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HENRY’S
Clinical Diagnosis
AND Management

BY Laboratory Methods
 ASSOCIATE EDITORS

Martin H. Bluth, MD, PhD Mark S. Lifshitz, MD

Professor, Department of Pathology Director, Clinical Laboratories
Wayne State University School of Medicine New York University Langone Medical Center
Associate Director, Transfusion Service Clinical Professor, Department of Pathology
Detroit Medical Center New York University School of Medicine
Detroit, Michigan New York, New York

Jay L. Bock, MD, PhD H. Davis Massey, DDS, MD, PhD

Professor and Vice Chair for Clinical Pathology Chief, Pathology and Laboratory Medicine
Director of Laboratories H.H. McGuire VA Medical Center
Department of Pathology Associate Professor of Pathology
Stony Brook Medicine Virginia Commonwealth University
Stony Brook, New York Richmond, Virginia

Wilbur B. Bowne, MD A. Koneti Rao, MBBS

Associate Professor of Surgery Sol Sherry Professor of Medicine
Associate Professor of Biochemistry and Molecular Professor, Department of Clinical Pathology and Laboratory
Biology Medicine
Department of Surgery Director, Benign Hematology, Hemostasis, and Thrombosis
Drexel University College of Medicine Co-Director, Sol Sherry Thrombosis Research Center
Philadelphia, Pennsylvania Temple University School of Medicine
Philadelphia, Pennsylvania
Robert E. Hutchison, MD
Director of Hematopathology and Clinical Pathology Elizabeth R. Unger, MD, PhD
Department of Pathology Chief, Chronic Viral Diseases Branch
State University of New York Upstate Medical University Division of High-Consequence Pathogens and Pathology
Syracuse, New York Centers for Disease Control and Prevention,
Atlanta, Georgia
Donald S. Karcher, MD
Professor of Pathology Gail L. Woods, MD
Chair, Department of Pathology Professor, Department of Pathology
Director of Laboratories and Chief, Flow Cytometry and University of Arkansas for Medical Sciences
Clinical Chemistry Services Chief of Pediatric Pathology, Department of Pathology
George Washington University Medical Center Arkansas Children’s Hospital
Washington, DC Little Rock, Arkansas

ii
 23 RD
EDITION

HENRY’S
Clinical Diagnosis
AND Management

BY Laboratory Methods

Richard A. McPherson, MD, MSc

Professor of Pathology, Retired
Virginia Commonwealth University
Richmond, Virginia

Matthew R. Pincus, MD, PhD

Professor of Pathology
State University of New York Downstate Medical Center
Brooklyn, New York
Chief, Department of Pathology and Laboratory Medicine
New York Harbor VA Medical Center
New York, New York
3251 Riverport Lane
St. Louis, Missouri 63043

HENRY’S CLINICAL DIAGNOSIS AND MANAGEMENT ISBN: 978-0-323-29568-0

BY LABORATORY METHODS, 23e

Copyright © 2017 by Elsevier Inc.

Martin H. Bluth retains copyright for his editorial and original contributions.
Elizabeth R. Unger’s contribution is in the public domain.
Previous editions copyrighted 2011, 2007, 2001, 1996, 1991, 1984, 1979, 1974, 1969, 1962, 1953, 1948,
1943, 1939, 1935, 1931, 1927, 1923, 1918, 1914, 1912, and 1908.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by
any means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek permission,
further information about the Publisher’s permissions policies, and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our
website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Names: McPherson, Richard A., editor. | Pincus, Matthew R., editor.

Title: Henry’s clinical diagnosis and management by laboratory methods / [edited by] Richard A.
McPherson, Matthew R. Pincus.
Other titles: Clinical diagnosis and management by laboratory methods
Description: Edition 23. | St. Louis, Missouri : Elsevier, [2017] | Includes bibliographical references and
index.
Identifiers: LCCN 2016000370 | ISBN 9780323295680 (hardcover : alk. paper)
Subjects: | MESH: Clinical Laboratory Techniques | Clinical Laboratory Services
Classification: LCC RB37 | NLM QY 25 | DDC 616.07/56–dc23 LC record available at
http://lccn.loc.gov/2016000370

Executive Content Strategist: William Schmitt

Content Development Manager: Kathryn DeFrancesco
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Clay S. Broeker
Design Direction: Margaret Reid

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 CONTENTS

PART 1 The Clinical Laboratory 18 Cardiac Injury, Atherosclerosis, and Thrombotic

Disease 244
E D I T E D BY Mark S. Lifshitz, Matthew R. Pincus Jay L. Bock

1 General Concepts and Administrative Issues 2 19 Specific Proteins 253

Tim Hilbert, Anthony Kurec, Mark S. Lifshitz Richard A. McPherson

2 Optimizing Laboratory Workflow and Performance 11 20 Clinical Enzymology 267

Mark S. Lifshitz Robert P. Carty, Matthew R. Pincus, Ehsan Sarafraz-Yazdi

3 Preanalysis 20 21 Evaluation of Liver Function 289

Mark S. Lifshitz Matthew R. Pincus, Philip M. Tierno Jr., Elizabeth Gleeson,
Wilbur B. Bowne, Martin H. Bluth
4 Analysis: Principles of Instrumentation 33
Matthew R. Pincus, Mark S. Lifshitz, Jay L. Bock 22 Laboratory Diagnosis of Gastrointestinal and Pancreatic
Disorders 306
5 Analysis: Clinical Laboratory Automation 60 Haseeb A. Siddiqi, Martin J. Salwen, Mohammad F. Shaikh,
Timothy E. Caragher, Mark S. Lifshitz, Robert DeCresce Wilbur B. Bowne

6 Point-of-Care Testing and Physician Office 23 Toxicology and Therapeutic Drug Monitoring 324
Laboratories 66 Matthew R. Pincus, Martin H. Bluth, Naif Z. Abraham Jr.
Lauren McVoy, Mark S. Lifshitz 24 Evaluation of Endocrine Function 362
Helena A. Guber, Amal F. Farag
7 Postanalysis: Medical Decision Making 73
Jeffrey S. Jhang, Mark S. Lifshitz 25 Reproductive Function and Pregnancy 400
Roohi Jeelani, Martin H. Bluth
8 Interpreting Laboratory Results 84
Matthew R. Pincus, Naif Z. Abraham Jr. 26 Vitamins and Trace Elements 416
Martin J. Salwen
9 Laboratory Statistics 102
Richard A. McPherson 27 Chemical Basis for Analyte Assays and Common
Interferences 428
10 Quality Control 112 Matthew R. Pincus, Jay L. Bock, Ralph Rossi, Donghong Cai
W. Greg Miller

11 Clinical Laboratory Informatics 130 PART 3 Urine and Other Bodily Fluids
Paul Tranchida, Mark S. Lifshitz, Martin H. Bluth
EDITED BY Donald S. Karcher, Richard A. McPherson,
12 Financial Management 137 Matthew R. Pincus
Mark S. Lifshitz, Robert DeCresce
28 Basic Examination of Urine 442
13 Biological, Chemical, and Nuclear Terrorism: Role of Roger S. Riley, Richard A. McPherson
the Laboratory 149 29 Cerebrospinal, Synovial, Serous Body Fluids, and
Philip M. Tierno Jr., Mark S. Lifshitz
Alternative Specimens 481
Donald S. Karcher, Richard A. McPherson
PART 2 Clinical Chemistry
E D I T E D BY Jay L. Bock, Martin H. Bluth, Matthew R. Pincus PART 4 Hematology and Transfusion
14 Evaluation of Renal Function, Water, Electrolytes, and
Medicine
Acid-Base Balance 162 EDITED BY Robert E. Hutchison, Richard A. McPherson,
Man S. Oh, Gary Briefel Martin H. Bluth

15 Biochemical Markers of Bone Metabolism 188 30 Basic Examination of Blood and Bone Marrow 510
Katrin M. Klemm, Michael J. Klein Neerja Vajpayee, Susan S. Graham, Sylva Bem

16 Carbohydrates 205 31 Hematopoiesis 540

Prashant Nadkarni, Ruth S. Weinstock Sharad C. Mathur, Robert E. Hutchison, Golam Mohi

17 Lipids and Dyslipoproteinemia 221 32 Erythrocytic Disorders 559

Xueying Chen, Liye Zhou, M. Mahmood Hussain M. Tarek Elghetany, Katherine I. Schexneider, Katalin Banki

v
 33 Leukocytic Disorders 606 50 The Major Histocompatibility Complex and
Contents
Robert E. Hutchison, Katherine I. Schexneider Disease 973
Attila Kumánovics, Julio C. Delgado
34 The Flow Cytometric Evaluation of Hematopoietic
Neoplasia 659 51 Immunodeficiency Disorders 983
Brent L. Wood, Sindhu Cherian, Michael J. Borowitz Patrick Michael Long, Kimberly W. Sanford, Martin H. Bluth

35 Immunohematology 680 52 Clinical and Laboratory Evaluation of Systemic

Laura Cooling, Theresa Downs Rheumatic Diseases 993
Carlos Alberto von Mühlen, Marvin J. Fritzler, Edward K. L. Chan
36 Transfusion Medicine 735
53 Vasculitis 1016
Matthew Elkins, Robertson Davenport, Paul D. Mintz
J. Charles Jennette, Eric T. Weimer, Jason Kidd

37 Hemapheresis 751 54 Organ-Specific Autoimmune Diseases 1032

Emily Rupp Patterson, Jeffrey L. Winters William E. Winter, Neil S. Harris, Kimberly L. Merkel,
Amy L. Collinsworth, William L. Clapp
38 Tissue Banking and Progenitor Cells 783
Nicholas J. Greco, Matthew Elkins 55 Allergic Diseases 1057
Henry A. Homburger, Robert G. Hamilton

PART 5 Hemostasis and Thrombosis

PART 7 Medical Microbiology
E D I T E D BY A. Koneti Rao, Matthew R. Pincus
EDITED BY Gail L. Woods, Richard A. McPherson
39 Coagulation and Fibrinolysis 794
Mariasanta Napolitano, Alvin H. Schmaier, Craig M. Kessler
56 Viral Infections 1072
Lech J. Mazur, Michael Costello
40 Platelet Disorders and von Willebrand Disease 812
57 Chlamydial, Rickettsial, and Mycoplasmal
Jonathan L. Miller, A. Koneti Rao
Infections 1099
Juan P. Olano, David H. Walker, Gail L. Woods
41 Laboratory Approach to Thrombotic Risk 834
John V. Mitsios, Jacob H. Rand 58 Medical Bacteriology 1114
Geraldine S. Hall, Gail L. Woods
42 Antithrombotic Therapy 842
Thomas L. Ortel 59 In Vitro Testing of Antimicrobial Agents 1153
Angella Charnot-Katsikas, Kathleen G. Beavis
PART 6 Immunology and 60 Spirochete Infections 1171
Immunopathology P. Rocco LaSala, Michael Loeffelholz

E D I T E D BY H. Davis Massey, Richard A. McPherson 61 Mycobacteria 1187

Gail L. Woods
43 Overview of the Immune System and Immunologic
Disorders 856 62 Mycotic Diseases 1198
Richard A. McPherson, H. Davis Massey Peter C. Iwen

44 Immunoassays and Immunochemistry 862 63 Medical Parasitology 1231

Katsumi Aoyagi, Yoshihiro Ashihara, Yasushi Kasahara Thomas Richard Fritsche, Bobbi S. Pritt

45 Laboratory Evaluation of the Cellular Immune 64 Specimen Collection and Handling for Diagnosis of
System 890 Infectious Diseases 1284
Kathleen G. Beavis, Angella Charnot-Katsikas
Roger S. Riley

46 Laboratory Evaluation of Immunoglobulin Function and PART 8 Molecular Pathology

Humoral Immunity 913
Richard A. McPherson, Roger S. Riley, H. Davis Massey EDITED BY Martin H. Bluth, Elizabeth R. Unger, Matthew R. Pincus

65 Introduction to Molecular Pathology 1300

47 Mediators of Inflammation: Complement, Cytokines,
Elizabeth R. Unger, Martin H. Bluth, Matthew R. Pincus
and Adhesion Molecules 929
H. Davis Massey, Richard A. McPherson, Sally A. Huber, 66 Molecular Diagnostics: Basic Principles and
Nancy S. Jenny Techniques 1303
Martin Steinau, Margaret Piper, Elizabeth R. Unger
48 Mediators of Inflammation: Cytokines and Adhesion
Molecules 944 67 Polymerase Chain Reaction and Other Nucleic Acid
Nancy S. Jenny, Sally A. Huber, Michael R. Lewis Amplification Technology 1316
Frederick S. Nolte, Julie Woolworth Hirschhorn, Charles E. Hill
49 Human Leukocyte Antigen: The Major
Histocompatibility Complex of Man 955 68 Hybridization Array Technologies 1328
Omar Roberto Fagoaga Martin H. Bluth

vi
69 Applications of Cytogenetics in Modern 75 Oncoproteins and Early Tumor Detection 1450

Contents
Pathology 1337 Matthew R. Pincus, Paul W. Brandt-Rauf, Martin H. Bluth,
Constance K. Stein Elizabeth Gleeson, Mohammad F. Shaikh, Wilbur B. Bowne,
Charles LaDoulis
70 Establishing a Molecular Diagnostics Laboratory 1360
Michael Weindel, Martin H. Bluth 76 Molecular Diagnosis of Hematopoietic
Neoplasms 1465
71 Molecular Diagnosis of Genetic Diseases 1377 Ali Gabali, Martin H. Bluth
Wayne W. Grody
77 Molecular Genetic Pathology of Solid Tumors 1492
72 Identity Analysis: Use of DNA Analysis in Parentage, Shilpa Jain, David Y. Zhang, Ruliang Xu, Matthew R. Pincus,
Forensic, and Missing Persons Testing 1396 Peng Lee
Rhonda K. Roby
78 High-Throughput Genomic and Proteomic Technologies
73 Pharmacogenomics and Personalized Medicine 1407 in the Postgenomic Era 1520
Jing Li, Martin H. Bluth Martin H. Bluth

PART 9 Molecular Pathology Index 1535

E D I T E D BY Matthew R. Pincus, Martin H. Bluth,
Richard A. McPherson, Wilbur B. Bowne

74 Diagnosis and Management of Cancer Using Serologic

and Other Body Fluid Markers 1432
Shilpa Jain, Matthew R. Pincus, Martin H. Bluth,
Richard A. McPherson, Wilbur B. Bowne, Peng Lee

vii
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 CONTRIBUTORS

Naif Z. Abraham Jr., MD, PhD Paul W. Brandt-Rauf, MD, ScD, DrPH
Director, Division of Clinical Pathology Dean
Assistant Professor of Pathology School of Public Health
State University of New York Upstate Medical University University of Illinois at Chicago
Syracuse, New York Chicago, Illinois

Katsumi Aoyagi, PhD Gary Briefel, MD

General Manager Clinical Associate Professor of Medicine
New Product Development and Product Lifecycle Management State University of New York Downstate Medical Center
Department Brooklyn, New York
Fujirebio Inc.
Tokyo, Japan Donghong Cai, MD
Clinical Assistant Instructor, Department of Pathology
Yoshihiro Ashihara, PhD State University of New York Health Sciences Center at Brooklyn
Senior Managing Director Brooklyn, New York
Board Member
Fujirebio Inc. Timothy E. Caragher, PhD
Tokyo, Japan Assistant Professor, Pathology and Clinical Laboratory Sciences
Rush University Medical Center
Katalin Banki, MD Chicago, Illinois
Associate Professor
Department of Pathology Robert P. Carty, PhD
State University of New York Upstate Medical University Associate Professor, Department of Biochemistry
Syracuse, New York State University of New York Downstate Medical Center
Brooklyn, New York
Kathleen G. Beavis, MD
Interim Director of Laboratories Edward K. L. Chan, PhD
Director, Microbiology and Immunology Laboratories University of Florida Research Foundation Professor
Department of Pathology Professor of Oral Biology
University of Chicago Medicine Professor of Anatomy and Cell Biology
Chicago, Illinois University of Florida
Gainesville, Florida
Sylva Bem, MD
Assistant Professor of Pathology Angella Charnot-Katsikas, MD
Upstate University Hospital Assistant Professor, Department of Pathology
State University of New York Assistant Director, Clinical Microbiology and Immunology Labs
Syracuse, New York University of Chicago
Chicago, Illinois
Martin H. Bluth, MD, PhD
Professor, Department of Pathology Xueying Chen, MD, PhD
Wayne State University School of Medicine Visiting Scholar, Department of Cell Biology
Associate Director, Transfusion Service State University of New York Downstate Medical Center
Detroit Medical Center Brooklyn, New York
Detroit, Michigan Attending Physician, Department of Cardiology
Zhongshan Hospital, Fudan University
Jay L. Bock, MD, PhD Shanghai, China
Professor and Vice Chair for Clinical Pathology
Director of Laboratories Sindu Cherian, MD
Department of Pathology Associate Professor, Laboratory Medicine
Stony Brook Medicine University of Washington,
Stony Brook, New York Seattle, Washington

Michael J. Borowitz, MD, PhD William L. Clapp, MD

Professor of Pathology and Oncology Professor of Pathology, Department of Pathology, Immunology, and
Executive Deputy Director, Department of Pathology Laboratory Medicine
Johns Hopkins Medical Institutions University of Florida College of Medicine
Baltimore, Maryland Gainesville, Florida

