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Case Studies in
Clinical Cardiac
Electrophysiology
 CONTENTS iii

Case Studies in
Clinical Cardiac
Electrophysiology
John M. Miller, MD
Professor of Medicine, Indiana University School of Medicine
Director, Clinical Cardiac Electrophysiology
Indianapolis, Indiana

Mithilesh K. Das, MD
Professor of Clinical Medicine, Indiana University School of Medicine
Indianapolis, Indiana

Douglas P. Zipes, MD
Distinguished Professor Emeritus of Medicine, Pharmacology and Toxicology
Indiana University School of Medicine
Emeritus Director, Krannert Institute of Cardiology
Indianapolis, Indiana
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY ISBN: 978-0-323-18772-5

Copyright © 2018 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
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their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
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Library of Congress Cataloging-in-Publication Data

Names: Miller, John M. (John Michael), 1954- author. | Das, Mithilesh K.,
author. | Zipes, Douglas P., author.
Title: Case studies in clinical cardiac electrophysiology / John Miller,
Mithilesh Das, Douglas Zipes.
Description: Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2016053043 | ISBN 9780323187725 (hardcover : alk. paper)
Subjects: | MESH: Heart Diseases--diagnosis | Electrophysiologic
Techniques,
Cardiac--methods | Case Reports
Classification: LCC RC683.5.E5 | NLM WG 141.5.F9 | DDC 616.1/2075--dc23
LC record available at https://lccn.loc.gov/2016053043

Content Strategist: Maureen Iannuzzi

Senior Content Development Specialist: Janice Galliard
Publishing Services Manager: Catherine Jackson
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Design Direction: Brian Salisbury

Printed in China

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

 Keenly aware of the time and energy diverted from our families that was required to
perform these procedures and assemble the recordings into a form accessible by readers, we
dedicate this volume to our beloved wives (Jeanne, Rekha, and Joan), who have allowed us
the privilege of putting this work together. We also dedicate this work to the readers, who we
hope will benefit from the lessons we have tried to convey, and finally to their patients, who
we hope will in turn benefit from their learning.
 CONTENTS

Foreword
The practice of clinical cardiac electrophysiology is one of clinical exploration that starts
with integration of the patient’s symptoms and cardiac evaluation with electrocardio-
graphic interpretation. One of the most gratifying experiences for patient and physician is
when this process culminates in the electrophysiology laboratory with confirmation of the
diagnosis and implementation of effective therapy for the arrhythmia with catheter abla-
tion. Mastery of each component is needed, and the knowledge that is gained from each
step can be applied to the previous step to refine one’s diagnostic acumen. We became
much better electrocardiographers by applying the knowledge gained from the pioneering
work that defined cardiac activation patterns and arrhythmia mechanisms using cardiac
mapping and programmed electrical stimulation. Expertise in the last step, interventional
electrophysiology, is the most challenging to acquire. It requires assimilation of complex
patterns of cardiac activation, interpretation of spontaneous changes in patterns, and ap-
plication of maneuvers to confirm a diagnosis, and this confirmation is critical for guiding
catheter ablation.
Drs. Miller, Das, and Zipes have assembled a wonderful book that captures the spirit of
clinical exploration leading to effective therapy. They use cases to describe pathophysio-
logic concepts that start with fundamentals and proceed to complex concepts. From the
electrophysiology laboratory they incorporate findings ranging from those that are classic
to those that are only recently described and that require a nuanced interpretation and
understanding, but that are critical to arriving at the correct diagnosis. Examples include
the newest technologies that are now being applied for delineation of arrhythmia mecha-
nisms and substrate.
The authors are renowned teachers who apply their wealth of experience in communi-
cating complex scenarios and concepts to make the cases accessible for the complete range
of students of clinical electrophysiology, from the trainee to the advanced practitioner.
The cases clarify concepts and provide fundamentals for the new student, but also provide
insights that will expand the knowledge of experienced clinicians. Dr Miller’s hand is
evident throughout in the superb graphics, for which he is widely known among teachers
of cardiology.
One of the amazing aspects of biology, medicine, and certainly extending to cardiac
electrophysiology, is the variability that one encounters from patient to patient. After
years in the field, one still encounters new arrhythmia problems. A solid basis in under-
standing mapping and diagnostic maneuvers is required for solving new puzzles in the
electrophysiology laboratory, and this learning is acquired from the study of cases. You
can never analyze too many cases. I congratulate the authors of Case Studies in Clinical
Cardiac Electrophysiology on a wonderful book.

