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Essentials of
Gross
Pathqlogy
> • Chief Editor
Ila Tyagi
Editor
,
fad Abhijit Das

V *
i m Ey
^ -
imm
CBS
CBS Publishers & Distributors Pvt Ltd
Essentials of

Gross
 Essentials of
Gross
Pathology
Chief Editor
Ila Tyagi DNB
Associate Professor, Department of Pathology
North Delhi Municipal Corporation (NDMC)
Medical College and Hindu Rao Hospital (HRH)
Delhi

Editor
Abhijit Das MD
Senior Resident
NDMC Medical College and HRH, Delhi

Associate Editors
Namrata Nargotra MD Srishti Gupta MD
Head, Department of Pathology Senior Resident
NDMC Medical College and HRH, Delhi NDMC Medical College and HRH, Delhi

Ritu Arora MD Dipti Kalita MD

Senior Resident Consultant Pathologist, Batra Hospital and Medical
NDMC Medical College and HRH, Delhi Research Centre, Delhi

CBS

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 Foreword

Gross pathology, a vital part of histopathology, is absolutely necessary in the curriculum of MBBS undergraduates,
pathology residents and paramedical students. There is a lacuna in the availability of books which specifically
focus on gross features and differential diagnoses of pathological specimens commonly asked in the exams. One
has to go through multiple books to gather all the information, which is not only a time consuming task but also
adds to a lot of confusion due to discrepancy in different books.
This book entitled Essentials of Gross Pathology authored by Dr Ila Tyagi, Dr Namrata Nargotra, Dr Dipti Kalita,
Dr Abhijit Das, Dr Srishti Gupta and Dr Ritu Arora is a unique publication. It is no exaggeration when I say that
this book is an "all-in-one" practical gross pathology book as it covers all aspects of histopathology specimens for
undergraduate's practical examination. It is a one stop source of in-depth and detailed information on the subject
written in a very lucid, concise and bullet point form. I am sure this book will be of immense benefit to one and all
working in this field .
It is my privilege and honor to be invited to contribute the foreword for this comprehensive practical book on
gross pathology. I can imagine the hard work put in by the authors preparing this book . I congratulate all of them
and specially Dr . Ila Tyagi for initiating such a venture, leading the team, her untiring efforts and her valuable
contributions to the subject. I wish all the authors the very best in their future endeavors!
Lastly, I thank CBS Publishing House Ltd., New Delhi, for håving readily agreed to publish the book. I know
they are second to none in the publication of a series of medical books of value.

Puja Sakhuja
Professor and Head
Department of Pathology
Govind Ballabh Pant Institute of
Postgraduate Medical Education and Research,
New Delhi-110002
 Preface

Gross pathology refers to macroscopic manifestation of diseases in organs, tissues and body cavities. Grossing is
the first step in surgical pathology and extremely important for correct interpretation and diagnosis. Though
several good books on pathology are available for students' consumption, there is a paucity of books on gross
pathology.
This book serves as a practical guide for the undergraduate museum in all the aspects of gross pathology, i.e.
reception of the specimen, fixation, gross examination and dissection, and differential diagnosis and techniques
of mounting of the specimens. It includes basic introduction to grossing techniques, a discussion of typical specimen
types and a strategic approach to the specimen along with schematic pictures illustrating the same progressing
through each organ system.
The chapters have been organized in the following fashion. Each chapter begins with a brief review of the
normal anatomy of an organ followed by its grossing techniques. We then discuss the salient gross features of
important specimens that frequently occur in undergraduate examinations. The chapter ends with a discussion
on differential diagnosis focusing predominantly on gross pathology. There are numerous gross pictures and
schematic diagrams to illustrate the normal anatomy, grossing techniques and pathology.
This book is unique for three reasons. Firstly, it is based on gross pathology—a very crucial aspect of
histopathology. Secondly, it provides an accurate and quick description of surgical and autopsy specimens that is
easy to digest for students. Lastly, it offers differential diagnosis of important specimens commonly asked in
examinations.
This book has been compiled after extensive research of current examination trends based on our discussions
and continuous interactions with students and faculty alike. In our constant endeavor to keep this book current
with examination trends, all suggestions for further improvement are welcomed .
We sincerely hope that this book will be of immense help to undergraduate students in their practicals and
viva voce examinations.

Editors
 Contributors List

Ila Tyagi DNB (Institute of Pathology, ICMR Delhi)
Associate Professor, Department of Pathology
North Delhi Municipal Corporation (NDMC) Medical
College and Hindu Rao Hospital, Delhi
Namrata Nargotra MD (AFMC Pune)
Head, Department of Pathology
NDMC Medical College and HRH, Delhi
Ritu Arora MD (GMC Amritsao
Senior Resident
NDMC Medical College and HRH, Delhi
Abhijit Das MD (AIIMS Deihi)
Senior Resident
NDMC Medical College and HRH, Delhi

Srishti Gupta MD (Army hospital, R &R Delhi) Dipti Kalita MD (AMC Dibrugarh)
Senior Resident Consultant Pathologist, Batra Hospital and Medical
NDMC Medical College and HRH, Delhi Research Centre, Delhi
 Acknowledgments

We extend our sincere thanks to a number of people without whom this book would not have become a reality.
We take this opportunity to thank Mr PK Gupta (Commissioner, MCD) and Mr Pankaj Kumar Singh (Additional,
Commissioner, MCD) who are the backbone of the newly formed NDMC Medical College.
Our special thanks to Mr Mayank Sharma (former Additional Commissioner, MCD), who played a major role
—
in the formation of this medical college. We also thank our Medical Superintendent Dr KL Khurana for
encouraging us and providing us with necessary support at all times.
We thank and acknowledge the Dean of our college, Dr Rani Kumar, for her constant encouragement and
support. She inspired us to write this book on gross pathology and has been the guiding light in our endeavor.
We are greatly indebted to our teacher, mentor and guide Prof Rajbala Yadav . With her vast experience in the
field of pathology, she has provided her expert insight to this work . We also thank the other faculty members of
our department Dr. Sompal Singh, Dr Manupriya Nain, Dr Jyotsna Nigam and Dr Ruchi Rathore for their support .
Our special thanks and acknowledgement to Dr Dinesh Negi, CMO Administration, NDMC Medical College
for his constant encouragement and invaluable ideas which have enthused us to strive to do better .
This acknowledgement wouldnT be complete without thanking faculty members of other colleges who helped
us immensely at all times of need and have been a source of constructive suggestions.
For her constant support and encouragement we would like to thank Dr Leela Pant, Medical Suprintendent,
Kasturba Hospital (former Head, Department of Pathology, Hindu Rao Hospital)
Our special thanks to Dr Vinay Kamal, Director Professor Pathology, MAMC for his constant encourgement,
guidance and constructive suggestions.
We are greatly indebted to Dr Puja Sakhuja, Head of the Department, Pathology, GB Pant Institute of
Postgraduate Medical Education and Research ( GIPMER ), New Delhi for readily helping us and graciously
providing us with gross photographs of gastrointestinal and neuropathology specimens. We also thank other
faculty members of GIPMER, Prof KR Saran, Prof Vinita Batra and Dr Kaushik Majumdar for their support.
We wholeheartedly thank Dr Sunita Saxena, Director and Dr Usha Agarwal, Additional Director, National
Institute of Pathology ( NIOP) for helping us.
We are greatly indebted to Dr Surider Paul HOD, Government Medical College, Amritsar for supporting us.
Constant inspiration and support from Dr Nidhi Verma, Dr Prerna Arora, Dr Meeta Singh (MAMC), Dr Monika
Matlani, Dr Meetu Agarwal (Safdarjung Hospital), Dr Fouzia Siraj, Dr Harpreet Walia ( NIOP) and Dr Kavita
Gaur (GIPMER ) kept us going through the course of this book .
We acknowledge and thank and our residents Dr Gaurav Jain, Dr . Mansi Chandana, Dr.Garima, Dr.Ruchi, Dr
Meenal, Dr Alek, Dr Meenakshi, Dr Ranjeet and Dr Varun, Dr Shakti, Dr Pinkey, Dr Anshu, Dr Malini, Dr Swapna,
Dr Amul and Dr Shilpi for their help and support .
We wholeheartedly thank CBS Publishers and Distributors specially Mr YN Arjuna (Senior Vice-President
Publishing, Editoriai and Publicity) for his immense support, encouragement and invaluable guidance for this project and
his team Ms Ritu Chawla ( AGM Production ), Neeraj Prasad (Graphic artist) with his untiring efforts on drawings,
Ms Jyoti Kaur ( DTP Operator ) for excellent formatting, Mr Kshirod Sahoo ( Proof -reader ) for his excellent work
and Mr Sunil Dutt for helping us come out with this book .
We sincerely thank the backbone of support-our technical staff Mrs Shakti Kalani, Mr Sukhvinder, Mr Ravi,
Mr Aman and Mr Nitish who helped us in setting up the Pathology Museum and mounting.
No work is complete without the unending support, patience, constant encouragement of a loving family
member . So we thank our family members ( Dr Anand Tyagi, Gen. Sarin, Dr Rajeev Bhagat, Dr Kunjahari Medhi,
Mrs Kankana Roy Das and Mr Tarun Aggrawal) for being there with us at times of need .
Above all we thank Almighty for the divine blessings without which no work can ever reach completion.