Wilbur B. Bowne, MD Amy L. Collinsworth, MD

Associate Professor of Surgery Clinical Assistant Professor, Department of Pathology, Immunology, and
Associate Professor of Biochemistry and Molecular Biology Laboratory Medicine
Department of Surgery University of Florida
Drexel University College of Medicine Gainesville, Florida
Philadelphia, Pennsylvania

viii
Laura Cooling, MD, MS Ali Gabali, MD, PhD

Contributors
Associate Professor, Department of Pathology Associate Professor
University of Michigan Head of Hematopathology Division
Ann Arbor, Michigan Director of Hematopathology Fellowship Program
Department of Pathology
Michael Costello, PhD Wayne State University School of Medicine
Technical Director, Microbiology Detroit, Michigan
ACL Central Lab
Rosemont, Illinois Elizabeth Gleeson, MD, MPH
Surgical Resident
Robertson Davenport, MD Department of Surgery
Associate Professor, Department of Pathology Drexel University College of Medicine
University of Michigan Philadelphia, Pennsylvania
Ann Arbor, Michigan
Susan S. Graham, MS, MT(ASCP)SH
Robert DeCresce, MD Associate Professor and Chair, Department of Clinical Laboratory
Harriet Borland Professor and Chair Science
Department of Pathology State University of New York Upstate Medical University
Rush Medical College Syracuse, New York
Chicago, Illinois
Nicholas J. Greco, BS, PhD
Julio C. Delgado, MD, MS Executive Director and Tissue Bank Director
Associate Professor of Pathology Faculty, Clinical Assistant Professor
University of Utah School of Medicine Department of Pathology
Chief Medical Director, Immunology Division Upstate Cord Blood Bank
ARUP Laboratories State University of New York Upstate Medical University
Director, Histocompatibility and Immunogenetics Laboratory Syracuse, New York
University of Utah School of Medicine
Salt Lake City, Utah Wayne W. Grody, MD, PhD
Professor, Departments of Pathology & Laboratory Medicine,
Theresa Downs, BS Pediatrics, and Human Genetics
Administrative Manager, Blood Bank and Transfusion Service UCLA School of Medicine
University of Michigan Hospitals Los Angeles, California
Ann Arbor, Michigan
Helena A. Guber, MD
M. Tarek Elghetany, MD Assistant Professor of Medicine
Professor of Pathology and Immunology and Pediatrics Chief, Department of Endocrinology
Baylor College of Medicine Veterans Health Administration
Texas Children’s Hospital NY Harbor Healthcare System, Brooklyn Campus
Houston, Texas Brooklyn, New York

Matthew Elkins, MD, PhD Geraldine S. Hall, PhD

Assistant Professor, Department of Pathology Retired, Clinical Microbiology
State University of New York Upstate Medical University Forestville, New York
Syracuse, New York
Robert G. Hamilton, PhD, D(ABMLI)
Omar Roberto Fagoaga, MS, PhD, D(ABHI) Professor of Medicine and Pathology
Associate Professor, Department of Pathology Johns Hopkins University School of Medicine
Wayne State University Medical School Director
Transplant Immunology Director Johns Hopkins Dermatology, Allergy and
Detroit Medical Center and Henry Ford Health Systems Clinical Immunology Reference Laboratory
Detroit, Michigan Baltimore, Maryland

Amal F. Farag, MD Neil S. Harris, MBChB, MD

Endocrine Consultant Clinical Associate Professor, Department of Pathology, Immunology,
Clinical Assistant Professor, Department of Medicine/College of and Laboratory Medicine
Medicine University of Florida College of Medicine
State University of New York Gainesville, Florida
Brooklyn, New York
Tim Hilbert, MD, PhD, JD
Thomas Richard Fritsche, MS, MD, PhD Assistant Professor, Department of Pathology
Director, Division of Laboratory Medicine and Pathology Medical Director, Blood Bank
Marshfield Clinic New York University Langone Medical Center
Marshfield, Wisconsin New York, New York
Adjunct Professor, Department of Microbiology
University of Wisconsin Charles E. Hill, MD, PhD
La Crosse, Wisconsin Director, Molecular Diagnostics Laboratory
Emory University Hospital
Marvin J. Fritzler, MD, PhD Associate Professor of Pathology and Laboratory Medicine
Professor, Department of Medicine Emory University School of Medicine
Cumming School of Medicine Atlanta, Georgia
University of Calgary
Calgary, Alberta, Canada

ix
 Julie Woolworth Hirschhorn, PhD Yasushi Kasahara, PhD, DMSc
Contributors
Associate Director of Molecular Pathology Visiting Professor, Department of Clinical Pathology
Assistant Professor, Department of Pathology and Laboratory Medicine School of Medicine, Showa University
Medical University of South Carolina Scientific Advisor, Research Laboratories
Charleston, South Carolina Fujirebio Inc.
Tokyo, Japan
Henry A. Homburger, MD, FCAP
Professor (emeritus), Department of Laboratory Medicine and Craig M. Kessler, MD
Pathology Professor of Medicine and Pathology
Mayo Clinic College of Medicine and Mayo Graduate School of Director, Division of Coagulation
Medicine Lombardi Comprehensive Cancer Center
Rochester, Minnesota Georgetown University Medical Center
Washington, DC
Sally A. Huber, PhD
Professor, Pathology and Laboratory Medicine Jason Kidd, MD
University of Vermont College of Medicine Assistant Professor
Colchester, Vermont Department of Internal Medicine, Division of Nephrology
VCU Medical Center
M. Mahmood Hussain, MD Richmond, Virginia
Professor, Department of Cell Biology
State University of New York Downstate Medical Center Michael J. Klein, MD
Brooklyn, New York Pathologist-in-Chief
Hospital for Special Surgery
Robert E. Hutchison, MD Professor of Pathology and Laboratory Medicine
Director of Hematopathology and Clinical Pathology Weill Cornell School of Medicine
Department of Pathology New York, New York
State University of New York Upstate Medical University
Syracuse, New York Katrin M. Klemm, MD
Medical Laboratory Director and Staff Pathologist
Peter C. Iwen, MS, PhD, D(ABMM) East Alabama Medical Center
Professor, Department of Pathology and Microbiology Medical Laboratory Director
University of Nebraska Medical Center Aperian Laboratory Solutions
Director Opelika, Alabama
Nebraska Public Health Laboratory
Omaha, Nebraska Attila Kumánovics, MD
Assistant Professor of Pathology
Shilpa Jain, MD University of Utah School of Medicine
Assistant Professor, Department of Pathology and Immunology Assistant Medical Director of Immunology and Co-Director of
Baylor College of Medicine Immunogenetics
Houston, Texas ARUP Laboratories
Salt Lake City, Utah
Roohi Jeelani, MD
Obstetrician and Gynecologist Anthony Kurec, MS, H(ASCP)DLM
Fellow, Wayne State University Clinical Associate Professor Emeritus, Department of Clinical
Royal Oak, Michigan Laboratory Science
State University of New York Upstate Medical University
J. Charles Jennette, MD Syracuse, New York
Kenneth M. Brinkhous Distinguished Professor and Chair, Department
of Pathology and Laboratory Medicine Charles LaDoulis, MD
School of Medicine Chairman Emeritus, Department of Pathology
University of North Carolina at Chapel Hill Maimonides Medical Center
Chief of Pathology and Laboratory Medicine Services Consultant in Pathology
UNC Hospitals Department of Pathology and Laboratory Medicine
Chapel Hill, North Carolina New York Harbor VA Medical Center
Brooklyn, New York
Nancy S. Jenny, PhD
Associate Professor, Pathology and Laboratory Medicine P. Rocco LaSala, MD
University of Vermont College of Medicine Director of Clinical Microbiology
Colchester, Vermont Associate Professor of Pathology
West Virginia University
Jeffrey S. Jhang, MD Morgantown, West Virginia
Director, Blood Bank and Transfusion Services
Mount Sinai Hospital Peng Lee, MD, PhD
Associate Professor, Department of Pathology Professor of Pathology and Urology
Icahn School of Medicine at Mount Sinai New York University Langone Medical Center and School of Medicine
New York, New York Director, Molecular Pathology
New York Harbor Healthcare System
Donald S. Karcher, MD New York, New York
Professor of Pathology
Chair, Department of Pathology Michael R. Lewis, MD, MBA
Director of Laboratories and Chief, Flow Cytometry and Clinical Associate Professor, Pathology and Laboratory Medicine
Chemistry Services Medical Director, Flow Cytometry Laboratory
George Washington University Medical Center Division Chief, Laboratory Medicine
Washington, DC University of Vermont Medical Center
Burlington, Vermont

x
Jing Li, PhD Paul D. Mintz, MD

Contributors
Associate Professor Director, Division of Hematology Clinical Review
Director, Pharmacology Core Center for Biologics Evaluation and Research
Karmanos Cancer Institute Food and Drug Administration
Department of Oncology Silver Spring, Maryland
Wayne State University School of Medicine
Detroit, Michigan John V. Mitsios, PhD
Assistant Professor of Pathology and Laboratory Medicine
Mark S. Lifshitz, MD Weill Cornell Medical College, New York Presbyterian Hospital
Director, Clinical Laboratories New York, New York
New York University Langone Medical Center
Clinical Professor, Department of Pathology Golam Mohi, PhD
New York University School of Medicine Associate Professor, Department of Pharmacology
New York, New York State University of New York Upstate Medical University
Syracuse, New York
Michael Loeffelholz, PhD
Professor, Department of Pathology Prashant Nadkarni, MD
Director, Clinical Microbiology Division Assistant Professor, Department of Medicine
University of Texas Medical Branch State University of New York Upstate Medical University
Galveston, Texas Syracuse, New York

Patrick Michael Long, PhD Mariasanta Napolitano, MD, PhD

Associate Professor, Pathology Assistant Professor of Hematology, Hematology Unit
Wayne State School of Medicine Reference Regional Center for Thrombosis and Haemostasis
Technical Director, Immunodiagnostics Università degli studi di Palermo
DMC University Laboratory Palermo, Italy
Detroit, Michigan
Frederick S. Nolte, PhD, D(ABMM), F(AAM)
H. Davis Massey, DDS, MD, PhD Professor, Pathology and Laboratory Medicine
Chief, Pathology and Laboratory Medicine Vice-Chair, Laboratory Medicine
H.H. McGuire VA Medical Center Director, Clinical Laboratories
Associate Professor of Pathology Medical University of South Carolina
Virginia Commonwealth University Charleston, South Carolina
Richmond, Virginia
Man S. Oh, MD
Sharad C. Mathur, MD Professor of Medicine, Division of Nephrology
Chief, Pathology and Laboratory Medicine Service State University of New York Downstate Medical Center
VA Medical Center Brooklyn, New York
Kansas City, Missouri
Associate Professor, Department of Pathology and Laboratory Medicine Juan P. Olano, MD
University of Kansas Professor, Department of Pathology
Kansas City, Kansas Director, Residency Training Program
University of Texas Medical Branch
Lech J. Mazur, MS, MLS(ASCP) Galveston, Texas
Technical Director, Department of Molecular Pathology
ACL Laboratories Thomas L. Ortel, MD, PhD
Rosemont, Illinois Professor, Department of Medicine
Duke University Medical Center
Richard A. McPherson, MD, MSc Durham, North Carolina
Professor of Pathology, Retired
Virginia Commonwealth University Emily Rupp Patterson, MD
Richmond, Virginia Surgical Pathology Fellow
Department of Laboratory Medicine and Pathology
Lauren McVoy, MD, PhD, D(ABMM) Mayo Clinic
Assistant Director, Clinical Laboratories Rochester, Minnesota
Clinical Assistant Professor, Department of Pathology
New York University School of Medicine Matthew R. Pincus, MD, PhD
New York, New York Professor of Pathology
State University of New York Downstate Medical Center
Kimberly L. Merkel, MD Brooklyn, New York
Assistant Chief, Dermatology Section Chief, Department of Pathology and Laboratory Medicine
North Florida/South Georgia Veterans Health System New York Harbor VA Medical Center
Gainesville, Florida New York, New York

Jonathan L. Miller, MD, PhD Margaret Piper, PhD, MPH

Clinical Professor, Department of Pathology Research Associate III
Medical Director, Coagulation Laboratory Kaiser Permanente Center for Health Research
University of Chicago Portland, Oregon
Chicago, Illinois
Bobbi S. Pritt, MD, MSc, (D)TMH
W. Greg Miller, PhD Director, Clinical Parasitology and Microbiology Initial Processing and
Professor, Department of Pathology Media Laboratories
Director of Clinical Chemistry Associate Professor of Pathology and Laboratory Medicine
Director of Pathology Information Systems Division of Clinical Microbiology
Virginia Commonwealth University Medical Center Mayo Clinic
Richmond, Virginia Rochester, Minnesota

xi
 Jacob H. Rand, MD Constance K. Stein, PhD
Contributors
Director of Clinical Laboratories Professor, Department of Pathology
New York Presbyterian Hospital, Weill Cornell Campus Director of Cytogenetics
Professor, Department of Pathology and Laboratory Medicine Associate Director of Molecular Diagnostics, Department of Clinical
Weill Cornell Medical College Pathology
New York, New York State University of New York Upstate Medical University
Syracuse, New York
A. Koneti Rao, MBBS
Sol Sherry Professor of Medicine Martin Steinau, PhD
Professor, Department of Clinical Pathology and Laboratory Medicine Senior Scientist, Chronic Viral Diseases Branch
Director, Benign Hematology, Hemostasis, and Thrombosis Division of High-Consequence Pathogens and Pathology
Co-Director, Sol Sherry Thrombosis Research Center National Center for Emerging and Zoonotic Infectious Diseases
Temple University School of Medicine Centers for Disease Control and Prevention
Philadelphia, Pennsylvania Atlanta, Georgia

Roger S. Riley, MD, PhD Philip M. Tierno Jr., PhD

Professor of Pathology Professor, Department of Microbiology & Pathology
Virginia Commonwealth University School of Medicine New York University School of Medicine
Richmond, Virginia New York, New York

Rhonda K. Roby, PhD, MPH Paul Tranchida, MD

Associate Professor, Department of Forensic and Investogative Genetics Assistant Professor, Department of Pathology
Project Coordinator Wayne State University
Center for Human Identification Detroit, Michigan
Institute of Investigative Genetics
University of North Texas Health Science Center Elizabeth R. Unger, MD, PhD
Fort Worth, Texas Chief, Chronic Viral Diseases Branch
Division of High-Consequence Pathogens and Pathology
Ralph Rossi, PhD Centers for Disease Control and Prevention,
Director, Division of Clinical Chemistry Atlanta, Georgia
Veterans Affairs New York Harbor Healthcare System
Brooklyn, New York Neerja Vajpayee, MD
Associate Professor, Department of Pathology
Martin J. Salwen, MD State University of New York Upstate Medical University
Distinguished Service Professor Emeritus Syracuse, New York
State University of New York Downstate Medical Center
Brooklyn, New York Carlos Alberto von Mühlen, MD, PhD
President, Brazilian Society of Autoimmunity
Kimberly W. Sanford, MD Full Professor of Internal Medicine and Rheumatology, Retired
Assistant Professor Pontifical Catholic University School of Medicine
Medical Director, Transfusion Medicine Porto Alegre, Brazil
Department of Pathology
Virginia Commonwealth University David H. Walker, MD
Richmond, Virginia Professor, Department of Pathology
University of Texas Medical Branch
Ehsan Sarafraz-Yazdi, PhD Executive Director, Center for Biodefense and Emerging Infectious
Assistant Professor, Division of Gynecologic Oncology Diseases
State University of New York Health Science Center, Galveston, Texas
Brooklyn, New York
Eric T. Weimer, PhD, D(ABMLI)
Katherine I. Schexneider, MD Assistant Professor, Department of Pathology and Laboratory Medicine
Medical Director, Transfusion Services University of North Carolina at Chapel Hill School of Medicine
Department of Laboratory Medicine Chapel Hill, North Carolina
Walter Reed National Military Medical Center
Associate Professor of Pathology Michael Weindel, MD
Uniformed Services University of the Health Sciences Pathology Fellow, Department of Pathology and Immunology
Bethesda, Maryland Baylor College of Medicine
Houston, Texas
Alvin H. Schmaier, MD
Robert W. Kellermeyer Professor of Hematology and Oncology Ruth S. Weinstock, MD, PhD
Department of Medicine State University of New York Distinguished Service Professor,
Case Western Reserve University Department of Medicine
University Hospitals Case Medical Center Chief, Endocrinology, Diabetes, and Metabolism
Cleveland, Ohio Medical Director, Clinical Research Unit
State University of New York Upstate Medical University
Mohammad F. Shaikh, MD Syracuse, New York
Surgical Resident, Department of Surgery
Drexel University College of Medicine William E. Winter, MD
Philadelphia, Pennsylvania Professor, Departments of Pathology, Immunology and Laboratory
Medicine, Pediatrics, and Molecular Genetics and Microbiology
Haseeb A. Siddiqi, PhD University of Florida
Professor, Departments of Cell Biology, Medicine, and Pathology Gainesville, Florida
State University of New York Downstate Medical Center
Brooklyn, New York

