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 E L E C T ROM YOGRA PH Y
I N C L I NI CA L PRACTI CE
ELECTROMYOGRAPHY IN
CLINICAL PRACTICE
A Case Study Approach

THIRD EDITION

Bashar Katirji, MD, FACP

DIRECTOR, NEUROMUSCULAR CENTER & EMG LABORATORY

THE NEUROLOGICAL INSTITUTE

UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER

PROFESSOR OF NEUROLOGY

CASE WESTERN RESERVE UNIVERSITY SCHOOL OF MEDICINE

CLEVELAND, OH

1
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2018
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Katirji, Bashar, author.
Title: Electromyography in clinical practice : a case study approach / Bashar Katirji.
Description: Third edition. | New York, NY : Oxford University Press, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2018001467 | ISBN 9780190603434 (alk. paper)
Subjects: | MESH: Neuromuscular Diseases—diagnosis | Electromyography | Case Reports
Classification: LCC RC77.5 | NLM WE 560 | DDC 616.7/407547—dc23
LC record available at https://lccn.loc.gov/2018001467
This material is not intended to be, and should not be considered, a substitute for medical or other professional ad-
vice. Treatment for the conditions described in this material is highly dependent on the individual circumstances.
And, while this material is designed to offer accurate information with respect to the subject matter covered and
to be current as of the time it was written, research and knowledge about medical and health issues is constantly
evolving and dose schedules for medications are being revised continually, with new side effects recognized and
accounted for regularly. Readers must therefore always check the product information and clinical procedures with
the most up-​to-​date published product information and data sheets provided by the manufacturers and the most
recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties
to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing,
the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages
mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for
any liability, loss or risk that may be claimed or incurred as a consequence of the use and/​or application of any of the
contents of this material.
9 8 7 6 5 4 3 2 1
Printed by Sheridan Books, Inc., United States of America
To my wife Patricia, my children Linda and Michael, and my
parents Malak and Zakaria.
Without their love, encouragement, and blessing, this work
could not have been achieved.
 CONTENTS

Preface to the Third Edition ix SECTION 2: UPPER EXTREMITIES 167

Preface to the Second Edition xi
CASE 9 169
Preface to the First Edition xiii
CASE 10 182
Acknowledgments xv
CASE 11 189
CASE 12 202
CASE 13 211
PART I: INTRODUCTION TO CLINICAL
CASE 14 222
ELECTROMYOGRAPHY  1
CASE 15 240

1. THE SCOPE OF THE EMG EXAMINATION 3 CASE 16 256

2. ROUTINE CLINICAL ELECTROMYOGRAPHY 12

3. SPECIALIZED ELECTRODIAGNOSTIC STUDIES 38 PART III: GENERALIZED DISORDERS 269
4. ELECTRODIAGNOSTIC FINDINGS IN NEUROMUSCULAR
DISORDERS 49 CASE 17 271
CASE 18 298
PART II: FOCAL DISORDERS 61 CASE 19 320
CASE 20 336
SECTION 1: LOWER EXTREMITIES 63 CASE 21 355
CASE 22 367
CASE 1 65
CASE 23 380
CASE 2 84
CASE 24 400
CASE 3 103
CASE 25 411
CASE 4 114
CASE 26 423
CASE 5 122
CASE 27 433
CASE 6 131
CASE 7 140
CASE 8 150
Index of Cases 443
Index of Diagnoses 445
Index447

vii
 PREFACE TO THE THIRD EDITION
It has been more than 10 years since the second edition of
Electromyography in Clinical Practice was published. During
this interval, there have been significant advances in the field
of neuromuscular medicine. New themes have emerged,
new methods and technologies have been adopted, and
old ideas have fallen by the wayside. Also, neuromuscular
medicine completed the process of formally accrediting
fellowship training programs by the Accreditation Council
for Graduate Medical Education and developed, in 2008, its
own subspecialty board under the auspices of the American
Board of Medical Specialties.
With the third edition of this book, I have kept the
essential backbone of the book the same as in previous
editions. The main themes of the book remain to present
and discuss real-​life neuromuscular cases that I encountered
in my clinical practice over the past 35 years. Part I contains
foundational chapters that explain simply the concepts of
electromyography that are core to the understanding of
the discipline. This section was added to the second edi-
tion for the beginner who may not be familiar with the
techniques, terminology, and basic concepts of clinical
electromyography. Subsequent chapters then built upon
those foundations. Part II contains cases with discussions
that explore focal disorders affecting the lower and upper
extremities. Part III discusses cases with generalized neuro-
muscular disorders.
The third edition is slightly longer than the second edition,
published in 2007. The new chapters are more extensive and
focus as much as possible on basic concepts and principles. All
the old chapters and cases were overhauled, most of them sig-
nificantly restructured, updated, and extended. There are many
new sections within the updated chapters and cases. I have
added and replaced many of the tables, diagrams, and figures
and updated all the references. In this edition, I changed the
organization of the case discussion and used a query format as
a heading for each of the subtitles.
Educators who have previously taught from this
book should find the revised third edition coherent and
comprehensive. The text provides basic-​science information
that is critical to the understanding of pathophysiology but
also focuses directly on crucial aspects of clinical practice.
Areas of emphasis include applied anatomy and physiology,
the approach to the patient, clinical features and differential
diagnosis, and state-​of-​the-​art electrodiagnostic findings.
To gain the most benefit, my suggestions on approaching
the book are as follows: Each case should be read without
knowledge of the diagnosis. The history and examination
should be read first, followed by analysis of the data of the
nerve conduction studies and needle EMG findings, both
shown in tabular forms. The reader should then make his
or her own final diagnosis/​differential diagnosis and an-
swer the questions that are intended to test his or her un-
derstanding of the case. Not all the answers to the questions
are easy or obvious, and some are specifically designed to
challenge. This will encourage the subsequent discussion
of the disorder pertinent to each case. I wrote the inter-
pretation of nerve conduction and needle EMG data in a
very simple and practical manner, mimicking bedside daily
discussions in the electromyography laboratory.
Electromyography in Clinical Practice is a single-​
author text designed to be used by trainees as well as med-
ical practitioners, nurses, and allied health professionals
involved in patient care. The text is presented in a way
that should make it accessible to anyone, independent
of prior knowledge in clinical electromyography. It is
suitable as a primer for residency and fellowship training
and as an introductory textbook for those pursuing a
career in neuromuscular medicine. The book is helpful
for students of clinical electromyography preparing to
take a board examination or recertification including
in the American Board of Psychiatry and Neurology,
neuromuscular medicine, clinical neurophysiology, or
electrodiagnostic medicine.
Bashar Katirji, MD, FACP
Cleveland, Ohio
ix
 PREFACE TO THE SECOND EDITION
I have been delighted with the enthusiastic reception
given by physicians to the first edition of this book since
its publication 10 years ago (1997). The aim of the book
was to provide case-​based learning of the most commonly
encountered neuromuscular disorders in the EMG labora-
tory. The second edition maintains the main mission of re-
ducing the gap between theory and practice in the field of
electrodiagnostic medicine. In this edition, a new section
(Part I) was added pertaining to the fundamentals of EMG.
This section serves as an orientation and a quick guide
to the readers who are not familiar with the techniques,
terminology, and basic concepts. It is divided into four
chapters: Chapter 1 introduces the field of electrodiagnostic
medicine and its scope; Chapter 2 covers the basic concepts
of nerve conduction studies and needle EMG; Chapter 3
discusses latent responses and repetitive nerve stimulations;
and Chapter 4 describes the findings in various neuromus-
cular diseases. Part II contains all the cases. Though most
cases were unchanged from the first edition, a few new ones
were added and many were enriched with new and improved
waveforms, tables, and updated references. The discussions
are longer in this edition and include new advances in the
field, such as the increased use of comparison internal nerve
conduction studies in the diagnosis of carpal tunnel syn-
drome, inching techniques in the diagnosis of ulnar nerve
lesions, and quantitative motor unit analysis in the diag-
nosis of myopathy and neurogenic disorders.
Bashar Katirji, MD, FACP
Cleveland, Ohio
xi
 PREFACE TO THE FIRST EDITION

A disease known is half cured. (such as when they are confronted with a similar patient),
Proverb (regarding diagnosis) I intentionally have repeated some of the important tables
and figures to prevent a painful search into other chapters.
The electromyographic examination is a powerful diag-
The organization of the chapters is kept uniform, with
nostic tool for assessing diseases of the peripheral nervous
minimal variability. Each case starts with a history and
system. Electromyography (EMG) is an extension of the
physical examination, in which the pertinent findings are
neurologic examination and is essential for the diagnosis
presented. After each case presentation, there are a few
and prognosis of most neuromuscular disorders.
questions, with corresponding answers placed at the end of
Electromyography in Clinical Practice is the result of al-
the discussion. The questions are not meant to be extensive
most 15 years of teaching EMG. I came to the conclusion, a
(or preparatory for examination) but are included mostly to
few years ago, that fellows, residents, and medical students
stimulate the reader before he or she proceeds into the dis-
enjoy the exercise of EMG problem-​solving. This usually is
cussion. A summary and analysis of the EMG and clinical
accomplished by discussing cases and analyzing the various
findings with final EMG diagnosis follows the case presen-
data obtained first on nerve conduction studies and then on
tation. At the beginning of the discussion, anatomy, path-
needle EMG to reach a final diagnosis. The objective of this
ophysiology, or pathology relevant to the case presented
book is to provide practical discussions of the most com-
are always incorporated. Clinical features are always
monly encountered disorders in the EMG laboratory, using
discussed, but less extensively than the EMG findings. The
typical and real case studies. The book is not intended to
electrodiagnostic discussions are emphasized and kept prac-
teach techniques, and it presumes certain basic knowledge
tical to reflect the objective of the book. A follow-​up and
of clinical neurophysiology.
final diagnosis complete the case. I have supplemented the
The book is composed of 27 cases, selected from a
discussions with many tables and figures, which I find ex-
teaching file I kept for the purpose of training in EMG.
tremely useful for both the novice and experienced clini-
To create a sense of unknown, these cases are organized
cian. Main articles are referenced as suggested readings and
randomly but placed into three large categories: (1) focal
kept to the most useful publications and reviews.
disorders of the lower extremity, (2) focal disorders of the
upper extremity, and (3) generalized disorders. Because Bashar Katirji, MD, FACP
I expect that many readers will read this book at their leisure Cleveland, Ohio

xiii
 ACKNOWLEDGMENTS
I am indebted to my mentor and friend, the late Dr. Asa
Wilbourn, who inspired me into the field, complemented
me about the first edition and encouraged me to write
the second. I am sure he would have pressed me to com-
plete this third edition. I also thank my longtime partner
and friend Dr. David Preston whose energy and enthu-
siasm has kept me interested and encouraged. My current
and former fellows at University Hospitals Cleveland
Medical Center played a pivotal role in starting and
sustaining this publication over the years. I am also
grateful to all the current and former staff, technologists,
and nurses at the EMG laboratory and neuromuscular
center, especially Bobbi Phelps, Peggy Neal, Karen
Spencer, Brenda Karlinchak, Kathleen Kelly, and Kim
Kapis. I would also like to thank Craig Panner, Oxford
University Press Associate Editorial Director, for his
support and encouragement into the publication of this
third edition. Emily Samulski, assistant editor, played a
key part in helping me keep track of the various chapters,
figures, and tables.
xv
PA RT I https://t.me/mebooksfree

INTRODUCTION TO CLINICAL ELECTROMYOGRAPHY

 1.
THE SCOPE OF THE EMG EXAMINATION
https://t.me/mebooksfree
E
lectromyography (EMG) is a term that was first
coined by Weddell et al. in 1943 to describe the clin-
ical application of needle electrode examination of
skeletal muscles. Since then, and at least in North America,
the nomenclature “EMG” or “clinical EMG” has been used
by physicians to refer to the electrophysiologic evaluation
of peripheral nerve and muscle that include the nerve con-
duction studies (NCS) as well as the needle examination
of muscles. These terms continue to cause confusion that
hinders communication among physicians and healthcare
workers. Some physicians refer to the study as EMG/​NCS,
reserving the name EMG solely to the needle EMG evalu-
ation and adding the term “NCS” to reflect the nerve con-
duction studies separately. Others have used the title needle
EMG or needle electrode examination to reflect the needle
evaluation of muscles, while keeping the term “EMG” to
describe the entire evaluation of nerve and muscle. More
recently, a nonspecific term, the “electrodiagnostic (EDX)
examination,” has gained popularity to serve as an umbrella
covering both the needle EMG and NCS. Other nomen-
clature used worldwide includes the electrophysiologic
examination, which may be confused with the cardiac elec-
trophysiological studies, and the electroneuromyographic
(ENMG) examination, which is the most accurate descrip-
tion of the study yet unfortunately not widely used.
Regardless, the designations EDX, EMG, clinical
EMG, or ENMG examinations are best used interchange-
ably to reflect the entire electrophysiological study of nerve
and muscle (NCS and needle EMG), while the terms
“needle EMG” or “needle electrode examination” should
be reserved for the specific testing which involves needle
electrode evaluation of muscle. I use the terms “EMG ex-
amination” and “EDX examination” interchangeably, while
referring to the needle examination of muscle as “needle
EMG.” These designations will be used in this book. Finally,
physicians performing and interpreting these studies are
called electromyographers, electrodiagnosticians, or EDX
consultants.
The EDX examination comprises a group of tests that
are usually complementary to each other and often necessary
to diagnose or exclude a neuromuscular problem (Box 1-​1).
These include principally the NCS that are s­ ensory, motor,
or mixed, and the needle EMG. The terms “concentric” or
“monopolar” needle EMG is sometimes utilized to r­ eflect
the type of needle electrode used. Occasionally, “conven-
tional” or “routine” needle EMG is used to distinguish
needle EMG studies from other procedures including
single-​fiber EMG and quantitative EMG.
In addition to the two main components of the EMG
examination, three late responses are often incorporated
with the NCS and have become an integral part of the NCS.
These include the F waves, also referred to as F responses;
the H reflexes, also known as H responses; and the blink
reflexes. Two specialized tests are often added to the routine
EDX study mainly in patients with suspected neuromus-
cular junction disorders. These include the repetitive nerve
stimulations (RNS) and the single fiber EMG. Finally, a
group of specialized studies that require special expertise
as well as sophisticated equipment and software, used as
clinical and research tools in the assessment of the micro-
environment of the motor unit, include motor unit action
potential (MUAP) morphology analysis, MUAP turns and
amplitudes analysis, macro EMG, motor unit number esti-
mate (MUNE), and near-​nerve recording studies.
T H E R E F E R R AL PROC E S S T O
T H E E MG LAB OR AT OR Y
Patients are referred to the EMG laboratory for EDX
studies following a clinical assessment by a physician who
suspects a disorder of the peripheral nervous system. For
example, a patient with intermittent hand paresthesia and
positive Phalen’s signs may be referred to the EMG labo-
ratory to evaluate a possible carpal tunnel syndrome. The
background and specialty of the referring physician plays a
3
 neurological findings. However, the electromyographer
THE SPECTRUM OF CLINICAL ELECTROMYOGRAPHY
BOX 1-​1 . may encounter one of two pitfalls. The first is that he
(ELECTRODIAGNOSIS) or she may perform a very limited and suboptimal
1. Nerve conduction studies (NCS)
study and become excessively biased by the clinical
•​ Sensory NCS
information, resulting in a significant number of
•​ Antidromic sensory NCS
diagnostic errors and presumptions. The second is that
•​ Orthodromic sensory NCS
the EDX consultants may change the interpretation
•​ Motor NCS
of similar findings among different studies to suit and
•​ Mixed NCS
support the clinical diagnosis. For example, a diabetic
patient with denervation of quadriceps, iliacus, thigh
2. Needle electromyography (EMG)—​routine or conventional adductors, and lumbar paraspinal muscles may be
•​ Concentric needle EMG diagnosed in the EMG laboratory as either upper
•​ Monopolar needle EMG lumbar radiculopathy or diabetic radiculoplexopathy
3. Late responses
(amyotrophy) depending on the clinical situation,
•​ F waves
including temporal course of the symptoms, pain
•​ H reflexes
characteristics, status of diabetic control, or findings on
•​ Blink reflexes
imaging of the spine.