Editors
 I Contents

Foreword by Puja Sakhuja v

Preface vii
Contributors list ix
1 . Fixation 1
2. Museum Preparation Techniques 4
3. General Approach to Grossing of Surgical Specimen 8
4. Heart 11
5. Lymph Node and Spleen 21
6. Respiratory System 31
7. Head and Neck 54
8. Gastrointestinal Tract 76
9. Liver, Pancreas and Gallbladder 103
lO. Urinary Tract 121
1 l . Male Genital Tract 151
12. Female Genital Tract 172
13. Breast 211
14. Bones and Joints 220
15. Soft Tissues 249

16. Central Nervous System 266

17 . Eye and the Orbit 279

Index 283
 Fixation

Fixation is the method of preserving cells and tissues • Preservation of chemical compounds and micro-
to prevent their autolysis and bacterial decomposition anatomic constituents so that further histochemistry
once they are removed from the body. Major objective is possible.
of fixation in pathology is to preserve tissues in a life • Effects on staining : Fixatives like formaldehyde
like manner as far as possible and allow them to intensifies the staining character of tissue especially
undergo further preparative procedures without much with hematoxylin.
change. It helps in maintaining clear and consistent
morphological features. Fixation of the Tissues can be
Fixation is defined as a complex series of chemical done by Two Methods
events which brings about changes in various chemical Physical methods: These include heating, microwaving
constituents of the cell and at the same time preserving etc. and are less commonly used .
its structural details and morphology . Appropriate Chemical methods: These are the mainstay for fixation
fixation of the tissues for histopathological examination of tissues for histopathological examination.
is extremely important for the diagnosis.
Chemical fixation: Both organic and nonorganic
Solutions are used to maintain adequate morphological
THE MAJOR EFFECTS OF FIXATION
preservation and they fall into following major
• Prevention of putrefaction (breakdown of tissue by categories . Various fixatives and their examples are
bacterial action often with formation of gas ) and given in Table 1.1.
autolysis ( dissolution of cells by enzymatic action
probably as a result of rupture of lysosomes) . COMMONLY USED FIXATIVES
• Preservation of cells and tissue constituents as far as Formaldehyde
possible in a life-like manner.
• Hardening of the tissue for section cutting of required Formaldehyde is the most commonly used fixative.
thickness and easy manipulation of soft tissue like Pure formaldehyde is a gas which is soluble in water .
brain, intestines, etc. Table 1.1: Categories of fixatives
• Making the cells insensitive to various Solutions used Category of fixative Common examples
in tissue processing.
Dehydrants Ethanol, methanol, acetone
• Solidification of colloid material: Fixative causes Aldehyde cross-linkers Formaldehyde, glutaraldehyde
cross - linking of proteins which causes their Combination mercuric chloride Zenker’s, B5
denaturation or coagulation so that their semifluid with formaldehyde or acetic acid
state is converted into semisolid state which Osmium tetroxide Post-fixation after glutaraldehyde
facilitates easy manipulation of tissues. Picric acid plus formalin and Bouin’s
• Optical differentiation, i.e. refractive index of the acetic acid
tissues is altered to varying degree so that the Combination alcohols plus Alcoholic formalin
formalin
unstained components are more easily visualized.
1
 Essentials of Gross Pathology
It is commercially available as 40% formaldehyde
solution in water (Formalin) . For routine fixation 10%
formalin is used. It is 10% solution of formalin, i.e. it
contains about 4% weights to volume of formaldehyde
(10 ml formalin and 90 ml water ). The amount of
fixative used should be 15-20 times the specimen volume .
Advantages
• Easily available and cheap.
• Rapid penetration into tissue.
• Retains the normal color of the tissue.
• Best fixative for neurological tissue.
Disadvantages
• Irritation of skin, mucous membrane and conjunctiva .
• Excessive hardening of the tissue.
• Formation of formalin pigment in tissues with
excessive blood .
Glutaraldehyde
Glutaraldehyde is used as a fixative in electron
microscopy usually in combination with osmium
tetroxide. It is commercially available as 25% solution
and is used as 4% solution.
Advantage
Extensive cross-linkingby glutaraldehyde causes better
preservation of ultrastructure.
Disadvantage
It penetrates the tissue slowly and is expensive.
FIXATION OF INDIVIDUAL TISSUES
There are certain important general principles of
fixation . The specimen to be fixed, should be placed
Fig. 1.1 a-c: Fixation of histopathological specimens . (a) Cotton is inserted in between the serial cuts and the specimen is kept in the
fixative over night for adequate fixation (arrow). (b) Specimen is serially sliced without completely separating the sections (preferably
at 1 cm distance from each other) for adequate fixation and exposing the pathological area (arrow heads) . (c) Inking of the margins
is done at this stage to help in the final diagnosis.
in a large container with three tofour times its volume
of fixative . Some specimens should be injected with
fixative ( e.g. brain, lungs and whole limbs ) if possible
to ensure adequate fixation as the tissues are more
easily and speedily fixed by injecting fixatives.
Hollow organ should be padded out with cotton and
if uncut, it should be pressure inflated . For example,
fixatives are injected through urethra into the bladder
and through trachea into the lungs . Solid organs
should be immediately sliced in a required size to
allow fixative to penetrate the exposed surface. Fresh
soft specimens should be fixed individually .
Specimens with their attached structures should be
fixed together .
Fixation and inking of histopathological specimens
are shown in Fig. 1.1a to c.
Eyes
• Fixed in normal buffered formalin usually for
48 hours.
• To speed up the fixation, 1 or 2 small windows can
be cut in the globe after 24 hours.
• After 24 hours anterior (iris ) and posterior (optic
nerve) are removed and fixed for additional 48 hours.
Brain
• Brain usually takes 2 weeks for fixation.
• With the help of perfusion technique (perfusion of
brain via middle cerebral arteries), it takes shorter
duration and report can be dispatched in 5-6 days.
Whole brain is fixed by injecting fixative into the
basilar artery and the artery is tied with a linen thread
and then the specimen is suspended in the fixative
in a bucket.
• Fixation can also be enhanced by use of microwave
technology.

