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vi UNIT IV: SPECIAL PROCEDURES AND ADDITIONAL DUTIES

Preface
Phlebotomy Essentials, fifth edition, was written for all who want to correctly and safely prac-
tice phlebotomy. The authors have over 70 years of combined experience in laboratory sci-
ences, phlebotomy program direction, and teaching many different levels and diverse popula-
tions of phlebotomy students. As with previous editions, the goal of Phlebotomy Essentials,
fifth edition, is to provide accurate, up-to-date, and practical information and instruction in
phlebotomy procedures and techniques along with a comprehensive background in phlebot-
omy theory and principles. It is appropriate for use as an instructional text or as a reference
for those who wish to update their skills or study for national certification.

Organization
Much care has been taken to present the material in a clear and concise manner that encour-
ages learning and promotes comprehension. A good deal of time was spent organizing and
formatting the information into a logical and student-friendly reading style in an order that
allows the reader to build on information from previous chapters.
The book is divided into four units. Unit I, The Healthcare Setting, presents a basic descrip-
tion of the healthcare system and the role of the phlebotomist within it. Major topics include
communication skills, healthcare financing and delivery with an emphasis on clinical labora-
tory services, quality assurance and legal issues and their relationship to the standard of care,
and comprehensive instruction in infection control and safety.
Unit II, Overview of the Human Body, provides a foundation in medical terminology and
a basic understanding of each of the body systems, including associated disorders and diag-
nostic tests. An entire chapter is devoted to the circulatory system, with special emphasis on
the vascular system, including blood vessel structure, vascular anatomy of the arm, and blood
composition.
Unit III, Blood Collection Procedures, describes phlebotomy equipment (including the latest
safety equipment and order of draw) and proper procedures and techniques for collecting
venipuncture and capillary specimens based upon the latest CLSI standards. Also included
is an extensive explanation of preanalytical variables, complications, and procedural errors
associated with blood collection.
Unit IV, Special Procedures, offers information and instruction on how to handle special
blood and nonblood specimen collections and the latest in point-of care instruments and
testing. Routine and special handling and processing of specimens, with an emphasis on the
latest rules of safety, are included in this section. Covered in this unit is an overview of the
Laboratory Information System (LIS)—how it supports the laboratory process and is used by
the phlebotomist in specimen collection. Also included is a discussion of nonblood specimens
and testing information, which can be an important part of the phlebotomist’s responsibilities,
as well as arterial puncture for those phlebotomists who do ABGs or who anticipate advanc-
ing beyond venous collection.
PREFACE vii
The appendices give readers ready access to helpful supplementary information as they
progress through the text.
• Appendix A is an alphabetical list of laboratory tests including specimen type, handling
considerations, and the department that does the testing. Not only does this help read-
ers categorize the many different tests performed by a laboratory, but it also provides
practice in using a reference manual.
• Appendix B, Laboratory Math, provides a quick review and reference for certain calcula-
tions that may be needed but are not always used enough to have been committed to
memory.
• English to Spanish translation of conversational phrases, including phonetic Spanish
pronunciation guidelines, found in Appendix C can help non–Spanish-speaking phle-
botomists provide safe and appropriate directions to patients who speak only Spanish.
• Appendix D identifies conditions that require work restrictions for healthcare workers, a
quick reference that can help phlebotomists learn when and how to protect themselves
and others from infection.
• Appendix E, Answers to Study and Review Questions and Case Studies, allows readers
to check their answers, reinforcing the material and assuring that they have learned it
correctly.
• Appendix F gives the reader immediate access to tube guides from two leading manu-
facturers for a quick reference and colorful way to learn by association.
There are many technical and specialized terms associated with healthcare in general and
phlebotomy in particular. The extensive updated and alphabetically arranged glossary makes
the meanings of unfamiliar terms within easy reach.
Features
The fifth edition includes various features meant to help the reader learn and retain the infor-
mation in Phlebotomy Essentials.
• Key Terms and Objectives open each chapter and help students recognize the important
terms and concepts that they will come across in reading the chapter.
• Consistently organized step-by-step Procedures, with an explanation or rationale for
each step, assist the student in learning and understanding phlebotomy techniques.
• Key Points emphasize important concepts to enhance student learning.
• Cautions highlight critical information to help students identify and avoid dangerous
practices.
• FYIs are interesting notes and fun facts that will enhance practical application of the
information.
• Memory Joggers offer a proven way to help students remember important information.
• Study and Review Questions at the end of each chapter provide a review of each chapter’s
content.
• Case studies at the end of each chapter bring concepts to life and enhance critical thinking
skills.
• A Media Menu at the end of each chapter points out online student resources available
for that chapter.
• Book Icons throughout the text refer readers to the Student Workbook for Phlebotomy
Essentials and the Phlebotomy Exam Review, for further opportunities to enrich their
learning (available for separate purchase).
• Online Icons throughout the text refer readers to corresponding videos and animations
on the book’s companion Web site, which bring the content to life (see “Additional
Resources,” below, for more information).
The content of this new edition of Phlebotomy Essentials was designed in accordance with
applicable National Accrediting Agency for Clinical Laboratory Science (NAACLS) competencies.
viii PREFACE
Procedures have been written to conform to the latest OSHA safety regulations and, wherever ap-
plicable, standards developed by the CLSI.
Additional Resources
Phlebotomy Essentials, fifth edition, includes additional resources for both instructors and students
that are available on the book’s companion Web site at http://thepoint.lww.com/McCall5e.
INSTRUCTORS
Approved adopting instructors will be given access to the following additional resources:
• Lesson Plans
• Critical Thinking Questions
• Brownstone Test Generator
• Image Collection
• All the appendixes from the book
• PowerPoint Slides with Images and Tables
• WebCT-/Blackboard-Ready Cartridges
• Signature Papers (i.e., HIPAA/confidentiality forms, blood-borne pathogen statements,
assumption-of-risk form, health declaration form)
• Log Examples
• Lab Skills Evaluation Checklists (i.e., venipuncture, skin puncture, special test procedures)
• Phlebotomy Program Pre-test and Post-test and their answer keys
STUDENTS
Students who have purchased Phlebotomy Essentials, fifth edition, have access to the follow-
ing additional resources:
• New to the fifth edition, interactive games and exercises offer a fun way to study and
review. Exercise types include Look and Label, Zooming In, Word Building, Body Build-
ing, Roboterms, Interactive Crossword Puzzles, Quiz Show, and Concentration.
• 23 videos, including 10 that are new to the fifth edition
• 17 animations, including 12 that are new to the fifth edition
• Audio flash cards and, new to the fifth edition, a flash card generator
• An audio glossary, new to the fifth edition
In addition, purchasers of the text can access the searchable Full Text On-line by going to
the Phlebotomy Essentials, fifth edition Web site at http://thepoint.lww.com/McCall5e. See
the inside front cover of this text for more details, including the passcode you will need to
gain access to the Web site.
Related Titles
The authors of this textbook have created the following two titles, available for separate
purchase, that correspond to Phlebotomy Essentials, fifth edition, to create an ideal study
package for phlebotomy training programs. Each corresponds to this main textbook in chapter
sequence.
• The companion workbook (McCall R, Tankersley C. Student Workbook for Phlebotomy
Essentials, 5th ed., available for separate purchase) provides students with chapter-by-
chapter exercises to reinforce text material, assessment tools to evaluate their skills, re-
alistic scenarios to gauge their grasp of key concepts, and skills logs to chart their prog-
ress. The workbook includes key terms matching exercises, chapter review questions,
PREFACE ix
crossword puzzles, skill and knowledge drills, requisition activities, case studies, and
procedure evaluation forms.
• The companion exam review book (McCall R, Tankersley C. Phlebotomy Exam Review,
4th ed., available for separate purchase) prepares students for all the national certifica-
tion exams in phlebotomy.
Acknowledgments
The authors wish to express their gratitude to the many individuals who gave of their time,
talent, and expertise to make this edition of Phlebotomy Essentials current and accurate. In
particular, we would like to thank Jane Adrian, David Berg, Theresa McGillvray-Dodd, Joyce
Hall, Maureane Hoffman, Glenda Hiddessen, Bob Kaplanis, Scott Leece, Jeri Litteral, Charez
Norris, Mary Robitaille, Phil Tate, and Janet Vittori.
In addition we would like to thank animator Mark Flanders, illustrator Christine Vernon,
photographer Bruce Knapus, videographer Michael Norde, and all who played a role in the
latest videos, including Jim Gregory, Lynette Hales, Nancy Jefferys, Bruce Knaphus, Patty
Lewis, April Meyers, Flavia Pradolin, Donald Pryor, and Maura Smith.
Finally, we would like to thank Acquisitions Editor Pete Sabatini and the production and
editorial staff at Lippincott Williams & Wilkins, especially those with whom we worked most
closely, with an extra special thank you to Senior Product Manager Meredith Brittain for her
patience, support, and dedication to this endeavor.
RUTH E. McCALL
CATHEE M. TANKERSLEY
x UNIT IV: SPECIAL PROCEDURES AND ADDITIONAL DUTIES
User’s Guide
Phlebotomy Essentials is designed for anyone wanting to correctly and safely practice
phlebotomy. This User’s Guide shows you how to put the features of this book to work
for you.
Chapter Opening Elements