4. Neuromuscular junction studies

•​ Repetitive nerve stimulation (RNS)
•​ Slow RNS
•​ Rapid RNS
•​ Single fiber electromyography (SFEMG)
•​ Voluntary (recruitment) SFEMG
•​ Stimulation SFEMG
5. Quantitative electromyography
•​ Quantitative motor unit action potential morphology
analysis
•​ Turns and amplitude analysis
•​ Macro electromyography
•​ Fiber density
•​ Motor unit number estimate
6. Near-​nerve recording studies
significant role in the planning and execution of the EDX
study. In my experience, this usually follows one of these
three scenarios:
1. The referring physician is also the EDX consultant
(electromyographer). In these situations, the patient
is examined first by the EDX consultant (usually a
neurologist or physiatrist) who then performs and
interprets the EDX study. This is not common or
practical in a busy EMG laboratory. The advantage
of this situation is that the neurological examination
is often thorough and the differential diagnosis is
limited. Hence, the selection of NCS and the choice of
sampled muscles on needle EMG are well guided by the
2. The referring physician is experienced in disorders of the
peripheral nervous system and the EDX examination.
The physician is often a neurologist or physiatrist but
sometimes a neurosurgeon or an orthopedic surgeon. In
this situation, the referral information includes brief, yet
focused, clinical information and a limited differential
diagnosis. In these situations, the EDX consultant
performs an EDX study on the symptomatic limb(s)
to confirm or exclude the suspected diagnosis or,
sometimes, makes an alternative diagnosis which may
have not been considered by the referring physician.
3. The referring physician is not well versed with
disorders of the peripheral nervous system. Often,
the referral working diagnoses in these patients are
vague, nonspecific, or extensive. Since the EDX
study has limitations related to patient discomfort,
expense, and time constraints, a directed neurological
history and a brief neurological examination is
often mandatory before planning and executing the
EDX study. Unfortunately, contacting the referring
physician or reading prior patient notes to extract
more specific information is often not helpful in
these situations.
E MG LAB OR AT OR Y PROC E DU R E S
TESTING AN ADULT
Patients referred to the EMG laboratory should have a
referral form completed by the referring physician with
relevant clinical information and preferably a pertinent

4 P art I . I ntroduction to C linical E lectromyography

Figure 1-​1. A sample of the referring request for an EMG examination.
neurological differential diagnosis (Figure 1-​1). Referring
physicians should also describe the EDX study to their adult
patients, particularly in regard to the discomfort associated
with it, without creating unnecessary heightened anxiety.
If unclear about the technical details of the procedure,
they should encourage their patients to contact the EMG
C hapter 1 . T he S cope of the E M G E xamination
laboratory prior to the test date to obtain a verbal or written
description of the procedure. Such written descriptions
should be widely available online or in referring physicians’
offices (Box 1-​2).
Upon arrival at the EMG laboratory for testing, the
patient should be informed in detail of the procedures
5

SAMPLE OF A DESCRIPTIVE EXPLANATION OF
BOX 1-​2 .
THE EMG EXAMINATION FOR PATIENTS BEFORE
UNDERGOING TESTING
What You Should Know About Your EMG Testing
The EMG (ElectroMyoGraphy) examination is a diagnostic
examination of nerve and muscle function. Your doctor has
arranged this test to assist in establishing a diagnosis and
plan treatment. The EMG examination includes (1) nerve con-
duction studies and (2) muscle testing.
• Nerve conduction studies are performed by placing discs
on the skin over nerves and muscles or rings over fingers
and recording the responses to electrical stimulation of
the nerves. The nerves are stimulated with mild electrical
impulses that give an unusual and surprising sensation
(much like the sensation in the fingers experienced when
you hit your elbow on a desk).
• The muscle testing involves direct recording of muscle
activity at rest and during contraction by inserting small
needles into various muscles. A pinprick sensation is
experienced when the needle is inserted and sometimes
a mild, dull ache is noted while the needle is in place. No
electrical shocks are given. The needle picks up the activity
generated normally by the muscle which is displayed on a
screen and over a loudspeaker so that the physician can
see and hear it.
The EMG examination is safe, well tolerated, and involves only
minor discomfort. It takes an average of about one and a half
hours to complete the study. However, it is not unusual for
more time to be required.
Special Instructions
At the time of your EMG appointment, your skin should be clean
and without lotions, oils, or creams. No special preparation
is required. You can take all your medications as prescribed
by your doctor. Please notify the technologist and physician
if you are taking a blood thinner, are on medication for myas-
thenia gravis, or have a pacemaker or stimulator. There are no
after-​effects, and you may return to your usual activities upon
leaving the EMG laboratory.
Test Results
The results of the EMG examination are sent to your doctor,
who, in turn, will explain them in more detail to you and plan
the appropriate treatment.
6 P art I . I ntroduction to C linical E lectromyography
planned based on the referral information and clinical
manifestations. Reading a written description is useful, but
a verbal description of the procedure by the EDX technol-
ogist, the electromyographer, or both is usually more com-
forting and reassuring to the patient.
The practice of electrodiagnosis is widely regarded as a
practice of medicine. The electromyographer must have a
good knowledge of the anatomy, physiology, and disorders
of the peripheral nervous system and be familiar with the
techniques that are necessary for performing the EDX
study. Although formal training in neuromuscular medicine
or clinical neurophysiology with an emphasis on clinical
EMG is necessary, the skills of the electromyographer are
usually based on the number and type of patients studied.
In practice, the electromyographer functions similar to a
radiologist, by providing diagnostic studies directed by the
patient clinical symptoms and working diagnosis. Hence,
the EMG study should serve as an independent procedure
and provide an objective neurophysiological assessment of
the neuromuscular system.
NCS and RNS may be performed by the
electromyographer, EDX technologist, or both. Well-​
trained, preferably certified EDX technologists should
work under close supervision of the electromyographer. All
NCS and RNS should be viewed by the physician before
proceeding with the needle EMG. Additional NCS may
also be added later based on the needle EMG findings. For
example, the saphenous sensory NCS should be added to
the routine NCS of the lower extremity in a patient with
lumbar radicular pain, if the needle EMG examination
reveals denervation in L4 innervated muscles, in order to
confirm that the lesion is confined to the intraspinal canal
as seen with an L4 radiculopathy.
Needle EMG is performed by the electromyographer.
The data are obtained live and are not easily stored or
reviewed, except for teaching purposes. A concentric or
monopolar needle electrode with the smallest diameter
possible should be utilized, to reduce the pain and discom-
fort associated with needle insertion. The patient should be
comforted throughout the procedure; if requested, a pause
should be granted in the midst of the study.
TESTING A CHILD
The EMG examination often creates extreme anxiety in
young children and their parents. When explaining the study,
it is important to avoid terms with negative connotations
such as “shock” or “needle.” If possible, children should be
accompanied by at least one parent throughout the study
for comfort purposes. The parent may hold the child’s hand
or sit next to the child. Occasionally, both parents may not
withstand observing the test performed on their child, and,
in these situations, they are better kept away during the
active portion of testing.
Most teenagers tolerate the test well. In infants, using a
pediatric stimulator is recommended since the distance be-
tween the cathode and anode is small. Shock artifacts that
occasionally obliterate the response partially or completely
or prevent accurate measurement of amplitude or latency are
common with distal stimulations at the wrists and ankles.
This is due to the very short distance between the cathodes
and recording electrodes with distal stimulations. High
current nerve stimulations that are excessively supramaximal
should be avoided to reduce the pain and discomfort.
In an extremely anxious child (and occasionally adult),
the needle EMG should focus on muscles with the highest
likelihood of abnormality, since only few muscles may be ul-
timately sampled. For example, sampling the vastus lateralis
and deltoid may be the only possible muscles examined
in an anxious child with possible proximal myopathy. In
addition, it is not always possible to evaluate insertional and
spontaneous activities in children first followed by volun-
tary activity, as done in adults. Children often move with
needle insertion, so MUAP recruitment and morphology
could be assessed first. Recording a long sweep of voluntary
activity is also helpful and is available in most new EMG
equipment, so MUAPs could be evaluated later.
Sedation of young children, particularly those be-
tween the ages of 2 and 10 years, is advocated. Infants can
be immobilized by an assistant, and the study can be done
swiftly. However, toddlers are often extremely fearful and
boisterous and often will not cooperate. Sedation has the
advantage of allowing the performance of NCS and RNS
thoroughly without any concern about movement artifacts.
However, sedation has the disadvantage of rendering the
needle EMG more difficult, if the child does not activate
enough MUAPs needed for accurate analysis. In these
situations, the evaluation of both MUAP morphology and
recruitment may be suboptimal. Sedation of young chil-
dren is not without risks and should be done under a physi-
cian, preferably anesthesiologist, and nurse supervision and
constant monitoring of vital signs and oxygenation. In the
past, chloral hydrate was used but was not always successful
and occasionally resulted in deep and prolonged sedation.
In the modern day, conscious sedation with rapid hypnosis
without excitation is commonly used using intravenous
sedative-​hypnotic agents such as midazolam hydrochloride
(Versed®) or propofol (Diprivan®).
C hapter 1 . T he S cope of the E M G E xamination
Propofol (Diprivan®) is the most popular intravenous
sedative-​hypnotic anesthetic widely used in the United
States because of its rapid onset of action and clearance.
Plasma levels decline quickly as a result of high meta-
bolic clearance and prompt distribution to the tissues.
These properties account for propofol’s rapid onset and
short duration of action. Clinically, maintenance of ad-
equate sedation requires a constant infusion of propofol.
Discontinuation of propofol anesthesia usually results
in a rapid decrease in plasma concentrations and prompt
awakening. Although the terminal elimination half-​life
of the drug is one to three days, the sedative effects typi-
cally dissipate within 5 to 10 minutes after the infusion is
discontinued. Longer anesthesia cases or sedation in the
intensive care unit (ICU) may produce higher plasma
concentrations and thus prolong awakening time. With the
advent of propofol, the use of sedation in young children
undergoing EMG testing has become more feasible since
the time to awakening after a one-​to two-​hour infusion
is extremely short. Also, it is possible to titrate the dose to
allow partial awakening. Hence, with the help of propofol
infusion, NCS and RNS are usually done. Similarly, needle
EMG may be performed, evaluating the spontaneous and
insertional activities while the child is sedated. Then, the
infusion is stopped or reduced, which allows the child to
emerge from sedation and move around, which is usually
good enough to assess MUAP morphology and recruit-
ment by needle EMG.
TESTING IN THE ICU
EDX testing of critically ill patients with suspected neu-
romuscular disorders in the ICU is often difficult and
challenging because of several limitations; some are related
to patient factors and others involve the environment of the
ICU (Table 1-​1). Particular attention should be given to the
patient’s skin temperature since peripheral vasoconstriction
is common and may lower skin temperature. A core temper-
ature of greater than 36°C or skin temperature greater than
32°C should be aimed for, since lower temperatures result
in slowing of distal latencies and conduction velocities.
Excessive tissue edema may be associated with low amplitude
sensory or motor responses or interferes with supramaximal
stimulations and giving a false impression of axonal loss.
The edema may be generalized (as with hypoalbuminemia)
or limited to the legs (such as with congestive heart failure),
hands (such as with extravasation of fluids from intrave-
nous lines), or neck (such as following tracheostomy or
central line placement). Many ICU patients have a bleeding
7
TA B L E 1 -​1 . LI M I TAT I O N S O F E L E C T RO D I AGN O S T I C TES TI N G I N THE I N TEN S I V E C A R E UN I T

Solution/​
Limitation Result Recommendation
NERVE CONDUCTION STUDIES

Cool extremities Delayed distal latencies and conduction velocities Try warming blanket; use temperature
conversion

Limb edema Low amplitude or unevoked sensory and motor responses Try contralateral limb

Excessive perspiration Artifacts and inadequate or unevoked responses Prepare skin well, use electrode gel
properly

Skin breakdown Inability to stimulate or record Do not test nerves in area

Central jugular or subclavian line Inability to stimulate near the line in fear of cardiac stimulation Avoid proximal stimulation (Erb’s point,
axilla); test contralateral side

Anterior neck swelling Inability to percutaneously achieve supramaximal simulation at Try contralateral side
Erb’s point or of the phrenic nerves

Internal pacemaker Inability to stimulate near the wires or pacer in fear of cardiac Avoid proximal stimulation (Erb’s point,
stimulation axilla); test contralateral side

External pacemaker High risk of electrical injury. Should not do EDX studies

NEEDLE EMG

Bleeding diasthesis Inability to complete a thorough needle EMG Avoid muscles close to large vessels

Coma, confusion, or deep sedation Inability to accurately assess MUAP morphology or recruitment Inquire if sedation could be reduced or
withheld temporarily

Agitation Inability to accurately assess the insertional and spontaneous Wait and allow for relaxation; inquire if mild
activities sedation could be given

Intubation/​ventilation Inability to turn the patient to needle test the gluteal or Test tensor fascia lata or gluteus medius
paraspinal muscles in supine
EDX = electrodiagnostic; EMG = electromyography; MUAP = motor unit action potential.

diasthesis or are on anticoagulation that prevents extensive
needle EMG testing. Excessive sweating, skin breakdown,
central lines, pacemakers, monitoring devices, or communi-
cable diseases also influence the type of procedure, the par-
ticular site, and the extremity tested.
In spite of these limitations, EDX testing, including
needle EMG, NCS, and RNS, may be performed safely in
the ICU and often provide significant assistance in neuro-
muscular diagnosis and prognosis. Reviewing the history,
physical examination, and medication history as well as
discussing the queries and testing plan with the ICU team
may prove beneficial to avoid possible pitfalls. Except in
rare situations, the EDX tests done in the ICU are often
less extensive than the studies done in the EMG laboratory,
often with fewer number of NCS and needle EMG muscle
sampling. However, enough details are usually obtained to
diagnose or exclude certain neuromuscular disorders that
may be encountered in the ICU. For acute conditions, such
as Guillain-​Barré syndrome or peripheral nerve trauma,
serial studies are often necessary for final diagnosis and
prognosis.
Testing of the respiratory system in the ICU is an-
other important part of the application of EDX testing
that has not been used frequently. Its major role is to in-
vestigate the cause of respiratory insufficiency or failure
to wean off mechanical ventilation by testing components
of the peripheral nervous system involved in ventilation,
including the diaphragm and phrenic nerve. Phrenic
motor NCS by surface stimulation, recording from the
skin over the diaphragm, may be performed in the ICU
setting but may be limited by neck swelling, central lines,
and pacemakers. Diaphragmatic needle EMG examina-
tion of the diaphragm may be performed but is more
difficult and risky in the ICU, and patients may not be
alert enough to cooperate with testing. Ultrasonography
of the diaphragm may be used to guide needle EMG in-
sertion safely and could be used to assess movement and
thickness of diaphragm.