Lung
• Surgical specimen of lung or specimen from the
postmortem room is fixed by inflation with 4%
buffered formaldehyde through a cannula into the
main bronchi and submersion in a large volume of
fixative.
• If tuberculosis is suspected specimen should be left
for one week before it is dissected.
• If immunological diseases are suspected, cryostat
section should be made and fixed briefly with either
acetone or methanol.
Lymphoid Tissue
Lymphoid tissue is usually sliced and a part of the
representative fresh tissue is taken for flow cytometry
or molecular analysis. The rest of the tissue is fixed in
normal buffered saline.
Fixation
Muscle Biopsies
Muscle biopsies are received fresh without any fixative.
A portion of muscle biopsy is separated for enzyme
histochemistry and the remaining portion is fixed in
normal buffered saline.
Renal Biopsies
• Core biopsies from kidney should be divided into
three portions and each portion is preserved in the
fixative on the basis of the method used for analysis.
• Normal buffered formalin is used for fixation for
routine histology (light microscopy ) .
• Buffered glutaraldehyde is used for ultrastructural
studies (electron microscopy) .
• Biopsy is snap frozen in liquid nitrogen and
isopentane for immune deposits (immunofluore-
scence).
 Museum Preparation
Techniques

Pathology museum is present in all the teaching

hospitals and is of great teaching value. It serves many
functions like permanent exhibition of common
specimens for undergraduate and postgraduate
teaching purposes, displaying rare specimens,
permanent source of histologic material and for gross
and microscopic photography ( Fig. 2.4 a, b ) . It also plays
a very crucial role in recording the history of medicine
as the common diseases of today may be rarities of
tomorrow. It is extremely important to retain the color
and original shape of the specimen . Record of the
patienFs medical history, relevant photographs and
radiographs should be maintained which are very
helpful for teaching purpose. The presentation, labeling Fig. 2.1: Receiving the specimen for histopathological examination.
and cataloguing of the specimens in the museum play
a major role. of patient, gross and microscopic findings where
available should be made.
BASIC MUSEUM TECHNIQUES All specimens received (Fig. 2.1) in the museum is
Specimens in the museum are handled in the following given an assessing number and year of the entry. The
steps: specimen carries this number even after it is given a
final catalogue number according to its place in the
• Reception of specimen collection.
• Preparation of specimen
• Fixation of specimen II . Preparation of the Specimen
• Restoration of specimen An ideal specimen is received fresh in unfixed state.
• Preservation of specimen However, in the museum, the specimen is mostly
• Mounting and presentation of specimen obtained from pathology laboratory after being
• Storage of the specimen examined, so it is already formalin fixed . After the entry
is made, it is checked whether the specimen is fresh or
I . Reception of Specimen is already in a fixative; any gross trimming of the section
Specimens for permanent display may come from a necessary, is carried out immediately using a long
number of sources like hospital, operation theater, bladed sharp knife giving a continuous stroke so that
postmortem room and from research laboratories . the cut surface is even and smooth.
Museum register is present at the reception in which If the specimen has arrived in an unfixed state, it
entry of all the specimens along with relevant details must not be allow to dry or discolor and should be
like name of the hospital, clinical history and diagnosis immediately immersed in a fixative. It is important to
4

note that the specimen should never be washed with
water as it causes hemolysis and permanent staining
of final mounting solution . Excess blood should be
washed off with the fixative.
It it is planned to use a specimen for museum, part
of it can be kept without disturbing, e.g. it a specimen
of kidney is received, it can be bisected and one half
kept aside for museum or adequate tissue for
histopathological examination should be taken without
much distortion of the specimen. As far as possible it
should be taken from back of the specimen with the
help of a sharp scalpel or neatly removed from the front .
The specimen should be put into a fixative immediately.
It the fixative is not available, the specimen should be
immersed in saline and stored in refrigerator at 2-8°C.
III . Fixation of Specimen
Depending upon the technique employed various
fixatives are used; but 10% formal saline can be used as
a primary fixative and later on the specimen can be
transferred to a special fixative.
The technique most widely used all over the world
for mounting of museum specimens is the modification
of the method described by Kaiserling .
Kaiserling recommended that the initial fixation
should be done in a neutral formalin; Kaiserlings I
solution ( Kl) and then transferred to a final preserving
glycerin solution Kaiserling III ( KIII) for long term
display . Color preservation is also maintained with
these Solutions. Kaiserling stressed the importance of
the exclusion of air and the avoidance of acid formation
in the medium .
Kaiserling' s Technique of
Fixation of the Specimen
The specimen should be kept in a large container which
can accommodate specimen along with 3-4 times
volume of fixative. Specimen is stored in Kaiserling I
solution for 1 month depending on the size of the
specimen. The specimen should not rest on bottom of
the container as an artificial flat surface will be
produced on hardening due to fixation.
—
Kaiserling I solution (fixing solution) specimens can
be transferred to this fluid after fixation in formal saline
or they may be directly fixed in it. It is made of following
constituents:
Kaiserling I solution
• Formalin 2 liter
• Potassium acetate 425 gm
• Potassium nitrate 225 gm
• Distilled water make up to 20 liter
*Store specimen in this solution for 1 month depending on
the size of the specimen.
Museum Preparation Techniques
IV. Restoration of Specimen
After fixation, the natural color of the specimen is lost .
Therefore, it is necessary to restore the specimen to as
near to its original state and color as possible. There
are many ways in which this can be done and the one
recommended method is Kaiserling's method II.
This method involves removing the specimen from
fixative, washing in running water and transferring to
95% alcohol. The specimen is in alcohol for 10 minutes
to 1 hour depending upon the size of the specimen
during which time it is watched carefully as the color
develops throughout the specimen. Ensure that they
are removed when the optimum stage is reached; it kept
for longer periods the color fades and cannot be
restored . At this stage the specimen is photographed it
not already done. After this step, specimen is ready for
preservation.
Kaiserling II solution:
• Alcohol 95%
*Store specimen in this solution for 10 minutes to 1 hour
depending on size of specimen.
Rejuvenator solution :
• Pyridine 100 ml
• Sodium hydrosulphite 100 gm
• Distilled water 4 litre
^Formalin decreases the natural color of the specimen .
However, rejuvenator solution restores the color.
V. Preservation of Specimen
The recommended solution for this step is Kaiserling
III. This is the final solution in which the specimen will
remain for display. It is based on glycerin solution .
Glycerin has two important functions in a mounting
medium. First, it increases the optical density so that,
when using perspex jars, the effect of solid embedding
may be obtained . Second, it has a slight clearing effect
on the tissues, which emphasizes the fine structural
details.
Kaiserling III solution
• Potassium acetate 300 gm
• Glycerine 6 litre
• Distilled water make up to 10 liter
Thymol crystals are added to prevent molds.
Leave the solution to stand for 2-3 days before using
to ensure proper mixing of Chemicals.
Add 1% pyridine as stabilizer. This solution acts as
permanent fixative.
This solution turns yellowish and needs to be
replaced to restore color of the specimen from time to
time. The specimen will initially float to surface but
later sink to the bottom.
 Essentials of Gross Pathology