xii
Jeffrey L. Winters, MD Ruliang Xu, MD, PhD

Contributors
Professor, Laboratory Medicine and Pathology Associate Professor
Medical Director, Therapeutic Apheresis Treatment Unit Director, Gastrointestinal and Liver Pathology
Department of Laboratory Medicine and Pathology Department of Pathology
Division of Transfusion Medicine New York University Langone Medical Center
Mayo Clinic New York, New York
Rochester, Minnesota
David Y. Zhang, MD, PhD
Brent L. Wood, MD, PhD Professor
Professor, Laboratory Medicine and Pathology Director, Molecular Pathology Laboratory
University of Washington Department of Pathology
Seattle, Washington Icahn School of Medicine at Mount Sinai
New York, New York
Gail L. Woods, MD
Professor, Department of Pathology Liye Zhou, MS
University of Arkansas for Medical Sciences School of Graduate Studies, Molecular and Cell Biology Program
Chief of Pediatric Pathology, Department of Pathology Departments of Cell Biology and Pediatrics
Arkansas Children’s Hospital State University of New York Downstate Medical Center
Little Rock, Arkansas Brooklyn, New York

xiii
 PREFACE

Clinical laboratory measurements form the scientific basis upon which tion, and automation are presented in Chapters 4 and 5. The growing
medical diagnosis and management of patients is established. These results arena of near-patient laboratory services beyond central hospital laborato-
constitute the largest section of the medical record of patients, and labora- ries in the format of point-of-care testing is presented in Chapter 6 along
tory examinations will only continue to grow in number as new procedures with presentation on this application in the military. Postanalysis processes
are offered and well-established ones are ordered more frequently in the of result reporting, medical decision making, and interpretation of results
future. The modern concept of an electronic health record encompasses are presented in Chapter 7, while selection of laboratory testing and inter-
information from a patient’s birth through that individual’s entire life, and pretation for the most cost-effective and efficient information gathering
laboratory testing is a significant component of that record from prenatal for medical problem solving by clinical laboratory testing is discussed in
and newborn screening through childhood, adulthood, and geriatric years. Chapter 8. A key component to all phases of laboratory processes, inter-
Traditional areas of testing are well established in clinical chemistry, hema- pretation of results, and decision making is statistical analysis, which is
tology, coagulation, microbiology, immunology, and transfusion medicine. introduced in Chapter 9. Explicit applications of statistics are in quality
Genetic testing for hereditary disease risk assessment is becoming a reality, control and proficiency testing for oversight of the entire analytic process
beginning with individual disease testing that is expected to be followed (Chapter 10). Maintaining order for the complexities of laboratory test
by whole genome screening for a multitude of conditions. The rapid pace result ordering and reporting and the management of clinical information
in the introduction of new testing procedures demands that laboratory are possible only through sophisticated information systems that are essen-
practitioners be experts in several divergent aspects of this profession. The tial to all clinical laboratories (Chapter 11). Management decisions in the
environment of clinical laboratories is extremely well suited for translation clinical laboratory involve the choice of analytic instrumentation, automa-
of research procedures into diagnostic assays because of their traditional tion to process and deliver specimens to analytic stations, and computer
involvement in basic analysis, quality control, professional competencies, systems to coordinate all of the preanalytic, analytic, and postanalytic
and cost-effective strategies of operation. All of these applications are made processes to meet the mission of the institution. These choices determine
stronger for occurring under regulations of federal and state governments the productivity that a laboratory can achieve (especially its ability to
as well as the standards of accreditation of professional pathology organiza- respond to increased volumes of testing and complexity of measurements
tions. Clinical laboratories excel in these tasks, and they are now respond- and examinations as the standards of practice advance). Paramount is the
ing to pressures for even greater accomplishments in areas of informatics, manner in which the laboratory can muster its resources in equipment,
advanced analytic methods, interpretation of complex data, and commu- personnel, reagent supplies, and ingenuity of its leadership to respond to
nication of medical information in a meaningful way to physician col- the needs of health care providers and patients in terms of access, timeli-
leagues and even directly to patients in some health care models. The most ness, cost, and quality of test results. New challenges continue to emerge
successful practitioners of laboratory medicine will incorporate all of these for the laboratory to provide excellent quality services at a fiscally respon-
approaches into their daily lives and will be leaders in their institutions for sible expense; the changing models of reimbursement for medical and
developing initiatives to promote outstanding health care in a fiscally laboratory services demand that pathologists and laboratory leaders
responsible endeavor. This textbook strives to provide the background develop and maintain a strong understanding of the principles of financial
knowledge by which trainees can be introduced to these practices and to management and be well aware of mechanisms that laboratories can utilize
serve as a resource for pathologists and other laboratory personnel to for responding to these new approaches to reimbursement (Chapter 12).
update their knowledge to solve problems that they encounter daily. Laboratory organization should also include preparedness for threats to
This twenty-third edition marks more than 100 years since A Manual our security through bioterrorism and related activities (Chapter 13).
of Clinical Diagnosis, authored by James Campbell Todd, was introduced in Part 2, Clinical Chemistry, is organized to present laboratory examina-
1908. In its current format as Henry’s Clinical Diagnosis and Management tions according to organ systems and their disorders. Some of the most
by Laboratory Methods, this textbook remains the authoritative source of commonly ordered laboratory tests are directed at the evaluation of renal
information for residents, students, and other trainees in the disciplines of function, water, electrolytes, metabolic intermediates and nitrogenous
clinical pathology and laboratory medicine, and for physicians and labora- wastes, and acid-base balance, all of which are critically important for
tory practitioners. The current edition continues the tradition of partner- monitoring acutely ill patients and in the management of patients with
ship between laboratory examinations and the formulation and confirmation kidney and pulmonary disorders (Chapter 14). The important field of bone
of clinical diagnoses followed by monitoring of body functions, therapeutic metabolism and bone diseases, stemming from the enormous public inter-
drug levels, other results of medical treatments, and risk assessment for est in osteoporosis of our aging population, is covered in Chapter 15. The
disease. Beginning with the twenty-first edition, color illustrations have significance of carbohydrate measurements, with particular emphasis on
been used throughout the book to accurately and realistically depict clini- diabetes mellitus, the overall hormonal regulation of glucose metabolism,
cal laboratory test findings and their analysis. The overriding mission of and disorders of other sugars, is reviewed in Chapter 16. Chapter 17 covers
this book is to incorporate new discoveries and their clinical diagnostic the extremely important topic of lipids and disorders in their metabolism
applications alongside the wealth of information that forms the core and highlights the critical patterns in lipoprotein profiles that indicate
knowledge base of clinical pathology and laboratory medicine. Our con- disposition to atherosclerosis and cardiac malfunction, especially myocar-
tributing authors, who are experts in their specialties, present to the reader dial infarction. In Chapter 18, the serodiagnostic markers for cardiac injury
the essential basic and new information that is central to clinical laboratory evaluation and the related disorders of stroke are elaborated. The clinical
practice. significance of specific proteins and their analysis, with emphasis on elec-
Part 1, The Clinical Laboratory, covers the organization, purposes, and trophoresis of blood and body fluids, is covered in Chapter 19. The field
practices of analysis, interpretation of results, and management of the of clinical enzymology, with applications to assessment of organ injury, is
clinical laboratory from quality control through informatics and finances. covered in Chapter 20. The principles of enzymology (e.g., transition state
The general structure of this section includes general management prin- theory) have been used directly in the design of new effective drugs against
ciples, with emphasis on preanalytic, analytic, and postanalytic components specific diseases such as hypertension and AIDS. Laboratory assessment
of laboratory analysis as well as oversight functions. Administrative con- of liver function is presented in Chapter 21 (which now includes new
cepts for the laboratory are considered in Chapter 1, with optimization of treatments for hepatitis C) and that of gastrointestinal and pancreatic
workflow presented in Chapter 2. Preanalytic factors such as variations disorders in Chapter 22. Toxicological analysis and therapeutic drug moni-
arising from specimen collection, transport, and handling and other vari- toring are covered in Chapter 23, with applications of both immunoassays
ables are discussed in Chapter 3. The principles of analysis, instrumenta- and mass spectroscopy emerging in endocrinology (Chapter 24) and

xiv
pregnancy and perinatal testing as well (Chapter 25). Nutritional analysis, 61), with immense concern about emergence of resistant strains; mycotic

Preface
with examination of vitamins and trace metals, is presented in Chapter 26. diseases (Chapter 62), with a wide array of photographs of cultures and
Chapter 27 elaborates the chemical principles of analysis, which is crucial photomicrographs; and medical parasitology (Chapter 63), with a world-
to the understanding of virtually all laboratory measurements and the wide significance that is growing as large numbers of people move between
common interferences encountered with blood and biological fluids. countries and continents. In line with the importance of achieving
Part 3, Urine and Other Body Fluids, reviews the utility and methods maximum diagnostic benefit from the laboratory, specimen collection and
for examining fluids other than blood. Chapter 28 presents the basic handling for diagnosis of infectious disease are detailed in Chapter 64.
examination of urine, with extensive discussions of both chemical testing Although classic techniques have consisted of culturing microbiological
and microscopic examination of urine sediment. A special area for consid- organisms with identification and antimicrobial susceptibility testing
eration is body fluid analysis, which has received national attention recently through functional bioassays, modern methods of nucleic acid amplifica-
in terms of standardizing the approach to testing of typical fluids and other tion and detection are now becoming widespread for each type of micro-
alternative specimens (Chapter 29). A large range of specimen types is biological organism; these applications are described in each chapter about
considered in this discussion, with extensive coverage of both microscopic the various organisms.
and chemical examinations. Part 8, Molecular Pathology, covers some of the most rapidly chang-
Part 4, Hematology, Coagulation, and Transfusion Medicine, intro- ing and exciting areas of clinical laboratory testing. Chapter 65 provides
duces techniques for the basic examination of blood and bone marrow an introduction to the role of molecular diagnostics, with an updated
(Chapter 30) and provides a wealth of background on the physiological discussion of the principles and techniques of the field in Chapter 66.
processes involved in hematopoiesis (Chapter 31). Erythrocytic disorders Similar updates are provided for the vital molecular diagnostic techniques
and leukocytic disorders and their diagnosis are covered in Chapters 32 of polymerase chain reaction and other amplification methods (Chapter
and 33, respectively. Modern techniques for use of flow cytometry for 67) and newer approaches to nucleic acid hybridization (Chapter 68). The
diagnosis of hematopoietic neoplasias are presented in Chapter 34 to application of cytogenetics, with modern methods of karyotyping, includ-
round out the approaches to diagnosis in this rapidly changing field. ing fluorescent in situ hybridization and examination for chromosomal
Immunohematology, which is so important for the understanding of eryth- abnormalities, is covered in Chapter 69. Translation of research tech-
rocyte antibodies and their impact on transfusion, is covered in Chapter niques to the molecular diagnostic laboratory is presented in Chapter 70,
35. Blood component manufacture and utilization are covered in Chapter which also deals with procedures for establishing a molecular diagnostics
36 along with transfusion reactions. Chapters 37 and 38 deal with the laboratory that follows all of the expectations for well-standardized testing
rapidly expanding areas of apheresis, with its applications to therapy of and is fully compliant with regulations and good laboratory practices.
multiple blood disorders as well as the collection, processing, and dispens- This section is rounded out with excellent presentations on the applica-
ing of hematopoietic progenitor cells (adult stem cells) from bone marrow, tion of molecular diagnostics to genetic diseases, for which screening is
peripheral blood, and cord blood for treatment of both malignant and becoming more important (Chapter 71), and to identity testing as used in
non-malignant diseases. parentage testing and forensic analysis (Chapter 72). Finally, an entirely
Part 5, Hemostasis and Thrombosis covers the vast increase in our new presentation on pharmacogenomics (Chapter 73) provides an under-
knowledge of the pathways involved in clotting and in fibrinolysis and the standing of how molecular analysis of selected genes crucial for response
panoply of new testing and therapeutic modalities that have evolved as a to therapeutic drugs or for the metabolism of drugs can be used to opti-
result. This section continues to reflect the impact of our growing knowl- mize individualized treatment plans, also known as personalized or preci-
edge of coagulation and fibrinolysis (Chapter 39) plus that of platelet sion medicine.
function disorders, with emphasis on von Willebrand disease (Chapter 40). Part 9, Clinical Pathology of Cancer, is a further outgrowth of this
Advances in the diagnosis and monitoring of thrombotic disorders are section that was new in the twenty-first edition. Because of the explosion
covered extensively in Chapter 41, with particular interest in the prediction of new diagnostic information as a result of the successful sequencing of
of thromboembolic risk. Along with our better understanding of throm- the human genome, genetic profiles of different forms of cancers are now
bosis have come new drugs for treatment of patients with vascular occlusive available. Specific forms of cancer are beginning to be diagnosed using
disorders, particularly ischemic events in the heart or brain. Principles of microchips containing gene arrays in which patterns of gene expression
antithrombotic therapy and the laboratory’s role in its monitoring are and mutation are evaluated. In addition, new methods of proteomics (i.e.,
covered in Chapter 42. Also discussed in this section is the major advance determination of the patterns of expression of multiple proteins in patients’
in pharmacogenomics (fully discussed later in Chapter 73) as it impacts body fluids and tissues) allow for cancer detection, monitoring, and treat-
anticoagulant therapies for individual patients. ment. Thus there has been a vast increase in information about the prin-
Part 6, Immunology and Immunopathology, presents a framework both ciples and applications of laboratory methods for diagnosis and monitoring
for classifying disorders of the immune system and for the role of labora- of malignancies in just the past few years. Chapter 74 deals with the
tory testing in diagnosing those diseases (Chapter 43). Measurements important protein markers for cancer in blood and tissues that are com-
based on immunoassays have long been the essential components of under- monly used for the diagnosis and management of malignant diseases.
standing a multitude of disorders; an excellent account of the principles of Chapter 75 extends this discussion through exciting new applications of
immunoassay and immunochemistry is included in Chapter 44. Evaluation oncoproteins and growth factors and their receptors in the assessment of
of the cellular immune system for diagnosing and monitoring immune malignancies and modification of therapies. A broad spectrum of molecular
defects is described in Chapter 45, which is newly updated. Humoral and cytogenetic markers is now commonly used for the initial evaluation
immunity and the examination of immunoglobulins in disease are covered of hematopoietic neoplasms (Chapter 76) that could well become a model
in Chapter 46, with particular emphasis on the evaluation of monoclonal for assessment of most, if not all, malignancies. Because the methods in
disorders in the blood. Material on complement and its role in inflamma- molecular pathology used in diagnosing cancer in body fluids are the same
tion is presented in Chapter 47. Chapter 48 is a new presentation on as in solid-tissue diagnosis, breaking down the barriers between anatomic
cytokines and adhesion molecules that are vital to inflammation and have and clinical pathology, we have now included a new chapter on the evalu-
become targets for therapeutic interventions. Also brought up to date are ation of solid tumors by these methods in Chapter 77.
Chapter 49 on the major histocompatibility complex (MHC), with its The prospects for early detection, prognosis, and implementation of
significant applications to organ transplantation, and Chapter 50, which treatment regimens for cancer based on specific alterations in the genome
looks at MHC and disease associations. The evaluation of immunodefi- have never been more apparent. These chapters on cancer diagnostics
ciency disorders includes many standard examinations for protein and emphasize genome-based approaches and other new methods such as pro-
cellular functions plus new genetic tests for specific abnormalities (Chapter teomics, which has the potential to identify patterns of protein alterations
51). The assessment of autoimmune diseases is presented for the systemic that can be used both for discovery of new targets for examination and for
rheumatic diseases (Chapter 52), with new chapters covering the vasculi- direct detection of clinical abnormalities. Many of these technologies have
tides (Chapter 53) and organ-specific diseases (Chapter 54). Allergic dis- been developed in the past few years, and many more versions of them are
eases, with their ever-increasing laboratory evaluations, are presented in sure to appear as the competitive advantage of rapid and inexpensive
Chapter 55. genomic analysis emerges. We think it is vital for pathologists to under-
Part 7, Medical Microbiology, covers an enormous spectrum of infec- stand the bases of molecular diagnostics, the power of this type of analysis
tious diseases and related topics that include viral infections (Chapter 56); for clinical decision making, and the paths such testing is likely to take in
chlamydial, rickettsial, and mycoplasmal infections (Chapter 57); classical the future. To this end, the final chapter (Chapter 78) presents the diag-
medical bacteriology (Chapter 58); and susceptibility testing of antimicro- nostic and prognostic impact of high-throughput genomic and proteomic
bial agents (Chapter 59). Other major topics and infectious organisms of technologies and the role they can play in the present and future practice
special note are spirochete infections (Chapter 60); mycobacteria (Chapter of pathology.