Each chapter begins with the following elements to introduce the material and help make
your experience consistent!
CHAPTER
1
Past and Present and
The Healthcare Setting
KEY TERMS are listed at the begin- KEY TERMS AHCCCS HMOs PHS
ning of each chapter and defined in Do the Match-
ing Exercises in the
APC ICD-9-CM phlebotomy
case manager IDS polycythemia
the glossary. WORKBOOK to
gain familiarity with
certification kinesic slip PPOs
CLIA ’88 kinesics primary care
these terms.
CMS MCOs proxemics
communication barriers Medicaid reference laboratories
CPT Medicare secondary care
exsanguinate MLS tertiary care
HIPAA PHI third-party payer
OBJECTIVES provide a quick OBJECTIVES

1 Define the key terms and abbreviations listed at the beginning of this chapter.
Upon successful
overview of content to be covered. completion of 2 Describe the evolution of phlebotomy and the role of the phlebotomist in today’s
this chapter, the healthcare setting.
reader should be
3 Describe the traits that form the professional image and identify national
able to:
organizations that support professional recognition of phlebotomists.
4 Describe the basic concepts of communication as they relate to healthcare and how
appearance and nonverbal messages affect the communication process.
5 Describe proper telephone protocol in a laboratory or other healthcare setting.
6 Demonstrate an awareness of the different types of healthcare settings.
7 Compare types of third-party payers, coverage, and methods of payment to the

patient, provider, and institutions.
8 Describe traditional hospital organization and identify the healthcare providers in

the inpatient facility.
9 List the clinical analysis areas of the laboratory and the types of laboratory
procedures performed in the different areas.
10 Describe the different levels of personnel found in the clinical laboratory and how
Clinical Laboratory Improvement Amendment regulations affect their job descriptions.
USER’S GUIDE xi
Special Features
Unique chapter features draw your attention to crucial material and heighten your compre-
hension and retention of information.
KEY POINTS help you to identify