VI. Mounting and Presentation of

Specimen
• Mounting techniques and presentation of specimens
are shown in Figs 2.2 a-d and 2.3.
• Position should be anatomically correct as per as
possible.
• Removal of irregular surface of the specimen.
• Trimming of outer edges of the specimen such as
skin and intestine.
• Filling the cavities by arsenious acid gelatin after
removing cotton wool ( Figs 2.2a-d and 2.3).
• Color perspex arrows or rods can be used to identify
important structures.
• Friable specimens can be covered with a thin layer
of arsenious acid gelatin and it can also be used
locally to hold fragments such as blood clot in
position.
• Bile stained specimen should be soaked in a saturated
solution of calcium chloride for 24 hours.
• Specimen is placed by allowing half inch clearance
at the top and sides and one inch at the bottom
(without sodium hydrosulphite). Extra clearance at
the bottom is for the label to be fitted without
obscuring the specimen.
• Sodium hydrosulphite ( 0.4 g / dl ) is added
immediately before sealing the jar.
• The solution should be crystal clear; if not, filter the
solution or 50 ml of saturated solution of camphor
in alcohol should be added to one liter of solution to
produce sparkling clarity.
• Glass jars lid is to be sealed tightly so that there is no
leakage of the fixative fluid .
• Each jar with the mounted specimen should be
labeled with the specimen number (number given
in the museum catalogue).
• Museum catalogue should be prepared.
Specimens in older medical museum were mounted
in a cylindrical glass jars and were suspended by string.
Rectangular jars gradually replaced the cylindrical ones.
They had an advantage as their polished flat phase
prevented magnification and distortion.
With the introduction of Perspex, the museum jar
could be constructed to any specification and had the
advantage of getting completely filled with mounting
solution; the specimen could be attached to reagent
supporting plates with the jar and were tight and
strong.
Plastic is however, attacked by absolute alcohol and
fixatives . It is, therefore, necessary to mount the
specimens in rectangular glass jars. The position in
which the specimens are to be mounted should be
anatomically correct to enable easy Identification of the Fig. 2.2 a- d: Mounting of specimen in the museum (Dept. of
structures . Pathology, NDMC Medical College & HRH).
 Museum Preparation Techniques
Fig. 2.3: Mounted museum specimens (Dept. of Pathology, NDMC
Medical College and HRH).
When perspex boxes are used, the specimen is
arranged in desired position on a central perspex plate
by stitches made by linen or nylon thread to hold the
specimen. When glass jars are used, a perspex or glass
center plate or a bent glass rod to form a frame which
just fits into the jar is taken and the specimen is stitched
to the frame or tied with nylon threads. Double knots
should be made by threads, on the specimen surface.
Vll. Storage of Specimen
Storage of specimens is an important part of museum
technique since the supply of specimens is always more
than the number actually mounted ( Fig. 2.4a, b ) . As far
as possible specimens should be stored in separate
containers so as to avoid damage caused by contact with Fig. 2.4a , b : Gross discussion and museum study (MBBS batch, 2013).
others.
The containers should be labeled adequately on the period up to six months. A reference book should be
outside and label should be tied to specimen with linen maintained to record necessary details about the
thread. The fluid used may be Kaiserling's fluid I for a specimens .
 • Anatomy may be distorted in autopsy specimens
and in presence of congenital anomalies.
4. Examine the external surface for adhesions, scar,
petechiae, haemorrhage.
5. Fix the heart for 48 hours in formalin before
dissecting it .
6. Note the diameter of valve orifice.
7. Examine the valves for presence of thrombi and
vegetations .
8. Open the coronaries by a series of transverse
incisions at spaces approx . 3 mm apart. Look for
thrombi and calcification.
Dissection of Heart
Two commonly followed methods are:
Inftow -outfow Method
Dissection of heart is shown in Figs 4.8 and 4.9. Opening
of heart following the direction of blood flow:
Open the right atrium by inserting scissors in the
opening of inferior vena cava and cutting the right atrial
appendage obliquely. Superior vena cava should be
spared with region of the sinus node.
Open the right ventricle by cutting along the right
lateral border of heart by directing the scissors / knife
from right atrium downwards through the posterior
tricuspid valve leaflet .
Open the outfloiv tract of the right ventricle by cutting
its wall lem away from ventricular septum, passing
upwards through the pulmonary valve at the junetion
of the anterior cusps to the pulmonary artery.
Open the left atrium by cutting between the openings
of the right and left upper pulmonary veins and then
Fig. 4.8: Dissection procedure of heart via inflow-outflow tract
(1 to 7: Cut sections) .
Fig. 4.9: Dissection procedure of heart via transverse sectioning.
between the upper and lower pulmonary veins on each
side. This incision can further be extended to the left
atrial appendage to assess for mural thrombus.
Open the left ventricle by cutting along left lateral
border through the midportion of posterior mitral valve
leaflet towards the apex.
Open the out flow tract of left ventricle by cutting the
wall lateral to the ventricular septum up to the root of
aorta by an incision starting from the apex directing
upwards through the aortic valve.
Transverse Sectioning of Heart
Transverse sectioning of heart is done at 1 cm interval
from the apex to just below the atrioventricular
apparatus. This method is preferred in demonstrating
pathology of ventricular wall in cardiac hypertrophy,
myocardial infarction and inflammatory lesions like
granulomas and abscesses.
After opening the heart remove blood clots. Examine
the endocardium and myocardium as well as valves.
Examine the walls of great vessels especially aorta for
atherosclerotic plaques.
Dissect the coronary arteries systematically. Start at
the orifice of the left main coronary artery and serially
section the vessel down its branches . Similarly section
the right coronary artery.
Examine each vessel for narrowing, thrombi in the
lumen, intimal proliferation, hemorrhage or
atheromatous plaques. Document the location and
percentage narrowing caused by any lesion.
Sections for Histology
In diseases associated with pancarditis, sections are
taken from following sites:
1. Posterior border of left atrium.
1 Essentials of Gross Pathology
2. Posterior leaflet of mitral valve.
3. Posterior papillary muscles of left ventricle.
4. Tissue from aorta, aortic valve and mitral valve.
5. Pulmonary artery and valve.
6 . Right atrium and right ventricle.
7. Right atrial appendage.
8. Left atrial appendage.
9 . Aorta .
10. Coronary arteries: Blocks of 3 mm thickness from
both coronaries about 1.5 cm from their origin.
11. Any grossly abnormal area .
If ischemic heart disease is suspected, tissues are
selected from following sites to reveal myocardial
pathology :
1. Anterior left ventricle and adjacent ventricular
septum approx. 2 cm above the apex.
2. Posterior wall.
3. Posterior basal portion of myocardium and adjacent
ventricular septum.
4. Anterior papillary muscle and subjacent myocardium.
5. Mid anterior wall of right ventricle inferior to
pulmonary valve.
6. Posterior wall of right atrium.
7. Posterior wall of left atrium.
8. Any grossly abnormal area.
Gross Description
1. Weight and dimensions of heart and attached great
vessels .
2. Thickness of ventricular walls.
3. Epicardium : Any abnormality like petechiae,
adhesions, scar, graft.
4. Valves : Stenosis, calcification, thrombi and
vegetations.
5. Myocardium: Size and location of recent or remote
infarct, focal punctuate lesion, hemorrhage, fibrosis,
scar, necrosis.
6. Coronary arteries : Number, course, percentage of
narrowing of lumen by atherosclerotic plaque,
hemorrhage, calcification, presence of metal stents.
7. Any anomaly of cardiac chamber if present.
EXCISED HEART VALVE
FOLLOWING VALVE REPLACEMENT
In heart valve replacement operation, usually the
diseased valve or leaflet is removed and is sent for
histopathological examination.
Basic Structure of Heart Valves
The AV valves are composed of an annulus, leaflets,
chorda tendinae and papillary muscles. The semilunar
valves are made up of three cusps, each with a sinus.
The cusps meet at three commissures.
Grossing Procedure
1. Fix the specimen. If culture is required, send small
fragment for culture before fixation.
2. Document whether the valve is intact or in pieces.
3. Document dimensions of valve and valvular orifice.
4. Examine each component:
a . Leaflet- Number, edges — rolling / commissural
fusion / any abnormality like fibrosis / calcifica-
tion / thrombi / vegetation / myxoid change. If
present note their appearance, extent and location.
—
b. For AV valves Chordae tendinae-shortened /
thickened / stretched / fused / ruptured or normal.
c Papillary muscle — Normal / any evidence of
.
infarction / scarring / hypertrophy / elongation.
d. For semilunar valves: Similar to AV valve plus
cusps-number / size / whether equal or not.
Gross Description
It should include all findings as mentioned above.
Sections for Histology
Submit sections which should include valve leaflet, free
edge, chorda and papillary muscle if present .
BLOOD VESSELS
Grossing Procedure and Sampling
1. Measure the length, external and internal diameters
of the vessel.
2. Examine the lumen for thrombi, document
percentage of luminal narrowing.
3. Take sections both longitudinal and perpendicular
to the long axis of the vessel. Longitudinal section
will demonstrate alteration involving the media and
perpendicular section demonstrates the alteration of
luminal diameter .
Temporal Artery Biopsy
The average biopsy is 12 cm long. Divide it into four
parts and get each of them embedded, so that at the
end we get four sets of step sections with each set
containing at least three H&E stained sections, and one
elastin stained section to examine.
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CHAPTER III.
 “LITTLE MASTER.”