xv
 The fundamental task for trainees in laboratory medicine is to achieve gies. Although these new technologies will likely be expensive to implement
Preface
a sound understanding of analytic principles and the power and limitations initially, the hope is that they will reduce costs in other parts of the health
of laboratory examinations so that they can interpret whether abnormal care system through initiating prevention or treatment earlier than would
results are due to a patient’s physical condition or to other potential inter- be possible without such complex and intimate information about a patient’s
ferences such as altered physiological state, drug interactions, or abnor- disease state or propensity to develop a disease.
malities introduced by specimen mishandling. Based on mastery of these Within this context, it is clear that the role of the clinical laboratory in
technical aspects of test performance and interpretation, pathologists the future will involve more than simply providing numeric results for
should be able to recommend strategies to provide the appropriate level physicians to glance at during rounds or after clinic duty. The complexity
of care for multiple purposes: to screen for disease, to confirm a diagnosis, and enormity of the test results that will be routinely available will require
to establish a prognosis, to monitor the effects of treatment, and (more entirely new approaches to data presentation and interpretation to provide
recently) to assess the future risk of disease. National practice recommenda- useful information for clinical diagnosis and management. The challenge
tions from the American Medical Association and the U.S. Department of to laboratories and clinicians alike is to develop “meaningful uses” in which
Health and Human Services have led to the formulation of standardized electronic health records can store and present all of this information about
panels of multiple individual tests that are targeted to several organ systems, a patient—from cradle through an entire life—into which several segments
such as the basic metabolic panel and comprehensive metabolic panel are integrated: genetic background, environmental factors, previous diag-
(Appendix 7, available online with the other appendices). These panels nostic and monitoring tests, and contemporaneous monitoring tests. All
consist of individual tests that are highly automated and can be conveniently of these aspects of a patient’s history have the potential to be meaningful
and inexpensively delivered through most hospital laboratories. Such con- in the most rigorous sense to provide personalized medical treatments.
venience was not always the case when the assays for basic constituents This textbook provides grounding in the practice of modern laboratory
such as potassium, sodium, chloride, bicarbonate, calcium, bilirubin, and medicine, and it points the way to new disciplines that will contribute to
all the various metabolites, proteins, and enzyme activities were performed the evolution of strategies for creating, analyzing, and presenting medical
manually, as documented in previous editions of this textbook. Beyond information in the future. We hope that the discussions in this textbook
those relatively simple tests, immunoassays have also undergone a similar will stimulate our colleagues at all levels to embrace new diagnostic labora-
transformation. A mere 35 years ago, the rapid assay for thyroid-stimulating tory technologies (in addition to those that are now standard) and to retain
hormone (TSH) required 2 days, whereas today a third-generation TSH the most valuable from each of these into practices of the future. The
measurement can be completed in 20 minutes or less. Conversion from legacy of this book over the past century has been to provide a clear and
highly complex and operator-interactive testing to immediately available useful account of laboratory tests that generate the solid scientific informa-
and inexpensive assays will almost certainly occur with procedures that are tion upon which medical decisions are based. Building on that foundation,
now at the cutting edge of technology and require elaborate instrumenta- we enthusiastically anticipate new diagnostic capabilities, and we hope that
tion and special expertise to perform. These include tandem mass spec- this textbook will be a stimulus to their development.
trometry for small molecules such as hormones, vitamins, and drugs; whole It is a privilege and an honor to serve as editors for this twenty-third
genome sequencing for assessing the risk of developing hereditary disor- edition.
ders and diagnosing malignancies; and proteomics for screening a wide
array of proteins in blood, body fluids, and tissues for disease detection Richard A. McPherson, MD, MSc
and evidence of progression. The configuration of these assays will con- Matthew R. Pincus, MD, PhD
solidate multiple analyses onto miniature platforms such as chip technolo- February 2016

xvi
 Visit https://ebookmass.com
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 ACKNOWLEDGMENTS

We gratefully acknowledge the outstanding contributions made by our Hougie, MD; Abraham Braude, MD; Charles Davis, MD; James A. Rose,
expert colleagues and collaborators who served as associate editors: Martin MD; Robert P. Carty, PhD; Donald West King, MD; George Teebor, MD;
H. Bluth, MD, PhD; Jay L. Bock, MD, PhD; Wilbur B. Bowne, MD; Phillip Prose, MD; Fred Davey, MD; and Gerald Gordon, MD. We will
Robert E. Hutchison, MD; Donald S. Karcher, MD; Mark S. Lifshitz, always remember them and the standards for excellence they set.
MD; H. Davis Massey, DDS, MD, PhD; A. Koneti Rao, MBBS; Elizabeth The development of this edition, with its myriad details, would not
R. Unger, MD, PhD; and Gail L. Woods, MD. They all have made exten- have been possible without the outstanding professional efforts of our
sive contributions to the quality of this book, both through development editors at Elsevier: William R. Schmitt, Kathryn DeFrancesco, and Clay
of textual matter and through the exercise of practiced review of the chap- Broeker, each of whom added tremendously to this enterprise. We are
ters under their guidance. We deeply appreciate their efforts in this edition. sincerely grateful to them and to all the staff of Elsevier. They have made
We gratefully acknowledge the participation in previous editions of Dr. this endeavor a happy one. We also send very special thanks to Anne
Jonathan Miller, Professor of Pathology and Vice Chairman of the Depart- Erickson, who has drawn many of the illustrations in the twenty-first,
ment of Pathology at the University of Chicago Medical Center, under twenty-second, and twenty-third editions with a fine eye to beauty in
whose guidance Part 5, Hemostasis and Thrombosis, was developed in the presentation and ease of comprehension.
twenty-first edition of this book, and who first discovered platelet-type von We are grateful to all of the authors for accepting the challenge to
Willibrand disease; David J. Bylund, MD: David R. Czuchlewski, MD; participate in the education of future and present laboratorians and physi-
Thomas J. Dilts, MT(ASCP), MBPA; Andrea Ferreira-Gonzalez, PhD; cians in all fields of medicine by distilling the essential information from
Louis Fink, MD; Richard S. Larson, MD, PhD; Richard A. Marlar, PhD; each of their fields of expertise and creating a readable and authoritative
Rex M. McCallum, MD; Ankoor Shah, MD; Gregory A. Threatte, MD; text for our audience. Special thanks to the authors who have created
David S. Viswanatha, MD; and David S. Wilkinson, MD, PhD. We also wholly new chapters on molecular pathology and cancer diagnostics for
acknowledge our gratitude to them for the opportunity to revise their prior this edition.
chapters from the twenty-second edition for this, the twenty-third one. We also remember with perpetual gratitude the inspiration provided
It is with sadness that we note the passing of Herbert F. Polesky, MD, to us by John Bernard Henry, MD. He provided leadership for seven edi-
a world-renowned expert in identity testing, who authored chapters in tions of this book. Moreover, he encouraged us, guided us, and demanded
multiple editions of this book. We also recognize Robert F. Nakamura, excellence from us in our profession.
MD, who died just prior to the twenty-second edition; he is remembered Upon the completion of this twenty-third edition, we humbly thank
for his expertise and leadership in immunopathology. all the individuals who have played roles in making it possible. It is not
All of our students, residents, and colleagues have for decades contrib- possible to name all of the individuals who have contributed to this text-
uted enormously to the development of our knowledge of human disease book. To those mentioned here and to those not explicitly named, we thank
and the use of laboratories for diagnosis and patient management. We are you for your prodigious efforts and support.
grateful for all of their questions and the stimulus they have provided to
our professional growth. We are especially grateful for the mentorship and Richard A. McPherson, MD, MSc
encouragement provided in our careers by Alfred Zettner, MD; Cecil Matthew R. Pincus, MD, PhD

xvii
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We went to the Tower and saw the lions—two very fine fellows—a leopard and some other
wild creatures, and enjoyed the fearful pleasure of feeding the great brown bear with
cakes. On the way home, my uncle took us to see some of the goldsmiths' and other fine
shops, and bought us each a fairing. At one place, a silk mercer's, he asked the elderly
man in attendance about his son.

"He hath not yet returned," said the old man, shaking his head; "a dangerous service,
Master Corbet—a dangerous service; but we must not withhold even Isaac when the Lord
calls for him."

"Truly not, my brother," answered mine uncle; "but I hope the need of these perilous
journeys may soon be past. I heard it from one that knows what goes on at Court, that his
Grace is like to be moved of his royal bounty to give to this land a free gospel before long."

The old man's face lighted up: "The Lord fulfill it—the Lord fulfill it, Master Corbet. But
think you it is true? The Chancellor is very bitter against Master Tyndale?"

"The Chancellor is like to need his breath to cool his own porridge, if all tales be true," said
my uncle; "but this is not the place, nor does it become us to be talking of such matters. I
hope your son may soon return in safety."

When we reached home, which we did in time for supper, Betty was missing. Anne, the
laundry-woman, slept in our room that night. The next day we heard that Betty had been
sent to her home in the country, and old Madge had gone with her, not choosing to stay
after her favorite grandchild was disgraced. I don't think my aunt was very sorry to have
the old woman go of her own accord, though she would never have sent her away, for the
poor thing was grown so cankered and jealous that she kept the house in hot water. After
Betty's departure, some of the other maids were very forward in their tales of her
dishonest practices and running out of nights, but my aunt treated these tales with very
little ceremony, saying that the time to have told them was not behind Betty's back, but
when she was there to speak for herself. I hardly ever saw any one with such a strong
sense of justice as Aunt Joyce. It showed itself in all she did, and was one secret of her
success in governing a household.

Things had now returned to their usual course. I went about my lessons and my play with
the other children, and, warned by what had happened, was careful to give no just cause
of offense. My uncle was kinder to me than ever, but there was a cloud on his brow and a
look of sadness on his face when his eyes rested on me that I could not understand, and
which made me vaguely uneasy.

Once I heard my aunt say in a tone of deep regret, "Ah, nephew, if only you had not been
so hasty."

And my uncle muttered, "Mea culpa, mea culpa," and hid his face in his hands.

It was about two weeks after the affair of the flowers that I was coming in from the
garden, when I saw some one that I knew to be a priest by his dress, passing into mine
uncle's private room. I was not greatly surprised, for we had many clerical visitors, but
they were usually secular priests, while this man was a regular.

I went up to my room—we had been promoted to the tapestry room since Madge went
away, and felt quite grown up in consequence—washed my hands, and put on a clean
kerchief and pinafore, those I wore being the worse for my labors in the garden. As I was
finishing my dressing operations, my aunt entered the room, and I saw in a moment that
she had been weeping. All of a sudden—I don't know how—a cold weight seemed to fall on
my heart. I have had many such premonitions of evil in my day, and they have never come
without cause.

"My dear child," said she, and then she fell a-weeping as if her heart would break, for a
minute or two, I standing by, wondering what could have happened, and feeling sure that
whatever it was, it concerned myself. All of a sudden, a notion came across me, and I cried
out in anguish:

"Oh, aunt, have they come to take me away to the convent?"

"It is even so, my child," said my aunt, commanding herself with a great effort. "The
prioress of the convent at Dartford hath sent for you, and my nephew hath no choice but
to let you go."

If a tree that is torn up by the roots can feel, it must feel very much as I did that morning.
I had taken very deep root in my new home, and, except during the sad time when I was
in trouble about the flowers, I had been very happy. I had come to love my aunt and uncle
dearly, and the twins had become, as it were, a part of my very heart. I loved the
pleasant, easy ways of my uncle's household, where each was made comfortable according
to his degree; where abundance and cheerful hospitality sat at the board, and peace and
love were our chamber-mates, and watched over our pillows. My uncle was hasty-
tempered, it was true, but even a child as I was could see what a watch he kept over
himself in this respect.

But alas, and woe is me. Such a temper is like a package of gunpowder. The fire thereof is
out in an instant, but in that instant it hath done damage that can never be repaired.

I was absolutely stricken dumb by the greatness of the calamity which had overtaken me,
and could not speak a word. I think my aunt was frightened at my silence; for she kissed
and tried to rouse me. At last I faltered—

"Must I go to-day?"

"I fear so, my dear lamb. The prioress of the convent has sent for you by the hands of
their priest, and as two ladies are to travel down into Kent with him, you will be well
attended."

With that, my aunt bestirred herself, and called Anne, the laundry-woman, to help in
getting my clothes together. The twins had come in by that time; they had been away to
visit some old kinswoman of their mother's, and they had to be told the news: Both
Katherine and Avice cried bitterly, but I could not cry. I was like one stunned.

At last, at my uncle's summons, I was called down to the parlor to speak with the priest.
He was a good-natured looking, easy-going specimen of a regular, and greeted me kindly
enough, bestowing his blessing as I kneeled to receive it, in that rapid, mechanical fashion
I so well remembered in Father Barnaby and Father John.

"And so you are coming to the convent to be a holy sister, as my good Lady Peckham
desires!" said he. Then to my uncle: "In truth, 'tis a fair offering, Master Corbet. I almost
wonder that having such a jewel in your hands, you should give her up—that is, if she be
as towardly as she is fair of face?"

"Loveday is a good child in the main, though she has her faults and follies like other
children!" replied my uncle.
"And grown folks, too, eh, Master Corbet?" said the priest, with a jolly laugh. "I don't know
that the follies of youth are worse than the follies of age, do you?"

"They are not a tenth part as bad!" said mine uncle, with a good deal of bitterness. "'There
is no fool like an old fool,' is a true and pithy saying."

"Even over true!" returned the priest; then turning to me: "Well, daughter, you must have
wondered that you were left so long, that is, if you thought of it at all. The truth is, Sister
Benedict, who had the matter in charge, died soon after she came to us, and the affair was
quite forgotten, till your good uncle's letter reminding the prioress of her duty; she looked
over some papers Sister Benedict had left, and found my Lady Peckham's letter."

So it was my uncle's doing. I remembered all at once his own words: "I will not have an
obstinate liar in my family—" and the cloud that had rested on his brow ever since. He had
done the deed in one of his hasty fits of temper, and only for him, the prioress would never
have thought of sending for me.

Folks are apt to talk slightingly of the sorrows of childhood, but they must be those who do
not remember their own. When a cup is full, it is full, and that whether it hold a gill or a
gallon. I had been unhappy enough before at the prospect of going away, but that
unhappiness was nothing to the tide of wretchedness, of disappointed love and impotent
anger that swept over me. I think my first clear thought was that I would never let my
uncle see that I was sorry to go away. So when the priest asked me again whether I would
like to go to the convent I courtesied and said, in a voice which did not somehow seem to
be my own:

"Yes, reverend father, I shall like it very much!"

My uncle looked at me with a face of grieved surprise.

"Are you indeed so glad to leave us, niece!" said he.

"I am glad to go, if you want me to go, uncle!" I answered, in the same hard voice. "I
don't want to stay when you want to get rid of me, only—" and here I broke down—"only I
wish they had buried me in the same grave with my father and mother, and then I should
not be given away from one to another, like a poor fool or a dog that is in every one's
way!"

I do think I was the boldest, naughtiest child that ever lived, or I should not have dared to
speak so to my elders.

My uncle started from his chair as if something had stung him, and went hastily out of the
room.

The priest looked out of the window. My aunt laid her hand on my shoulder with that soft
yet firm touch which always had a great effect in calming my tantrums, as old Madge used
to call them, and whispered me to recollect myself and not anger my uncle.

Presently Father Austin called me to him, and began in a gentle, fatherly way, to tell me
how pleasant was the priory at Dartford, what a nice garden the ladies had, and what fine
sweetmeats they made—talking as one like himself would naturally talk to a child. He was
ever a kind soul, and glad I am that I have had it in my power to succor his reverend age.
But that is going a very long way before my tale.

"I trust the lady prioress will be kind to my niece," said my Aunt Joyce.
"I think you need have no fear on that score," answered Father Austin; "though the little
one is not like to have much to do with her. She will be under the care of the mistress of
the novices, an excellent woman, though I say it that should not, she being mine own
sister, and you need have no fears for her well-being."

Sambo now announced dinner, and my aunt led the way to the dining-room, where she
had prepared quite a feast to do honor to our guest, and perhaps to put him in a good
humor, though that was quite needless. I think the good man was the only one who
enjoyed the collation, though my uncle strove to eat out of courtesy, and my aunt heaped
my plate with delicacies which I could not touch.

"And now we must be stirring, for the days grow shorter than they were, and I would fain
be at home before dark, though we travel in good company," said the priest. "There are
two young ladies of the family of Sir James Brandon who travel down with us, and the
knight will send a sufficient escort with them. So, if it please you, Mistress Holland, let the
child be made ready as soon as may be."

"Her packing is all done, and it remains but to say farewell," said my aunt. "My nephew
hath also provided two serving men, one to ride before Loveday, and the other to drive
down and bring back the Sumpter mule."

"Sumpter mule! What is that about a sumpter mule?" asked Father Austin. "Does my
young mistress need a sumpter mule to carry her court dresses? She will have small need
of finery where she is going, Mistress Holland."

"A child of eight years has small need of finery any where, to my thinking," answered
Mistress Holland. "I am not one that likes to see a young maid dizzened out. But my
brother has prepared a present for the ladies."

"But a web or two of Hollands and black Cyprus lawn, with some packets of spices, sugar,
and the like," said my uncle, carelessly. "And since your reverence is pleased to like the
white wine, I have ordered a case to be put up for your own drinking. 'Tis a light and
wholesome beverage."

"Many thanks—many thanks!" said the monk. "Some people might say you meant to
secure a good reception for your niece—but, indeed, you need not fear for her," he added,
kindly. "The house at Dartford is of good repute, and our prioress is a most excellent lady,
of the noble family of Percy. Most of our sisters are also gentlewomen of good family. I
give you my word, Master Corbet, that Mistress Loveday shall have every care, though I
dare not promise her such feasts and luxuries as Mistress Holland provides."