and retain important concepts.
CAUTION BOXES alert you to po-
tential mistakes and problems so
you can avoid them!
ICONS THROUGHOUT THE TEXT

refer readers to the McCall/Tanker-
sley workbook and exam review
texts for further opportunities to
enrich their learning.
MEMORY JOGGERS help you to

learn and recall key tips and facts
long into your practice.
FYI BOXES offer interesting and

relevant information.
xii USER’S GUIDE
TABLES give you important infor-

mation in an easy-to-understand
format.
ONLINE ICONS direct you to in-

formative videos and animations
on the book’s companion website at
http://thepoint.lww.com/McCall5e
that bring material to life.
PROCEDURES present you with

easy-to-follow steps with explana-
tions.
USER’S GUIDE xiii
Chapter Closing Elements

Each chapter closes with the following elements to help you study and test your knowledge
of what you’ve learned:
STUDY AND REVIEW QUES-

TIONS provoke thought and help
test your comprehension of each
chapter’s major concepts.
CASE STUDIES Enhance critical

thinking skills and show how to
apply concepts in the real world.
MEDIA MENUS point out online

student resources available for that
chapter.
Additional Learning Resources

In addition to the helpful tools outlined here, you also have access to a variety of free re-
sources at http://thepoint.lww.com/McCall5e designed to help make learning exciting and
effective. These include:
• Interactive games and exercises that offer a fun way to study and review. Exercise types
include Look and Label, Word Building, Body Building, Roboterms, Interactive Cross-
word Puzzles, Quiz Show, and Concentration.
• 23 videos and 17 animations that illustrate important procedures and concepts
• Audio flash cards, flash card generator, and audio glossary
• Fully searchable Full Text Online
xiv UNIT IV: SPECIAL PROCEDURES AND ADDITIONAL DUTIES
Reviewers
Carol Abshire, MLT, BGS Mary Ellen Brown, CMA Nancy Heldt, MS, MT (ASCP)
Laboratory Manager/Coordinator (AAMA), PBT (ASCP) Professor of Medical Laboratory
Arts & Science Instructor Technology
Lamar State College—Orange Medical Assisting Department Division of Science and Health
Orange, Texas Lincoln Technical Institute Careers
Hamden, Connecticut Oakton Community College
Diana Alagna, RN, RMA Des Plaines, Illinois
Program Director Susen Edwards, MA
Medical Assisting Program Coordinator Claudia N. Hewlett, AS
Branford Hall Career Institute Allied Health Senior MA Lead Instructor
Southington, Connecticut Middlesex County College Allied Health
Edison, New Jersey Remington College
David E. Berg, MS, FAHA Memphis, Tennessee
Director, Arizona Research Foundation Nancy Feulner, MS Ed
Phoenix, Arizona Program Coordinator Maureane Hoffman, MD, PhD
Health Science Professor
Judith Blaney, AMT, MCLS College of DuPage Pathology
Phlebotomy Internship Coordinator Glen Ellyn, Illinois Duke University Medical Center
Allied Health Department Durham, North Carolina
Manchester Community College Tammy Gallagher, BS, MT
Manchester, New Hampshire Medical Technologist Carol Itatani, PhD, MS, MT
Butler County Community College (ASCP)
Gerry Brasin, AS, CMA Butler, Pennsylvania Professor
(AAMA), CPC Department of Biological Sciences
Coordinator Kathi Gilmore, AS California State University, Long Beach
Education/Compliance Master Instructor Long Beach, California
Premier Education Group Medical Assisting
Springfield, Massachusetts Remington College, Nashville Cherika de Jesus, CMA/AAMA
Campus Lead Medical Assistant Chair
Marilyn Braswell, BA, MT Nashville, Tennessee Medical Assistant
(ASCP), SBB Globe University Minnesota School
Phlebotomy Instructor Joyce Hall, C (ASCP) of Business
Healthcare Continuing Education Laboratory Administrative Brooklyn Center, Minnesota
Central Piedmont Community Manager
College John C. Lincoln—North Mountain Paula Furlan Kimball, MS,
Charlotte, North Carolina Phoenix, Arizona MLT, AHI
Assistant Master Technical
Lou Brown, BS, MT (ASCP), Andrea T. Harper, MS, MLS Instructor
CMA (AAMA) (ASCP) Department of Allied Health—MLT
Program Director Adjunct Faculty Phlebotomy Program
Medical Assisting and Phlebotomy Instructor University of Texas at Brownsville
Wayne Community College Manchester Community College and Texas Southmost College
Goldsboro, North Carolina Manchester, New Hampshire Brownsville, Texas
REVIEWERS xv
Robin Gaynor Krefetz, M.Ed Michael Murphy, CMA (AAMA) Mary Robitaille, BS, MT
MLS (ASCP) PBT Program Coordinator (ASCP)
CLT and Phlebotomy Program Berdan Institute at The Summit Phlebotomy Instructor
Director Medical Group CNM Community College
Community College of Philadelphia Union, New Jersey Albuquerque, New Mexico
Philadelphia, Pennsylvania
Sonja Nehr-Kanet, MS, MLS Mary E. Stassi, RN-BC
Tanya O. Mace, MSN, RN, PBT (ASCP) Health Occupations Coordinator
(ASCP) CLS Program Director/Clinical St. Charles Community College
Program Director Associate Professor Cottleville, Missouri
Nursing and Phlebotomy Clinical/Medical Laboratory Science
Brunswick Community College Program Philip Tate, DA
Supply, North Carolina Idaho State University Author, Seeley’s Principles of
Meridian, Idaho Anatomy and Physiology,
James R. McGee, MA, MT 2010
(ASCP) Charez Norris, RRT Lubbock, Texas
Instructor, Phlebotomy Training and Clinical Educator, Respiratory
Exploring Medical Language Services Scott Tharpe, CLS (CA), MT
Retired, Part Time Instructor John C. Lincoln—North Mountain Program Director, Clinical
Healthcare Continuing Education Phoenix, Arizona Laboratory Sciences
Central Piedmont Community Health Science
College Robert Plick, RMA, RPT, CET, BS Saddleback College
Charlotte, North Carolina American Heart Association CPR Mission Viejo, California
Instructor
D. Gayle Melberg, MS, MT 9 Health Fair Phlebotomy Task Marie Thomas, CLT, CMA
(ASCP) Force Clinical Instructor/Lead
Adjunct Faculty Externship and Community Affairs Medical Assisting
Medical Laboratory Technician Coordinator, Medical Instructor Berdan Institute
J. Sargeant Reynolds Community Medical Instructor, Medical Lab Wayne, New Jersey
College Assistant/Phlebotomist and
Richmond, Virginia Associate Minister Church of Christ Barbara Vaiden, BS, MT
Education Department (ASCP)
Cheryl Milish, AAS Alta/Westwood College Supervisor
Instructor Denver, Colorado Phlebotomy
Allied Health OSF Saint Anthony Medical
Southwestern College Pamela B. Primrose, PhD, MT Center
Florence, Kentucky (ASCP) Rockford, Illinois
Professor and Program Chair
Judith Miller, BS, MT (ASCP) Medical Laboratory Technology/ Janet Vittori, BS, MT
Clinical Coordinator Phlebotomy (ASCP)
Medical Laboratory Technician School of Health Sciences Point-of-Care Testing
Program Ivy Tech Community College Coordinator
Barton County Community College South Bend, Indiana Laboratory Supervisor
Great Bend, Kansas John C Lincoln Hospital—North
Debbie Reasoner, Mountain
Lane Miller, MBA/HCM (NHA)-CPT-CHI Phoenix, Arizona
Director Director and Instructor
Continuing Education Phlebotomy/Lab Assistant
Medical Careers Institute West Coast Phlebotomy, Inc.
Virginia Beach, Virginia Oregon City, Oregon
xvi UNIT IV: SPECIAL PROCEDURES AND ADDITIONAL DUTIES
Brief Contents
UNIT I THE HEALTHCARE SETTING 1
1 Past and Present and The Healthcare Setting 3
2 Quality Assurance and Legal Issues 39
3 Infection Control, Safety, First Aid, and Personal Wellness 63
UNIT II OVERVIEW OF THE HUMAN BODY 105