“For when the morn came dim and sad

And chill with early showers,
His quiet eyelids closed—he had
Another morn than ours.”
Thomas Hood.

HAD Mr. Guildford been a native of Sothernshire, he could not but

have been familiar with the name of the Methvyns of Carling, one of
the oldest and wealthiest families of the county. Had he been in the
least addicted to local gossip, or less preoccupied, he could hardly
have failed, even at Sothern, to hear casual mention of them and of
their younger branch, the Methvyns of Greystone. But if he had ever
heard of either Carling or Greystone, he had forgotten all about it;
and as he was whirled along to Haverstock that cold February
evening, his mind was a perfect blank as regarded Methvyns of
anywhere. Nor did he feel much interest or curiosity respecting the
summons he had received.
 He had brought a book with him, but the lamp gave so feeble and
uncertain a light that reading was out of the question. So for the half-
hour of his railway journey, Mr. Guildford set himself to think instead;
to work out in his head the results of a certain shadowy theory or
suggestion bearing upon an obscure and hitherto but slightly
considered department of medical science, which had lately come
under his notice for the first time. It had interested and even
fascinated him, but he had so often fancied himself on the brink of a
great discovery, so often imagined that he saw the flashing of “some
bright truth in its prism,” only to be disappointed, that he was already
learning to be sceptical and cautious, keen to criticise and slow to
pronounce. Outward circumstances too, helped to check his
impetuosity, to moderate without damping his ardour—the apparent
disadvantage of his leisure consisting mostly of odd snatches of
time, liable at any moment to interruption; the being constantly
recalled to matters of present fact, obliged suddenly to concentrate
his powers on subjects seldom presenting anything in common with
his chosen studies; all this was excellent training for an excitable,
enthusiastic temperament naturally impatient of discipline or
restriction. Gradually he acquired great inward self-control—mental
independence of, or rather superiority to, his external surroundings
for the time being. He learnt to choose and limit his subjects of
thought; a habit as valuable to a man of his profession, as was in
another direction the great soldier’s far-famed capability of “sleeping
to order.”
So Mr. Guildford was really thinking—not merely dreaming, or
passively receiving the impressions of the objects around him when
the train stopped, and the railway officials’ equivalent for
“Haverstock,” was shouted along the little platform. It was only a
roadside station, badly lighted and dreary looking. Though not yet
ten o’clock, there was a sort of middle-of-the-night air about the
place, and the two or three men to be seen looked as if they had
been wakened out of their first sleep. For a moment or two Mr.
Guildford, as he stood alone mechanically watching the green light of
the train that had brought him, as it disappeared in the darkness, felt
bewildered and confused. But a voice at his side recalled him to
what was before him.
 “Are you the doctor, sir, if you please—the doctor from
Sothernbay?” and turning at the question, Mr. Guildford saw that the
speaker was a pleasant-looking man-servant, buttoned up to the
chin in a thick driving coat; his tone was eager and anxious.
“Yes. I have come from Sothernbay in answer to a telegram I
received this evening,” he replied. “Are you Colonel Methvyn’s man,
—have you come to meet me?”
“I have been here since five o’clock, sir. ’Twas I sent off the
message. The dog cart is waiting at the gate, and if you please, sir, I
was to say as Miss Cicely—my master, I should say,—hoped you’d
excuse the dog-cart instead of a close carriage; the road from here
to the Abbey is terrible bad just now, and a heavy carriage would
have taken twice as long,” said the man, as he led the way through
the station-gate to where a two-wheeled vehicle and an impatient-
looking horse stood ready for them.
“I prefer it, thank you,” said Mr. Guildford good-naturedly. Like
many self-contained people, he had a liking for a frank manner on
the part of others, especially perhaps when they were his inferiors.
“You see, sir,” continued the man, “I was hurried both ways, first to
get the telegram off, and then to get you to the Abbey when you
came.”
His remarks were interrupted by the zeal with which he set to
work to tuck Mr. Guildford up in the rugs, of which there appeared a
profusion.
“Miss Cicely—leastways my master, I should say, though for that
matter it were Miss Cicely, she never forgets nothing,—she told me
as I were to be sure to bring plenty of wraps,” he observed, his
language becoming comfortably ungrammatical as he felt himself
growing at ease with the “strange doctor.”
“Thank you, that will do capitally,” said Mr. Guildford, as they
started off at a brisk pace. “But it doesn’t seem to me as cold here as
at Sothernbay, or is there a change in the weather?” he added,
glancing up at the sky, in which but few stars were visible.
 “Bless you, sir! yes to be sure, there’s a thaw,” said the servant
eagerly; “it began this afternoon. We was all so glad, thinking it might
be better for little master. Shouldn’t you think so, sir?” he asked with
an anxiety in his voice that Mr. Guildford could not understand.
“I have not heard who it is that is ill, my good fellow,” he said
kindly; “is ‘little master’ the patient? I am all in the dark, you see; I
know nothing except what was in the telegram you sent off.”
“Of course not, sir, of course not,” exclaimed the man. “You see,
sir, we’ve been thinking of little else all these days, and it seemed
like as if every one must be the same. Yes, sir, it’s little master, bless
him! as is ill; it begun with the croup, he’s had that many a time;
many a night Miss Cicely has called me up to fetch the old doctor—
there’s a bell rings into my room on purpose,—but this time it’s
turned to worse. I can’t exactly say what it is. Miss Cicely’s never
closed a eye these three nights, Mrs. Moore told me; I’m afraid he’s
very bad. But now you’ve come, and the break in the weather, he’ll
pull through; don’t you think so, sir?” he inquired wistfully, as if the
question of life or death hung upon the opinion it was utterly
impossible for Mr. Guildford to express.
“You forget, my good fellow,” said the doctor again, “you forget I
have not yet seen the poor little boy; but of one thing you may be
sure, I shall do my very best.”
“Thank you, sir,” said the groom fervently.
“Is Dr. Farmer still at the Abbey—was he there when you left?”
asked Mr. Guildford.
“Yes, sir, but I don’t think you’ll see him tonight; he was quite wore
out, poor old gentleman, and I heard Miss Cicely telling him as I
came away he must go to bed. He’s gettin’ on in years is the old
doctor.”
“Miss Cicely” again. A passing feeling of curiosity crossed Mr.
Guildford’s mind as to whom she could be. A maiden sister or aunt
perhaps of Colonel Methvyn’s, who managed his household and
looked after his children. The name suggested a quaint old-
fashioned maiden lady, and, so far, there had been no mention of a
Mrs. Methvyn. “Miss Cicely” was evidently the ruling spirit of
Greystone Abbey. But it was not Mr. Guildford’s habit to obtain in
formation about either people or things save from head-quarters, so
he put no more questions to his communicative companion. The
road was now becoming so bad that it took all the driver’s skill to
avoid catastrophes.
“Do you never have any repairs done hereabouts?” inquired the
stranger; “this road is really sadly in want of looking after.”
“It isn’t no road at all, sir, by rights,” replied the servant, when he
had time to draw breath after the “joltiest bit” they had yet passed,
“it’s only a short cut to Haverstock. Haverstock isn’t our station—not
the Abbey station; by the highway, Haverstock is good six mile from
us. Our station is Greybridge, but the fast trains don’t stop there,
unless notice is given special; and there’s no telegraphy at
Greybridge. That’s how I had to bring you such a rough way, sir; it
saves four mile and more.”
“Ah! yes, I see,” said Mr. Guildford.
“We’re near home now, sir,” said the man, and the remaining few
minutes were passed in silence.
It was far too dark to distinguish anything plainly. Mr. Guildford
felt, rather than saw, when they turned off the road or lane into
enclosed grounds; the change from the jolting and jogging they had
been enduring for the last quarter of an hour to the smooth roll of a
well-kept gravel drive was very pleasant.
“We’re going in by the side way, sir,” said the groom, “I left the
gate open as I came out; it’s not often this way is used now.”
A few minutes more and they drew up at the front entrance. A
wide porch, with deep stone seats at each side, lighted by a heavy
iron-bound lamp hanging from the roof, was all Mr. Guildford could
distinguish of the outside of Greystone Abbey, It looked more like the
entrance to an ancient church than to a modern dwelling house; it