"Luxuries are of little account to children, but kindness is every thing," said my uncle.

"And that, I promise you, she shall not lack," answered the priest, seriously; then, turning
to me: "Come, daughter, ask your uncle's blessing, and take leave of your cousins. Some
day, perhaps, they may come and see you, but it skills not lingering when parting must
come at last."

Mechanically, I kneeled to my uncle, who folded me in his arms.

"The blessing and prayers of an unworthy sinner go with thee, my poor child!" said he.
"Remember, whatever happens, thou wilt ever have a home and a portion in thy uncle's
house."

"She may need it yet, if things go on as they have begun," muttered the priest.
My cousins kissed me, and sobbed out their farewells as well as they could for weeping. I
went out to the side door, where the priest's sleek mule, and my uncle's two men were
waiting with their animals. My uncle kissed me again as he lifted me to my place behind
Jacob Saunders, and whispered:

"I shall come to see thee soon, dear child. Try to be happy, and remember my house and
heart are always open when you need a home."

"Why did you send me away, then?" I said bitterly, more to myself than him.

He heard me though, and answered, solemnly:

"Because I was a hasty fool, child. Pray for your poor uncle, and if you can, for your own
sake, forgive him."

The priest now mounted his mule, and exchanged a courteous farewell with my uncle and
aunt. The beasts were put in motion, we turned the corner, and in a moment, I lost sight
of the house where I had been so happy for four long months. It was many a year before I
saw it again. So closed one chapter of my life. It always did seem to me that I left my
childhood behind me at that moment.

I have been the more particular in my account of my days in London, as matters have so
greatly changed since that time. The little almshouses where we used to go to carry milk
to the poor bedesmen and women are all swept away, and the ground mostly built over.
What became of the old people I know not, but Sir Thomas Audley came into possession of
the land, which he afterward gave to Maudlin College at Cambridge. There is not a
religious foundation of any kind left in London, and St. Anthony and his pigs are equally to
seek. St. Paul's hath been burned to the ground—by lightning, as was believed at the time
and long after, till the sexton confessed on his death-bed that it was by his own fault—and
is now in process of rebuilding.

The city of London is almost twice as large as it was then; many places which I knew as
open fields being built up, and whole streets stretching out into the country. America,
which at that time was not known to many people at all—I am sure I never heard of it till I
came to London—is now visited by English ships every year, and merchandise brought
from thence. It is a changed world, and on the whole much for the better, whatever old
folks may say.

CHAPTER IV.
 A NEW LIFE.

WHEN we reached the Strand, we found the rest of our escort waiting for us before a
handsome house which I had often seen in my walks. There were two or three stout
fellows well-armed, and a sober, somewhat vinegar-faced man, dressed like a steward or
something of that sort. Two other men led palfreys caparisoned for women's use. As we
drew near and joined the group, the door opened and two ladies were led forth. They were
closely veiled, yet I could see that one was young and handsome. As she was put upon her
horse, she raised her veil for a moment and looked about with a wild, despairing glance,
like that of some small, helpless, trapped animal, seeking a way of escape. In a moment,
the veil was dropped again, the other lady mounted her horse, and the whole cavalcade
set forward as briskly as the state of the road would permit.

The fresh, sharp, autumn air; the quick movement, and the change of scene, roused me a
little from the heavy stupor of grief and rage—I know not what else to call it—which had
oppressed me, and I began to look about me. Father Austin seemed to note the change,
and began gently to point out different objects of interest. He showed me the house where
he himself was born and brought up—a comfortable old red brick hall, looking like the very
home of peace and plenty in its ancient elm and nut trees, and began to tell me little tales
of his boyhood, of his mother and sisters and his pet rabbits.

At first I was conscious of nothing but a wish to be let alone, but almost insensibly I began
to listen, to be interested, and asked little questions. The sharp, heavy distress was at my
heart still, but as one suffering from the pain of a wound is yet willing to be a little diverted
from his misery, albeit the pain is not lessened thereby, so I was not sorry to listen to the
kind father's tale. Presently we passed a building shut in by high walls, like a convent, and
as the road wound close by the gate, we could hear within sounds of somewhat unbridled
mirth and laughter.

"What house is that?" asked the steward, who rode close by us.

"It was the house of Our Lord once," said the father, dryly. "Now it belongs to Master
Cromwell."

The man bit his lip as if he had received some sort of check, and fell back a little. The
house was, in fact, one of the many small convents which had fallen during the past few
years.

We stopped at a way-side inn for some refreshment, and one of the men brought me a
glass of small ale, but I could not take it, and begged for a drink of pure water instead. My
head ached, and I felt parched with thirst. The priest asked the buxom hostess who
brought me the water, if there were any news.

"Nothing your reverence, save that the foxes have caught and carried off two or three
lambs, but 'tis thought their den will be broken up before long."

I saw two or three of the men who were standing about wink at each other as if there were
some jest concealed under the woman's words. Father Austin answered her gently:

"There are many sorts of foxes, and other beasts also, which spoil the flocks, and the
worst of all, are wolves which come in sheep's clothing: remember that, my daughter."

Young and distraught as I was, I could not but notice the difference between the treatment
of the priest here, and that which he would have received in our neighborhood at Peckham
Hall. There, whenever the abbot or Father Barnaby rode abroad, all bowed before them, as
if they had been the pope himself, and even our own old fat, sleepy Sir John, was greeted
with bared heads; but here, such as we met contented themselves with a careless lifting of
hat or cap for a moment, and many gave Father Austin no greeting at all. Others on the
contrary were very forward in craving his blessing, even kissing the hem of his robe or the
furniture of his mule.

The two ladies rode along close together, but never, that I could see, exchanging a word.
However, the elder did speak to the younger once or twice, but she got no answer save an
impatient shake of the head. It was now drawing toward evening, and I well remember
how the level rays of the setting sun shone through the orchards, making the ripening
apples glow like balls of gold and fire among the dusky leaves. The sight recalled so clearly
to my mind the orchards of my native West Country, that when we ascended a little rising
ground, and the priest remarked that we should soon see home, I looked out, expecting
for a moment to behold the gray battlements of Peckham Hall. But no doubt my head was
bewildered even then by the fever which was stealing over me.

"There, daughters, that is your future home," said Father Austin, pointing downward, when
we had attained the top of the little eminence.

The younger lady uttered an exclamation of some sort, and turned her horse as though
she would have fled, but her sister and the steward both at once laid their hands upon her
bridle rein, and she made no further move. I roused myself from the sort of stupor that
was bewildering me, and looked. I saw a large garden and orchard, surrounded by a high
stone wall, having an embattled gateway. In the midst was a pile of old red brick buildings
and a church. The little river Darent ran close by, and a stream seemed to be diverted
from it to water the convent grounds; I could see the water sparkling in the sun. It was, I
suppose, the hour of recreation; for various black-veiled and white-veiled figures were
walking in the orchard and garden, while even at this distance, the fitful sound of music
reached our ears. It was indeed a sweet and peaceful scene.

"That is Sister Cecilia practicing in the church! We have the best pair of organs in all the
country," said Father Austin, with simple pride; "there is nothing like them in all London."

We now put our horses to a brisk pace, and passing through the gateway I have spoken of,
we entered a sort of paved outer court, where the men dismounted, and we women folk
were also taken from our horses. We were led through an inner gate which opened upon a
long paved walk leading up through the orchard and garden to the house. I was growing
more and more confused; but I remember well all the sisters pausing to look at us, as was
but natural, poor things, and my feeling an unreasoning anger against them for so doing. I
have also a vivid impression of some bright flowers growing by the path. Two or three of
the dark-robed group now came forward to meet us.

"Here are our new daughters," said the priest, "and tired enough they are, poor things. I
fear the child is not well."

"Holy Virgin! I trust she hath not brought the sickness among us," said one of the number,
shrinking back.

"I dare say she is only weary with her journey," said a kind voice, and one of the ladies
took my hand to lead me into the house. "Come with me, my child, and we will find some
supper and a bed for these tired little bones."

I am conscious of hearing the words, but they sounded far and strange, as talk does in the
very early morning, when one is half-asleep. I heard also an exclamation of surprise and
pity, and then my senses failed me. The next I knew, I found myself being undressed and
put into bed, while my teeth chattered and every limb was shaking under the influence of
a strong ague.

From that time, for several weeks, my recollections are mostly a blank. I remember
begging for water, water, and loathing the apple-tea and gruel they brought me instead. I
remember seeing people about me and hearing voices, but it is all dim and dreamlike. At
last, one day, I woke and saw Father Austin standing by my bed, with a lady so exactly like
him, that if they had changed clothes no one would have known which was which.

"Water!" I gasped. It was always my first word on waking.

"Do you think I might give her a little?" asked the lady. "She does crave it so, poor little
thing."

"Yes, give her what she wants; it will make no difference," said the priest, sadly.

He went away, and the lady brought me a small cup of cool, fresh water. I drained every
drop and begged for more.

"You shall have more by and by, if this does not hurt you," said the lady. "Be a good child."

I dropped again into a doze. When I waked, I was alone, and the jug, from which my nurse
had poured the water, stood on a little table near by. An overmastering desire took
possession of me. I crept out of bed, and, steadying myself by the wall, I reached the jug,
and though I could hardly lift it so as to get at its contents, I drained every drop. There
must have been nearly a quart. Then getting back into bed, I fell asleep and slept soundly.
I woke from a dream of my home before I went to Peckham Hall, and found that it was
dark and the lady I had seen before was standing by me with a light in her hand. She bent
down and put her hand on my forehead.

"The saints be praised, here is a blessed change," said she. "The fever is wholly gone, and
your skin is cool and moist. Do you feel better?"

I made a motion of assent. Now that the fever had left me, I was as weak as an infant.

"Well, well. Perhaps the water did you good, after all. Do you want more?"

I nodded. She took up the jug, and seemed surprised to find it empty, but asked no
questions, and gave it to an attendant outside, who presently returned, and I had another
delightful drink, but I was not so thirsty as before.

"Do you think you could eat something, my child?" asked my new friend.

I assented eagerly, for I had begun to feel decidedly hungry. She again gave some orders
to the person outside, who, by and by, brought I know not what delicate preparation of
milk. I took all that was given me, and would gladly have had more.

From that hour my recovery was rapid, and I was soon able to walk about the room, which
was a large one with several beds, and was, indeed, the infirmary for the pupils. Then I
was allowed to walk in the gallery, and so, by degrees, I took my place in the family, and
began to understand somewhat of its constitution and politics.

Dartford nunnery was a place of no little consequence in my time, having some twenty
professed nuns besides the prioress and other needful officers, such as sacristan, mother
assistant and mistress of novices. It was a wealthy foundation, owning, besides its fair
home domain, other wide fields and orchards which brought in a good revenue. Most, if
not all of the sisters were ladies of family and breeding.

The house had a good reputation for sanctity, and certainly there were no scandals in my
time, or at least so I think, and I was always sufficiently sharp-sighted.

When I was able to walk about and see my new home, which was not till cold weather, I
had to confess that it was a fair one. The garden was very large and contained many fine
fruit trees, apples, plums, and cherries, besides great grape vines and apricots, trained in
curious fashion against the south wall.

The house had been founded in 1371, and it was said, though I doubt it, that a part of the
first fabric was still standing in my time. Any how some of the building was very old, and it
had been added to as convenience dictated, till there was no regularity to it; yet the
material being the same throughout, and the walls much overgrown with ivy, there
subsisted a certain harmony in the parts which was pleasing to the eye.

The church was a fine one and contained some valuable relics, such as Mary Magdalene's
girdle—she must have had a good many girdles in her time—a bottle containing some
smoke from the Virgin's fire, and a glass of St. Anne's tears, * with others which I don't
now remember, all inclosed in rich reliquaries and boxes, or highly ornamented shrines.
They were exposed in the church on feast days for the adoration of the faithful.

* All these relics are authentic, and may be found in Leighton's list contained in his
letters.

But the faithful were not so much disposed to adore as in times past. The leaven of
incredulity was spreading among the poor, and the new Learning, as it was called, among
the rich. It was understood that the king himself had his doubts about such matters; he
was at drawn daggers with the pope about his divorce; the great cardinal was in disgrace
and likely to lose all his preferments, and nobody knew what was likely to come next.

But we young ones, shut in by the gray stone walls, were happily unconscious of the
storms that raged without. Children are easily reconciled to any change that is not greatly
for the worse, and I soon became as much at home as if I had always lived here. I must
needs say that every one was kind to me, especially so when I was recovering.

I used to have terrible fits of homesickness, which were not lessened by the anger which
still dwelt in my heart against my uncle. These usually ended in a fit of crying and that in a
chill, so it is no wonder that Mother Joanna (that was the name of the Mistress of the
Novices) had a dread of them. So, at the last, she took to setting me tasks and work, and
finding that I had a talent for music, she put Sister Cicely upon giving me lessons upon the
lute and in singing, which lessons have since been of great use to me.

At my first recovery from my sickness, as I have said, my mind was almost a blank; but by
and by my memory came back and I began to recollect and compare things, and to ask
questions. Mother Joanna liked me about her when she was busy. Her eyesight was not as
good as it had been, and she found it convenient to have me thread her needles when she
was sewing, and do other little offices for her. One day, she was preparing some work for
the children (for we had a day-school in a little house near the gate, where the girls from
the village learned to sew and spin and to say their prayers); one day, I say, when we
were thus engaged, I ventured to ask:

"Dear mother, did my uncle come to see me when I was sick?"

"No, child, your uncle is gone abroad, as I understand, to Holland, about some matters of
business—but your aunt sent to inquire for you twice."

"Who came?" I inquired.

"How do I know, child! You ask too many questions. It was an elderly serving man with a
scar on his face."

"Joseph Saunders," I said. "Do you know if my aunt and cousins were well?"

"Yes, they are all well. I asked because I thought you would like to know."

"Dear mother, you are very kind."

"Well, I mean to be kind, and so I am going to talk plainly to you, child. You must give up
all notion of going back to your uncle's house, for that will never be. My Lady Peckham has
given you to this house—she having absolute control of you since Sir Edward's death—"

"Is Sir Edward dead?" I asked, in dismay.

"Yes, he died in Scotland. There, don't cry, my dear; I thought you knew it, or I would not
have told you so suddenly. I know it is natural for you to grieve for him, but we must curb
even natural affections when they stand in the way of our duty."

But I could not help crying. Sir Edward had been uniformly kind to me, and I loved him
dearly. The news of his death was a dreadful shock, and the end of it was, that I had
another ague and was sick for several days.

When I got able to be about again, I was sent for to the prioress's parlor. I had hitherto
seen this lady, only at an awful distance, and, so far as I know, she had never spoken to
me. She was a very great lady being some way, I know not how, akin to Bishop Gardner.

By the rule of our constitution, we were to elect a prioress every three years, but there
was nothing to hinder the same person from being elected again and again, and Mother
Paulina was such a Queen Log that I imagine nobody cared to get rid of her. She was an
indolent, easy-going body, caring, I do think, more for her own ease and comfort than any
thing else, and very little troubled as to how matters went in the house, so long as they
did not come in her way. Like many such persons, however, she now and then took a fit of
activity and authority, when she would go about the house interfering in every body's
business whether she knew any thing about the matter in hand or not, giving contradictory
orders and setting things generally at sixes and sevens. This happily accomplished, and
her conscience discharged, she would relapse into her great chair and her indolence again,
and leave matters to settle as they might.

One of these fits was on her just now. She had been out in the garden in the morning,
scolding the gardener about the management of the winter celery and the training of the
apricots, of which she knew as much as she did of Hebrew. I saw her two attendant sisters
fairly laughing behind her back.

As for the gardener, he was a sober old Scotsman, who had come to this country in the
train of some of the banished Scots lords, and liked it too well to leave it. He understood
his business, and his mistress, too. He would stand, cap in hand, in an attitude of the
deepest humility, listening to his lady's lectures and throwing in a word now and then, as—

"Na doot, madam! Ye'll hae the right o't. I would say so!"
Then he would go on his own course, precisely as if she had not spoken, and she, having
said her say without contradiction, would imagine she had had her own way. (It is not a
bad way to deal with unreasonable people, as I have learned by experience.)

I found the lady sitting in her great chair, beside a table on which was a crucifix of gold
and ivory, a vase for holy water, and a box which I supposed to contain some holy relic. A
handsome rug was before her chair, and she rested her feet on an embroidered hassock.
According to the custom of the house, two sisters stood behind her. The younger sisters
took this duty in rotation.

"So!" said she, when I had made my obeisance. "You are the child who was sent hither by
my Lady Peckham."

This in a severe tone, as if I had been much to blame for being such a child.

"And why did not you come hither at once, instead of stopping four months in London, and
putting me to all that trouble of looking over poor Sister Benedict's things, and finding my
lady's letter."

To which I could only answer that I did not know. As if a little chit like myself would have
any hand in her own disposal.

"Well, now you are here, you must be content. Mother Joanna says you are homesick and
make yourself ill by crying. That must be stopped. If I hear any more of it, I will try what
virtue is in a birch twig to cure ague. I am afraid you are a naughty child, or your uncle
would not have been in such a hurry to get rid of you."