4 Medical Terminology 107
5 Human Anatomy and Physiology Review 121
6 The Circulatory System 153
UNIT III BLOOD COLLECTION PROCEDURES 189

7 Blood Collection Equipment, Additives, and Order of Draw 191
8 Venipuncture Procedures 225
9 Preanalytical Considerations 283
10 Capillary Puncture Equipment and Procedures 319
UNIT IV SPECIAL PROCEDURES 355

11 Special Collections and Point-of-Care Testing 357
12 Computers and Specimen Handling and Processing 411
13 Nonblood Specimens and Tests 435
14 Arterial Puncture Procedures 455
BRIEF CONTENTS xvii
APPENDIX A
Laboratory Tests 477
APPENDIX B
Laboratory Mathematics 487
APPENDIX C
Conversational Phrases in English and Spanish 493
APPENDIX D
Work Restrictions for Healthcare Employees 495
APPENDIX E
Answers to Study & Review Questions and Case Studies 497
APPENDIX F
Tube Guides 503
GLOSSARY 507
Index 523
xviii UNIT IV: SPECIAL PROCEDURES AND ADDITIONAL DUTIES
Detailed Contents
About the Authors iv
Preface vi
User’s Guide x
Reviewers xiv
Brief Contents xvi
List of Procedures xxviii
UNIT I THE HEALTHCARE SETTING 1

KEY TERMS 3
OBJECTIVES 3
PHLEBOTOMY: A HISTORICAL PERSPECTIVE 4
PHLEBOTOMY TODAY 6
The Changing Role of the Phlebotomist in the Emerging Healthcare Environment 6
Official Recognition 7
Patient–Client Interaction 8
Communication Skills 12
THE HEALTHCARE SETTING 16
Healthcare Delivery 16
Healthcare Financing 18
The Changing Healthcare System 20
Organization of Hospital Services 21
Clinical Laboratory Services 23
Clinical Laboratory Personnel 33
Clinical Laboratory Improvement Act 34
STUDY AND REVIEW QUESTIONS 35
CASE STUDIES 36
BIBLIOGRAPHY AND SUGGESTED READINGS 36
MEDIA MENU 37

KEY TERMS 39
OBJECTIVES 39
QUALITY ASSURANCE IN HEALTHCARE 40
National Standard and Regulatory Agencies 40
Quality Assurance in Phlebotomy 43
Areas of Phlebotomy Subject to Quality Assessment 46
Documentation 49
Risk Management 52
LEGAL ISSUES 54
Tort 55
Malpractice Insurance 57
DETAILED CONTENTS xix
Avoiding Lawsuits 57
Patient Consent 57
The Litigation Process 59
Legal Cases Involving Phlebotomy Procedures 59
CASE STUDIES 61
MEDIA MENU 62