William G. Stevenson, MD
Director, Cardiac Arrhythmia Program
Cardiovascular Division
Brigham and Women's Hospital
Professor of Medicine, Harvard Medical School
Boston, Massachusetts

vii
 CONTENTS

Preface
The understanding and care of patients with heart rhythm disturbances (clinical cardiac
electrophysiology [EP]) has evolved in the last three decades from simple diagnostic stud-
ies of the conduction system using a few electrodes, to complex diagnostic and therapeutic
procedures involving recording and stimulation from a large number of electrodes, for the
purpose of finding and ablating arrhythmogenic tissue. With this dramatic change in the
character of EP studies has come the critical need for careful analysis and thorough under-
standing of the meaning of recordings that are made and results of stimulation in order to
achieve optimal results from ablation. At the same time, EP training programs have come
under increasing pressure to perform more procedures in a shorter amount of time, result-
ing in compromising time for careful and methodical study of and learning from these
procedures that are rich with teaching material. Although many excellent texts in our field
explain the principles of recording and stimulation in treatment of arrhythmias, for ex-
ample, Clinical Arrhythmology and Electrophysiology, few are structured to show their
practical application in a case-study format. In light of this, the purpose of this volume is
to take the reader through a representative series of EP procedures from start to finish,
evaluating results of diagnostic pacing maneuvers, sampling and comparing characteristics
of electrograms, and selection of appropriate sites for ablation. It is our hope that readers
will benefit from this mode of presentation, highlighting some of the limitations of tech-
niques that are used on a daily basis, with the aim of improving the efficacy and safety of
procedures they perform on their patients.

Acknowledgments
We gratefully acknowledge the role played by our nursing and technical staff with whom
we performed the procedures reviewed in this work, as well as electrophysiology fellows,
whose patience in keeping catheters in place during long procedures contributed greatly to
the quality of the figures. We also acknowledge our patients, who provide a constant source
for learning.

ix
PA RT 1 Sinus Node, AV Node, and His-Purkinje System

Sinus Node and Atrioventricular

Conduction Disease 1
Case Presentation
A 56-year-old man experienced syncope while walking at work. Coworkers called emer-
gency medical services (EMS). Upon the arrival of EMS, he was awake and feeling normal
but was convinced to go to the emergency room (ER). The patient had a history of anterior
wall myocardial infarction (MI), percutaneous coronary intervention (PCI), to left anterior
descending coronary artery (LAD) several years before, and a negative stress test within the
last 6 months. Examination results were normal except for obesity. ECG showed sinus
rhythm, long PR, right bundle branch block (RBBB), left anterior fascicular block (LAFB),
and anterior scar. Echocardiogram revealed ejection fraction (EF) 40% and anterior hypo-
kinesis. The patient was referred for electrophysiology (EP) study.

Baseline ECG

I aVR V1 V4

II aVL V2 V5 Figure 1-1

III aVF V3 V6

II

The ECG in Fig. 1-1 shows sinus rhythm with a prolonged P wave (left atrial abnormality),
slightly prolonged PR interval, RBBB and left anterior fascicular block, and an extensive
anterior infarction. On the basis of this, there are many possible causes of syncope—atrial
arrhythmias (atrial flutter and fibrillation, other reentrant atrial tachycardias), heart block
(either in AV node or His-Purkinje system), or ventricular arrhythmia (ventricular tachy-
cardia or fibrillation). There is nothing in the ECG to favor one cause of syncope over
another, and because treatment strategies are very different depending on the cause
(medications or ablation for atrial arrhythmias; pacemaker for heart block; implantable
defibrillator for ventricular arrhythmias), further investigation is needed.

1
2 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Evaluation
Baseline Intracardiac Recordings
1
2

V1

V6

HRA
Figure 1-2 A V
H
Hisprox

Hismid

Hisdist
RBB
AH 85 ms HV 85 ms
RV
200 ms

Intracardiac recordings during sinus rhythm (Fig. 1-2) show atrial (A), His (H), and
ventricular (V) recordings as noted. This confirms the presence of His-Purkinje disease,
with an HV interval of 85 ms—prolonged (normal, 40 to 55 ms), but not enough to
implicate His-Purkinje dysfunction as a cause of heart block. Surprisingly, though the PR
interval is somewhat prolonged, the AH interval is normal (85 ms [normal, 60 to 125 ms]).
Usually, prolongation of the PR interval is caused by the AV nodal (AH) component, be-
cause to prolong the PR even 60 ms from His-Purkinje disease would require a lengthening
of the HV to a degree (that is, from 40 ms to 100 ms) that 1:1 conduction would be unlikely.
Note also that there is a delay between the distal His recording and right bundle branch
(RBB)—there is usually ,10 ms between these—and that the RBBB is further caused by
delay or block between the RBB and RV apical electrogram, with a QRS onset (dashed blue
line) to RV electrogram of 75 ms (normal, 10 to 35 ms).