8 P art I . I ntroduction to C linical E lectromyography

 (A)

(B)

Figure 1-​2. Sample of an EMG report. (A) Demograhics and Nerve conduction studies. (B) Needle EMG.
 EM G L A BORATO RY REPO RT
When completed, the EDX consultant should explain the
findings in brief to the patient, bearing in mind that the
electromyographer is often not the referring or treating
physician. Discussion of a serious illness, such as amyo-
trophic lateral sclerosis, may be best left to the referring
physician. Suggestions for clinical management should not
be discussed with the patient (except in general terms if nec-
essary) unless the referring physician has requested a formal
neuromuscular consultation.
The results of the EDX study should be conveyed
promptly to the referring physician(s). An EMG laboratory
report is the best way to transmit the results of the EDX
assessment to the referring physician. Occasionally, the
EDX consultant should contact the referring physician if
the EMG study confirmed a grave disease or if a planned
surgery needs to proceed or be canceled based on the EMG
study findings.
Generating a concise and understandable EMG
laboratory report is an important function of the
electromyographer. The EDX report should be legible and
typed (not handwritten) since it constitutes an integral part
of the patient’s medical records. The report should contain
all the pertinent data acquired during the study, despite that
some referring physicians are only interested in the final
conclusion (Figure 1-​2). In addition to the demographic
data (patient name, age, birth date, sex, hospital number,
date of study, and referring physician), the EMG laboratory
report should include the following:
1. Skin temperature of studied limb(s). This is very
important documentation since cooling affects nerve
conduction and needle EMG studies.
2. Reason for referral to the EMG laboratory. This should
include a brief and pertinent clinical history, the
temporal course of the illness (with date of onset if
applicable), and the complicating factors which may
influence the EDX findings. These factors include
diabetes mellitus, local swelling, limb deformity,
history of poliomyelitis, or previous lumbar or cervical
spinal surgery. An example of a brief history and the
reason for referral is the following: “Acute right wrist
drop noted after recent abdominal surgery 12 days ago.
The patient has had diabetes mellitus for 3 years and a
remote history of anterior cervical discectomy. Evaluate
for right radial neuropathy and brachial plexopathy.”
3. NCS. This segment of the report should always be
part of the EMG laboratory report and is particularly
10
directed to physicians who are well versed with
the EDX examination. Age of patient should be
clearly shown since NCS parameters change with
age, particularly in infants, young children, and the
elderly. Recording and revealing limb(s) temperature
at the time of the study is essential, since most NCS
parameters are greatly affected by cool limbs. The
patient’s height should be also shown on the report
since latencies of late responses (F waves and H reflexes)
are dependent on limb length and height. A tabulated
NCS form should be detailed but not overcrowded
with unnecessary data. Nerves stimulated, stimulation
sites, and recording points are extremely important.
Amplitudes (distal and proximal), distal latencies,
conduction velocities, and F wave latencies should
be noted. Normal laboratory values should also be
shown and side-​to-​side comparisons highlighted when
appropriate (Figure 1-​2A).
4. Needle EMG. This should list the name and side of the
muscles tested with their detailed findings, preferably
in a tabulated form. The table should report on the
insertional activity (increased, decreased, myotonic
discharges, etc.); spontaneous activity (fibrillation
potentials, fasciculation potentials, complex repetitive
discharges, myokymic discharges, neuromyotonic
discharges); and MUAP activation (normal, fair, poor),
recruitment (normal, decreased, early), morphology
(amplitude, duration, percentage polyphasia), and
stability (Figure 1-​2B).
5. If RNS or single fiber EMG was done, the nerve/​muscle
tested and data and/​or waveforms should be shown or
reported in detail.
6. If an advanced EMG study is done (quantitative MUAP
analysis, MUNE, macro EMG), the results should be
outlined in detail.
7. Summary. It is a good practice to review the pertinent
findings of the EDX study in one or two paragraphs.
All the abnormalities and relevant negatives should
be highlighted. This summary sets the stage for
formulating a meaningful impression.
8. Impression (or conclusion). This is the most important
component of the EMG report since it represents the
final link between the electromyographer and referring
physician. The impression should be brief and clear
and disclose a clinically and physiologically relevant
interpretation of the findings. The EDX examination
often is able to make an anatomic or physiologic
P art I . I ntroduction to C linical E lectromyography
 diagnosis or both, with details on location of pathology,
as well as the pathophysiology, severity and acuity of
the process, and prognosis if applicable. The study,
however, often may not be capable of making a final
clinical diagnosis. For example, the EDX study often
diagnoses a median mononeuropathy at the wrist
but not a carpal tunnel syndrome, or a necrotizing
myopathy but not dermatomyositis. In these
situations, the electromyographer may conclude that
the findings are “consistent with or compatible with”
the suspected clinical entity. The electromyographer
may also provide a brief list of differential diagnoses
based on the EDX findings. For example, if myotonia
is detected on needle EMG, a list of the common
dystrophic and nondystrophic myotonic disorders
and the drug-​induced myotonias may be useful to the
referring physician. Rarely, the EDX examination may
be diagnostic of a specific disorder such as with the
Lambert-​Eaton myasthenic syndrome.
The impression should also state that the study has
excluded other diagnoses suspected by the referring phy-
sician. In situations where multiple EDX findings are
detected, they should preferably be listed in order of clin-
ical relevance with the suspected diagnosis shown first,
followed by the less clinical important and likely inci-
dental or asymptomatic diagnoses. If a repeat EMG study
is needed, the impression should state the proposed time
frame for such a study. If the EDX examination was limited
or incomplete, such as due to poor patient tolerance, severe
limb edema or trauma, or the use of anticoagulation, this
should be explicitly explained in the impression.
Although the EDX study is an extension of the neu-
rological examination, the electromyographer should be as
C hapter 1 . T he S cope of the E M G E xamination
objective as possible and not rely fully on the clinical in-
formation in making a diagnosis that is not substantiated
by the EDX findings. For example, the EDX of a patient
with a remote elbow fracture and suspected tardy ulnar
palsy may show an axon-​ loss ulnar mononeuropathy
without focal slowing or conduction block but with de-
nervation of the ulnar innervated muscles in the forearm.
The electromyographer should report that the ulnar
mononeuropathy is localized at or above the elbow and re-
frain from localizing the lesion to the elbow. Apart from
prognostication in certain situations such as in patients
with peripheral nerve lesions, the EDX report should not
include treatment or management recommendations. In
situations where the electromyographer is the treating phy-
sician or is asked to provide a neuromuscular consultation, a
separate consultation report detailing the history of illness,
examination, diagnosis, management, and prognosis should
be produced.
S U GGE S T E D R E ADINGS
Katirji B. Clinical electromyography. In: Daroff RB, Jankovic J, eds.
Bradley’s Neurology in Clinical Practice, 6th ed. Philadelphia: Elsevier,
2016:366–​390.
Katirji B. The clinical electromyography examination. An overview.
Neurol Clin N Am. 2002;20:291–​303.
Katirji B., ed. Clinical Electromyography (Neurology Clinics).
Philadelphia: WB Saunders, 2002.
Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and
Practice, 4th ed. New York: Oxford University Press, 2013.
Preston DC, Shapiro BE. Electromyography and Neuromuscular
Disorders, 3rd ed. Philadelphia: Elsevier/​Saunders, 2012.
Rubin DI, Daube JR. Clinical Neurophysiology, 4th ed. New York: Oxford
University Press, 2016.
Shapiro BE, Katirji B, Preston DC. Clinical electromyography. In: Katirji
B, Kaminski HJ, Ruff RL, eds. Neuromuscular Disorders in Clinical
Practice, 2nd ed. New York: Springer, 2014:80–​140.
11
 2.
ROUTINE CLINICAL ELECTROMYOGRAPHY
NERVE C ONDUCTI O N STUD I ES
Nerve conduction studies (NCS) are usually performed
first, soon after reviewing the history and physical examina-
tion or after obtaining a history and performing a focused
physical examination. The NCS findings assist in planning
and completing the needle electromyography (EMG),
which is often done afterwards. Not infrequently, addi-
tional NCS are done based on needle EMG findings that
require further confirmation.
Electrical stimulation of nerve fibers initiates impulses
that travel along motor, sensory, or mixed axons and evoke
a compound action potential. There are three types of NCS
that are used in clinical practice: motor, sensory, and mixed
NCS. The motor fibers are assessed indirectly by stimu-
lating a nerve while recording from a muscle and analyzing
the evoked compound muscle action potential (CMAP),
also referred to as the motor response or the M wave (M
for motor). The sensory fibers are evaluated by stimulating
and recording from a nerve and studying the evoked sen-
sory nerve action potential (SNAP), also referred to as
the sensory response. Mixed NCS are less commonly used
and assess directly the sensory and motor fibers in combi-
nation by stimulating and recording from a mixed nerve
and analyzing the evoked mixed nerve action potential
(MNAP).
STIMULATION PRINCIPLES
AND TECHNIQUES
Percutaneous (surface) stimulation of a peripheral nerve
is the most widely used nerve conduction technique in
clinical practice. The output impulse is a rectangular
wave with a duration of 0.1 or 0.2 ms, although this may
be increased up to 1 ms in order to record a maximal re-
sponse. Two different types of percutaneous (surface)
electric stimulators are used: both are bipolar with a
12
cathode (negative pole) and anode (positive pole). The
first type is a constant voltage stimulator that regulates
voltage output so that current varies inversely with the
impedance of the skin and subcutaneous tissues. The
second type is a constant current stimulator that changes
voltage according to impedance, so that the amount of
current that reaches the nerve is specified within the
limits of skin resistance. In bipolar stimulation, both
electrodes are placed over the nerve trunk. As the current
flows between the cathode and anode, negative charges
accumulate under the cathode depolarizing the nerve, and
positive charges gather under the anode hyperpolarizing
the nerve.
With bipolar stimulation, the cathode should be, in
most situations, closer to the recording site. If the cathode
and anode of the stimulator are inadvertently reversed,
anodal conduction block of the propagated impulse may
occur. This is due to hyperpolarization at the anode that
may prevent the depolarization that occurs under the
cathode from proceeding past the anode. In situations
where it is intended for the volley to travel proximally
(such as with F wave or H reflex recordings), the bipolar
stimulator is switched and the cathode is placed more
proximally.
Supramaximal stimulation of nerves that results in de-
polarization of all the available axons is a paramount prereq-
uisite to all NCS measurements. To achieve supramaximal
stimulation, current (or voltage) intensity is slowly
increased until it reaches a level where the recorded poten-
tial is at its maximum. Then the current should be increased
an additional 20% to 30% to ensure that the potential
does not increase in size further (Figure 2-​1). Stimulation
via a needle electrode deeply inserted near a nerve is used
less often in clinical practice. This is usually reserved for
circumstances where surface stimulation is not possible,
such as in deep-​seated nerves (e.g., sciatic nerve or cervical
root stimulation).
 5 mV/D 3 ms/D
3.6 mA
8.6 mA
12.4 mA
17.8 mA
22 mA
Figure 2-​1. Supramaximal stimulation of a peripheral nerve during a motor
nerve conduction study (median nerve stimulating at the wrist while
recording APB). With a subthreshold stimulus of 3.6 mA (top response),
none of the fibers are stimulated and no response is evoked. With a
higher stimulus of 8.6 mA (second response), few fibers are stimulated
and a low-​amplitude CMAP is recorded. A further increase in the
current to 12.4 mA (third response) reveals a larger CMAP that is still
submaximal. A 17.4 mA stimulus results in a maximal CMAP (fourth
response). This can only be confirmed after increasing the stimulus
intensity by 20% to 25% (supramaximal stimulus of 22 mA, fifth response)
and evoking a CMAP that is identical to the maximal CMAP. With maximal
and supramaximal stimulations, all nerve fibers are stimulated.
RECORDING ELECTRODES
AND TECHNIQUES
Surface electrodes are most often used for nerve conduction
recordings. Surface recording electrodes are often made as
small discs that are placed over the belly of the muscle or
the nerve (Figure 2-​2). The advantages of surface recording
are that the evoked response is reproducible and changes
only slightly with the position of the recording electrode.
Also, the size (amplitude and area) of the response is a
semiquantitative measure of the number of axons conducting
between the stimulating and recording electrodes.
With motor NCS, the belly-​tendon setup (or montage)
is often used. The active recording electrode (also known
C hapter 2 . R outine C linical E lectromyography
Figure 2-​2. Belly-​tendon recording of CMAP. The settings are for peroneal
motor conduction study recording the EDB and stimulating distally at the
ankle. Note that the active electrode (G1) is over the belly of the muscle
while the reference electrode (G2) is over the tendon. The ground electrode
is placed nearby.
as G1) is placed over the belly of the muscle that correlates
with the endplate zone. This ensures that muscle activity
at the moment of depolarization is recorded as soon as the
nerve action potential has arrived at the endplate. The refer-
ence electrode (also known as G2) is placed over the tendon
of the muscle.
With sensory NCS, the antidromic sensory potentials
are obtained by stimulating toward the sensory receptors,
such as stimulating the median or ulnar nerves at the
wrist and recording from digital nerves. Conversely, or-
thodromic sensory potentials are obtained by stimulating
away from the sensory receptors such as stimulating the
hand digital nerves while recording the median or ulnar
nerves at the wrist. Disc or bar electrodes are often used to
obtain sensory potentials while ring electrodes are conven-
ient to record from hand digital nerves over the proximal
and distal interphalangeal joints (Figure 2-​3). These ring
electrodes could act as stimulation points with recording
from the wrist.
Nerve conduction studies using needle recording is also
possible but is less widespread and reserved for situations
where the recording sites are deep-​seated muscles, proximal
muscles not excitable in isolation, or deep nerves. Needle
recordings are also useful to improve the recording of low
amplitude potentials from a severely injured nerve or a small
atrophic muscle. In contrast to surface recording, needle
electrode recording registers only a small portion of the
13
 The amplifier sensitivity determines the amplitude of
the potential. Overamplification of the response truncates
the response, which results in false measurements of evoked
response amplitude and area, while underamplification
prevents accurate measurements of the take-​off point from
baseline. Typically, sensory studies are recorded with a sen-
sitivity of 10 to 20 μV/​division and motor studies with a
sensitivity of 2 to 5 mV/​division.

RECORDING PROCEDURE

A pre-​pulse preceding the stimulus triggers the sweep on a

Figure 2-​3. Ring electrodes used in recording SNAP. The settings are for
antidromic median SNAP recording index finger.
muscle or nerve action potentials, and the amplitude of the
evoked response is extremely variable and highly dependent
on the exact location of the needle. Hence, amplitude and
area measurement are not reproducible, which renders this
technique mostly as a way to establish nerve continuity and
not valuable in assessing conduction block or estimating the
extent of axonal loss (see later discussion).
storage oscilloscope. A stimulus artifact occurs at the begin-
ning of the sweep and serves as an indicator of the time when
the shock occurred from which point latencies are meas-
ured. Digital averaging is a major improvement in recording
low-​amplitude responses by eliminating artifacts and noise.
Signals time-​locked to the stimulus summate at a constant
latency and appear as an evoked potential, distinct from
the background noise. The signal-​to-​noise ratio increases
in proportion to the square root of the trial number. For
example, four trials give twice as big a response as a single
stimulus, whereas nine trials give three times the amplitude.
Modern instruments digitally indicate the latency and am-
plitude when the desired cursoron the waveform is marked.