KEY TERMS 63
OBJECTIVES 63
INFECTION CONTROL 64
Infection 64
The Chain of Infection 65
Breaking the Chain of Infection 69
Infection-Control Programs 69
Infection Control Methods 70
Isolation Procedures 75
SAFETY 80
Biosafety 81
Electrical Safety 88
Radiation Safety 92
Chemical Safety 93
FIRST AID 98
External Hemorrhage 98
Shock 98
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 99
PERSONAL WELLNESS 99
Personal Hygiene 100
Proper Nutrition 100
Rest and Exercise 100
Back Protection 101
Stress Management 102
CASE STUDIES 103
MEDIA MENU 104
UNIT II OVERVIEW OF THE HUMAN BODY 105

4 Medical Terminology 107
KEY TERMS 107
OBJECTIVES 107
WORD ROOTS 108
PREFIXES 108
SUFFIXES 109
COMBINING VOWELS/FORMS 110
DISCREPANCIES IN THE CLASSIFICATION OF WORD ELEMENTS 111
UNIQUE PLURAL ENDINGS 112
PRONUNCIATION 112
ABBREVIATIONS AND SYMBOLS 112
THE JOINT COMMISSION‘S “DO NOT USE” LIST 112
CASE STUDIES 118
MEDIA MENU 119
xx DETAILED CONTENTS
5 Human Anatomy and Physiology Review 121

KEY TERMS 121
OBJECTIVES 121
BODY POSITIONS 122
Anatomic Position 122
Other Positions 122
BODY PLANES 122
BODY DIRECTIONAL TERMS 123
BODY CAVITIES 123
BODY FUNCTIONS 125
Homeostasis 125
Metabolism 125
BODY ORGANIZATION 126
Cells 126
Tissues 127
Organs 128
BODY SYSTEMS 128
Skeletal System 128
Muscular System 129
Integumentary System 131
Nervous System 135
Endocrine System 137
Digestive System 141
Reproductive System 143
Urinary System 144
Respiratory System 146
CASE STUDIES 151
MEDIA MENU 152
6 The Circulatory System 153

KEY TERMS 153
OBJECTIVES 153
THE HEART 154
Heart Structure 154
Heart Function 157
Heart Disorders and Diagnostic Tests 160
THE VASCULAR SYSTEM 161
Functions 161
Structures 161
Blood Vessel Structure 163
The Flow of Blood 166
Phlebotomy-Related Vascular Anatomy 166
Vascular System Disorders and Diagnostic Tests 170
THE BLOOD 170
Blood Composition 170
Blood Type 174
Blood Specimens 175
Blood Disorders and Diagnostic Tests 177
HEMOSTASIS AND COAGULATION 177
Coagulation Factors and Pathways 177
The Role of Thrombin 180
The Hemostatic Process In Vivo 181
The Role of the Liver in Hemostasis 184
Hemostatic Disorders and Diagnostic Tests 184
THE LYMPHATIC SYSTEM 184
Functions 184
Structures 185
DETAILED CONTENTS xxi
Lymph Flow 185

Lymphatic System Disorders and Diagnostic Tests 186
CASE STUDIES 188
MEDIA MENU 188
UNIT III BLOOD COLLECTION PROCEDURES 189

7 Blood Collection Equipment, Additives, and Order of Draw 191
KEY TERMS 191
OBJECTIVES 191
GENERAL BLOOD COLLECTION EQUIPMENT AND SUPPLIES 192
Blood-Drawing Station 192
Phlebotomy Chairs 192
Equipment Carriers 193
Gloves and Glove Liners 194
Antiseptics 194
Disinfectants 195
Hand Sanitizers 195
Gauze Pads/Cotton Balls 196
Bandages 196
Needle and Sharps Disposal Containers 197
Biohazard Bags 197
Slides 197
Pen 197
Watch 197
VENIPUNCTURE EQUIPMENT 198
Vein-Locating Devices 198
Tourniquet 198
Needles 200
Evacuated Tube System 202
NEEDLE AND HOLDER UNITS 205
Syringe System 210
Winged Infusion Set 212
Combination Systems 213
BLOOD COLLECTION ADDITIVES 213
Anticoagulants 215
Special-Use Anticoagulants 218
Antiglycolytic Agents 218
Clot Activators 219
Thixotropic Gel Separator 219
Trace Element–Free Tubes 220
ORDER OF DRAW 220
Carryover/Cross-Contamination 220
Tissue Thromboplastin Contamination 222
Microbial Contamination 222
CASE STUDIES 223
MEDIA MENU 224
8 Venipuncture Procedures 225

KEY TERMS 225
OBJECTIVES 225
VENIPUNCTURE STEPS 226
Step 1: Review and Accession Test Request 226
Receipt of the Test Request 228
xxii DETAILED CONTENTS
Reviewing the Requisition 229

