

Sweat gland

Pacinian corpuscle Sensory nn.

Subcutaneous a.

Cutaneous n.

Subcutaneous v.

Elastic fibers Skin ligs. (retinacula cutis)

Motor (autonomic) n.

FIGURE 1-4 Layers of the Skin.

Chapter 1

Introduction to the Human Body

1

5

Clinical Focus 1-1 Psoriasis Psoriasis is a chronic inflammatory skin disorder that affects approximately 1% to 3% of the population (women and men equally). It is characterized by defined red plaques capped with a surface scale of desquamated epidermis. Although the pathogenesis is unknown, psoriasis seems to involve a genetic predisposition.

Histopathologic features

Munro microabscess (sterile)

Surface “silver” scale Erythematous base Persistence of nuclei stratum corneum (parakeratosis) Increased mitotic activity indicative of high cell turnover rate Dilation and tortuosity of papillary vessels

Typical distribution

Scalp Groin and genitalia Edema and inflammation of dermis

Increased number of Langerhans cells

Transverse ridges

Typical appearance of cutaneous lesions (plaque lesion)

• •

Nail pits

Elbow

Knee Intergluteal cleft

Sacrum

Hand and nails

Nail

Onycholysis

Epidermis: outer protective layer consisting of a keratinized stratified squamous epithelium derived from the embryonic ectoderm.

Dermis: dense connective tissue layer that gives skin most of its thickness and support, and is derived from the embryonic mesoderm.

Fascia is a connective tissue sheet that may contain variable amounts of fat. It can interconnect structures, provide a conduit for vessels and nerves (termed neurovascular bundles), and provide a sheath around structures (e.g., muscles) that permits them to slide over one another easily.

Superficial fascia is attached to and lies just beneath the dermis of the skin and can vary in thickness and density; it acts as a cushion, contains variable amounts of fat, and allows the skin to glide over its surface. Deep fascia usually consists of a dense connective tissue, is attached to the

Primarily on extension surfaces

deep surface of the superficial fascia, and often ensheathes muscles and divides them into functional groupings. Extensions of the deep fascia encasing muscles also may course inward and attach to the skeleton, dividing groups of muscles with intermuscular septa.

• • •

First-degree: burn damage is limited to the superficial layers of the epidermis; termed a superficial burn, clinically it causes erythema.

Second-degree: burn damage includes all the epidermis and extends into the superficial dermis; termed a partial-thickness burn, it causes blisters but spares the hair follicles and sweat glands.

Third-degree: burn damage includes all the epidermis and dermis and may even involve the subcutaneous tissue and underlying deep fascia and muscle; termed a fullthickness burn, it causes charring.

6

Chapter 1

Introduction to the Human Body

Clinical Focus 1-2 Burns Burns to the skin are classified into three degrees of severity based on the depth of the burn:

Partial thickness

Full thickness

Pink or light red. Tender.

1st degree

Epidermis

Superficial 2nd degree

Red, weeping, blister formation. Painful.

2nd degree Deep 2nd degree

Dermis

Pale, slightly moist, less red.

Diminished sensation.

3rd degree

Subcutaneous tissue

Hair Sebaceous Sweat gland follicle gland

Pearly white or charred, parchmentlike, translucent (veins show through). Insensate.

Clinical Focus 1-3 Langer’s Lines Collagen in the skin creates tension lines called Langer’s lines. Often, surgeons may use these lines to make skin incisions. The resulting incision wounds tend to gape less when the incision is parallel to Langer’s lines, and this usually leaves a smaller scar after healing of the incision.

Chapter 1

Introduction to the Human Body

3. SKELETAL SYSTEM Descriptive Regions The human skeleton is divided into two descriptive regions (Fig. 1-5):

• •

Axial skeleton: bones of the skull, vertebral column (spine), ribs, and sternum, which form the “axis” or central line of the body (80 bones).

Appendicular skeleton: bones of the limbs, including the pectoral and pelvic girdles, which attach the limbs to the body’s axis (134 bones).

Appendicular skeleton (134)

Pectoral girdle (4)

Clavicle (2) Scapula (2)

7

Shapes and Function of Bones The skeleton is composed of a living, dynamic, rigid connective tissue that forms the bones and cartilages. Generally, humans have about 214 bones, although this number varies, particularly in the number of small sesamoid bones that may be present. (Many resources claim we have only 206 bones but have not counted the eight sesamoid bones of the hands and feet.) Cartilage is attached to some bones, especially where flexibility is important, or covers the surfaces of bones at points of articulation. About 99% of the body’s calcium is stored in bone, and many bones possess a central cavity that contains bone marrow—a Axial skeleton (80) Skull (22) Cranium (8) Face (14) Associated Skull and associated bones (29) bones (7) Auditory ossicles (6) Hyoid (1) Sternum (1)