How easy it is for idle or careless hands to gall a sore wound. Her words were like a stab to
me, but I set my teeth and clenched my hands and made no sign.

"But now you must understand, once for all, that I will have no more crying or
homesickness!" pursued the lady, who was like a stone that once set a-going down hill
rolls on by its own weight.

"You are in a good home and a holy house, where you may grow up without danger of
being infected by the heresies, which, as we hear, are so rife in London. Your good
mistress, Lady Peckham, will give you a dowry when you are professed, and some time
you may come to be prioress, and sit in this chair; who knows?" concluded the lady,
relapsing into an easy talking tone, having, I suppose, sustained her dignity as long as was
convenient. "So now be a good child, and here is a piece of candied angelica for you!" she
added, taking the cover from what I had taken for a reliquary, "and pray don't let us have
any more crying."

I took the sweetmeat with a courtesy, and afterward gave it to one of the lay sisters,
having no great fondness for such things.

"And how did you leave my Lady Peckham?" pursued the prioress; then, without waiting
for an answer: "We were girls at school together, though she was older than I—oh, yes,
quite a good deal older, I should say. Let me see, she married twice, I think. What was her
first husband's name?"

"Walter Corbet, madam?" I managed to say.

I was feeling very queer by that time, being weak and unused to standing so long. The
prioress was pursuing her catechism, when I saw the two attendant sisters look at each
other, and then one of them bent down as if to whisper in the lady's ear. That was the last
I did see or know till I woke, as it were, to find myself on the floor, with one of the sisters
bathing my face with some strong waters, and the prioress fussing about, wringing her
hands and calling on all the saints in the calendar. I felt very dreamy and strange, and, I
fancy, lost myself again, for the next thing I heard was Mother Joanna's voice, speaking in
the tone which showed she was displeased.

"You kept her standing too long, that is all. Nobody recovering from a fever should be kept
standing."

"You don't think she will die, do you, mother?" asked one of the sisters, I do believe out of
sheer mischief.

"Holy Virgin! You don't think so?" cried the prioress. "Holy Saint Joseph! What shall I do?
Send for Father Austin, somebody, quick! Bring her the holy Magdalene's girdle, or the
thumb of Saint Bartholomew. Holy Magdalene! I will vow—"

"Reverend mother, please do be quiet!" interposed Mother Joanna, with very little
ceremony. "The child is not dying, if she be not scared to death by all this noise. Sister
Priscilla, go and see that her bed is ready. Come, Loveday," in her crisp, kindly tone,
"rouse yourself, child. Why, that is well!" As I opened my eyes—"There, don't try to sit up,
but take what the sister is giving you, and we will soon have you better. Open the
casement a moment, Sister Anne; the room is stifling."

"Really, sister!" said the prioress, in an injured tone, "I think you should remember that
you are in my apartment, before you take such a liberty. The child will do well enough, I
dare say. It is more than half pretense to get herself noticed, and I believe might be
whipped out of her," she pursued, for having a little gotten over her fright, she was
beginning to be angry with the cause of it.

Mother Joanna treated the reproof and the suggestion with equally little ceremony, and
gathering me up in her strong arms, she bore me off to my bed in the dormitory, and went
to bring me some soup. I was quite myself in a few hours, and from that time, my health
improved so that I was soon as well as I had ever been in my life. Every one was kind to
me, as I have said. I went to work with great zeal at my lessons in music and needlework,
both of which I loved.

One day, I was holding some silk for Sister Denys. She was the novice who had entered
the house at the same time as myself, and had taken the white veil while I was ill. She was
very young, and, but for her unvarying expression of listless sadness, would have been
very pretty; but she moved more like a machine, than a living creature, never spoke if she
could help it, and faded day by day, like a waning moon. I more than once saw Mother
Joanna shake her head sadly as she looked at the poor thing.

Well, as I said, I was holding some thread for her, when somehow, I don't know how it
happened, I made use of a Latin phrase. I saw that she started, and her eyes brightened.

"Do you know Latin, child—I mean, so as to understand it?"

I was as much surprised as if the image of Mary Magdalene in the chapel had spoken to
me, but I made haste to answer—

"Yes, Sister Denys; I have learned it for two or three years. And I have read through the
'Orbis Sensualium Pietus;' * and some of Cornelius Nepos, and I have read a part of St.
Matthew his Gospel in the Vulgate—" (so I had, with my uncle). "I wish I had lessons
here," I added, regretfully. "I have forgot so much since I had the fever, and I love my
Latin, because I used to read it with Walter."

* I am not sure that I have not antedated this wonderful schoolbook.

"Who was Walter—your brother?"

"No, sister; my cousin," and then, in answer to her questions, I began, nothing loth, to tell
her of my home in Somersetshire.

Presently she dropped the silk, and I saw she was weeping bitterly.

"Never mind, little maiden—you have done me good," she said at last, as I stood by her
side, dismayed at her sorrow, yet feeling by instinct that it was better to let her have her
cry out, without calling any one. She made a great effort to check her sobs, and presently,
kissing me, she added:

"I know Latin, and I will teach you, if the mother is willing."

"I am sure she will be willing!" I answered. "She said herself it was a pity I should lose
what I had gained."

And the mother passing at the moment, I preferred my petition to her. I think she was
unfeignedly pleased to see poor Sister Denys interested in any thing. She did not go
through the usual form of referring to the prioress, as indeed, she was not obliged to do,
she having the whole care of the novices and pupils, but bade me fetch my books, which
had been sent me from London, and take a lesson on the spot.

For a while these lessons went on very prosperously. Sister Denys was a good Latin
scholar, and finding that I was diligent, reasonably quick, and liked learning for its own
sake, she began also to teach me French. All that winter I studied hard, and between
Sister Denys, Sister Cicely, with her music lessons, and Sister Theresa, with her
embroidery, I had my hands full. I did no more work than was good for me, and had plenty
of play and sleep, and, on the whole, I was very well content with my new home, though I
used, now and then, to have fits of longing after my Aunt Joyce and my cousins.

One day in spring, I was called to the parlor. Supposing I was wanted to do some errand—I
was errand-boy, or rather girl, for the establishment—I went carelessly enough. The
prioress was there, with her attendant sisters and mother assistant, and as I came forward
to the wide grating that divided the room, I found myself face to face with my aunt and
cousins.

What a meeting it was! Aunt Joyce had grown older and looked careworn, and the twins
were a head taller, but that was all the change. The mother assistant whispered to the
prioress, who assented.

"There, you may go outside the grating and speak to your aunt and cousins, child!" said
she. "You are not professed; so it can do no harm."

In another minute I was in my aunt's arms, smothered with kisses, and turning from one
to the other in a very bewilderment of joy. I could not help hoping for a moment that they
had come to take me away, but my hopes were quickly dashed.
They had come on another errand, namely, to bid me a long farewell. My uncle had been
back and forth between London and Antwerp several times, but now he had removed his
business wholly to that city, and determined to settle there for the rest of his life. There
was a great deal of commerce between Antwerp and London at that time, and more things
were brought over in the way of merchandise than passed the customs.

Again the mother assistant whispered the prioress, and then addressed herself to me.

"Loveday, you may take your aunt and cousins to see the church and the garden and
orchard. I am sure they will take no undue advantage."

"Surely not, reverend mother!" said my aunt, with a deep reverence. "It will be a great
pleasure to me to see my niece's future home. Joseph Saunders is waiting without with a
present for the house, and I have ventured to take the liberty of bringing down our cat, if
the ladies are fond of such pets. He is a fine creature and somewhat uncommon."

"I saw in a moment that mother assistant was gratified. She loved pet animals, and
indeed, that was about the only indulgence she ever permitted herself.

"A cat—oh, yes. Mother assistant will be delighted, I am sure!" said the prioress, rather
peevishly. "She loves a cat better than a Christian, any day."

"And my nephew hath sent a case or two of foreign sweetmeats and some Basle
gingerbread," * continued my aunt, without noticing this not very dignified outburst—"with
some loaves of sugar and a packet of spices. He hopes my lady prioress will condescend to
accept them as a token of gratitude for her kindness to his niece."

"Certainly—certainly, and with thanks!" answered the prioress, with alacrity. "Tell him, he
shall have our prayers for his journey. I am sure he cannot be inclined to heresy as they
say, or he would never send such nice presents to our house."

* Basle then, as now, was famous for its gingerbread, which is, in fact, a rich and spicy
kind of iced plum cake—made to keep long.

"There, go child, and show your cousins the garden and the orchard!" said the mother
assistant, interposing rather more hastily than was consistent with good discipline. "I will
come presently and make acquaintance with this wonderful cat."

I was not slow in availing myself of the permission.

As I stopped to shut the door, whereof the lock was out of order, I heard the prioress say,
in an aggrieved tone, "Really, sister—" and I knew she was, as usual, asserting her dignity,
and defending her authority, which took a good deal of defending, certainly.

I drew my aunt and cousins out to the gate, and we quickly released Turk from his
imprisonment. He was hugely indignant at first. But finding himself among friends, and
being invited to partake of refreshment, he very soon smoothed his ruffled plumes, and
before long was entirely at home.

"We could not well take him with us, and my uncle thought you would like to have him,"
said my aunt. "But let us look at you, child. How well you look, and how you have grown.
You are happy here, are you not?"

"Yes, aunt!" said I, indifferently. "If I cannot be with you and my cousins, I might as well
be here. They are all kind. But oh, aunt, why does my uncle go away so far—and to a
strange country, too?"

"I cannot tell you, dear child. He has good reasons, or he would never do so. You may
guess it is hard, in my old age, to be transplanted to a foreign soil, and have to learn new
ways and new tongues; but God knows best. His will be done."

"There are a great many English in Antwerp, my father says!" observed Katherine.

"Yes, that is true, and some that we know—at least, that your father knows."

"And my father says his house is a fine one—even finer than ours in London," said Avice;
"but I know I shall never like it as well."

"But tell me all about it!" said I. "Is Sambo going?"

"Yes, and Anne the launder, and Joseph Saunders, but no one else. Master Davis, the silk
mercer, hath hired our house, and he loves flowers as well as my father, so the garden will
be cared for."

"I should not think Joseph would go—he is so old!"

"He hath been there with my nephew and knows the ways and the language; so he will be
a help in getting settled!" said Aunt Joyce, who seemed to feel the change far more than
the girls, as was indeed natural. "But, after all, life is short, and Paradise is as near to
Antwerp as to London. That is the great comfort. But Loveday, now that we are alone
together, I must give you your uncle's charge and his letter."

The letter was short, but earnest. My uncle bade me make myself contented so far as I
could, but he charged me to remember that I was not to be professed till I was twenty-
one.

"Should any thing happen to make you need a home—as is not

impossible, if I read the signs of the times aright," so the letter
proceeded, "do you go to my old friend, Master Davis, the silk mercer,
who will always know where I am, and how to send to me. His wife is a
good woman, and they will gladly give you a home."

My uncle concluded by once more asking my forgiveness for his hasty

action, and most solemnly gave me his blessing.

My aunt bade me give her back the letter, and I did so, however reluctantly, knowing that
it would not be well to have it found with me. In a convent, nothing is one's own, and one
is all the time watched.

When we had seen the garden and orchard, the church and such other parts of the domain
as it was proper to show to strangers, we were called into the refectory where an elegant
little repast was provided, of which I was allowed to partake with them. The time for
parting came all too soon, for the ride to town was not a short one, and though the days
were now at the longest, the party could not more than reach home before dark.

I will not dwell on that sorrowful parting. Mother Joanna led me away, and when I had
wept awhile, she began to quiet me. She said what was true, that I had been greatly
indulged in being allowed such free intercourse with my friends, and that I must show my
gratitude by striving to restrain my grief so as not to make myself ill. She said a good deal,
too, in her sweet, gentle way, of submitting our wills to the will of Heaven, because that
will is sure to be best for us, since our heavenly Father seeing the end from the beginning,
and having, as it were, our whole lives spread out before him, can judge far better than we
can. (I began to observe, about this time, that while the prioress and the other ladies
invoked saints by the gross on all occasions, the mother assistant and Mother Joanna
rarely or never did so.) The dear mother understood me well. I saw the reasonableness of
what she urged, and made a great effort to control my feelings, and though my pillow was
wet with tears for that, and more than one night afterward, I took care that my grief
should be troublesome to no one.

It was not long after my aunt's visit, that another friend was taken, who proved a great
loss to me, and that was Sister Denys. She had gradually improved in health, and I believe
the interest she took in my lessons was a great benefit to her; but I do not think she
became a whit more reconciled to her way of life. She used to remind me of a vixen *
Walter had, which, though tame enough to know and love her keeper, and eat out of his
hand, did yet never give up trying to escape from her captivity. I remember old Ralph
saying that if the creature did once really give up the hope of getting away, she would die.

* All my readers may not know that Vixen is the proper name of a female fox.

Sister Denys was like that vixen, I think—the hope of escape kept her alive. About this
time, she began greatly to frequent a little chapel of our patron saint built in our orchard,
and more than once I had seen her talking with an old man, a great, awkward, shambling
creature with one eye, whom old Adam, our Scotch gardener, had hired to assist him. I
wondered what she wanted with him, but I had learned by that time enough of convent
politics to see much and say nothing.

One fine morning, Sister Denys and the old lame gardener were both missing, and when I
ventured to ask what had become of them, I was told that Sister Denys had gone to
another house to be professed, and that the gardener had been dismissed. Young as I was,
a kind of inkling of the truth came over me, but I did not know the whole of it till long and
long after that time. Of course, there was not a word of truth in the story, but almost any
thing is allowable to save scandal, as the phrase is, and a pretty big fib told in the interest
of the church is, at worst, a venial sin.

CHAPTER V.

THE THUNDER STRIKES.

I DO not propose to go very minutely into the details of my convent life. I remained at
Dartford for several years, fairly content for the most part, though I now and then had a
great desire after more freedom. I wearied of the trim grass plots, the orderly garden, and
the orchard shut in from the rest of the world by high walls, and longed to find myself in
the open fields, with no visible bound to my footsteps. I remembered my uncle's house in
London, and wished myself back there, or with the family in their new home. For a time
after their removal to Antwerp, I heard from the family. At least twice a year, a packet
came with letters for me, and some valuable present for the house, of spice, or comfits, or
wonderful lace, such as they know how to make in those parts. But after a time, these
packets stopped coming, and for many a year, I had no news of these dear ones at all.

I had one visit from my Lady Peckham during this time. She came to London on some
business about her husband's estate, which could not be easily settled, as there was no
absolute proof that Randall was dead. The next heir was a distant relation of Sir Edward's,
who lived near London. But this gentleman was an easy-going sort of person I fancy, or
perhaps he did not care about burying himself in that wild part of Somersetshire. Any how,
he agreed, in consideration of a certain share of the rents of the estate, to let Lady
Peckham live in the house as long as she pleased. She had brought Sir Edward a good
fortune, which was settled wholly on herself, so she was very well-to-do.

It seemed to me that she had altered very little. She had accepted the mantle and veil,
and made the vow of perpetual widowhood, and so might be looked upon as, in some sort,
a religious person as the phrase went in those times. She staid with us a month or more,
and was, or professed to be, very much edified, though I think she was rather scandalized
at the easiness of our rule, which was, indeed, very different from the discipline which
used to be enforced at the house to which I had been first destined at Bridgewater. I do
not mean to say that there was any disorder—far from it: but things went on in a
comfortable, business-like fashion. There were so many services to be gone through, and
they were gone through with all due gravity and decorum. We had beautiful singing, which
people came from far and near to hear. We kept our fast days strictly enough as regards
the eating of flesh meat, but our own stews gave us abundance of fish, and our orchard
and garden supplied fruit and vegetables, so that we certainly did not suffer from our
abstinence.

However, I suppose my lady must have been well pleased on the whole, for she tried very
hard to make me consent to take the white or novice's veil. This, however, I would not do,
pleading my solemn promise to Sir Edward and my uncle Gabriel. My lady declared that
such promises made by a child amounted to nothing, and appealed to Father Austin. I
don't know what he said to her, but it must have been something conclusive, since she
said no more to me on the matter.

I ventured to ask about my old friend and playmate, Walter Corbet. She told me that he
was still with Sir John Lambert, at Bridgewater, assisting in the care of the parish, but that
he had some prospect of a new field of his own in Devon, not far from my old home.

"'Tis a wild and lonely place, and almost a savage people, so I am told," said my lady. "But
Walter seems to think the prospect of burying himself among them a delightful one. Oh, if
he would but have taken the vows at Glastonbury, he might come to be abbot in time,
instead of living and dying in the gray walls of Ashcombe vicarage."

But those same gray walls are still whole and warm, while Glastonbury is but a stately
ruin, wasted by all the airs that blow freely through its deserted halls. This, by the way.
My lady left us, as I have said, at the end of a month, to return to Peckham Hall, though at
her first coming she had talked of spending the remainder of her days among us. But I
think she was wise. Such a life as ours would not have suited her at all. She liked to rule
wherever she was, and had been used many years to almost absolute authority, for Sir
Edward rarely interfered in any matter which concerned the household; and she was too
old and too set to learn new ways. From something I overheard, I don't think mother
assistant favored the notion. I have heard her say myself that a nun ought to be professed
before she is twenty. I never saw my lady again, though I heard from her now and then.