SENSORY NERVE CONDUCTION STUDIES

RECORDING SETTINGS AND FILTERS
Sensory NCS are performed by stimulating a nerve while re-
Filters are set in the recording equipment to reject low-​and cording the transmitted potential from the same nerve at a
high-​frequency electrical noise. Low-​frequency (high-​pass) different site. Hence, SNAPs are true nerve action potentials.
filters exclude signals below a set frequency, while high-​ Antidromic sensory NCS are performed by recording
frequency (low-​pass) filters exclude signals above a cer- potentials directed toward the sensory receptors while ortho-
tain frequency. Filtering results in some loss or alteration dromic studies are obtained by recording potentials directed
of the signal of interest. For instance, as the low-​frequency away from these receptors. Sensory latencies and conduc-
filter is reduced, more low-​frequency signals pass through, tion velocities are identical with either method, but SNAP
and the duration of the recorded potential increases amplitudes are higher in antidromic studies and, hence, more
slightly. Likewise, as the high-​frequency filter is lowered, easily obtained without the need for averaging techniques.
more high-​frequency signals are excluded, and the ampli- Since the thresholds of some motor axons are similar to those
tude of the recorded potential usually decreases. Hence, of large myelinated sensory axons, superimposition of muscle
all potentials should be obtained with standardized filter action potentials may obscure the recorded antidromic
settings and only compared to normal values collected SNAPs. These volume-​conducted muscle potentials often
using the same filter settings. The recommended low and occur with mixed nerve stimulation or may result from direct
high filter settings for motor conduction studies are 10 Hz muscle costimulations. Fortunately, SNAPs can still be meas-
and 10 kHz, respectively. The high-​frequency filter is set ured accurately in most cases because large-​diameter sensory
lower for sensory NCS than for motor nerve conduction fibers conduct 5% to 10% faster than motor fibers. This re-
since high-​frequency noise (>10 kHz) commonly obscures lationship may change in disease states that selectively affect
high-​frequency sensory potentials. For sensory conduction different fibers. In contrast to the antidromic studies, the or-
studies, the low-​and high-​frequency filters settings are typ- thodromic responses are small in amplitude, more difficult to
ically 20 Hz and 2 kHz, respectively. obtain, and might require averaging techniques (Figure 2-​4).

14 P art I . I ntroduction to C linical E lectromyography

 2 ms/D
20 µV/D
(A)
(B)
Figure 2-​4. Antidromic and orthodromic median SNAPs. The response in
(A) is antidromic, that is, stimulating the wrist and recording the index
finger. The response in (B) is orthodromic, that is, stimulating the index
and recording at the wrist. Note that the peak latencies are comparable
while the antidromic response is much larger in amplitude than its
orthodromic counterpart.
SNAPs may be obtained by (1) stimulating and recording
a pure sensory nerve (such as the sural and radial sensory
responses), (2) stimulating a mixed nerve while recording
distally over a cutaneous branch (such as the antidromic
median and ulnar sensory responses), or (3) stimulating a
distal cutaneous branch while recording over a proximal
mixed nerve (such as the orthodromic median and ulnar
sensory studies). The active recording electrode (G1) is
placed over the nerve, and the reference electrode (G2) is
positioned slightly more distal with antidromic recordings
or slightly more proximal with orthodromic techniques.
The distance between G1 and G2 electrodes should be fixed
(usually at about 3–​4 cm), since it has a significant effect
on SNAP amplitude. The SNAP is usually triphasic with
an initial small positive phase, followed by a large negative
phase and a positive phase. Several measurements may be
recorded with sensory NCS (Figure 2-​5):
1. SNAP amplitude. This is a semiquantitative measure
of the number of sensory axons that conduct between
the stimulation and recording sites. It is usually
calculated from the baseline (or the initial positive
peak, if present) to the negative peak (baseline-​to-​peak
amplitude). It may also be measured from negative
peak to positive peak (peak-​to-​peak amplitude).
SNAP amplitudes are expressed in microvolts (μV).
SNAP duration and area may be measured but are not
C hapter 2 . R outine C linical E lectromyography
Peak latency 1
Amplitude Area
Duration
Onset latency
Shock artifact
20 µV
2 msec
Figure 2-​5. Antidromic median SNAP stimulating wrist while recording
middle finger revealing commonly measured parameters including a shock
(stimulation) artifact.
useful because of significant temporal dispersion and
phase cancellation that accompany sensory NCS (see
temporal dispersion and phase cancellation).
2. SNAP latencies. Sensory distal latencies may be measured
(in ms) from the stimulus artifact to the onset of the
SNAP (onset latency) or from the stimulus artifact to
the peak of the negative phase (peak latency). Onset
latency may be obscured by a large shock artifact, a noisy
background, or a wavy baseline. Though peak latency
does not reflect the fastest conducting sensory fibers, it is
easily defined and more precise than onset latency.
3. Sensory conduction velocity. This requires stimulation at
a single site only because the latency consists of only the
nerve conduction time from the stimulus point under the
cathode to the recording electrode. Sensory conduction
velocities are calculated using onset latencies (not peak
latencies), in order to calculate the speed of the fastest
conducting fibers, and the distance between the stimulating
cathode and the active recording electrode (G1).
Distance
Sensory conduction velocity =
Onset Latency
15
 Sensory conduction velocity may also be calculated
after a distal and a proximal stimulation and measurement.
For example, the median sensory SNAPs are obtained at
the wrist and elbows and the conduction velocity is meas-
ured as follows:
Sensory conduction velocity
Distance
=
Proximal Onset Latency − Distal Onset Latency
MOTOR NERVE CONDUCTION STUDIES
Motor NCS is performed by stimulating a motor or mixed
peripheral nerve while recording the CMAP from a muscle
innervated by that nerve. The CMAP is the summated
recording of synchronously activated muscle action
potentials. The advantage of this technique is a magnifica-
tion effect based on motor unit principles: Stimulation of
each motor axon results in up to several hundred muscle
action potentials with this number depending on the in-
nervation ratio (number of muscle fibers per axon) of the
examined muscle.
A belly-​ tendon recording is a typical electrode
placement to obtain a CMAP: a pair of recording
electrodes are used with an active lead (G1) placed on
the belly of the muscle and a reference lead (G2) on
the tendon (see Figure 2-​2). Both active and reference
electrodes locations are an essential determinant of the
CMAP size, shape, and latency. The propagating muscle
action potential, originating near the motor point and
under G1, gives rise to a simple biphasic waveform with an
initial large negative phase followed by a smaller positive
phase. With incorrect positioning of the active electrode
away from the endplate, the CMAP will show an initial
positive phase that corresponds to the approaching elec-
trical field of the impulses from muscle fibers toward the
electrode. Similar initial positivity is also recorded with
a volume-​conducted potential from distant muscles acti-
vated by anomalous innervation or by accidental spread of
stimulation to other nerves.
Whenever possible, the nerve is stimulated at two or
more points along its course. Typically, it is stimulated dis-
tally near the recording electrode and more proximally to
evaluate its proximal segment. Several measurements are
evaluated with motor NCS (Figure 2-​6):
1. CMAP amplitude. This is usually measured from
baseline to negative peak and expressed in millivolts
(mV). CMAP amplitude, recorded with surface
electrodes, is a semiquantitative measure of the number
16
1
Distal Distal Area 5 mV
Amplitude
2 msec
Distal
Distal Duration 2
Latency
Proximal Proximal Area
Amplitude
Proximal
Duration
Proximal
Latency
Figure 2-​6. Median motor nerve conduction study revealing commonly
measured parameters following distal stimulation at the wrist (top) and
proximal stimulation at the elbow (bottom).
of axons conducting between the stimulating and the
recording points. CMAP amplitude is also dependent
on the relative conduction speed of the axons, the
integrity of the neuromuscular junctions, and the
number of muscle fibers that are able to generate action
potentials.
2. CMAP duration. This is usually measured as the
duration of the negative phase of the evoked potential
and is expressed in milliseconds (ms). It is a function
of the conduction rates of the various motor axons
within the tested nerve and the distance between the
stimulation and recording electrodes. The CMAP
generated from proximal stimulation has a longer
duration and a lower amplitude than that obtained
from distal stimulation (see temporal dispersion and
phase cancellation).
3. CMAP area. This is usually restricted to the negative
phase area under the waveform and shows linear
correlation with the product of the amplitude and
duration. It is measured in mVms and requires
electronic integration using computerized equipment.
The ability to quantify CMAP area has almost replaced
the need to measure its duration since the duration is
incorporated in the area calculation.
4. CMAP latencies. This is the time interval between
nerve stimulation (shock artifact) and the onset of
the CMAP. It is expressed in ms and reflects the
conduction rate of the fastest conducting axon. Since
P art I . I ntroduction to C linical E lectromyography
 the nerve is typically stimulated at two points, distal 1 ms/D
latency is measured following a stimulation at a distal 20 µV/D

point near the recording site, and a proximal latency is

obtained with a more proximal stimulation point. Both
latencies are dependent mostly on the length of the
nerve segment but also include the slower conduction
along the terminal nerve segments and neuromuscular
transmission time, and possibly some conduction time
along muscle fibers.
Figure 2-​7. Mixed nerve action potential. This is a median palmar
5. Conduction velocity. This is a computed measurement response stimulating the mixed median nerve in the palm and recording
of the speed of conduction and is expressed in meters orthodromically the median nerve at the wrist.
per second (m/​s). Measurement of conduction
velocity allows the comparison of the speed of
conduction between different nerves and subjects, SEGMENTAL STIMULATION IN SHORT
irrespective of the length of the nerve and the INCREMENTS
exact sites of stimulations. Also, motor conduction
Routine NCS are often sufficient to localize the site of
velocity reflects the pure speed of the largest
lesion in entrapment neuropathies. However, during the
motor axon and, in contrast to distal and proximal
evaluation of a focal nerve lesion, inclusion of the unaf-
latencies, does not include any neuromuscular
fected segments in conduction velocity calculation dilutes
transmission time or propagation time along the
the effect of slowing at the injured site and decreases the
muscle membrane. Motor conduction velocity is
sensitivity of the test. Therefore, incremental stimulation
calculated after incorporating the length of the nerve
across the shorter segment helps localize an abnormality
segment between distal and proximal stimulation
that might otherwise escape detection. More precise local-
sites. The nerve length is estimated by measuring the
ization requires moving the stimulus in short increments
surface distance along the course of the nerve and
along the course of the nerve while keeping the recoding
should be more than 10 cm to improve the accuracy
site constant. This procedure is often labeled inching (or
of surface measurement. Motor conduction velocity
actually centimetering) since 1 cm increment is a common
is calculated as follows:
distance measurement. The large per-​step increase in la-
tency more than compensates for the inherent measure-
Motor conduction velocity
ment error associated with stimulating multiple times in
Distance
= short increments. The analysis of the waveform usually
Proximal Latency − Distal Latency
focuses on sudden changes in latency values or abrupt drop
in amplitude.
MIXED NERVE CONDUCTION STUDIES
The inching technique is particularly useful in assessing
patients with carpal tunnel syndrome, ulnar neuropathies
Mixed NCS are done by stimulating and recording from at the elbow or wrist, or peroneal neuropathy at the fib-
nerve trunks with sensory and motor axons. Often, these ular neck. For example, with stimulation of a normal
tests are done by stimulating a nerve trunk distally and median nerve in 1 cm increments across the wrist, the la-
recording more proximally, since the reverse is often tency changes approximately 0.16 to 0.21 ms per cm from
contaminated by large CMAP that obscures the rela- midpalm to distal forearm. A sharply localized latency in-
tively low-​amplitude MNAP. The MNAP may be very low crease across a 1 cm segment indicates a focal abnormality
in amplitude or unelicitable, due to considerable tissue of the median nerve.
interposing between the nerve and recording electrode, in
sites where the nerve is deep (such as the elbow or knee).
PHYSIOLOGIC VARIABILITIES
Hence, these studies are not common in clinical practice
and are restricted to evaluating mixed nerves in distal nerve Temperature. Nerve impulses propagate slower by 2.4 m/​
segments, such as in the hand or foot during the evaluation s or approximately 5% per degree Celsius as the limb cools
of carpal tunnel syndrome and tarsal tunnel syndrome, re- from 38°C to 29°C. Also, cooling results in a higher CMAP
spectively (Figure 2-​7). and SNAP amplitude and longer duration probably because