Step 2: Approach, Identify, and Prepare Patient 229
Step 3: Verify Diet Restrictions and Latex Sensitivity 237
Step 4: Sanitize Hands 238
Step 5: Position Patient, Apply Tourniquet, and Ask Patient to Make a Fist 239
Step 6: Select Vein, Release Tourniquet, and Ask Patient to Open Fist 240
Step 7: Clean and Air-Dry the Site 244
Step 8: Prepare Equipment and Put on Gloves 246
Step 9: Reapply Tourniquet, Uncap and Inspect Needle 247
Step 10: Ask Patient to Remake a Fist, Anchor Vein, and Insert Needle 247
Step 11: Establish Blood Flow, Release Tourniquet, and Ask Patient to Open Fist 249
Step 12: Fill, Remove, and Mix Tubes in Order of Draw or Fill Syringe 250
Step 13: Place Gauze, Remove Needle, Activate Safety Feature, and Apply Pressure 251
Step 14: Discard Collection Unit, Syringe Needle, or Transfer Device 252
Step 15: Label Tubes 252
Step 16: Observe Special Handling Instructions 253
Step 17: Check Patient’s Arm and Apply Bandage 253
Step 18: Dispose of Contaminated Materials 253
Step 19: Thank Patient, Remove Gloves, and Sanitize Hands 253
Step 20: Transport Specimen to the Lab 254
ROUTINE ETS VENIPUNCTURE 254
BUTTERFLY PROCEDURE 262
SYRINGE VENIPUNCTURE PROCEDURE 265
PROCEDURE FOR INABILITY TO COLLECT SPECIMEN 265
PEDIATRIC VENIPUNCTURE 270
Challenges 270
Dealing With Parents or Guardians 271
Dealing With the Child 271
Pain Interventions 272
Selecting a Method of Restraint 272
Equipment Selection 273
Procedures 273
GERIATRIC VENIPUNCTURE 273
Challenges 273
Safety Issues 276
Patients in Wheelchairs 276
Blood-Collection Procedures 277
DIALYSIS PATIENTS 278
LONG-TERM CARE PATIENTS 278
HOME CARE PATIENTS 279
HOSPICE PATIENTS 279
CASE STUDIES 281
MEDIA MENU 282
9 Preanalytical Considerations 283

KEY TERMS 283
OBJECTIVES 283
REFERENCE RANGES/INTERVALS 284
BASAL STATE 284
PHYSIOLOGICAL VARIABLES 284
Altitude 285
Dehydration 285
Diet 285
Diurnal/Circadian Variations 287
Drug Therapy 287
Exercise 288
Fever 288
DETAILED CONTENTS xxiii
Gender 288
Intramuscular Injection 288
Jaundice 289
Position 289
Pregnancy 290
Smoking 290
Stress 290
Temperature and Humidity 290
PROBLEM SITES 291
Burns, Scars, and Tattoos 291
Damaged Veins 291
Edema 291
Hematoma 291
Mastectomy 291
Obesity 292
VASCULAR ACCESS DEVICES (VADS) AND SITES 293
Arterial Line 293
Arteriovenous Shunt, Fistula, or Graft 293
Blood Sampling Device 293
Heparin or Saline Lock 296
Intravenous Sites 296
Previously Active IV Sites 297
Central Vascular Access Devices 297
PATIENT COMPLICATIONS AND CONDITIONS 300
Allergies to Equipment and Supplies 300
Excessive Bleeding 301
Fainting 301
Nausea and Vomiting 303
Pain 303
Petechiae 303
Seizures/Convulsion 304
PROCEDURAL ERROR RISKS 304
Hematoma Formation 304
Iatrogenic Anemia 305
Inadvertent Arterial Puncture 305
Infection 306
Nerve Injury 306
Reflux of Additive 306
Vein Damage 307
SPECIMEN QUALITY CONCERNS 307
Hemoconcentration 307
Hemolysis 308
Partially Filled Tubes 309
Specimen Contamination 311
Wrong or Expired Collection Tube 311
TROUBLESHOOTING FAILED VENIPUNCTURE 311
Tube Position 311
Needle Position 311
Collapsed Vein 314
Tube Vacuum 315
CASE STUDIES 316
MEDIA MENU 317
10 Capillary Puncture Equipment and Procedures 319

KEY TERMS 319
OBJECTIVES 319
CAPILLARY PUNCTURE EQUIPMENT 320
xxiv DETAILED CONTENTS
Lancets/Incision Devices 320

Laser Lancets 320
Microcollection Containers 320
Microhematocrit Tubes and Sealants 322
Capillary Blood Gas Equipment 323
Microscope Slides 324
Warming Devices 324
CAPILLARY PUNCTURE PRINCIPLES 324
Composition of Capillary Specimens 324
Reference Values 325
Indications for Capillary Puncture 325
Tests That Cannot Be Collected by Capillary Puncture 325
Order of Draw 326
CAPILLARY PUNCTURE STEPS 326
Step 1: Review and Accession Test Request 326
Step 2: Approach, Identify, and Prepare Patient 326
Step 3: Verify Diet Restrictions and Latex Sensitivity 326
Step 4: Sanitize Hands and Put on Gloves 326
Step 5: Position Patient 326
Step 6: Select the Puncture/Incision Site 326
Step 7: Warm the Site if Applicable 329
Step 8: Clean and Air-Dry Site 330
Step 9: Prepare Equipment 330
Step 10: Puncture the Site and Discard Lancet 330
Step 11: Wipe Away the First Blood Drop 331
Step 12: Fill and Mix Tubes/Containers in Order of Draw 331
Step 13: Place Gauze and Apply Pressure 332
Step 14: Label Specimen and Observe Special Handling Instructions 332
Step 15: Check the Site and Apply Bandage 332
Step 16: Dispose of Used and Contaminated Materials 333
Step 17: Thank Patient, Remove Gloves, and Sanitize Hands 333
Step 18: Transport Specimen to the Lab 333
CAPILLARY PUNCTURE PROCEDURES 333
SPECIAL CAPILLARY PUNCTURE PROCEDURES 340
Capillary Blood Gases 340
Neonatal Bilirubin Collection 341
Newborn/Neonatal Screening 343
Routine Blood Film/Smear Preparation 348
Thick Blood Smear Preparation 351
CASE STUDIES 353
MEDIA MENU 354
UNIT IV SPECIAL PROCEDURES 355