Mother assistant was now the real head and ruler of the house, for the prioress grew more
and more indolent every day. She excused herself on the score of her health, though I
cannot but think she would have been well enough if she had taken more exercise and
eaten fewer sweetmeats. She could not have had a better deputy than the mother
assistant, who was an excellent woman and well fitted to rule a household. I never saw a
woman of a more even temper, and she had that precious faculty of making every one do
her best in her own place.

Mother Joanna continued mistress of the novices, though her task was a light one, for we
had very few accessions; our elections were regularly gone through with, but they were no
more than a form, since the very same officers were elected over and over, save when
some one died. Sister Sacristine, who was only a middle-aged woman when I came to
Dartford, was growing old and feeble. Two new bursars had been elected. The trees had
grown older, and the old Scotch gardener more opinionated. Sister Cicely's hands grew too
stiff to manage the organ at times, and I often took her place, and acquitted myself to the
satisfaction of my hearers; and these are about all the changes I remember, till the great
change of all.

I have said our lives were very quiet, and so they were. But when a storm is raging, it is
hard to keep all knowledge or sign of it out of the house. We heard, now and again,
rumors of the changes that were going on outside. I remember well when Sister Emma,
the stewardess, heard from Dame Hurst, who now and then brought oysters and other
sea-fish for sale, that a great English Bible had been chained to a pillar in the parish
church at Dartford; where any one who listed could go and hear it read, or read it for
themselves, if they pleased. Sister Emma told us this wonderful piece of news when we
were all assembled under the grape-arbor, shelling of peas for our fast day mess.

It was received with a degree of horror and amazement, which seems strange as I
remember it, now that every householder who can afford it may have a Bible of his own.

"What an indignity!" exclaimed Sister Agnes. "To think that the Holy Scripture should be
chained to a pillar, like a man in a pillory, to be thumbed over by every village clown or
dirty fisherman who can make shift to spell out a few words."

"You would not compare a pillar in the house of our Lord to a pillory, would you, sister?"
asked mother assistant, with that gentle smile of ridicule which I, for one, dreaded more
than the rod, when I had been naughty.

"Why, no, reverend mother, not exactly," answered Sister Agnes, in some confusion.

"Any how, it is not the true Word of God, but only the heretics' translation," said Sister
Margaret, sharply. "So it does not matter what is done with it."

"I don't know about that," remarked another sister, rather timidly. "I suppose it could not
be put in the churches every where, without the consent of the bishops and the other
clergy; and they would not allow an heretical and false translation in such a place, surely.
Only it is a pity the poor people should be allowed to peril their souls' salvation by reading
the Scriptures in the vulgar tongue."

Even then, I remember, it struck me as curious, that peoples' salvation should be

endangered by reading the Word of God, but I said nothing.

"They will never put any such thing in my church—chained or unchained—that I know,"
said Sister Sacristine, with great emphasis, and in her earnestness emptying the peas in
her lap among the cods in the basket. "I would tear up the book with my own hands,
before such things should be allowed near to the shrine of the Holy Magdalene. Thank the
saints, we are not subject either to bishop or archbishop, but to our own visitor, and I am
very sure he would never order such a thing."

"In that case, it is hardly worth while to waste one's breath discussing the matter," said
mother assistant. "Loveday, you had better pick up the peas that Sister Sacristine has
scattered. It is a pity they should be wasted."

"There is no telling what will happen—no telling," said a very old sister, who was warming
herself in the sun. "I have strange visions—I do. I saw last night the walls of the fold
pulled down, and the sheep scattered far and wide. But I hope it won't come in my time. I
have lived here in these very walls almost eighty years, and I don't want to live any where
else."

"No, there is no telling, and therefore we may dismiss the subject," said mother assistant.
"When they come to ask us to chain a Bible in our church, it will be time for us to refuse it.
'Each day's trouble is sufficient for the same selfe day.'"

The striking of the bell warned us of the end of recreation, and sent us about our several
tasks; but the mother's words lingered in my ears, and I found myself wondering again
and again where I had heard them before. At last I remembered; I had read them in my
uncle's great book—Master Tyndale's book of the New Testament, as I afterward knew it to
be—on the very first day that I came to London.

Well, the days went on, and though we heard rumors of this and that—of the disgrace of
poor Queen Katherine (which I do maintain was an infamous shame), and the marriage of
the King with Anne Boleyn, mother of our present good Queen—of the burning of heretics
here and there, and the king's taking church matters more and more into his own hands—
though, as I say, we heard rumors of all these things, they did not greatly disturb our
peace. Our gray circling walls were like the magic circle of the enchanter, and though
strange and malign shapes were seen in very active exercise outside its bounds, yet none
had as yet broken through. But our time was to come.

It was on a pleasant day in the end of September, in the year of grace 1538, that the first
blow fell upon us.

By the same token we had, on that very day, buried old Turk in the garden under a
beautiful laylock tree. The poor old cat had been very decrepit for a long time, having lost
most of his teeth, so that he had to be fed with hashed meat, and bread soaked in cream.
Old Adam had said more than once that the poor thing would be better put out of his pain,
but I don't believe you could have hired him to do the deed—no, not with a Dutch tulip-
root.

Well, it was on that very day that, coming in from the orchard with a basket of early
apples, I saw Father Austin walking up the paved path, which led from his house to the
church, with such a perturbed face as I never saw him wear before. He passed through the
church, and presently the whole family were called together in a great hall which joined
the church, and was called—I don't know why—the chapter-room. It was the room in
which our elections were held, and was seldom or never used on other occasions. There we
were, old and young, all standing according to our degree, and some of us looking scared
enough, for rumor flies fast, and we all had an idea that something dreadful was going to
happen.

The prioress sat in her great chair, with her attendant sisters behind her, and looked about
with a dazed, helpless expression. She had grown very stout and unwieldy, and some of us
thought she was not quite right in her mind. The elders of the house were at her right
hand, and near by stood Father Austin and another priest, with a thin, clever, crafty face,
whom we knew to be Bishop Gardiner's chaplain, and a person of great consideration. I
always had a dislike to this man; chiefly because the shape of his head—very flat behind,
and with prominent angles at the jaw-bones—reminded me of a viper. I could not help
thinking at that moment that he watched the prioress as a viper might watch a fat frog on
which he had a design.

When we were all settled, Father Austin raised his hand, and spoke: "My mothers and
sisters, your reverend prioress has called you together to hear a most important message
which our visitor has sent us by his chaplain, Father Simon, who will now deliver the
same."

With that he was silent, and Father Simon spoke. I cannot remember his words, but the
gist of the matter was this: The king had wholly broken off with the pope, and, by consent
of the parliament, had proclaimed himself supreme head of the English Church. All
bishops, heads of religious houses, and certain other officers were required to take the
oath of supremacy, as it was called, under severe penalties—even that of death—as was
like to be the case with the Bishop of Rochester, who was now in prison and threatened
with the loss of his head. (He really did come to the scaffold soon after.) It was probable
that commissioners would shortly be sent to our house to administer this oath, and Bishop
Gardiner—who, though not our bishop, was our regular visitor by some ecclesiastical
arrangement which I never understood—had himself taken this oath, and advised us to
submit to the same, as a necessity of the times.

I was watching the prioress's face during this harangue, which was delivered in a very
gentle and insinuating manner. (My eyes should have been on the ground, but they have
always had an unlucky trick of wandering.) I say, mine eyes should have been on the
ground, but they were watching our mother's face instead, and I was surprised to see the
change that came over it, as the words and meaning of the father's address penetrated
her understanding. Usually her visage had about as much expression as a slack-baked pie,
and was nearly the same color. By degrees, as she understood the matter, her dull eyes
opened wide, and grew bright and clear, her loose under-lip was compressed, and a little
color came into her cheeks. When the chaplain was silent, she spoke, and with such a clear
voice and so much dignity of manner that the sisters glanced at each other in surprise.

"I am somewhat slow of comprehension, good father. I pray you bear with me, if my
questions seem not to the purpose. What is it that the king hath declared himself?"

The chaplain once more explained that the king now called himself supreme head of the
church.

"But the pope—our Holy Father at Rome—is supreme head of the church in all
Christendom!" said the prioress. "How, then, can that title belong to His Grace, the King of
England? There cannot be two supreme heads."
I saw the chaplain cast a keen glance of satirical amusement at Father Austin before he
proceeded to explain once more that the king, having quarreled with the pope, in the
matter of his wife's divorce and some other things, utterly denied him any authority or
jurisdiction over the realm of England or its dependencies, and required all persons to
submit to him, as formerly to the pope.

"But he is not the head, so what difference does it make what he calls himself?" persisted
the prioress. "And how can the bishop, who is himself sworn to obey the pope in all things,
obey the king when the king is opposed to him."

"I am not here to explain or justify the conduct of your venerable visitor, reverend
mother!" said the chaplain, rather arrogantly. "But only to convey you his counsels and
commands. The further continuance of this holy community—nay, your own life—may
depend on your obedience. You would not like to be put in prison, like the Bishop of
Rochester!"

Knowing the mother's love of ease, I suppose he thought this a knock-down argument, but
he was mistaken. One may know a person very well, and yet not be able to foretell what
that person will do in an emergency.

"I should not like it at all!" said the prioress. "It would be very uncomfortable to lie upon
straw and have nothing but bread and water, and cold water always makes me ill. But I do
not see how that makes any difference about the pope being head of the church, and if he
is supreme head, then the king cannot be. That is all about it."

With that the chaplain took on a higher tone, and began to bluster a little. Would she, a
mere woman, pretend to sit in judgment not only on a bishop and her visitor, but also on
the king himself? Was it not her duty as a religious to have no mind of her own, but only
to do as she was told?

"You did not think so, reverend father, when the question was of placing an English Bible in
the church for the sisters to read when they pleased!" said the prioress. "That was the
king's will, too, as I understand, and yet both our visitor and yourself said I was right in
refusing, because ours was not a parish church. And the very Bible that was sent down lies
locked up in the press in the sacristy. Does it not, mother assistant?"

"It was there at one time, but I have had it removed to a safer place!" answered the
mother assistant, quietly. I saw the sisters exchange glances of amazement from under
their down-dropped lids. This was the first time we had heard of any such book. But that is
the way in a convent. A measure which affects your very life may be settled, and you be
none the wiser.

"Very well, reverend mother, I shall say no more at this time!" said the chaplain, after a
moment's pause. "I will report to your reverend visitor that you have decided to take
matters into your own hands, and that being the case, he will doubtless leave this house
and its inhabitants to their fate—that fate which has already overtaken so many religious
communities. When the commissioners come down and you see your revenues confiscated
and your daughters turned out, and the beautiful shrine of the Holy Magdalene stripped of
all its ornaments and treasures, I hope you will be satisfied with your contumacy."

"I shall not be satisfied at all, and I don't want my daughters turned out!" said the
prioress. "And I am not contumacious, either. I have always done just as our visitor
directed about every thing, and you know I have, Father Simon; only I can't see how the
king can be supreme head of the church, when the pope is the head! I would lay down my
life for this house!" she added, raising herself from her chair and standing erect with a
dignity that might have belonged to St. Katherine of Egypt, or any other sainted queen. "I
would be torn by wild beasts before my dear, dutiful children should be turned out upon
the world; but I can not deny the authority of our Holy Father the Pope, and put another in
his place, without greater and better reason than I see now, and so with my humble duty
and reverence, you may tell his reverence, Sir Chaplain."

We looked at each other without disguise now, so great was our amazement. If the figure
of the Holy Virgin in the Lady Chapel had spoken, we should not have been more
surprised. But we had not long to indulge our wonder. I saw the mother assistant move
nearer to the prioress, and in another instant the poor lady had sunk down in her chair in a
fit.

The room was all in confusion for a moment; but nuns, like soldiers, feel the power of
habitual discipline, and in a minute or two, mother assistant had restored order. She and
the sick-nurse were supporting the prioress, and she called me to help her, as I was one of
the strongest of the family, bidding the others betake themselves to the work-rooms,
where was their place at this hour.

We carried the lady to her own room, with the help of the two priests—we could hardly
have done it without them, she was so heavy—and Father Austin, who was surgeon as well
as priest, proceeded to bleed her. The blood would hardly flow at first, but at last it did,
and the treatment was so far successful, that the mother opened her eyes, and swallowed
the restorative which was put into her mouth, though she did not try to speak, and
seemed to know no one. We undressed her, and got her into bed, and then mother
assistant dismissed me, bidding me go and take the air a little for that I looked pale.
Indeed I had had much ado to keep from fainting, as I had never seen any person bled
before, but I summoned all my resolution, and held out.

I went to the workroom where all the sisters were assembled round the frames, on which
the new hangings were being worked for the Lady Chapel. We were permitted so much
converse as was actually needful, at such times, and not uncommonly the liberty was
stretched a little, for, as I said before, the discipline of our house was not over strict; but I
never heard such a gabble as was now going on. As I entered and went to the press to find
my own particular bit of work (which was a piece of needle lace on a small frame),
intending to take it out into the summer-house, I was assailed by a volley of questions.

"How is the reverend mother?" "Hath she spoken?" "Will she die?" "Will she live?" "Will she
take the oath?" "Where is the mother assistant, and Mother Joanna?"

It vexed me to see them all so ready to take advantage of their elder's absence, and I
answered, rather sharply, I fear.

"How many more? The mother is better, but she has not spoken, and no one knows
whether she will live or die—much more whether she will take the oath. As to mother
assistant, and Mother Joanna, it is very plain that wherever they are, they are not here.
One could tell that half a mile off."

Some of the sisters looked ashamed, but Sister Perpetua answered me sharply:

"You are very pert, Sister Postulant." (That had been my rank for a good while now, for I
had no other thought than to end my days at St. Magdalene's.) "It does not become you to
reprove and check your elders."

"It does not become her elders to give cause of reproof!" said Sister Bridget, a quiet,
retiring woman, the elder of the party: "The child is right, and we have been to blame. As
the oldest present, I must request you, sisters, to be quiet and attend to your work."

"You are not the oldest present," answered Sister Perpetua. "Sister Anne is older than
you."

"No, indeed, I am not!" said Sister Anne, with some sharpness. "Sister Bridget is fully half
a dozen years older than I am, are you not, sister?"

"More than that, I should say," replied Sister Bridget, tranquilly. (N. B. * She was very
pretty and young looking, while Sister Anne was both plain and wrinkled.) "But you know
as well as I, sister, that it is not age, but standing in the house, that settles such matters.
Again, as the oldest present, I must request you, sisters, to pursue your work in silence.
Prayers and psalms and holy meditations are better fitted for people in our evil case,
threatened not only with the death of our reverend mother, but with the loss of all things,
than such laughing and gossip as has gone on for the last half hour. I take shame to
myself, and thank the child for her reproof, though it might have been more gently
spoken."

* N. B.—nota bene

"I beg your pardon, sister," said I.

She had spoken with a great deal of gravity, and feeling, and most of the sisters had the
grace to look ashamed, only Sister Perpetua muttered under her breath, but so I heard
her:

"Fine airs, to be sure. But you are not prioress just yet, and many things may happen."

I don't know what brought her to a religious house, I am sure, unless it was that her
friends wished to get rid of her, which was the reason a great many nuns were professed in
those days. I am very sure she never had any vocation for such a life, and she showed it
after she got out.

By that time my faintness was gone, but I thought I would like to be alone, so I told Sister
Bridget what mother assistant had said, and withdrew.

I had plenty to think about as I worked. Could it be possible that our house would be
turned out of windows, as that of the Gray Nuns at Bridgewater had been—that venerable
institution founded in the days of the Confessor—and if so, what would become of all? I
had not heard from my uncle, nor from Lady Peckham in several years, and knew not
whether they were alive or dead. However, I was not so greatly concerned about my own
fate. I was young and strong, a good needle-woman and musician, and I thought I could
easily find a place as waiting-woman, or to attend upon young gentlewomen.

But what would become of such as Sister Bridget and Sister Cicely, and Sister Sacristine
and Mother Joanna—old women who had spent all their lives in those walls, and knew
nothing of the world beyond their boundary. Then I began to think about that Bible and to
wonder where it was, and what was in it. I remembered the text mother assistant had
quoted, and wondered—not without blaming myself for the thought—if she had read it in
that same Bible.

We had heard before, that though people were permitted to read the Word of God, they
were forbidden to discuss or dispute about it, which was much as if one should open the
floodgates a little and then forbid the water to run through.
I was so lost in my musings, that I started as if I had been shot when the bell rung for
vespers. We heard at supper that the prioress had rallied a little, but neither Father Austin
nor the doctor, who had been sent for, believed she could get well.

That was an anxious time. The prioress lingered for several days, sometimes quite herself
for a few hours at a time, but mostly lying in a death-like stupor. The elders were of course
much with her, and the discipline of the house was unusually relaxed.

It was a time that showed what people were made of. The really sincere and religious
sisters went on with their duties just as usual, being perhaps a little more punctilious in
their performance; others took advantage, broke rules, got together in knots and coteries
and gossiped—not always in the most edifying way—of what was coming to pass, and what
they would do when they got out. I was very angry with them then, but I can make more
excuse for them in these days. Many of them, like Sister Perpetua, had no real calling to a
religious life (it was called the religious life in those days, as if no one could be religious
out a cloister). They were mostly younger daughters and orphan sisters, who were not
likely to marry well and were sent to the convent as a safe and respectable place out of
the way. Not that all were so, by any means, but we had enough of that element to rejoice
in any relaxation of rules.