was in keeping, however, with the associations of the name, and Mr.
Guildford’s perceptions were acute enough for him to infer from what
he saw that by daylight the old house must be picturesque and
quaintly beautiful.
The door was opened, almost before the servant had time to ring,
—anxious ears evidently were on the alert for the first sound of
carriage-wheels,—and two or three servants hurried forward. The
hall into which Mr. Guildford was ushered was a picture of comfort; a
great log fire blazed in the wide open grate, antlered heads threw
grotesque shadows on the wainscoted walls, there were furry fleecy
rugs under foot, armchairs and sofas, and little tables in every
corner; everything looked homelike and inviting, and seemed to tell
of happy gatherings and merry voices. And the pet and pride of the
house—the “little master”—upstairs dying! Little as the young doctor
knew of the Methvyns, a sort of chill seemed to strike through him at
the thought.
His arrival had been quickly announced, for almost immediately a
door at the opposite side of the hall opened, and a stout elderly
person in black silk, and with a general indescribable look of
responsibility and trustworthiness, came forward. She made a sort of
curtsey as she drew near the stranger, a salutation which said as
plainly as any words, “I am the housekeeper, if you please,” and
destroyed instantaneously a passing suspicion of Mr. Guildford’s that
“the managing spirit” of Greystone Abbey stood before him.
“I am so very glad you have come, sir,” said the housekeeper
respectfully; “it will be a great satisfaction. There are refreshments,
sir, in the library, but—if you are not very tired and cold, perhaps—
Miss Cicely is so very anxious to see you. Would you take a glass of
wine now, sir, and something else later?”
But Mr. Guildford declined everything of the kind for the present. “I
should much prefer seeing my patient at once,” he said decidedly;
“will you show me the way?”
“Certainly, sir,” she replied, looking relieved. “Miss Cicely wished
me to take you upstairs as soon as possible.”
Always “Miss Cicely.” She was becoming a sort of “Marquis de
Carabbas” to Mr. Guildford. No mention of the heads of the
household; to judge by appearances, Miss Cicely might be the owner
as well as the ruler of the whole place. So thought the new-comer, as
he followed the worthy Mrs. Moore out of the hall, down a long dimly
lighted passage, looking like enclosed cloisters from the vaulted
ceiling and succession of narrow sharp-pointed windows along one
side, widening at the end into a small square hall, round two sides of
which curved a broad shallow-stepped spiral stair case. Upstairs, a
long passage again, somewhat wider than the one below, with doors
at both sides; at one of these the housekeeper stopped, tapped
softly, but, receiving no answer, went in, beckoning to Mr. Guildford
to follow her. The room which he entered was small and plainly
furnished; it looked almost as if it had once been a schoolroom, but
its present contents were somewhat heterogeneous; the carpet was
nearly threadbare, the windows had no curtains, but there were two
or three good pictures on the walls, a beautiful stand of ferns,
several cages, whose little occupants had all retired for the night,
each carefully shaded by a curtain drawn round the wires; a glass,
filled with lovely flowers, on the table, a Skye terrier asleep on the
hearth rug, a bookcase full of books, of which some of the titles
would have surprised Mr. Guildford had he read them.
He had time for a certain amount of observation, for the
housekeeper, whispering to him a request to wait where he was for a
minute, left the room quickly by another door. It was still cold,
notwithstanding the thaw. Mr. Guildford instinctively turned towards
the fire; the Skye terrier, disturbed by his intrusion, peered up at him
for a moment through its shaggy hair with its bright beady eyes,
growled lazily, and went off to sleep again. So the stranger took up
his position on the hearthrug with his back to the fire, and looked
about him with some curiosity. There was a history in this little room
—the history not so much of a life, as of a character. But it was not
for many a long day that the man who entered it to-night for the first
time learnt to read it. There are many such histories that are never
read at all.
Still he was conscious vaguely of a certain impress of individuality
in the room—some body lived in it and loved all these things thus
much was visible at a glance. Perhaps “the marquise” was of the
genial order of old maids after all, neither managing nor
domineering! Mr. Guildford was smiling at his fancy when the door—
the second again. It was not Mrs. Moore returning. Who was it?
Could this be “Miss Cicely?”
A tall, fair girl in a crimson dress, with coils of hair that must be
sunny by daylight; with a pale, quiet face, and soft, grave eyes. She
stood for a moment in the doorway, the lamp-light falling full upon
her. Some pictures—a few in a lifetime only—take far less time than
our clumsy words can express to imprint themselves for ever on the
brain. This was one of them. Through all the chequered future,
through happy days and “days of cloudy weather,” in her presence or
absent from her, Edmond Guildford never forgot this first vision of
Cicely Methvyn, pale, grave Cicely, standing there for a fairy’s
moment, in her brilliant crimson dress.
The dress, not improbably, had something to do with the vividness
of the impression. Little as he was given to observing such matters, it
could not fail to strike him, both from its beauty and extreme
unsuitability to the girl’s present occupation. It was of velvet of the
richest and loveliest shade of damask red; there was exquisite lace
round the throat and wrists, and there was something quaint and
peculiar in the shape of the bodice. And to add to the effect, Miss
Methvyn wore a thick gold chain round her neck, from which hung a
very beautiful, very large, and evidently antique gold cross, which
shone out with a rich, dull lustre from its crimson background.
Mr. Guildford stood with his eyes fixed upon her for a moment in
absolute amazement. Afterwards he tried to define to himself his
exact impression of the young girl. Was she “pretty?” The word
seemed utterly unsuited to her. Was she beautiful? Hardly. He could
describe her by no words that satisfied his sense of correctness.
She was tall and fair—and then he stopped. She was neither
graceful nor dignified, or rather perhaps she was, strictly speaking,
both. Only the words did not seem to suit her, for they implied a
suspicion of self-consciousness, from which her bearing, her
expression—everything about her, was utterly and unmistakably
free.
 But just now he had hardly time to realise anything but surprise
before she came forward and spoke. She spoke rather slowly; it was
evidently her habit to do so, her voice was low but clear, and
perfectly calm.
“I am so very, very glad you have come,” she said. “It is
exceedingly kind of you to have come so quickly. Charlie—it is
Charlie that is so ill, did you know?” Mr. Guildford made a slight
gesture of assent. “He is in the next room. Will you come in and see
him? He is asleep.”
Mr. Guildford hesitated for a moment.
“Shall I not see Dr. Farmer first?” he said. “Is he here?”
“Oh! I was forgetting to tell you,” she said. “No, Dr. Farmer has
gone home. I made him go, and promised to send for him if you did
not come. He lives only a mile away. He was so knocked up, I really
begged him to go. He left this note for you, and he said he was sure I
could tell you everything.”
She drew a letter out of her pocket as she spoke and gave it to
Mr. Guildford. As he read it, his face grew graver. She, watching him,
observed this.
“I think Charlie is better than when Dr. Farmer left,” she said. “He
is less restless. I asked him how he was just before he went go to
sleep, and he answered me quite distinctly, and his voice sounded
much more like itself.”
“How did he say he felt?” asked Mr. Guildford, stopping for a
moment as he was going to follow Miss Methvyn.
“He said he was sleepy,” she replied. “I asked him if he felt very
‘sore,’ that is his word for ‘ill,’” she explained with a faint little smile,
“and he said, ‘Not so wenny bad, Cissy,’ He calls me ‘Cissy.’ ”
“Ah!” said Mr. Guildford. Then they went into the room, and Cicely
led the stranger to the child’s bedside.
He lay there, propped up with pillows to ease his laboured
breathing. He was sleeping, the girl had said, but, ah! what a
different sleep from the rosy, easy rest of healthy infancy! It was very
pitiful—terribly pitiful. Mr. Guildford looked at the child steadily for
some moments. Then he turned to the young lady.
“Dr. Farmer has told me all that has been done,” he said.
“Everything has been tried, I see. I should like to watch the little
fellow for the next hour or two. I hear you have been up for two or
three nights. Will you not go to bed now and let me, who am quite
fresh, take my turn?”
For the first time there was a slight quiver in the pale young face