C hapter 2 . R outine C linical E lectromyography 17

of accelerated and slowed Na+ channel inactivation. Hence,
a CMAP or SNAP with high amplitude and slow distal la-
tency or conduction velocity should be highly suspicious of
a cool limb (Figure 2-​8).
To reduce this type of variability, skin temperature is
measured with a plate thermistor that correlates linearly
with the subcutaneous and intramuscular temperatures. If
the skin temperature falls below 33° to 34°C, it is neces-
sary to warm the limbs by immersion in warm water, using
warming packs, or using hydroculator pads, the latter being
very useful when testing bedridden or intensive care unit
patients. Adding 5% of the calculated conduction velocity
for each degree below 33°C theoretically normalizes the re-
sult. However, such conversion factors are based on experi-
ence with healthy individuals and do not apply to patients
with abnormal nerves.
Age. Nerve conduction velocities are slow at birth
since myelination is incomplete. They are roughly one-​half
the adult value in full-​term newborns and one-​third that
of term newborns in 23-​to 24-​week premature newborns.
They reach adult values at three to five years. Then, motor
and sensory nerve conduction velocities tend to slightly in-
crease in the arms and decrease in the legs during childhood
up to 19 years. With aging, conduction velocities slowly de-
cline after 30 to 40 years of age so that the mean conduction
velocity is reduced about 10% at 60 years of age.
Aging also causes a diminution in SNAP and CMAP
amplitudes, which decline slowly after the age of 60 years.
This affects SNAP amplitudes more prominently, so that
20 µV/D 2 ms/D
(B)
(A)
Figure 2-​8. The effect of temperature on antidromic median SNAP
stimulating at the wrist and recording the index finger. Response obtained
with a skin palm temperature of (A) 33.5ºC and (B) 29.5ºC. Note that cool
limb results in a SNAP with slower onset and peak latencies and higher
amplitude.
18
normal upper limb SNAP amplitude drops up to 50% by
age 70, and lower limb SNAPs in healthy subjects above
the age of 60 years may become unevokable. Hence, ab-
sent lower extremity SNAPs in the elderly must always be
interpreted with caution and are not necessarily considered
abnormal without other confirmatory data.
Height and nerve segments. An inverse relationship
between height and nerve conduction velocity suggests that
longer nerves generally conduct slower than shorter nerves.
For example, the nerve conduction velocities of the pero-
neal and tibial nerves are 7 to 10 m/​s slower than the me-
dian and ulnar nerves. This cannot be explained entirely by
the small reduction in temperature of the legs as compared
with the arms. Possible factors to account for the length-​
related slowing include abrupt distal axonal tapering, pro-
gressive reduction in axonal diameter, or shorter internodal
distances. For similar reasons, nerve impulses propagate
faster in proximal than in distal nerve segments. Hence,
adjustments of normal values must be made for individuals
of extreme height, which is usually no more than 2 to 4 m/​s
below the lower limit of normal.
Anomalies. Anomalous peripheral innervations may
mislead the electrodiagnostic physician and occasionally
lead to erroneous diagnosis and treatment. There are several
anomalous peripheral innervations that are important to
recognize since they have a significant effect on NCS.
1. Martin-​Gruber anastomosis. Martin-​Gruber
anastomosis is named after anatomist Martin in 1763
and Gruber in 1870. This is an anomalous connection
between the median and the ulnar nerves in the
forearm that usually consists of motor axons. Two or
three communicating branches in the forearm leave the
median nerve and join the ulnar nerve to innervate the
ulnar-​innervated intrinsic hand muscles, in particular
the first dorsal interosseous muscle (the most common
target), the hypothenar muscles (abductor digiti
minimi), the thenar muscles (adductor pollicis, deep
head of flexor pollicis brevis), or a combination of these
muscles (Figure 2-​9). Martin-​Gruber anastomosis,
also referred to as median-​to-​ulnar anastomosis in the
forearm, is present in approximately 15% to 20% of the
population and is sometimes bilateral. This anomaly
manifests during ulnar or median NCS depending on
where the anomalous fibers terminate.
a. In situations where the communicating fibers
terminate in the first dorsal interosseous muscle or
the hypothenar muscles, the ulnar NCS, recording
first dorsal interosseous, or abductor digiti minimi
P art I . I ntroduction to C linical E lectromyography
 Median nerve Ulnar nerve
Elbow
Martin-Gruber
anastomosis
Wrist
Motor branch Deep motor
of median
ulnar nerve
nerve Motor branch of
ulnar nerve to
hypothenar muscles
Sensory branches Sensory branches
Figure 2-​9. Schematic representation of the Martin-​Gruber anastomosis in
the forearm. This shows fibers destined to the deep palmar branch of
the ulnar, usually terminating in the dorsal interossei (including the first
dorsal interosseous) and ulnar thenar muscles.
(ADM), manifests with a drop in the ulnar
CMAP amplitude between distal and proximal
stimulation sites (conduction block). With distal
stimulation at the wrist, the CMAP reflects all
ulnar motor fibers, while proximal stimulations
(usually below and above elbow) activate only the
uncrossed fibers which are fewer in number and
result in lower CMAP amplitudes. This anomalous
pseudo-​conduction block is confirmed by median
nerve stimulation at the elbow that evokes a small
CMAP from the abductor digiti minimi, which
is not present on median nerve stimulation at the
wrist (Figure 2-​10). With median stimulation at the
wrist recording the first dorsal interosseous, there
is often a small evoked CMAP that reflects volume
conduction from the neighboring median thenar
muscles (Figures 2-​11 and 2-​12).
b. When anomalous fibers innervate the thenar
muscles, stimulation of the median nerve at the
elbow activates the nerve and the crossing ulnar
fibers resulting in a large CMAP, often with an
initial positivity caused by volume conduction of
action potential from ulnar thenar muscles to the
median thenar muscles. In contrast, distal median
nerve stimulation evokes a smaller thenar CMAP
without the positive dip since the crossed fibers are
not present at the wrist. Also, the median nerve
conduction velocity in the forearm is spuriously
fast, particularly in the presence of carpal tunnel
C hapter 2 . R outine C linical E lectromyography
5 mV
3 ms
(A) 6.3 mV
(B) 0.3 mV
(C) 0.3 mV
(D)
No response
(E)
5.1 mV
Figure 2-​10. Martin-​Gruber anastomosis with evidence of prominent median
to ulnar anastomosis recording hypothenar muscle (ADM). The figure
shows an ulnar motor conduction study recording hypothenar muscle
(ADM), stimulating the ulnar nerve at the wrist (A), below elbow (B), and
above elbow (C). It also reveals an absent response following stimulating
the median nerve at the wrist (D) and a large CMAP stimulating the
median nerve at the elbow (E).
syndrome, since the CMAP onset represents a
different population of fibers at the wrist compared
to the elbow (Figures 2-​13 and 2-​14). An accurate
conduction velocity may be obtained by using
collision studies that abolish action potentials of the
crossed fibers.
2. Accessory deep peroneal nerve. This anomaly is present
in about in 19% to 28% of the general population, likely
with an autosomal dominant mode of inheritance. The
anomalous nerve is a branch of the superficial peroneal
nerve that usually arises as a continuation of the muscular
branch to the peroneus longus and brevis muscles. It
passes behind the lateral malleolus near the sural nerve
to reach the dorsum of the foot (see Figure C8-6). The
accessory deep peroneal nerve (ADPN) consistently
sends sensory branches to the ankle joint, tendons and
ligaments, and motor branches to the peroneus brevis,
and occasionally motor branches to the peroneus longus
and extensor digitorum brevis (EDB). The anomalous
19
 10 mV/D 3 ms/D 5 mV
3 ms
(A) 8.0 mV
14.5 mV
(A)
(B) 0.7 mV

5.8 mV (C) 0.7 mV

(B)

(D) 1.0 mV
5.5 mV
(C)

(E) 6.8 mV

(D) 0.3 mV

Figure 2-​12. Martin-​Gruber anastomosis with evidence of prominent median

to ulnar anastomosis recording first dorsal interosseous muscle. The
figure shows an ulnar motor conduction study recording first dorsal
6.6 mV interosseous muscle, stimulating the ulnar nerve at the wrist (A), below
(E) elbow (B), and above elbow (C). It also reveals the response following
stimulating the median nerve at the wrist (D) and the elbow (E). The
anastomosis amplitude equals the differences between CMAPs obtained
in E and D (6.8−1.0 = 5.8 mV), since CMAP amplitude stimulating the
Figure 2-​11. Martin-​Gruber anastomosis with evidence of median to ulnar median nerve at the wrist (D) represents volume conduction from median
anastomosis recording first dorsal interosseous muscle. The figure shows thenar muscles to first dorsal interosseous muscle.
an ulnar motor conduction study recording first dorsal interosseous
muscle, stimulating the ulnar nerve at the wrist (A), below elbow (B),
and above elbow (C). It also reveals the CMAPs following stimulating
the median nerve at the wrist (D) and the elbow (E). Note the drop in
CMAP amplitude (and area) between wrist and below elbow stimulation
(14.5 mV vs. 5.8 mV), along with a robust CMAP upon stimulation of
median nerve at elbow (6.6 mV) with a small CMAP upon stimulation of
5 mV/D 2 ms/D
median nerve at wrist (mV) due to volume conduction between median
thenar muscles and first dorsal interosseous muscle. The actual CMAP
amplitude from median to ulnar crossover is 6.6–​0.3 = 6.3 mV.

fibers usually innervate the lateral part of the EDB

(A) 9.2 mV
muscle, particularly the segment that extends the fourth
toe, but sometimes the third and fifth toes.
  During peroneal motor NCS recording the EDB,
the peroneal CMAP amplitude is larger stimulating
proximally than distally since the anomalous fibers are 10.1 mV
(B)
not present at the ankle. This anomaly can be confirmed
by stimulating behind the lateral malleolus. This yields
a CMAP (not present in normal situations) that, when
added to the distal CMAP, is approximately equal
or higher than the CMAP obtained with proximal
Conduction velocity = 94.7 m/s
peroneal nerve stimulations (Figures 2-​15 and 2-​16).
  Total innervation of the EDB by the ADPN is Figure 2-​13. Martin-​Gruber anastomosis with evidence of median to ulnar
uncommon. In these situations, peroneal motor study anastomosis recording APB. The figure shows a median motor conduction
with recording from the EDB will show an absent study recording APB (A, distal; B, proximal). Arrow indicates the positive
dip seen on proximal but not distal stimulation, caused by volume
CMAP upon stimulating at the ankle and normal conduction from ulnar thenar muscles into APB.

20 P art I . I ntroduction to C linical E lectromyography

 1 mV
5 mV 3 ms
(A)
0.1 mV

7.0 mV 3 msec
7.1 msec

(B) 1.8 mV
8.2 msec 7.3 mV

CV = distance/latency difference
= 230/1.0
= 230 m/s 2.0 mV
(C)
Figure 2-​14. Martin-​Gruber anastomosis with evidence of median to ulnar
anastomosis recording APB in a patient with moderate carpal tunnel
syndrome. The figure shows a median motor conduction study recording
APB (A, distal; B, proximal). Note the slowing of the distal latency (7.1
ms, N < 4.0 ms) which is compatible with carpal tunnel syndrome. There Figure 2-​16. Prominent ADPN anomaly. Note here that the distal CMAP was
is a spuriously rapid conduction velocity with a larger proximal thenar extremely low in amplitude (A) while the proximal CMAP is higher (B).
CMAP exhibiting a positive dip (arrow). Similar to Figure 2-​12, stimulation behind the lateral malleolus yielded
a relatively large CMAP (C). However, in this example, most fibers were
directed to the EDB through the ADPN, leaving only a few to travel through
the main trunk of the deep peroneal nerve.
1 mV

3 ms CMAPs upon stimulating above and below the fibular

1.5 mV neck. A large CMAP is then recorded upon stimulating
the ADPN behind the lateral malleolus, which confirm
(A)
the total innervation of the EDB muscle by the ADPN.
Hence, an absent peroneal CMAP, stimulating at the
ankle while recording EDB, does not automatically
imply the presence of a peroneal nerve lesion since it may
be due to an anomalous ADPN. Proximal stimulation
of the peroneal nerve below and above the fibular neck
(B) 2.2 mV
should be done routinely despite an absent distal (ankle)
motor response. If a proximal CMAP is present, then
stimulation behind the lateral malleolus should be done
to confirm the presence of ADPN. The presence of an
ADPN with total or prominent innervation of the EDB
should also be sought in extremely rare cases of severe
deep peroneal nerve lesion associated with complete or
1.0 mV
partial preservation extension of lateral toes.
(C)
3. Riche-​Cannieu anastomosis. Riche-​Cannieu anastomosis
was first described by both Riche and Cannieu in
1897. It is a neural connection in the palm between
the deep branch of the ulnar nerve and the recurrent
Figure 2-​15. Accessory deep peroneal nerve anomaly shown while
motor branch of the median nerve (Figure 2-​17). This
performing a peroneal motor conduction study recording EDB. The distal anastomosis classically carries motor fibers and destined
stimulation at the ankle (A) results in a CMAP that was lower in amplitude to the abductor pollicis brevis (APB) and opponens
that the proximal response following knee stimulation (B). Stimulation
behind the lateral malleolus yielded a CMAP (C). Note that the summation
pollicis. Riche-​Cannieu anastomosis is rather common;
of the CMAPs at (A) and (C) were higher than the CMAP at (B). anatomical studies on the prevalence of Riche-​Cannieu

C hapter 2 . R outine C linical E lectromyography 21

 Median nerve
Ulnar nerve
Riches cannieu anostomosis
Figure 2-​17. Riche-​Cannieu anastomosis anatomy. There is a connection
between the deep palmar branch of the ulnar nerve and the recurrent
motor branch of the median nerve (circles). Triangles are ulnar innervated
muscles and squares are median innervated muscles.
anastomosis have varied from 50% to 80% of the general
population, with a likely autosomal dominant hereditary
pattern. Electrophysiological studies have shown that
in about 80% of hands, there is some ulnar innervation
of the APB (mean 27% of total innervation), while
in 10% of hands, the APB is predominantly supplied
by the ulnar nerve. The clinical implication of Riche-​
Cannieu anastomosis is that intrinsic hand muscles
typically innervated by the median nerve are innervated
by the ulnar nerve resulting in the so-​called All-​ulnar
hand. When this anomaly is prominent, denervation in
median hand muscles may be present following an ulnar
nerve lesion. Also, a severe median nerve lesion may be
associated with relative sparing of median innervated
muscles in the hand. If Riche-​Cannieu anastomosis is
not identified, one may incorrectly diagnoses a C8 or
T1 plexopathy or radiculopathy, or additional median
neuropathy.
  Riche-​Cannieu anastomosis should be suspected in
the EMG laboratory if the median CMAP amplitude
is low stimulating palm, wrist, and elbow recording
APB, with no focal slowing of distal latency, normal
median motor conduction velocity, normal median
sensory studies, normal internal comparison studies
22
(or inching), and normal needle EMG of APB. The
anastomosis may be confirmed by stimulating the ulnar
nerve at the wrist and elbow, recording APB. If present,
this will result in a CMAP and a small positive dip
(due to volume conduction for ulnar thenar muscles).
Extreme care should be taken in avoiding costimulation
of the median nerve at the wrist (Figure 2-​18).
4. Pre-​and postfixed brachial plexus. In most individuals,
the brachial plexus arises from the C5 to T1 cervical
roots. In some, the plexus origin shifts up one level,
arising from C4 to C8, and in others it shifts one level
down, originating from C6 to T2. The former situation
is referred to as a prefixed brachial plexus, while the
latter is a postfixed brachial plexus. These anomalies
10 mV/D 5 ms/D
(A)
(B)
(C)
(D)
Figure 2-​18. Riche-​Cannieu anastomosis, nerve conduction findings. A 36-​
year-​old left-​handed woman was referred for possible left carpal tunnel
syndrome. She describes intermittent numbness in the left index and
middle finger and left distal ventral forearm with neck pain radiating
to the arm. She had a normal neurological examination including
normal sensation, reflexes, and muscle strength, as well as normal
thenar muscle bulk and strength. The median sensory studies, internal
comparison studies (palmar mixed, median/​ulnar comparison to ring
finger and median/​ulnar comparison to second lumbrical/​interossei), and
needle EMG of several muscles including the APB were normal. However,
on motor conduction studies, the median CMAP recording APB was
very low in amplitude (0.8 mV) with normal distal latency (3.6 ms) upon
stimulating at the wrist (A) with similarly low amplitude upon proximal
stimulation (B) with normal conduction velocity (55 m/​sec). With ulnar
stimulation at the wrist recording APB (C) a large CMAP (15.3 mV) was
recorded which was also present with elbow stimulation (D).
P art I . I ntroduction to C linical E lectromyography
 have implications for the precise localization of cervical
root lesions based on myotomal representation. In a
prefixed plexus, the location of the cervical lesion is one
level higher than that concluded based on the clinical
examination and electrodiagnostic studies. In contrast,
with a postfixed plexus, the cervical root lesion is one
level lower.
Temporal dispersion and phase cancellation. The
CMAP, evoked by supramaximal stimulation, represents
the summation of all individual muscle action potentials
directed to the muscle through the stimulated nerve.
Typically, as the stimulus site moves proximally, the CMAPs
increase in duration and slightly drop in amplitude and area.
The increase in duration is caused by temporal dispersion
where the velocity of impulses in slow-​conducting fibers
lags increasingly behind those of fast-​conducting fibers as
conduction distance increases. With dispersion, there is
also a slight positive/​negative phases overlap resulting in
phase cancellation of motor unit action potential (MUAP)
waveforms. The final result of temporal dispersion and
phase cancellation is a reduction of CMAP amplitude and
area and prolongation of its duration.
Physiological temporal dispersion and phase can-
cellation affects the SNAP more than the CMAP. This
is related to two factors. First is the difference in dura-
tion of individual unit discharges between nerve and
muscle. With short-​duration biphasic SNAPs, a slight
Figure 2-​19. Temporal dispersion and phase cancellation of two surface-​recorded motor unit potentials at distal and proximal sites. This can be translated
into many similar biphasic potentials, which contribute to the CMAP. (Reproduced from Kimura J et al. Relation between size of compound sensory or
muscle action potentials, and length of nerve segment. Neurology. 1986;36:647–​652, with permission.)
C hapter 2 . R outine C linical E lectromyography
latency difference could line up the positive peaks of the
fast fibers with the negative peaks of the slow fibers and
cancel both. In longer-​duration motor unit potentials,
the same latency shift would only partially superimpose
peaks of opposite polarity, and cancellation would be less
of a factor (Figures 2-​19 and 2-​20). The second factor is
the disparity between sensory fiber and motor fiber con-
duction velocities. The range of conduction velocities
between the fastest and slowest individual human mye-
linated sensory axons is almost twice that of the motor
axons (25 m/​s versus 12 m/​s). This results in more disper-
sion of individual SNAPs and leads to more prominent
phase cancellation.
Intertrial variability. Principal factors contributing to
an intertrial variability include errors in determining sur-
face distance and in measuring latencies and amplitudes of
the recorded response. A slight shift in recording site results
in significant amplitude variability. NCS are more repro-
ducible when done by the same examiner because of the sig-
nificant degree of interexaminer variability.
COMMON NONPHYSIOLOGICAL SOURCES
OF ERROR
Several major pitfalls in NCS may result in erroneous
measurements, calculations, and conclusions. These are
usually due to technical errors related to a large obscuring
stimulus artifact, increased background electrical noise,
Individual Summated
responses response
23
 Individual Summated
responses response