11 Special Collections and Point-of-Care Testing 357
KEY TERMS 357
OBJECTIVES 357
SPECIAL PROCEDURES 358
Blood Bank Specimens 358
Type, Screen, and Cross-Match 360
Blood Donor Collection 360
Blood Cultures 362
Antimicrobial Neutralization Products 371
Coagulation Specimens 372
2-Hour Postprandial Glucose 372
Glucose Tolerance Test 372
DETAILED CONTENTS xxv
Lactose Tolerance Test 375

Paternity/Parentage Testing 375
Therapeutic Drug Monitoring 376
Therapeutic Phlebotomy 377
Toxicology Specimens 378
Trace Elements 380
POINT-OF-CARE TESTING 381
Quality and Safety in Point-of-Care Testing 381
Coagulation Monitoring by POCT 383
Arterial Blood Gases and Electrolytes 389
Multiple-Test-Panel Monitoring by POCT 390
Other Tests Performed by POCT 392
CASE STUDIES 407
MEDIA MENU 409
12 Computers and Specimen Handling and Processing 411

KEY TERMS 411
OBJECTIVES 411
COMPUTERIZATION IN HEALTHCARE 412
Computer Networks 413
Computer Components 413
Elements of the Computer 414
Laboratory Information System (LIS) 415
General Laboratory Computer Skills 420
Computerized Analyzers 420
Interfacing 420
Connectivity Industry Consortium (CIC) 421
Computerization Trends 421
SPECIMEN HANDLING 421
Routine Handling 422
Special Handling 425
SPECIMEN PROCESSING 426
Specimen Suitability 427
Centrifugation 428
Aliquot Preparation 431
CASE STUDY 433
MEDIA MENU 434
13 Nonblood Specimens and Tests 435

KEY TERMS 435
OBJECTIVES 435
NONBLOOD SPECIMEN LABELING AND HANDLING 436
NONBLOOD BODY-FLUID SPECIMENS 436
Urine 436
Amniotic Fluid 444
Cerebrospinal Fluid 444
Gastric Fluid/Gastric Analysis 445
Nasopharyngeal Secretions 445
Saliva 445
Semen 445
Serous Fluid 445
Sputum 446
Sweat 446
Synovial Fluid 447
xxvi DETAILED CONTENTS
OTHER NONBLOOD SPECIMENS 447

Buccal Swabs 447
Bone Marrow 447
Breath Samples 448
Feces (Stool) 449
Hair 449
Throat Swabs 450
Tissue Specimens 450
CASE STUDY 452
MEDIA MENU 453
14 Arterial Puncture Procedures 455

KEY TERMS 455
OBJECTIVES 455
ABGS 456
PERSONNEL WHO PERFORM ARTERIAL PUNCTURE 457
SITE-SELECTION CRITERIA 457
ARTERIAL PUNCTURE SITES 458
The Radial Artery 458
The Brachial Artery 460
The Femoral Artery 460
Other Sites 461
ABG SPECIMEN COLLECTION 461
Test Requisition 461
Equipment and Supplies 462
Patient Preparation 464
Radial ABG Procedure 467
ABG Collection from Other Sites 472
HAZARDS AND COMPLICATIONS OF ARTERIAL PUNCTURE 472
Arteriospasm 472
Artery Damage 473
Discomfort 473
Infection 473
Hematoma 473
Numbness 473
Thrombus Formation 473
Vasovagal Response 473
SAMPLING ERRORS 474
Air Bubbles 474
Delay in Analysis 474
Improper Mixing 474
Improper Syringe 474
Obtaining Venous Blood by Mistake 474
Use of Improper Anticoagulant 474
Use of Too Much or Too Little Heparin 475
CRITERIA FOR ABG SPECIMEN REJECTION 475
CASE STUDIES 476
MEDIA MENU 476
DETAILED CONTENTS xxvii
APPENDIX A
Laboratory Tests 477
APPENDIX B
Laboratory Mathematics 487
APPENDIX C
Conversational Phrases in English and Spanish 493
APPENDIX D
Work Restrictions for Healthcare Employees 495
APPENDIX E
Answers to Study & Review Questions and Case Studies 497
APPENDIX F
Tube Guides 503
GLOSSARY 507
Index 523
xxviii UNIT IV: SPECIAL PROCEDURES AND ADDITIONAL DUTIES
List of Procedures
PROCEDURE 3-1 Hand-Washing Technique 71
PROCEDURE 3-2 Cleanup Procedures for Blood and

Other Body Fluid Spills 88
PROCEDURE 8-1 Tourniquet Application 241
PROCEDURE 8-2 Routine ETS Venipuncture 254
PROCEDURE 8-3 Venipuncture of a Hand Vein Using a Butterfly and ETS

Holder 262
PROCEDURE 8-4 Needle-and-Syringe Venipuncture 265
PROCEDURE 8-5 Using a Syringe Transfer Device 268
PROCEDURE 9-1 Performing Venipuncture Below an IV 297
PROCEDURE 9-2 Steps to Follow if a Patient Starts to Faint During

Venipuncture 302
PROCEDURE 10-1 Fingerstick Procedure 333
PROCEDURE 10-2 Heelstick Procedure 336
PROCEDURE 10-3 Collection of a Capillary Blood Gas (CBG)

Specimen by Heel Puncture 340
PROCEDURE 10-4 Newborn Screening Blood Spot Collection 346
PROCEDURE 10-5 Preparing a Blood Smear from a