as she looked up at Mr. Guildford.
“Won’t you tell me first what you think of him?” she said. “I have
been so anxious to hear your opinion.”
Mr. Guildford turned away with a very, very slight gesture of
impatience. He was beginning to be very sorry for Miss Methvyn, but
he felt the position an uncomfortable one. He was by no means sure
that it would be right to express his real opinion to this girl, so young
and apparently so lonely. He wished Dr. Farmer had stayed; or at
least that he could see the heads of the house, the child’s parents.
“I don’t think you should ask me for my opinion just yet,” he said
somewhat brusquely. “If you will leave me here to watch him, I shall
soon be able to judge better. Shall I not see your parents? Your
father, perhaps I should say? I should like to speak to him about your
little brother.”
“He is not my brother,” she answered quietly. “He is my nephew,
my only sister’s child. My father is a chronic invalid and suffers a
great deal, and my mother is constantly with him. That is why it is
impossible for her to nurse Charlie. He is my especial charge; my
sister left him in my care when she went to India some months ago. I
fancied you understood or I would have explained this before.”
She spoke very gently, almost apologetically. But to Mr. Guildford
it sounded like a reproach.
“I should not have given you the trouble of explaining anything,”
he said quickly. “But will you not do as I proposed? Will you not take
a little rest for an hour or two? I shall stay till the morning. I arranged
to do so before I left home.”
 Just then Mrs. Moore, who had left the room before they entered
it, came back again. She heard what Mr. Guildford was urging upon
Cicely.
“Oh! do, Miss Cicely,” she said earnestly. “You will be quite
knocked up soon, and what would Master Charlie do then?”
“If he wakes and I am not beside him, he will be so frightened,”
said the girl.
“I promise to send for you the moment he wakes—or—or in case
of any change.” said Mr. Guildford.
So at last she gave in. Could Mr. Guildford have realised the
agony her submission was costing her, he would hardly have had the
heart to enforce it, though his motives were of the best. But how was
he, a perfect stranger, seeing her for the first time, to pierce below
the quiet exterior that puzzled many who had known her for years?
She stooped and kissed the little pale drawn face, and repeating,
“You will promise to call me?” went softly out of the room.
Mr. Guildford had no intention of deceiving her. His fears were
great, but so far, he perceived a chance—a faint chance of their not
being realised, and he had no belief in the wisdom of preparing
oneself or others for the worst by crushing prematurely the last little
blossom of hope which may serve its purpose by cheering hours of
otherwise unendurable anguish. But as the night went on, his own
hopes faded slowly. He did the little that was possible to alleviate the
suffering, more painful, it is to be trusted, at this last sad stage, to
witness than to endure; but long before the morning dawned, it
became evident that the little life was ebbing away. There was no
fear of Charlie waking to miss his young aunt; the short journey
through the dark valley was all but over; Charlie’s waking would be in
the bright country “beyond the sun.”
“I think you had better call Miss Methvyn. I promised to send for
her if there was any change,” said Mr. Guildford to the housekeeper,
who had remained with him. There was no need to tell her what the
only change would be now. But almost before he had finished
speaking the door opened swiftly, and Cicely, still in her beautiful
dress, stood again by the bed side.
“I could not stay away any longer. I tried to sleep, but,” she was
beginning; but the words died upon her lips. “Oh! he is not better, he
is worse,” she exclaimed, catching sight of the baby-face, and
reading in Mr. Guildford’s quiet sadness the confirmation of her
terror. “Oh! my darling, my dear, dear little Charlie.”
The anguish of her tone was unmistakable; still, by a supreme
effort of self-control, she forced herself to speak quietly. “Will he not
know me when he wakes?” she whispered to Mr. Guildford.
“He will never wake to consciousness again; all his suffering is
over,” said Mr. Guildford very gently, but Cicely interrupted him with a
faint cry. “What is that? He has never looked like that. Oh! is that
dying?” she sobbed—a slight convulsion had momentarily distorted
the exhausted little frame.
“It does not hurt him, he feels no pain. It is far sadder for you than
for him,” said Mr. Guildford, wishing he could spare her this ordeal.
But it was not protracted; soon, very soon there was no little
Charlie lying there; only the deserted dwelling in which his innocent
spirit had sojourned for four short years.
Then the young girl could no longer restrain her grief. The
incentive to self-control was gone, the unnatural strain broken at last.
She was weakened by her days and nights of watching, and such
sorrow as this was new to her. She laid her head down on the pillow
beside the still white face of the child she had loved so dearly, and
cried as if literally her heart was breaking. She was not a girl who
cried often or easily, and to such natures extreme emotion from its
very rarity is terribly prostrating. Mrs. Moore took the commonplace
view of the matter.
“I never saw Miss Cicely like this,” she said, “but it is better she
should cry. It will do her good in the end; will it not, sir?”
“I don’t know about that,” said Mr. Guildford. “If she seldom cries,
she will be sadly exhausted by this. There is a good deal of
nonsense talked about tears. To some natures they are like drops of
blood.”
He made one or two efforts to persuade her to come away, but for
some time it was useless.
“Oh! do let me stay here a little,” she prayed. “There is no need to
tell any one yet. There is nothing to do. I must not cry to-morrow, for
it would distress my father and mother; but do leave me for tonight.
And, oh! to-morrow, I must write and tell Amy. Oh! how can I? Her
little Charlie that I was to take care of till she came back. And now I
can never do anything for him again. I even put on this dress to
please him this morning, or was it yesterday morning?” she said
confusedly, lifting her head suddenly and looking up in Mr.
Guildford’s face with an almost wild expression in her blue eyes. “He
was so fond of it, he called it my picture frock. I shall never, never put
it on again. I should like never to see it again. Oh, Charlie!”
Then she buried her face in the pillow, and her whole figure shook
convulsively. Mrs. Moore looked at Mr. Guildford in despair.
Suddenly an idea struck her.
“Miss Cicely, my dear,” she said, “I am very sorry to disturb you,
but I think you are forgetting that Mr. Guildford must be very tired. He
came from Sothernbay in a hurry, you know, and has been up all
night and has had nothing to eat. And it is nearly morning now.”
A faint streak of dawn was creeping in at the window—the cold
ghastly dawn of a rainy February morning. Cicely sat up, but
shivered as she saw it. This time yesterday she had been glad to
see the daylight, for the night had been long and trying, and Charlie
had wished many times “morning would come.” Oh! how dreadful
these trifling associations sometimes are. “This time yesterday” our
darling was still here; “this day last week,” bright and full of life
perhaps; “this time last year,”—ah! what bitter changes since then;—
to the young, the first tear-stained entries in life’s calendar seem to
dim all the leaves of the book, even the white blank sheets of the
future; to the old, the gentle, merciful haze of distance mellows and
softens the darkness of even the darkest pages.
 But Cicely was young, not old, and today the sight of the cold,
careless daylight returning again, “as if nothing were the matter,” was
strange and repulsive. She shivered, and for a moment covered her
face with her hands. But the old servant had touched the right chord.
When Miss Methvyn spoke again, it was in quite a different tone.
“I have been very selfish,” she said with a sort of simple dignity,
“very selfish and thoughtless. Mr. Guildford, you must for give me.”
Then she stood up and was moving away, when a thought struck
her, and she turned back.
“I have not thanked you,” she said, looking up at Mr. Guildford and
holding out her hand. “Good-bye, and thank you very much. It will
always be a comfort to us that you came so quickly, otherwise we
might have thought that something else might have been done.”
Her lips quivered again, in spite of her effort to be calm. She
turned quickly, and stooping over the bedside, once more kissed the
little face and then hurried away.
An hour later, when the grey dreary dawn was growing into dull
daylight, Mr. Guildford was driven away again—to Greybridge
Station this time. The same young groom drove as on the night
before, but he was very silent this morning, and his eyes looked as if
he had been crying all night.
“Little Master” had left some sore hearts behind him.
CHAPTER IV.
 A SECOND SUMMONS.