Thoracic cage (25)

Ribs (24)

Humerus (2) Radius (2)

Upper limbs (64)

Vertebrae (24) Sacrum (1)

Ulna (2)

Coccyx (1)

Carpela bones (16) Metacarpal bones (10) Phalanges (proximal, middle, distal) (28) Sesamoids (4)

Pelvic girdle (2)

Coxal bone (hip bone) (2) Femur (2) Patella (2) Tibia (2)

Lower limbs (64)

1

Fibula (2) Tarsal bones (14) Metatarsal bones (10) Phalanges (28) Sesamoids (4)

FIGURE 1-5 Axial and Appendicular Regions of Skeleton.

Vertebral column (26)

8

Chapter 1

Introduction to the Human Body

collection of hemopoietic (blood-forming) cells.

Most of the bones can be classified into one of the following five shapes (Fig. 1-6):

•• •• • •• • ••

The functions of the skeletal system include: Support Protection of vital organs A mechanism, along with muscles, for movement Storage of calcium and other salts A source of blood cells

There are two types of bone:

• •

Compact: a relatively solid mass of bone, commonly seen as a superficial layer of bone, that provides strength.

Spongy (trabecular or cancellous): a less dense trabeculated network of bone spicules making up the substance of most bones and surrounding an inner marrow cavity.

Long bones also are divided into the following descriptive regions (Fig. 1-7):

• • • •

Epiphysis: the ends of long bones, which develop from secondary ossification centers.

Epiphysial plate: site of growth in length; contains cartilage in actively growing bones.

Metaphysis: site where the bone’s shaft joins the epiphysis and epiphysial plate.

Diaphysis: the shaft of a long bone, which represents the primary ossification center and the site where growth in width occurs.

As a living, dynamic tissue, bone receives a rich blood supply from:

• •

Long bone (humerus)

Long Short Flat Irregular Sesamoid

Nutrient arteries: usually one or several larger arteries that pass through the diaphysis and supply the compact and spongy bone, as well as the bone marrow.

Metaphysial and epiphysial arteries: usually from articular branches supplying the joint.

Short bones (carpals)

Flat bone (parietal)

Irregular bone (vertebra)

Sesamoid bone (patella)

FIGURE 1-6 Bone Classification Based on Shape.

•

Periosteal arteries: numerous small arteries from adjacent vessels that supply the compact bone.

Markings on the Bones Various surface features of bones (ridges, grooves, and bumps) result from the tension placed on them by the attachment of tendons, ligaments, and fascia, as well as by vessels or other structures that pass along the bone. Descriptively, these features include the following:

• •• • • • • •• ••

Condyle: rounded articular surface covered with articular (hyaline) cartilage Crest: a ridge (narrow or wide) of bone Epicondyle: prominent ridge or eminence superior to a condyle Facet: flat, smooth articular surface, usually covered with articular (hyaline) cartilage Fissure: very narrow “slitlike” opening in a bone Foramen: round or oval “hole” in the bone for passage of another structure (nerve or vessel) Fossa: a “cuplike” depression in the bone, usually for articulation with another bone Groove: a furrow in the bone Line: fine linear ridge of bone, but less prominent than a crest Malleolus: a rounded eminence Meatus: a passageway or canal in a bone

Chapter 1

Introduction to the Human Body

1

9 Epiphysial capillaries

Proliferating hyaline cartilage Canals, containing Hypertrophic capillaries, periosteal calcifying mesenchymal cells, cartilage and osteoblasts

Perichondrium

Periosteum

A. At 8 weeks

Cancellous endochondral bone laid down on spicules of calcified cartilage Primordial marrow cavities

Thin collar of cancellous bone

B. At 9 weeks C. At 10 weeks

Calcified cartilage

Epiphysial ossification centers

Epiphysial (secondary) ossification center Outer part of periosteal bone transforming into compact bone

Proliferating growth cartilage Proximal epiphysial growth plate Sites of growth in length of bone

Central marrow cavity

D. At birth Calcified cartilage

Distal epiphysial growth plate

Hypertrophic calcifying cartilage

Endochondral bone laid down on spicules of degenerating calcified cartilage

Diaphysis; growth in width occurs by periosteal bone formation Metaphysis Bone of epiphysis Articular cartilage

Proliferating growth cartilage

E. At 5 years

Articular cartilage Bone of epiphysis

F. At 10 years FIGURE 1-7 Growth and Ossification of Long Bones (Midfrontal Sections).

• • • •• ••

Process: bony prominence that may be sharp or blunt Protuberance: protruding eminence on an otherwise smooth surface Ramus: thin part of a bone that joins a thicker process of the same bone Spine: sharp process projecting from a bone Trochanter: large, blunt process for muscle tendon or ligament attachment Tubercle: small, elevated process Tuberosity: large, rounded eminence that may be coarse or rough

Bone Development Bones develop in one of the following two ways:

• •

Intramembranous formation: most flat bones develop in this way by direct calcium deposition into a mesenchymal (primitive mesoderm) precursor or model of the bone.