Capillary Puncture 348
PROCEDURE 11-1 Blood Culture Specimen Collection 365
PROCEDURE 11-2 GTT Procedure 374
PROCEDURE 11-3 Bleeding-Time Test 387
PROCEDURE 11-4 Pregnancy Testing 400
PROCEDURE 11-5 TB Test Administration 404
PROCEDURE 13-1 24-Hour Urine Collection Procedure 441

LIST OF PROCEDURES xxix
PROCEDURE 13-2 Clean-Catch Urine Collection

Procedure for Women 442
PROCEDURE 13-3 Clean-Catch Urine Collection

Procedure for Men 443
PROCEDURE 13-4 Throat Culture Specimen Collection 450
PROCEDURE 14-1 Modified Allen Test 465
PROCEDURE 14-2 Preparing and Administering Local Anesthetic 466
PROCEDURE 14-3 Radial ABG Procedure 470

UNIT I
THE HEALTHCARE SETTING

CHAPTER
1
Past and Present and
The Healthcare Setting
KEY TERMS AHCCCS HMOs PHS

Do the Match- APC ICD-9-CM phlebotomy
ing Exercises in the case manager IDS polycythemia
WORKBOOK to certification kinesic slip PPOs
gain familiarity with
CLIA ’88 kinesics primary care
these terms.
CMS MCOs proxemics
communication barriers Medicaid reference laboratories
CPT Medicare secondary care
exsanguinate MLS tertiary care
HIPAA PHI third-party payer
OBJECTIVES
1 Define the key terms and abbreviations listed at the beginning of this chapter.
Upon successful
completion of 2 Describe the evolution of phlebotomy and the role of the phlebotomist in today’s
this chapter, the healthcare setting.
reader should be
3 Describe the traits that form the professional image and identify national
able to:
organizations that support professional recognition of phlebotomists.
4 Describe the basic concepts of communication as they relate to healthcare and how
appearance and nonverbal messages affect the communication process.
5 Describe proper telephone protocol in a laboratory or other healthcare setting.
6 Demonstrate an awareness of the different types of healthcare settings.
7 Compare types of third-party payers, coverage, and methods of payment to the

patient, provider, and institutions.
8 Describe traditional hospital organization and identify the healthcare providers in

the inpatient facility.
9 List the clinical analysis areas of the laboratory and the types of laboratory
procedures performed in the different areas.
10 Describe the different levels of personnel found in the clinical laboratory and how
Clinical Laboratory Improvement Amendment regulations affect their job descriptions.
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Chapter Opening Elements

OBJECTIVES provide a quick OBJECTIVES

5 Describe proper telephone protocol in a laboratory or other healthcare setting.

6 Demonstrate an awareness of the different types of healthcare settings.

7 Compare types of third-party payers, coverage, and methods of payment to the

8 Describe traditional hospital organization and identify the healthcare providers in

KEY POINTS help you to identify

ICONS THROUGHOUT THE TEXT

MEMORY JOGGERS help you to

FYI BOXES offer interesting and

TABLES give you important infor-

ONLINE ICONS direct you to in-

PROCEDURES present you with

Chapter Closing Elements

STUDY AND REVIEW QUES-

CASE STUDIES Enhance critical

MEDIA MENUS point out online

Additional Learning Resources

UNIT II OVERVIEW OF THE HUMAN BODY 105

UNIT III BLOOD COLLECTION PROCEDURES 189

UNIT IV SPECIAL PROCEDURES 355

UNIT I THE HEALTHCARE SETTING 1

2 Quality Assurance and Legal Issues 39

3 Infection Control, Safety, First Aid, and Personal Wellness 63

UNIT II OVERVIEW OF THE HUMAN BODY 105

5 Human Anatomy and Physiology Review 121

6 The Circulatory System 153

Lymph Flow 185

UNIT III BLOOD COLLECTION PROCEDURES 189

8 Venipuncture Procedures 225

Reviewing the Requisition 229

9 Preanalytical Considerations 283

10 Capillary Puncture Equipment and Procedures 319

Lancets/Incision Devices 320

UNIT IV SPECIAL PROCEDURES 355

Lactose Tolerance Test 375

12 Computers and Specimen Handling and Processing 411

13 Nonblood Specimens and Tests 435

OTHER NONBLOOD SPECIMENS 447

14 Arterial Puncture Procedures 455

PROCEDURE 3-2 Cleanup Procedures for Blood and

PROCEDURE 8-1 Tourniquet Application 241

PROCEDURE 8-2 Routine ETS Venipuncture 254

PROCEDURE 8-3 Venipuncture of a Hand Vein Using a Butterﬂy and ETS

PROCEDURE 8-4 Needle-and-Syringe Venipuncture 265

PROCEDURE 8-5 Using a Syringe Transfer Device 268

PROCEDURE 9-1 Performing Venipuncture Below an IV 297

PROCEDURE 9-2 Steps to Follow if a Patient Starts to Faint During

PROCEDURE 10-1 Fingerstick Procedure 333

PROCEDURE 10-2 Heelstick Procedure 336

PROCEDURE 10-3 Collection of a Capillary Blood Gas (CBG)

PROCEDURE 10-4 Newborn Screening Blood Spot Collection 346

PROCEDURE 10-5 Preparing a Blood Smear from a

PROCEDURE 11-1 Blood Culture Specimen Collection 365

PROCEDURE 11-2 GTT Procedure 374

PROCEDURE 11-3 Bleeding-Time Test 387

PROCEDURE 11-4 Pregnancy Testing 400

PROCEDURE 11-5 TB Test Administration 404