“Se non e vero, e ben trovato.”

Italian Saying.

“All the land. . . .

Smelt of the coming summer, as one large cloud
Drew downward; but all else of heaven was pure
Up to the sun, and May from verge to verge,
And May with me from head to heel.”
The Gardener’s Daughter.

A FEW weeks past, and with the exception of a note from old Dr.
Farmer, thanking him in Colonel Methvyn’s name for his readiness in
obeying the summons, Mr. Guildford heard no more of the family at
Greystone. Sometimes he could almost have fancied the whole
occurrence a dream.
 The weather grew steadily milder: some of the Sothernbay
invalids began to talk of going home; others improved enough to be
a good deal cheerier than they had been; a few, too far gone to be
recalled by even the balmiest air and brightest sun shine, died. Mr.
Guildford was used to sad sights, yet not so used to them as to be
insensible to the ever-varying individual sadness of each; but among
the many phases of sorrow and suffering he had witnessed during
this last winter, no scene had left a stronger impression upon him
than that of the death of the little boy at Greystone Abbey. He had
come upon it so suddenly and unexpectedly; it seemed peculiarly
sad that the little fellow was so far away from his parents, that weeks
must pass before they could even know of their loss. He could not
forget the anguish in the young aunt’s voice when she had
exclaimed, “to-morrow, oh! to-morrow, I must write to tell Amy.” He
often thought about her, and always with pity and interest. But few
things seemed more unlikely than his ever learning more of Miss
Methvyn or her family.
Two months after the February night of his fruitless journey to
Haverstock, Mr. Guildford was surprised at receiving another letter
from old Dr. Farmer, expressing a great wish to see him on as early
a day as he could conveniently name. Dr. Farmer wrote of himself as
in bad health, and on the eve of leaving home for some months. He
offered to meet Mr. Guildford at Sothernbay if necessary, but at the
same time showed plainly that he would be glad to be spared the
journey. Mr. Guildford was not very busy, the “slack season” for
Sothernbay was beginning; he wrote therefore to Dr. Farmer
expressing his readiness to meet him at the old doctor’s own house
at Greybridge, wondering a little as he did so what he could be
wanted for this time, and feeling some curiosity as to whether the
summons was again connected with the family at Greystone Abbey.
It proved to be so.
“Bessie,” said Mr. Guildford to his sister the evening after he had
been over at Greybridge to see Dr. Farmer, “you are always wanting
me to have a change. I am thinking of arranging to have one every
week.”
 “What do you mean, Edmond?” said Mrs. Crichton. “A change
that came every week wouldn’t be a change. You might as well say
Sunday was a change.”
“So it is—to me at least. That is to say, when I can go to church. I
like going to church very much. One can think so comfortably, with
such perfect security from interruption; that’s a very pleasant change
to me,” said Mr. Guildford.
“Is that all you go to church for?” said Bessie with mild reproach.
“And you used to be such a good little boy! I remember the first time
you went to church, how still you sat, and how everybody praised
you when we came out.”
“Well, I don’t jump about now, do I?” said Mr. Guildford. “I don’t
see why I should never be praised now as well as when I was a little
boy. Why don’t you praise me, Bessie? It’s very nice to be praised;
and it’s far harder to be good when one’s big than when one’s little.
You should remember that, Bessie, and encourage me sometimes.
You know I do everything you tell me, don’t I?”
But Mrs. Crichton knitted on perseveringly, counting the stitches in
a low voice, and taking no notice of her brother’s remarks. She was
not fond of being made fun of, and when Edmond talked in this half-
lazy, half-bantering way, she waxed suspicious.
“One, two, three, four, take two together,” she murmured. “These
socks are for you, Edmond,” she observed, in a “coals of-fire-on-
your-head” tone.
“Are they? It’s very good of you to make them for me, but I hope
they are not of that prickly wool, Bessie. Some you knitted for me,
made me feel as if little needles were running into my feet. Did you
knit my socks for me when I was a little boy? If you did, I expect they
were of soft wool then; weren’t they?”
Mrs. Crichton tried to go on knitting gravely, but her brother,
standing behind her, managed to give every now and then judicious
little jogs to her elbows, which much interfered with the progress of
the socks. At first, Mrs. Crichton thought the jogs were accidental,
and bore them philosophically enough, with a “Take care, Edmond,”
or, “Please don’t shake my chair.” But a more energetic jog than
usual exhausted her patience.
“Edmond, you are really too bad,” she exclaimed, “I believe you
are shaking me on purpose. Just look now, I have dropped two
stitches! What is the matter with you, you great, idle boy? Who would
think you were a learned man, a solemn, wise doctor?”
She let her knitting fall on her lap, and turning round her pleasant
face, looked up at him with fond pride shining out of her eyes. She
was only ten years his senior, but her affection for him was almost
motherly—she had been the only mother he had known, and no child
of her own had ever interfered with her love for her early orphaned
little brother.
“What are you looking at me for, Bessie?” he asked.
“I was wondering if you are handsome. I mean if any one else
would think you so,” she said naïvely.
Mr. Guildford laughed. “I don’t suppose anybody but you ever
thought about it,” he said carelessly.
“Your wife will,” said Bessie. And as she said so, she thought to
herself that this shadowy personage would be hard to please were
she other than proud of her husband. The bare possibility of her not
being so, gave Bessie a momentary grudge at her imaginary sister-
in-law. Yet Mr. Guildford was not handsome, not even interestingly
ugly, which often serves the purpose just as well. He was well made
and well proportioned; he was neither very tall nor very short, he had
no striking peculiarity of appearance of any kind. But the grave face
could look sunny enough sometimes, the keen grey eyes could
soften into sympathy and tenderness, the dark brown hair seemed
still to have some of the brightness of boyhood about it—he looked
like a man for whom the best things of life were yet to come; whose
full powers were fresh and unexhausted. There was plenty of
strength in the face; strength which the future might possibly harden
into inflexibility; strength which already faintly threatened to destroy
some of the finer touches of the young man’s character, by