Figure 2-​20. Temporal dispersion and phase cancellation of two surface-​recorded single-​fiber sensory potentials at distal and proximal sites. This can be
translated into many similar biphasic potentials, which contribute to the SNAP. (Reproduced from Kimura J et al. Relation between size of compound
sensory or muscle action potentials, and length of nerve segment. Neurology. 1986;36:647–​652, with permission.)

submaximal stimulations at distal or proximal sites or both,
spread of the stimulating current to a nerve not under study,
eliciting an unwanted potential from distant muscles, mis-
placement of recording or reference electrodes, or errors in
the measurement of nerve length and conduction time.
Large Stimulus Artifact
A stimulus artifact occurs with every stimulus in all NCS
and serves a useful purpose by indicating when the shock
occurred and from which point latencies should be meas-
ured. The stimulus artifact, however, may obscure the onset
of the recorded potential when the artifact is high in am-
plitude with its trailing edge overlaps with that potential,
leading to inaccurate measurements of both amplitude and
latency. This occurs most commonly with sensory NCS and
is exacerbated when the recording electrode and the stimu-
lating probe are too close or when the stimulus intensity is
high (see Figure 2-​5). In these situations, the trailing edge
of the shock artifact overlaps with the potential, leading
to inaccurate measurements of both amplitude and onset
latency: a large negative artifact will result in a lower ampli-
tude and longer onset latency while a large positive artifact
yields a higher amplitude and shorter onset latency. The
negative effect of the shock artifact on the recorded poten-
tial improves by increasing the distance between stimulator
and recording electrodes or by decreasing the stimulation
intensity. This artifact may also be reduced by slight rotation
of the stimulator’s anode while maintaining the cathode in
place, placing the ground electrode between the stimulator
and recording electrodes, and ensuring that the stimulator
and recording electrode cables do not overlap.
Increased Electrode Noise
Electrode noise usually interferes with recording small
potentials, such as SNAPs or fibrillation potentials. The
most common cause of electrical noise in the EMG labora-
tory is 60 or 50 Hz interference generated from other elec-
trical devices. “Impedance” is an electrical term combining
the effects of resistance to flow for a DC current and ca-
pacitance for an AC current. As per Ohm’s law, the voltage

24 P art I . I ntroduction to C linical E lectromyography

(E) from electrical noise equals the current (I) induced
from the electrical noise multiplied by the resistance (R) or
impedance (E = IR). Signals recorded during the NCS (and
needle EMG) are the result of differential amplification, in
which the difference between the signals at the active (G1)
and reference (G2) electrodes is amplified and displayed.
Therefore, if the same electrical noise is present at both the
active and reference electrodes (such as with closely placed
G1 and G2 electrodes), it is subtracted out, and only the
signal of interest is amplified (i.e., common mode rejec-
tion). However, if the resistance or impedance is different
at each electrode, then the same electrical noise will induce
a different voltage at each electrode input. This difference is
then amplified and displayed, often obscuring the signal of
interest. Hence, preventing electrode impedance mismatch
is the best way to achieve identical electrical noise at each
electrode.
To prevent electrode noise, intact electrodes without
frayed or broken connections should be used, and the
skin should be cleaned with either alcohol or acetone.
Conducting electrode jelly is then applied to the electrode
before it is attached to the skin. The recording electrodes
should be held firmly against the skin with adhesive tape or
a Velcro band.
Submaximal Stimulation
An erroneous diagnosis of conduction block may occur if
submaximal stimulation was not achieved at a proximal
stimulation site only while the distal stimulation site was
supramaximal. Conversely, a submaximal stimulation at
a distal site with supramaximal stimulation at a proximal
site may erroneously suggest an anomalous innervation.
A misdiagnosis of axonal loss may be made if a nerve is
not supramaximally stimulated at both its distal and prox-
imal sites. In addition to their effect on CMAP and SNAP
amplitudes, submaximal stimulations at all stimulation sites
result in prolonged latencies and conduction velocities,
since the largest fibers have the highest threshold for stimu-
lation and are evoked last.
Costimulation of Adjacent Nerves
The stimulating current may spread to excite nearby
nerves, which may result in a spuriously large amplitude
potential, caused by the inadvertent corecording of ad-
ditional nerve or muscle potentials beyond the potential
of interest. Inadvertent costimulation of adjacent nerves
distally but not proximally may be mistaken for conduc-
tion block. Proximal without distal costimulation may
C hapter 2 . R outine C linical E lectromyography
obscure a true conduction block or erroneously suggest
an anomalous innervation. To avoid costimulation of ad-
jacent nerves, the examiner should watch the morphology
of the waveform carefully and for the muscle twitch with
all stimulations. If there is an abrupt change in waveform
configuration or in muscle twitch pattern, especially at
higher currents, costimulation of adjacent nerves may have
occurred. Common sites of nerve costimulation are the
median and ulnar nerve stimulations at the wrist, elbow,
or axilla and the common peroneal and tibial nerves
stimulations at the knee. Costimulation of multiple nerve
elements is unavoidable with percutaneous stimulation
of the supraclavicular elements of the brachial plexus at
Erb’s point.
Recording or Reference Electrode Misplacement
With the belly-​tendon method of recording, the CMAP
shows an initial positive deflection if the active (G1) re-
cording electrode is not placed over the endplate. This
occurs since the volume-​conducted depolarization poten-
tial first occurs at a distance from the recording electrode.
This electrode misplacement results in error in measuring
the latency, and the CMAP amplitude may be reduced.
The SNAP or MNAP may be low in amplitude when
the recording electrode is inadvertently placed lateral or
medial to the nerve trunk, since the amplitude of the po-
tential decays dramatically with increasing distance from
the generator. This occurs most frequently with sensory
conduction studies of anatomically variable sensory
nerve trunks, such as the sural, superficial peroneal, sa-
phenous, and medial and lateral antebrachial cutaneous
nerves.
The location of the reference electrode (G2), when
accurately placed over the muscle tendon, has little influ-
ence on the CMAP since it is almost inactive at that site.
However, the distance between the G1 and G2 electrodes
influences the SNAP and MNAP, since the active and ref-
erence electrodes are both typically placed over the nerve
trunk. Accordingly, the nerve segment under the active
electrode depolarizes first, followed by depolarization of
the segment underneath the reference electrode. If the
active and reference electrodes are too close, they may
briefly become electrically active at the same time, resulting
in a lower potential amplitude. Taking into account the
normal range of nerve conduction velocities, the preferred
interelectrode distance between the active (G1) and ref-
erence (G2) recording electrodes for sensory and mixed
nerve recordings is 3 to 4 cm, which ensures that depolari-
zation will not occur under both electrodes simultaneously.
25
Distance Measurement Error
The surface distance is a fair estimate of the true length of the
studied nerve. However, nerves may run an oblique course
or turn around a bony structure. This may result in a large
discrepancy between the measured and actual length of the
nerve and lead to erroneous conduction velocity. Estimating
the true length of the ulnar nerve across the elbow is the most
notable representative of measurement error that continues
to be debated. The ulnar nerve in most subjects is redundant
when the arm is in the extended elbow position and stretched
to its full distance during the flexed position. If measurements
of the ulnar nerve are made in the extended position, the true
length of the underlying nerve is underestimated, resulting
in erroneous focal slowing across the elbow. With the elbow
in a flexed position, the measured surface distance across the
elbow better reflects the true underlying length of the nerve,
resulting in a more valid calculation of conduction velocity.
Other examples of nerve segments that are subject to sur-
face measurement errors include the radial nerve around the
spiral groove, the peroneal nerve around the fibular neck,
and the median and ulnar nerves between the axilla and Erb’s
point (supraclavicular fossa).
NEEDL E EL ECTRO MYO G RAPHI C
EXA M INATIO N
MOTOR UNITS AND MUSCLE FIBERS
The motor unit consists of a single motor neuron and all
the muscle fibers it innervates. The number of muscle fibers
innervated by a single motor axon is the innervation ratio,
which is variable ranging from 3 to 1 for extrinsic eye mus-
cles to several hundreds to 1 for limb muscles. A low ratio
occurs in muscles with greater ability for fine gradations of
movement and is typically found in the extraocular, facial,
and hand muscles.
Muscle fibers are classified based on their mechanical
properties and resistance to fatigue. Based on the speed of the
actin–​myosin reaction and the Ca2+-​dependent activation
and relaxation regulatory systems, muscle fibers are either
slow or fast. They are also either fatigue-​resistant with higher
mitochondrial content or fatigable. Hence, muscle fibers are
usually labeled as type I (slow and fatigue-​resistant), type II
A (fast and fatigue-​resistant), or type II B (fast and fatigable)
fibers (Table 2-​1). All muscle fibers of each individual motor
unit are of one specific type. The distribution of muscle fibers
of a single motor unit within a muscle is wide with consider-
able overlap among the territories of motor units.
26
All muscle fibers in one motor unit discharge simultane-
ously when stimulated by synaptic input to the lower motor
neuron or by electrical stimulation of the axon. Based on
the “size principle,” the smallest motor neurons are activated
first with larger motor neurons recruited later with progres-
sive increase in force. This order of recruitment correlates
with the functional properties of the motor units (i.e., the
small motor units are slow and fatigue-​resistant and are ac-
tivated first and for longer periods of time than the large
motor units that are fast and fatigable and recruited later
and for shorter periods of time).
PRINCIPLES
The skeletal muscle fiber has a resting potential of 90
mV, with negativity inside the cell. These fibers, as well as
neurons and other excitable cells, generate action potentials
when the potential difference across the plasma membrane
is depolarized past a specific threshold. This follows an “all-​
or-​none” rule, which means that increasing the stimulus
does not change the shape of the action potential. The gen-
eration of an action potential reverses the transmembrane
potential, which then becomes positive inside the cell. An
extracellular electrode, as used in needle EMG, records
the activity resulting from this switch of polarity as a pre-
dominantly negative potential (usually triphasic, positive–​
negative–​positive waveforms). However, when recording
near a damaged region, action potentials consist of a large
positivity followed by a small negativity.
Concentric and Teflon-​ coated monopolar needle
electrodes are equally satisfactory in recording muscle
potentials, with few appreciable differences (Table 2-​2).
Though monopolar needles are less painful, they require an
additional reference electrode nearby which often results
in greater electrical noise due to electrode impedance mis-
match between the intramuscular active electrode and the
surface reference disk.
TECHNIQUES
The needle EMG study is an essential component of the
electrodiagnostic evaluation. It provides an efficient and
rapid means of testing the electrical activity of motor units
in a large number of muscles. The selection of muscle to be
sampled is based on the working and differential diagnoses
as determined by the clinical manifestations and NCS
findings. The accessibility of the muscle, the ability to acti-
vate it, and the degree of pain associated with needle inser-
tion particularly in children and anxious adults also play a
role in that choice.
P art I . I ntroduction to C linical E lectromyography
 TAB LE 2-​1 . S KE L E TA L MUS C L E F I B ER TYP ES

Slow Fast, Fatigue-​Resistant Fast, Fatigable

Type I Type IIA Type IIB

Diameter + ++ +++

Capillary supply +++ +++ +

Mitochondrial content +++ +++ +

SR volume + +++ +++

Myofibrillar ATPase + +++ ++++

Myofibrillar Ca sensitivity
2+
+++ + +

SR Ca2+ uptake Slow Fast Fast

Myoglobin content +++ +++ +

NADH dehydrogenase +++ +++ +

Succinate dehydrogenase +++ +++ +

Glycerophosphate dehydrogenase + +++ +++

Lactate dehydrogenase + +++ +++

Twitch kinetics Slow Fast Fast

Speed of shortening Slow Fast Fast

Fatigue resistant Yes Yes No

SR = sarcoplasmic reticulum

Knowledge of the anatomy of muscles is a prerequi- 1. Inserting or slightly moving the needle within the relaxed
site for needle EMG. This includes their exact location, muscle causes insertional activity that results from needle
segmental and peripheral innervations, and activation injury of muscle fibers. This also assesses spontaneous
maneuvers. The electromyographer first identifies the activity by moving the needle a small distance and
needle insertion point by recognizing the proper anatom- pausing a few seconds. At least four to six brief needle
ical landmark of the sampled muscle. The initial insertion movements should be made in four quadrants of the
of the needle electrode should occur when the muscle is re- muscle to assess insertional and spontaneous activity.
laxed and not contracted since this is less painful. Needle
EMG evaluation is performed in three steps: 2. A minimal contraction is obtained to assess the
morphology of several MUAPs that are measured on
the oscilloscope or hard copy. If sharp MUAPs are not
D I F F ER E N C E B E T W E E N M O N O P O L A R A N D
TA B L E 2 -​2 .
seen with minimal contraction, the needle should be
C O N C ENTRI C N E E D L E E L E C T RO D E S
moved slightly (pulled back or moved slightly deeper).
Concentric Monopolar
3. The intensity of muscle contraction is increased to
–D
 oes not requires a reference –R
 equires an independent assess the recruitment pattern of MUAPs. Maximal
electrode reference electrode
contraction normally fills the screen, producing the
– More painful – Less painful interference pattern.
– More expensive – Less expensive

– Low baseline noise – High baseline noise Oscilloscope sweep speeds of 10 ms per division bests
– Lower MUAP amplitude – Higher MUAP amplitude
define spontaneous and voluntary activities. A 50 μV/​
division-​sensitivity is the usual amplification for the eval-
– Sharper MUAP rise time – MUAP rise time not as sharp
uation of insertional and spontaneous activities, while a
– Shorter MUAP duration – Longer MUAP duration 200 μV/​division-​sensitivity is used for analysis of voluntary
MUAP = motor unit action potential. motor activity.