Endochondral formation: most long and irregularly shaped bones develop by calcium

deposition into a cartilaginous model of the bone that provides a scaffold for the future bone.

The following sequence of events defines endochondral bone formation (Fig. 1-7, A-F):

• • • • ••

Formation of a thin collar of bone around a hyaline cartilage model Cavitation of the primary ossification center and invasion of vessels, nerves, lymphatics, red marrow elements, and osteoblasts Formation of spongy (cancellous) endochondral bone on calcified spicules Diaphysis elongation, formation of the central marrow cavity, and appearance of the secondary ossification centers in the epiphyses Long bone growth during childhood Epiphysial fusion occurring from puberty into maturity (early to mid-20s)

10

Chapter 1

Types of Joints Joints are the sites of union or articulation of two or more bones or cartilages and are classified into one of the following three types (Fig. 1-8):

• • •

Fibrous (synarthroses): bones joined by fibrous connective tissue.

Cartilaginous (amphiarthroses): bones joined by cartilage, or by cartilage and fibrous tissue.

Synovial (diarthroses): bones joined by a joint cavity filled with a small amount of synovial fluid and surrounded by a capsule; the bony articular surfaces are covered with hyaline cartilage.

Introduction to the Human Body

surfaces and an intervening fibrocartilaginous disc. Primary joints allow for growth and some bending, whereas secondary joints allow for strength and some flexibility.

Synovial joints generally allow for considerable movement and are classified according to their shape and the type of movement that they permit (uni-, bi-, or multiaxial movement) (Fig. 1-9), as follows:

• • • • • •

Fibrous joints include sutures (flat bones of the skull), syndesmoses (two bones connected by a fibrous membrane), and gomphoses (teeth fitting into fibrous tissue-lined sockets).

Cartilaginous joints include primary (synchondrosis) joints between surfaces lined by hyaline cartilage (epiphysial plate connecting the diaphysis with the epiphysis), and secondary (symphysis) joints between hyaline-lined articular

Hinge (ginglymus): uniaxial joints for flexion and extension Pivot (trochoid): uniaxial joints for rotation Saddle: biaxial joints for flexion, extension, abduction, adduction, and circumduction Condyloid (ellipsoid; sometimes classified separately): biaxial joints for flexion, extension, abduction, adduction, and circum­ duction Plane (gliding): joints that only allow simple gliding movements Ball-and-socket (spheroid): multiaxial joints for flexion, extension, abduction, adduction, mediolateral rotation, and circumduction

Suture Compact bone Diploë

Fibrous capsule

Compact bone

Synovial membrane Joint cavity Articular cartilage Ulna

Coronal suture

Radius

Fibrous

Synovial joint

Interosseous membrane

Head of femur Body of vertebra Epiphyseal plate

Syndesmosis

Intervertebral disc

Femur

Secondary cartilaginous

Primary cartilaginous FIGURE 1-8 Types of Joints.

Chapter 1

Introduction to the Human Body

1

11 Dens

Humerus Atlas

Axis of the atlanto-axial pivot joint

Ulna of the elbow’s hinge joint

A. Hinge

B. Pivot

Metacarpal of the thumb’s saddle joint

Femur

Trapezium

C. Saddle

D. Condyloid

Scapula of the acromioclavicular plane joint at the shoulder: plane joint between the acromion of the scapula and clavicle

Acetabulum

Acromion

Femur of the hip’s ball-and-socket joint: acetabulum of the pelvis forms the “socket” of this joint

E. Ball-and-socket

Tibia of the knee’s condyloid joint

F. Plane FIGURE 1-9 Types of Synovial Joints.

Clavicle

12

Chapter 1

Introduction to the Human Body

Clinical Focus 1-4 Fractures Fractures are classified as either closed (the skin is intact) or open (the skin is perforated; often referred to as a compound fracture). Additionally, the fracture may be classified with respect to its anatomical appearance (e.g., transverse, spiral).

Closed fracture with hematoma

Open fracture with bleeding

Intraarticular fracture with hemarthrosis Pathologic fracture (tumor or bone disease)

Transverse fracture

Oblique fracture

Spiral fracture

Greenstick fracture

Torus (buckle) fracture

In children

Comminuted fracture

Segmental fracture

Impacted fracture

Avulsion (greater tuberosity of humerus avulsed by supraspinatus m.)

Compression fracture

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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 stillborn 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 wateringplace; 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