One day at sunset, however, the suspense was at an end so far as the prioress was
concerned. We were all called into the ante-room of the apartment to assist at the last
rites, and after they were over, we stood watching our poor mother who, supported in the
arms of mother assistant, was painfully gasping her life away. Her face wore an anxious
expression, and her eyes turned from one to another in a way that showed she was quite
conscious. Now and then she said a word or two in a low tone—so low that we in the outer
room could not hear. At last mother assistant beckoned me, and whispered me to give her
a dry napkin from a pile that lay on the table.

As I did so, I heard the prioress say, in a distressed whisper:

"But Purgatory—that dreadful place—are you sure?"

Mother assistant bent down to her and whispered in her ear—I was close by and heard the
words plainly:

"The blood of Jesus Christ cleanseth us from all sin."

The poor lady smiled, and just as the last ray of the sun shot into the window, she passed
peacefully away.

She was a good woman in the main, and very much of a lady, but she had allowed
indolence—coming from an illness in the first place—to grow upon her, till it became an
overmastering passion—if one can call indolence a passion.

It came to that, that any call to exertion was looked upon as a positive misfortune. She
had such able assistants, that this state of things did not produce so much trouble as
might have been expected, but any one who knows what a houseful of ungoverned young
people is like, may guess what our community would have become but for Father Austin
and mother assistant.

As soon as it was decent, a new meeting was called, and no one was surprised at the
choice of mother assistant to be prioress. Mother Joanna was made assistant and Sister
Bridget put in her place—a very good choice.

At "obedience," when we were all assembled in her room, our now prioress made us an
address, and very noble and touching it was. She reminded us of our precarious condition,
likely at any time to be turned out. She said she had been pained to know that some—she
would name no names at present—but would leave the matter to our own consciences—
had taken advantage of the state of things to behave in a way which was unbecoming their
profession, and to good order. Here two or three of our best sisters who had been guilty of
some little acts of forgetfulness kneeled down and kissed the floor, while Sister Perpetua
and Sister Regina, who had been the ring-leaders, stood up as bold as brass. (It is always
those who deserve blame least who take it to themselves.)

She then pointed out the importance of good order and discipline, that our enemies might
have nothing whereof justly to accuse us. She would not conceal the fact that we stood in
great peril, but we were in higher hands than our own. She would have us neither anxious
nor careless, but pursuing a recollected and cheerful frame of mind, giving ourselves to
prayer and good works, and not being anxious about the morrow. She would pass over all
that had happened for the last few days, unless there were those who wished to clear their
consciences by confessing any breach of discipline: but hereafter, every thing would be
kept up to the standards of the house. She concluded by asking our prayers for herself and
her assistants, in a tone of true humility that brought tears to many eyes. We noticed that
she said nothing about praying for the soul of our departed mother, whereby we argued
that she believed that soul to be already in Paradise. She then dismissed us with her
blessing, and all things seemed to fall into their usual train.

I have heard that people who live where there are volcanoes, get used to them so that
they carry on their business just as if nothing was the matter. We were then living on the
crust of a volcano which might blow us into the air at any time, but we had already
become used to it, and as the autumn passed into winter, we almost forgot our danger.
Sister Perpetua, indeed, tried titles once or twice, but she soon found that while the
reverend mother had a house over her head, she meant to be mistress in it, and after
doing penance three whole days in the vaulted room under the sacristy on a diet of bread
and water, and not much of that, she was very meek and subdued for a while.

Somehow or other the storm was diverted for that time. I suppose that Bishop Gardiner,
being so great with the king, contrived to keep the matter from his knowledge. However it
was, the apples were gathered and garnered in peace, the usual stock of faggots laid in,
and we settled down to our in-door occupations as if nothing was the matter.

The reverend mother had a great deal of work put in hand, and instead of our usual
whispered conversations, we had loud reading in the Imitation of Christ, and other good
books. Sometimes our mother would read us passages out of the Gospels, from a little
written book which she held in her hand, copied I fancy from that same great Bible which
was never put in the church. I had read many of them before in the great book of Master
Tyndale's, which my uncle kept in his desk, and they set me thinking more than ever of
mine old home. These readings were much liked by the serious part of our community, and
as for the others, what ever they might feel, they knew enough to keep their own counsel.

It was about this time, I remember being struck with the fact that in the whole Imitation,
from beginning to end, there is not one single word or hint of any worship offered to the
Virgin. I ventured to say as much once to Father Austin, with whom I still did a Latin
lesson now and then, and to ask him what he thought was the reason; whereat he smiled,
and said when I saw Saint Thomas in Paradise I might ask him.
The orchards bore very plentifully that year, and we sold our crop at a good price. We were
helping to pick up the last of them one fine October day, when old Adam remarked that he
wondered who would have the ordering of those same trees another year.

"Why, you yourself—why not?" said I.

"Na, na, lassie, I'll no be here next year; at least I think not."

"You do not think you are going to die?" said I, anxiously, for he was a great friend of
mine. "Do you feel ill?"

"No, I have my health well enough for one of my years. But we Islesmen have whiles a
gliff of the second sight, and I have had strange visions concerning this house."

"Oh, you are thinking about the visit of the commissioners!" said I. "But you see that has
blown over and nothing has come of it."

"I have whiles seen a storm blow over and then come back!" said the old man, seriously.
"Na, na, lassie. Dinna be too confident. What's fristed * is no forgotten."

* Fristed is "covered up," or "skinned over."

CHAPTER VI.

THE LIGHTNING STRIKES AGAIN.

THE old man was right. With the spring came rumors of renewed attacks upon the
religious foundations all over the country. We heard before of the execution of the Bishop
of Rochester, who laid down his gray head upon the block because he would not
acknowledge the king to be pope—for that is what it amounted to. (Nothing can be more
absurd than to call Henry the Eighth a Protestant.) Our own prioress might be said to have
died in the same cause.

Nobody had appeared to administer the oath to our present head, however, and we had
begun to think that we were to be let alone. I do not believe that the reverend mother had
any such hopes. Our foundation was a wealthy one, and our church was well-known to be
unusually rich in gold and silver. There was abundance of shrines, reliquaries and boxes, as
valuable for their splendid workmanship as for the precious metals of which they were
made, and the jewels with which they were incrusted. Then there were missals set with
precious stones, beautiful hangings and vestments, and vessels, and candlesticks, and the
like. These articles were all displayed upon feast days, and when our great altar was
lighted up at the festival of our Patroness, it was a spectacle almost too bright for mortal
eyes.

Such a prey was not likely very long to escape the teeth and claws of my Lord Cromwell,
and his master. Bishop Gardiner himself was very forward in promoting the king's designs
upon the religious houses (for as devout as he afterward professed himself). He was our
visitor, as I have said, and when the very shepherd is in league with the wolves, the silly
sheep have little chance of escape.

It was on a beautiful morning in May that destruction overtook us. We had just come out
of chapel for our recreation, when we heard a thundering knocking at the great gate, and
the portress going to open it, found a couple of gentlemen, and our old friend, or enemy,
the bishop's chaplain, with letters from my Lord Cromwell and Bishop Gardiner for the
prioress and community.

We were all in the garden, huddled together and watching afar off, when the mother
assistant called us to come into the ante-room of the choir, where we were wont to put on
the long mantles which we wore in church. We were bid to array ourselves as quickly as
possible and get ourselves into the usual order of our procession. This being done, and
preceded by the cross-bearers, as was the way in our grand processionals, the singers
passed into the choir, singing as usual, I being at the organ, which I was accustomed to
play for all church services. The youngest sisters came first and the prioress last.

Father Austin stood near the altar, his head bowed down with grief, yet commanding
himself like a man. The bishop's chaplain and the two other visitors stood beside him, and
the latter were passing their remarks freely enough upon all they saw, and even on the
figures and faces of the sisters. Standing upon the chancel steps they could look directly
into the choir, which no one in the body of the church could see at all. I must do our ladies
the justice to say that they seemed, one and all, totally unconscious of the presence of
these strange men. Even Sister Perpetua was awed into decent behavior.

When all were in their places, the chaplain announced his errand. He had come, by the
authority of the king and his minister, my Lord Cromwell, to demand the surrender of the
charter of that house to his majesty, with all treasures of every sort, and all superstitious
relics, whereof my lord was well informed we possessed a great number. All members of
the family were to be at liberty to depart whither they would, being furnished, by the
king's liberality, with a suit of secular clothing. As to the house and its contents, they were
to be at the absolute disposition of the king, and no one was to presume, on pain of felony,
to secrete, carry off, or make away with any article whatever, though by the king's special
grace and favor toward the bishop, the sisters might take any books or other property of
their own, not above the value of three marks. * The visitors had brought down articles of
surrender for the prioress to sign, and two of the commissioners would remain to take an
inventory of our goods, and see such as were of value packed for removal.

* See many such surrenders in the Camden Miscellany and in Fuller's Church History.

I do not suppose that any one now can estimate the shock of this declaration. I do think, if
the earth had quaked and shaken down church and convent in one common ruin, it would
not have amazed and horrified us as much. I am sure when the spire was struck by
lightning—whereby two of our bells were melted—we were not nearly as astounded. *

I, hidden away in the organ loft, could watch the faces of the sisters. One or two burst into
tears, but the greater part were too much stunned to move. The prioress was very pale,
but she spoke in her usual even, somewhat deep voice.

* Fuller notes, as remarkable, the number of abbeys and priories which were, at one
time or another, burned by lightning. He gives a list of thirteen thus destroyed.

"These are heavy tidings you bring us, gentlemen. How have we been so unfortunate as to
fall under his Grace's displeasure?"

The gentlemen looked at each other, and one of them began reciting a long list of the sins
and shortcomings of the religious houses, whereby his majesty was moved, by his zeal for
true religion, to suppress all houses below a certain value—two hundred pounds a year—I
believe. The prioress heard him to the end, and answered in the same calm tone.

"For the misorders and scandals whereof you speak, I can answer for no house but my
own. Sure I am, that for the forty years I have lived in these hallowed walls, no such thing
has happened here, and as our revenues are nearer to three hundred a year than two, I
see not how his Grace's royal will applies to us."

"We will be the judges of that," answered the commissioner, arrogantly. "As to the matter
of scandals, we have been better informed by some of your own number. There have been
scandals enow, especially of late. Will you dare tell me, woman, that no young men have
been entertained in this house—that there has been no junketing and carousing in the very
parlor of the prioress herself. I tell you we have sure information, and will you dare to deny
it?"

The prioress paused for a little, and let her eyes travel from face to face round the circle.
When she came to Sister Perpetua and Sister Regina, she looked them in the face for a full
minute. There was no need to inquire further who was the false witness. Their visages
spoke for them. (It was much the same with all the religious houses. There was always
some traitor in the camp, ready, whether for greed of gain or to curry favor, or because of
weariness of their vows, to inform against their brethren.) The lady was about to speak
again, when the other commissioner interrupted her. He was the elder of the two, and
altogether more decent in his demeanor.

"Under your favor, honored lady, I would counsel you to take time for advisement, and to
read the letter sent you by your reverend visitor, which his chaplain will hand you. After
that, we will hear your decision."

"It is well spoken, sir," answered the prioress. "Meantime, please you, gentlemen, to
withdraw to the house of Father Austin, our priest and confessor, where I will give order for
your entertainment."

"Nay, reverend mother, methinks the common fare of your refectory will suit us well
enough," returned the younger man. "If all tales be true, we are not the first who have had
such entertainment, and methinks we were safer to make you our taster."

The reverend mother made no reply to his impudence, but giving a sign to the sisters,
they withdrew as they had entered. When all had passed but herself and the mother
assistant, she advanced to the wide grating which separated the choir from the church,
and held out her hand, covered with a fold of her robe, for the bishop's letter. The elder
man gave it her with a reverence for which I liked him all the better, and said, in a low
tone, as the other turned away:

"Be advised, madam. Resistance can do no good, and will bring only heavier calamity on
yourself and your flock. Be advised, and follow your visitor's counsel."

"I thank you, sir, for your words, which I see are kindly meant," said the prioress; "but I
must have little time to consider the matter. How long can you give me?"

He called back his brother commissioner, and after consultation, in which he seemed to
press some point which the other yielded unwillingly, he turned and said: "Till to-morrow
at this hour, madam."

"I thank you," said the lady once more—and passed out of the door. I closed my
instrument, not without a sob, as I thought I might never touch it again, and followed the
reverend mother.

It was now the time for dinner, but the bell had not been rung. The sisters were standing
talking together in excited groups, and many an angry and contemptuous glance was cast
at the two traitors. The prioress at once restored order, and bade the portress ring the bell
for dinner.

"Let us have no misorder—no relaxation of discipline on what may perhaps be our last day
in this blessed inclosure," said she. "Slandered we have been and may be, but let us keep
our own consciences clear and unstained. That comfort no one can take from us."

It was a feast day, and our cheer was better than common, but nobody felt like eating. The
ceremonies of the table went on as usual, however, and the reader's voice never faltered.
After dinner came recreation, and then the tongues were let loose again.

"Well, for my part, I care not what becomes of me after this," said Sister Sacristine. "I
have lived too long."

"Do not say that, sister," returned Mother Bridget, gently. "We cannot say what gracious
purpose may yet be in store for us."

"Don't talk of gracious purposes!" said the Sacristine, angrily. "Here have I been serving
the blessed Magdalene all these years, wearing my fingers to the bone cleaning of her
shrine with wash leather and hartshorn salts and what not, and this is what I get by it. And
to see the holy relics carried off and dispersed after all my care."

The poor old lady burst into tears and wept bitterly, and more than one joined her.

As for me, I stole away to a favorite place of retirement—a little shrine or oratory in the
orchard, half hidden by trees and thick, clustering ivy. Here I was used to keep certain
books of my own—a Latin Imitation and Psalter, and a prayer book which I had brought
from my old home at Peckham Hall. I hoped for a little solitude to collect my thoughts, but
I was disappointed.

As I drew near, I heard men's voices in the building, and recognized them for those of the
old Scotch gardener and Mr. Lethbridge, the younger commissioner.

"So this is the jaw-bone of St. Lawrence, is it?" said the latter; and peeping through a
crack, I saw with horror that he was tossing it up and down in his hand. "It looks more like
a pig's jaw to me."
"Maybe," answered Adam. "Ye'll be a better judge of that article than me. It was aye called
the jaw of St. Lawrence in my time."

"What of it—suppose it was?" said the other, arrogantly. "What good could it do any one?
For my part, I care no more for St. Lawrence's jaw than for Mahomet's."

"I would na speak scornfully of the jaw of Mahomet gin I were talking to a Turk," retorted
Adam. "I might argue wi' him, gin I thought it would be to edification, but I would na scorn
at him. I would think it ill manners."

For all answer, Mr. Lethbridge tossed the relic from him, and ordered the gardener to show
him the rest of the grounds. When they were gone, I entered the chapel, and having
gathered my books together, I picked up the jaw of St. Lawrence, which certainly had an
odd shape for a man's, wiped the dust from it, and laid it back in its place. Then, a sudden
thought striking me, I dug a hole in the earth, at the foot of the great honeysuckle, and
buried it; and there it may be now, for aught I know.

Our services went on as usual during the day—the last day, perhaps, they would ever be
performed in those walls which had heard prayers and chants for so many hundred years.
It was touching to see how punctiliously almost all the sisters performed every duty, even
the smallest.

There were exceptions, however. As I said, we had two or three who had no vocation
whatever, and they tried to take liberties, and were not ashamed to exchange mocking
glances and whispers, even in the hour of meditation. Nobody took any notice of them,
however, except to draw away when they came near as if they had the pestilence. I
remember Sister Regina took hold of the sleeve of Sister Anne's habit to draw her
attention to something, she being a little deaf, whereupon the old lady, having her scissors
in her hand, deliberately cut out the place Regina had touched and trampled it under her
feet. It was not a very Christian act, perhaps, but we were all glad of it. Sister Regina did
have the grace to look abashed for a moment, the more that she had always been rather a
favorite with Sister Anne.

That evening, just before bed-time, Sister Sacristine met me in the gallery and drew me
aside into the sacristy, and then into a little inner vaulted room where our most valuable
relics were stored, when not exposed to the adoration of the faithful. The precious shrines
which were used at these times were kept in another place, whereof the key was already
in the hands of the commissioners. Shutting the door, and opening a dark lantern which
she carried, she whispered in my ear:

"Loveday, you are a brave girl. I remember how you faced the bull that day he got out. Will
you help me to save our most precious relic from profanation?"

"If I can!" said I, doubtfully. "But what is it you want to do?"

She glanced round, and then whispered in my ear:

"I want to let out the Virgin's smoke. But the stopper is too stiff for my fingers, and I want
you to open it and let the smoke out. Then we can leave the bottle as we found it!"

Now this bottle of smoke from the Blessed Mother's hearth at Bethlehem was, indeed, our
most precious relic, and was looked upon with awful reverence. I fully sympathized with
Sister Sacristine's desire to save it from profanation, but I was rather scared at the idea of
touching it, not knowing exactly what it might do if it got out.