C hapter 2 . R outine C linical E lectromyography 27

INSERTIONAL AND SPONTANEOUS (A)
ACTIVITY 50 µV/D 20 ms/D

Normal Insertional and Spontaneous Activity

Brief bursts of electrical discharges accompany insertion
and repositioning of a needle electrode into the muscle,
slightly outlasting the movement of the needle, and usually
not lasting more than 300 ms. Insertional activity appears
as a cluster of positive or negative repetitive high-​frequency
spikes, which make a crisp static sound over the loudspeaker.
At rest, muscle is silent. It is, however, noisy in
the motor endplate region (the site of neuromuscular (B)
junctions), which is usually located near the center of the 50 µV/D 20 ms/D

muscle belly. Two types of normal endplate spontaneous ac-

tivity occur together or independently: endplate spikes and
endplate noise.
Endplate spikes. These are intermittent spikes and
represent discharges of individual muscle fibers generated
by activation of intramuscular nerve terminals irritated
by the needle. Their characteristic irregular firing pattern
distinguishes them from the regular-​ firing fibrillation
potentials (Figure 2-​21). The waveforms of endplate spikes
often have an initial negative deflection since the gener-
ator of the potential is usually underneath the needle’s
tip. Endplate spikes fire irregularly at 5 to 50 impulses per
second and measure 100 to 200 μV in amplitude and 3 to Figure 2-​22. Endplate noise. Note the low-​amplitude, high-​frequency, and
predominantly negative potentials (A). These may be seen in conjunction
4 ms in duration. They have a cracking sound on the loud-
with the endplate spikes (B).
speaker, imitating “sputtering fat in a frying pan.”
Endplate noise. The tip of the needle approaching
the endplate region frequently registers recurring irregular turn, are nonpropagating depolarizations caused by sponta-
negative potentials, 10 to 50 μV in amplitude and 1 to 2 neous release of acetylcholine quanta. Endplate potentials
ms in duration (Figure 2-​22). These potentials are the ex- produce a characteristic sound on loudspeaker much like a
tracellularly recorded miniature endplate potentials that, in “seashell held to the ear.”

50 µV/D 20 ms/D Abnormal Insertional Activity

Figure 2-​21. Endplate spikes. Note the irregular firing pattern and the
biphasic morphology with an initial negative deflection that separates
this from the brief spike form of fibrillation potentials. (Compare the
waveforms in this figure with those in Figure 2–​24.)
Increased insertional activity. An abnormally pro-
longed (increased) insertional activity that lasts longer than
300 ms and does not represent endplate potentials indicates
instability of the muscle membrane. It is often seen in con-
junction with denervation, myotonic disorders, or necro-
tizing myopathies.
Myotonic-​like or pseudomyotonic discharges. These
are insertional positive waves, initiated by needle movements
only and lasting a few seconds. This isolated activity is dis-
tinguished from true myotonic discharges by the stability
of the positive waves that do not wax or wane in amplitude
or frequency. These discharges are usually seen during early
denervation of muscle fibers such as one to two weeks after
acute nerve injury.

28 P art I . I ntroduction to C linical E lectromyography

Another random document with
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mortgages, and as I won't pick up much prize money, though it is the Gold
Coast we are bound for, I'll be up a tree one of these days. But, hollo, Bevil,
old man, what does your solitary epistle contain?' he suddenly exclaimed,
when, on glancing at his friend, he saw that the latter had changed colour,
that he became very pale and then flushed red, while, as he read over his
letter for the third time, his hands trembled so much that the paper rustled.

Goring then passed one hand across his forehead as if a little

bewildered, and handed the document to Jerry, saying,

'Read for yourself.'

'Does it concern Miss Cheyne?' asked Jerry.

'Please God it may in time,' was the curious reply of Goring, as he put a
dash of brandy into his coffee, and then looked over the shoulder of Jerry to
re-peruse his letter again.

It ran thus:

'Gray's Inn Square.

'DEAR SIR,

'We have the pleasure to inform you that by the death of your father's
much respected cousin, Bevil Goring, Esq., of Chowringee, Calcutta, you
have become his heir to a fortune of considerably above £20,000 per annum
in India stock, bank shares, Central India and other railway shares, &c., the
items of which we shall send you fully detailed in a few days. We shall take
all the necessary measures about proving the will, and, trusting that we shall
be continued as your legal advisers, we are, dear sir, yours faithfully,

'TAYPE, SHAWRPE, AND SCRAWLY,

'Solicitors.'
 More accustomed to wealth, and personally less interested in the
document, Jerry took in the situation at once.

'Whoop!' he exclaimed, as he wrung Goring's hand. 'Whoop and hurrah!

I congratulate you, I do, from my heart and soul, old fellow. There is not a
soul in the Brigade deserves good fortune more than you do. What a trump
this old Bevil was to die just in the nick of time, before the route came!'

'What do you mean by that, Jerry?'

'You'll be sending in your papers—cutting the Rifles now. A fortune, by

Jove—I always knew you had expectations, as they are called.'

'Every fellow has; they are often, too often, bad things to rely upon; and
yet how few—how very few amongst us can resist the temptation of doing
so in some fashion or other. But as for quitting the corps—with war
rumours in the air too—by Jove, that is the last thing I should think of
doing.'

'Egad! What a night we'll have of it at the mess hut to-night—a jolly
deep drink, and have the band out!'

'I wish this fortune—money or whatever it is—had only come a little

sooner,' said Goring, as his thoughts fled at once to the absent Alison.

'Better late than never!'

'There sounds the bugle, and now for every-day life, and a truce to the
world of dreams, if possible! What a lot I shall be able to do now for the
men of my company—their wives and little ones—for the corps generally!'

'Only take care that the mess don't begin to look upon you as their
factor, and be seized with a singular desire to possess your autograph. I
know what that sort of thing means,' added Jerry, as his mind wandered to
Mr. Chevenix and the mortgages.

'The worst of being poor is that one can never follow one's inclinations
for good.'
 'Or for evil,' added Jerry, cynically.

Never in his life before did Bevil Goring pass so extraordinary a time as
in the parade of that morning. In the pre-occupation of his mind he made
such a number of mistakes that the colonel and adjutant—knowing that he
was one of their most perfect officers—were at their wits' end with surprise;
though on parade, as in anything else, a man may act correctly and acquit
himself by mere force of habit, with Goring, in this instance, it was not so.

It was not the fortune that had so suddenly accrued to him, nor the
amplitude thereof, which affected him thus; it was only because the said
fortune—'the filthy lucre, the root of all evil,' as it is wrongly stigmatised—
might be, with him, the means of a great and happy end.

It might be the means, ere too late, of saving Alison Cheyne from a life
of misery, could he only discover her; but where was she? In what direction
was he to turn his steps—for that he would search, he had resolved, if the
corps did not depart, as seemed too probable, in a short time now. Amid the
routine of the parade these busy thoughts filled his brain, and in 'telling off'
the battalion, when Dalton called out 'Number one, Right Company,' Goring
responded with 'No. 20,000, Left Company,' at least so Jerry Wilmot
asserted.

All rejoiced in the good fortune of Goring, for he was a favourite with
people generally, and, as for the members of his battalion of the Rifle
Brigade, he was a 'pet,' with them all, from the colonel down to the
youngest little bugle boy; they loved him for his good temper, good heart,
and the strict impartiality with which he discharged his duties to all.

In the dawn of fresh hopes and the confidence which having a well-
lined pocket gives, he found himself at mess, joining heartily in the laughter
his own mistakes created, and 'standing' many rounds of champagne in
response to the congratulations of his brother officers on all hands.

He felt that wealth gave power.

'Laws grind the poor, and rich men rule the law,' says Goldsmith.
 In wealth he was still inferior to Cadbury, and the latter was a peer, he—
Bevil Goring—was a gentleman by many descents, and that, he knew,
counted much by Sir Ranald Cheyne.

Could he but trace the latter now!

'Letters of Readiness' came, and it was fully announced that the corps
was destined to take part in the war against Ashantee; but, with all his
military ardour, his zeal for the service and desire to add to the distinction
he had already won in India, Bevil Goring,—situated as he was with regard
to Alison Cheyne, with his great chance of losing her for ever—was not
sorry when he found he was one of those 'detailed' for the de pot, and would
thus, for a time at least, be left behind in England, and free to search and
look about him.

But before the 'Queen's morning drum' has announced in Aldershot the
morning on which the regiments march for embarkation—and before Bevil
Goring discovers the lost traces of his lost love—we have the two last
appeals to record of two pairs of lovers, appeals which had very different
sequels eventually; and the first we shall relate is that of Jerry Wilmot.

CHAPTER VII.

JERRY'S LAST APPEAL.

'The last time we three shall ride out of this gate together. Whenever I
do anything with a conviction that it is for the last time, I always feel
unconsciously a kind of sadness come over me. What do you think, Jerry?'

The speaker was Goring, as he, Dalton, and Jerry Wilmot quitted the
North Camp on horseback and separated—the two former, in hunting
costume, to have a 'spin' with the Royal Buckhounds, the latter to the
household at Wilmothurst, to which an hour or two more brought him by
train; and to the last interview with his mother, one brief enough—too brief
for Jerry's taste, as he found Lady Wilmot—afternoon tea over—preparing
to pay some carriage visits in the vicinity.

Her French maid, Mademoiselle Florine, was in the act of dressing her
ladyship's hair, and, as that was a very important matter, she could barely
turn her head to bid farewell to Jerry, who stood near her looking irresolute,
reproachful, and wistful with his heart and his eyes full together.

Lady Julia Wilmot, whilom a graceful beauty—a handsome woman still

—had a theory that worry of any kind told unfavourably on the female face,
that thought wrinkled the forehead, puckered the eyes and mouth, and
consequently she never thought or worried herself about anything, and
therefore was wonderfully young-looking and smooth-visaged for her years
—being one of the best preserved women in England.

She had a marquise air of bygone days about her, as the flattering
Mademoiselle Florine often said, and suggesting to her mind patches and
powdered hair, a long stomacher, hoop or sacque, and pomander ball.

'Actually going, and to that horrid place, my poor boy,' she said, without
quite turning her face towards him. 'You should have gone into the Guards,
Jerry, and have done your soldiering in Pall Mall and at Windsor.'

'The Guards, mother,' exclaimed Jerry, as he thought of his mortgages.

'Before I return, if I ever return at all, you may have to cut down the Wilmot
woods, and put down your carriages and horses.'

'Why, and for what?'

'To pay Mr. Chevenix his overdue interest.'

'Don't talk of him. I detest his name. By the way, Twesildown calls there
occasionally, I believe, the result of your introduction at the ball—and has
given the girl a huge fox-terrier.'

'A fox-terrier. Curious present for a lady.'

 'Very suitable in this instance, I should say.'

'And now, mother dearest—good-bye.'

Her cold manner and frigid kiss from her half-turned face, as Florine
brushed out her hair, pained him. He gave her another farewell glance, and
as he saw her slim figure, her perfect feet and hands, her placid face and
still magnificent hair, which Mademoiselle Florine was deftly manipulating,
he felt that all her retention of apparent youth was due to her utter want of
heart; and, after receiving a somewhat effusive kiss from Cousin Emily, he
thought of betaking himself to the path that led to the house of Mr.
Chevenix.

Albeit, used as he was to his aristocratic mother's fashionable

demeanour and coldness of heart, Jerry's grew sore at the general mode and
tenor of his farewell under all the circumstances. Thus he clung more
fondly to the hope that Bella Chevenix might be more tender, and send him
away with kindly thoughts of home and Old England.

He passed through the drawing-room, where his mother and cousin had
just had their afternoon tea. It was flooded with sunlight, and the delicate
Wedgwood china, and silver tea equipage, were yet on the blue velvet gipsy
table. It was a magnificent apartment; flowers from the conservatory were
in old-fashioned china bowls on the marble consoles, and in rich majolica
jardinières between the windows; and Jerry sighed as he gave a farewell
glance and turned away.

His mother might be deprived of all that luxury ere he returned to look
upon it again, if—as he said before—he ever returned at all; for many were
doubtless doomed to leave their bones amid the primeval forests that
overshadowed the Prah river and the wild jungles of horrible Coomassie.

The somewhat pert Mademoiselle Florine, who looked as if she had no

objection should the handsome Jerry have kissed her, began to sob when he
withdrew, an emotion which 'my Lady' at once snubbed by a calm, steady,
and enquiring stare, for she was a cold, proud woman, who, with all her
remains of undoubted beauty, had outlived all the memory of her youth, and
the genial impulses of her youth, if she ever had them. And she had to the
fullest extent that which a writer curiously styles 'the intense vulgarity
which passes by the name of high-breeding.'

Remembering—he had never forgotten it—the tenor of his last

conversation with Bella Chevenix and the way in which it ended, it was not
without a doubt whether he could see her if alone, and with a certain
clamorous emotion in his heart, that Jerry Wilmot—the usually jolly and
unabashed Jerry—approached the great red-bricked square villa that
overlooked the village green, and the walls of which were covered by
masses of Virginia creepers, roses, and clematis in summer.

'Mr. Chevenix was out—had ridden over to Langley Park,' was the
response of the domestic who received Jerry's card.

'Ah, considers it his own property, like the other places, no doubt,' was
the thought of Jerry, without anger, however.

'Miss Chevenix?'

'Is at home, sir.'

Another moment, and he was face to face with the smiling and brilliant
Bella, who received him with somewhat of a flutter. A hot colour swept
through the girl's soft face, and, retiring as suddenly, left her rather pale.

'I hope I don't intrude on you,' said Jerry, seized with a curious access of
bashfulness. 'I find you sitting, full of thought, with your head on one side,
like a canary.'

'Was I?' said she, caressing a great fox-terrier, with a plated collar—
Twesildown's present, no doubt, thought Jerry.

The latter had called in the hope of having a solemn leave-taking, if not
something better—one of those eternal adieux peculiar, he thought, to
heroes and heroines in novels and plays; thus he was rather bewildered to
find that Bella began to run on in a style of conversation (adopted to cover
her own nervousness or chagrin) that was 'sparkling;' thus she chatted away,
without waiting for answers, on subjects culled from the society papers,
fashionable journals, and so forth, leaving him for a time, as he thought,
'unable to get a word in, even edgeways,' till he announced to her that 'the
battalion had received its letters of readiness, and that the route had come.'

At these tidings her manner and colour changed at once, and her voice
and eyes softened, as she said,

'And you are really going away?'

'At last!'

'To Ashanti.'

'Yes, to Ashanti,' he replied.

Each seemed as if afraid to trust themselves to words of their own.

What he was doing while he spoke he scarcely knew; but he was trying to
fit on the top of his fingers in succession a tiny silver thimble picked from
her work-basket, and in every case without success.

The doubts in the mind of each still kept the cold cloud between them—
she believing that the love he might speak of again was prompted by
worldly selfishness combating with family pride: he fearing that she
received his love as inspired by fear of the mortgages alone.

'Surely this is very sudden?' said she, after a pause.

'Oh no, we have expected a move for some time past—you will miss
me, I hope?'

'We have not seen much of you lately.'

'However, I should like to take with me into my place of exile—for such

I deem it—a knowledge, a hope that you did miss me a little.'

Bella was about to reply, what she knew not, but a choking emotion
came into her white, slender throat. Jerry saw the emotion, and gathering
courage, said,
 'Do you remember, Bella, that more than once I had struggled with the
love with which you had inspired me till I could keep the secret no longer.'

Jerry was still on the wrong tack, and was again terribly misunderstood.
Bella's pride and indignation came again to her aid, and she replied, with a
haughty smile,

'I am not likely to forget, Captain Wilmot: women do not forget such
speeches, or when a friend takes up the rôle of a lover; but, after what you
did say, we can never be the same to each other again.'

'What did I say?' he exclaimed, regarding her earnestly and wistfully. 'I
remember that I made you an honest and straight-forward avowal of the
love that was in my heart, Bella.'

'Perhaps—but I only remember the terms in which you did make it,'
replied Bella, in whose mind the unfortunate and misconstrued term
'contempt of his world' was rankling.

'Once again, Bella,' said he, with his hand stretched out towards her, and
a great expression of entreaty in his eyes—'will you be my wife—will you
marry me?'

'It cannot be,' said she, with a firmness that was not entirely assumed;
'but let us part friends.'

'Nothing more?' he asked, sadly.

'Nothing more,' she replied, in a choking voice.

In her angry pride of heart, one moment she had gone near to hating
him, but she does not hate him now—oh, far, far from it, when looking
upon the handsome and earnest face, as perhaps she may be doing for the
last time, but, so far as her words go, she is as unyielding as ever. A little
indignation at her hardness began to gather in Jerry's heart, and he said, in a
light tone of reproach,
 'Of course, it is too much to expect an English girl to give up—on a
sudden, too—the comforts of an English home, the prospect of a season in
London and another at Brighton, to broil with a poor devil on the Gold
Coast, and share a South African bungalow.'

Bella took a peculiar view of this speech, and believed it was a sudden
way of 'shelving herself,' as she had refused him. She knew nothing of the
military etiquette and iron rule that prevented an officer from quitting in any
way after letters of readiness came, and thought that Jerry might retire when
he pleased, marry and keep his wife at home. She gave a little disdainful
smile and remained silent, so Jerry spoke again—

'When I was a big boy in knickerbockers, and you were a little girl in
short frocks, we used to be like Paul and Virginia in the Wilmot Woods.'

'Well, Paul and Virginia have grown up, and the young lady has come to
her senses.'

'If the gentleman has not.'

'He has come to his senses too, and has his eyes very wide open indeed.'

'She is referring to those infernal mortgages,' thought Jerry (which was

the case), 'and how shall I ever undeceive her?'

'In our boy and girl time you would have trusted me,' he urged.

'Perhaps, but I did not know you as I do now, and the world you live in.'

'The past, Bella——'

'Is past, Captain Wilmot; let us not refer to it again. I do not understand
you.'

'May I—can I—dare I explain?' he began, impetuously.

'Certainly not—there is nothing I wish explained,' said she, warmly,

though tears were in her eyes, and, as they seemed to be almost 'sparring
now,' Jerry rose to withdraw, yet lingered, with a heavy, loving, and angry
heart, and said,

'To me you are in no way what you were once, Bella, and what I hoped
you might have been. When I was last in Wilmothurst I saw that puppy
Twesildown hovering about; surely you—you don't encourage him?'

This was a blunt and unfortunate speech, for Bella's brown eyes
sparkled as she asked, hotly,

'How dare you think, much less ask, if I would encourage anyone?'

'I don't know—pardon me; I scarcely know what I think or what I say.'

'So it seems.'

Both were standing now, but apart. Oh, how Jerry longed to take her in
his arms and pour his farewell kisses on her lips and hair and eyes; but this
was not to be.

'How hard you are with me!' said he, after a pause.

'Have you deserved that I should be otherwise?'

'My mother has said——'

'Oh, I am infinitely obliged to Lady Julia for her opinion of me, of

course,' said Bella, cresting up her beautiful head; 'but what has she said of
me?'

'That you are the greatest flirt in Hampshire, and that, young as you are,
you have flirted with every man that came near you.'

'I think you must know more of me than she does, and may know how
much of all this is true; but she told me the same of you, and even more,
and that she could not get you off to your regiment soon enough.'

'Why?' asked Jerry, with surprise.

 'Because of a tendresse for her own maid; and that you have been
making love to every woman and girl since. But all this gossip does not
concern me, so let the conversation end. You came to bid me good-bye?'

'Yes,' said Jerry, in a hard tone.

'Had you not better bid papa good-bye too? I think I heard him come in.'

She put her hand upon the bell.

'Stay one moment—stay!' he said, imploringly.

She looked down and played nervously with the silver bangles on her
wrists, some of them the gift of Jerry in happier moments.

'Consider once again,' said he, brokenly; 'think of what my life will be
apart from you. Will you dream of me when I am gone?'

'Why should I dream—and dreams come unbidden?'

'Think of me, then?'

'A waste of time surely. I shall have much to think of—papa and my
poor people.'

'Why do you speak like this to me?' he said, with a flash of indignation.
'Is it because each day sees me a poorer and your father a richer man? or
has another touched your heart?'

An angry smile curled her lip at this question. She recollected the scene
in the conservatory, and remembered it has been said that 'a woman never
yields an inch, however innocently and generously, to a man that he does
not suspect her, sooner or later, of having given way in a similar manner to
some man who has come earlier.'

'I listen to all this too late. I know your motive. I thank you for the
honour you condescend to do me, but let the matter end,' said Bella, while a
shuddering sigh escaped her pale lips, for her respiration came in little
proud gasps and her heart throbbed painfully—painfully for the part that
pride inspired, and a doubt of the purity of Jerry's love, though at the time
loving him dearly herself. It was every way a curious situation, and at last
Jerry took up his hat and gloves.

'We have been somewhat apart of late,' said he; 'yet I do not wish—that
—that we should part coldly.'

'Oh no; why should we?' she asked, in her sweetest tone. 'I am,' she
thought, 'in reality—but for the encumbrances on his estate—nothing more
to him than all the other girls he has talked to, laughed with, and flirted
with, as his cold hard mother told me. So let me be on my guard—on my
guard!'

'You will—most probably—be married before I return, if I ever return at

all, which God only can foresee,' he said.

'I may never marry,' said Bella, with a curious ring in her voice.

'But you will think of me, Bella, won't you—broiling and fighting in far
away Africa—won't you? I would not like to think that you quite forgot me.'

'Nor shall I,' said she, making a super-human effort to repress her tears.

'Good-bye.'

'Good-bye.'

He was gone—gone, and no kiss was exchanged between those two—

only a clinging pressure of the hand, and that was all!

Could it be that, after all, he was no more to her—through her

misconception and doubt of him—than a stick or a stone? If her assumed
calm covered—as it really did—a sore, sore heart, how was he to know it?

With her hands interlaced above her head, as if to stay the throbbing of
her brain, and her swelling eyes cast upward, she said, in a husky voice,

'If I have erred, oh! may heaven protect him, and make his life happy in
some other way!'
 However, she did not say with another.

When Jerry was fairly gone, it seemed to Bella that an unnatural

stillness—a hush fell over all the house. She threw open a window to court
the cool atmosphere, for her temples were hot and quivering; she could hear
the murmur of the stream and the rustle of the trees, in shadow now, as the
sun had crept round to the back of the house, and a gloom was falling on the
landscape, even as a gloom was sinking on her heart; and she began to
upbraid herself with hardness and cruelty, and to feel she might never know
rest again.

And Jerry's voice lingered in her ears, as the expression of his face
clung to her memory, and, in a sudden revulsion of feeling, she wailed in
her heart—

'Oh, he is going away, and I have acted a cruel part to him—away to

face death, and our parting seems like a farewell of the dying; and his love
for me may be true, tender, and honest, after all! If so, what will he—what
must he think of me? But it is over and done with—over and done with
now!'

And she took refuge in floods of bitter, bitter tears. When, for good or
for evil, for love and for peace, should she see Jerry Wilmot again? Too
probably, never more!

CHAPTER VIII.

THE GAME THAT TWO CAN PLAY.

Goring and Dalton had gone to a meet of the Royal Buckhounds, as we

have stated in the preceding chapter, and the day's run had been a brilliant
one. The gathering took place at Salt Hill again, and there was a large field,
comprising the Master of the Hounds, the usual followers of the latter, and a
vast assemblage of spectators, on whom the two officers looked with some
interest, as it might be the last time they might see such a sight again—
together at least.

The hounds ran the deer by Stoke Park to Farnham village, near which
he got hung up in a wire fence, but broke away to the left and got shelter in
Brocas Wood, but only for a time. Driven out by the dogs, and followed by
a vast field, including many men in pink with faultless tops, and not a few
ladies, he was taken at last in Hedgerley Park.

Somewhere thereabout, at the close of the run, Goring lost sight of

Dalton, who, when leaping his horse over a hedge into a lane, nearly came
in contact with Mrs. Trelawney, who had also been at the meet, but by him
unseen hitherto. The animal she rode reared wildly, but she soothed it, and
Dalton caught it by the bridle.

'Pray pardon me,' he exclaimed; 'had I been a little nearer——'

'You might have unhorsed me,' said she, laughing.

She looked very bright and handsome in her riding-habit; the chef-
d'œuvre of some London tailor, it fitted her to perfection, and, being of a
bright blue colour, suited her brilliant complexion and blond style of beauty.
A French writer says, 'There is but one way in which a woman can be
handsome, but a hundred thousand in which she can be pretty;' and Mrs.
Trelawney had those ways in perfection.

Since his last visit Dalton had not seen her, and many of the speeches
she had in her petulance or pride permitted herself to say rankled in his
memory, exciting anger, sorrow, and surprise; while she, on her part, had
been thinking that she had gone quite far enough in the game she was
playing with him—for that she was playing a game we shall ere long show
—and had been anxiously hoping he would come to Chilcote Grange at
least once more ere the departure of his regiment, of which event she had
heard a rumour, but he never came.
 There was a little constraint in the manner of both, but being too natural
to act, it soon passed off.

'I was just thinking of you, curious to say, when you came flying over
that hedge,' said Mrs. Trelawney, with a smile in her bright, bewitching
hazel eyes, while the dark lashes that fringed their white lids seemed to
flicker. Oh, those wonderful hazel eyes! thought Dalton, as he replied.

'Well, it is said to be always a good point in a man's favour when a

pretty woman thinks about him in any way. And what were you thinking?'

'That I was certain we had not seen the last of each other—you
remember I said so.'

'It is my last day with the hounds. To-morrow my horses go to

Tattersall's. And you have done us the honour of following the field to-day?'
he added, as they rode slowly side by side.

'No—I only came to see them throw off, and am now riding home.'

'A pretty mare that of yours, and takes her fences like a bird, Goring
told me.'

'I never engage in these sports that way now.'

'Why?'

'Because I am getting too old,' she replied, with a pretty demure

expression.

'Old—is this a joke!'

'Besides, I must be careful of myself for little Nettie's sake. If aught

happened to me——'

'You are an expert whip—here is a low hedge, and I shall be charmed to

give you a lead.'

'Thanks—no; I would rather not.'

 How soldierly Tony Dalton looked, she was thinking, with his bronzed
complexion, thoughtful, dark eyes, his dark shorn hair, and long moustache
a shade darker, his erect and well-knit figure sitting well down in his saddle,
his hunting-coat soiled and stained by service and exposure to the weather.

'Then you have seen enough of the sport?' said he.

'Quite, and am now taking the road homeward.'

'Permit me to escort you.'

She bowed her assent. There was no reason why he should not do so,
and an expression of triumph made her eyes sparkle, and then she asked—

'Has Captain Goring utterly failed as yet to discover a trace of where

Miss Cheyne has sailed to, or rather of where her father has taken her?'

'Yes—quite.'

'It is very singular—people don't disappear in that way now-a-days.

Poor Goring; he is, I know, so passionately attached to her, but her father's
opposition is so resolute that I think he should school himself——'

'To relinquish her? oh, no—we cannot control our love, Mrs. Trelawney
—can we?'

'I think not.'

'If we could—if we could——'

'What a deal of trouble would be spared us in this world,' said she,

laughing; 'but Sir Ranald Cheyne is, no doubt, still unaware that Captain
Goring is now a very rich man, and will, I hear, remain in England for a
little time yet.'

'A little time only; the transport awaits us at Southampton; we are all in
readiness, and the order to march may come at any hour. This is the last
time we may see each other,' he said, in a suddenly somewhat broken voice;
'and perhaps it is as well, Laura—I have seen too much of you—too much
for my own peace.'

'Captain Dalton,' said she, looking him direct in the eyes, 'you have tried
to woo me. I need not mince words or matters with you, but I have one
question to ask.'

'Ask it,' said he, huskily.

'Are you at liberty to woo any woman honestly, honourably?'

Dalton grew very pale, but he replied, evasively,

'I have loved against my will—against my conscience—though your

very name should have repressed that love.'

'My name!'

'Your name of Laura.'

The name left his lips, as she remarked it had done before, in an
unwilling manner, as if it were familiar, yet most distasteful.

'Why?' she asked.

'I knew another Laura, and she—but let me not think of her at this
moment when I feel that I love you with a passion that I have sought in vain
to overcome.'

'Why?' she asked, impetuously.

'Because there are hopeless obstacles between us.'

'I have none,' was her somewhat pointed reply.

'But I have,' said he, while bead-drops coursed from his temples; and
she regarded him curiously through her veil, and said,
 'Then you should never have addressed me at all in the language of a
lover. I had good reason to suspect something of this kind,' she continued,
in a tone of severity.

'And hence it was that you always spoke so enigmatically to me.'

'Perhaps.'

'As one who would judge of a man by his past history rather than by his
capacity for good in the future, and so judged me harshly.'

He stooped from his saddle, and suddenly kissed her gloved hand. As he
did so she heard him whisper, as if to himself,

'My darling—my darling—without destroying your honour and my

own, I can hope for no nearer caress. Pardon me,' he added, aloud.

When he raised his head, she saw that his face was deadly pale; but
again the smile of triumph glittered in her half-closed hazel eyes as she
merely said,

'Captain Dalton, you have all the gallantry of a Spaniard, and seem
inclined to pass the rôle of Platonic affection I accorded to you; but you
must pardon me if I mean resolutely to live in my past.'

'We cannot—ought not to live for the dead alone,' said Dalton.

'It is said that we bury our dead out of our sight, and may try to forget
them, otherwise the world would not go on as it does. We may bury our
dead—true, but memory remains.'

'How she must have loved that fellow Trelawney,' thought Dalton, with
jealousy and sorrow.

'May there not be kindred souls that often meet too late?' she asked.

'And you apply this to yourself and me?'

'Yes.'
 'I always thought that such ideas of kindred thought and passionate
enthusiasm occurred only in youth, and were the result of propinquity and
daily intercourse.'

'How coldly you respond to me!'

'After the mysterious obstacle you so openly referred to, what would
you have me do or say?' she asked, with a certain hauteur of tone, and then
gave one of her merry little laughs.

Dalton could not help thinking that the alternate hauteur and mirth of
the handsome widow at his grave, solemn, and earnest love-making were—
to say the least of them—exceedingly ill-timed, while her pretty apparent
indifference to the strength of the passion that filled his soul, especially
when on the eve of his departure to a distant land, piqued and exasperated
him.

'Can the woman be a "free-lance," though still in society?' he surmised,

with pain in his heart, for, 'free-lance' or not, he felt that he loved her—yea,
madly—as only men at his age often do love a woman. He knew that she
was deemed by some what they termed rather a 'debatable widow,' whom
the social police in the vicinity of Aldershot, where she had rather suddenly
appeared—police who consist of embittered spinsters, inquisitive matrons
with unmarried daughters, whom her dazzling beauty eclipsed, were rather
addicted to 'tearing to pieces,' a process which Mrs. Trelawney treated with
profound indifference or disdain. There was a bold, gay bonhomie about her
that might be no more than a mere delight in the things of this life, a pretty
playfulness and recklessness of spirit that passed in a handsome young
matron, and which the 'social police' resented, adding 'that admiration was
food and drink to her.' '"Free-lance" or not,' he thought again; 'to see is to
admire, to know her is to love her; but she laughs at my passion as if it were
that of a love-sick boy.'

'Would to God I had never met you!' said he, 'for the meeting has ruined
a life that, but for you, if not a happy, was at least a contented one.'

'Ruined your life!' she exclaimed, as if with surprise.