Sinus Rhythm And Ventricular Pacing

1
2
3
V1

V6
Figure 1-3
HRA A V V A
H
Hisprox
H
Hismid

Hisdist

RV
200 ms S S
 CHAPTER 1 | SINUS NODE AND ATRIOVENTRICULAR CONDUCTION DISEASE 3

The left side of Fig. 1-3 shows a sinus rhythm complex as in the previous figure for refer-
ence, whereas the 2 complexes on the right are during pacing from the right ventricular
apical region. Note that there is retrograde conduction to the atria, with the His bundle
activated from distal to proximal as expected. Usually, the timing of the His potential is
before the local ventricular electrogram in the His recoding, because conduction proceeds
more rapidly up the RBB to the His than does muscle-to-muscle propagation from apex to
base. Because there is RBBB in this case, the impulse cannot ascend the RBB as it normally
would and instead must traverse the interventricular septum, enter the left bundle branch,
and then activate the His retrogradely. These findings just confirm the His-Purkinje disease
but give no further insight as to the cause of syncope.

Retrograde His-Purkinje Conduction

Normal RBBB

I I
II II
V1 V1

H H
HBp HBp

HBm HBm

HBd HBd
Figure 1-4
RVA V RVA V

LBB LBB

RBB RBB

As illustrated in Fig. 1-4, in patients with normal His-Purkinje function (at left), pacing
from the right ventricular apex (red circle) results in retrograde conduction over the RBB
(white line) that is more rapid than muscle-to-muscle conduction (wavy line in septum),
resulting in a His potential (H) inscribed before the larger local ventricular recording (V).
At right, in the presence of anterograde RBBB, the paced wavefront cannot ascend the
blocked right bundle and instead crosses the interventricular septum (wavy horizontal line)
to engage the left bundle, and then proceeds rapidly to the His that now appears after the
local ventricular recording (that is again generated after muscle-to-muscle spread).
4 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Atrial Pacing
1

V1

V6

Figure 1-5 HRA

S S S S S
AH 90 ms

Hisprox
A
HV
Hismid

Hisdist

HV 85 ms
RV 400 ms

Rapid pacing can often reveal abnormalities of AV conduction that were not very evident
at rest. In Fig. 1-5, pacing the atrium (S) slightly faster than the sinus rate shows minimal
change in either AH (90 ms) or HV (85 ms) intervals. It is useful to display multiple elec-
trode pairs of His recordings because the signal amplitude may vary enough between
complexes that the His potential may be poorly visible or even absent in one electrode pair
(Hisdist in this case), whereas it is readily visible in other electrode pairs.

Atrial Pacing

V1

V6
Figure 1-6 420 ms 400 ms 380 ms
HRA S S S S S S S S S S
AH (ms): 140 145 170 185 230 -- 115 130 190 230
Hisprox
H H H H H ∗ H H H H
Hismid
HV (ms): 100 110 112 115 115 90 115 --
Hisdist

RV
400 ms

More rapid pacing starts to reveal some abnormalities. As the pacing rate increases (cycle
length decreases), the AH is expected to prolong but the HV interval usually remains con-
stant. In Fig. 1-6, the AH (in blue) does prolong, but so does the HV interval (in green). The
asterisk denotes where AV nodal block occurs (no subsequent His potential), but three
cycles after this, there is a His potential not followed by a QRS (infra-His block; green dash)
 CHAPTER 1 | SINUS NODE AND ATRIOVENTRICULAR CONDUCTION DISEASE 5

and the HV intervals on the prior two cycles had prolonged (thus, infra-His Wenckebach).
This is distinctly abnormal and likely warrants pacemaker implantation. However, this may
not be the reason that syncope had occurred (there may be other abnormalities that have
not yet been uncovered during the study).

Atrial Pacing

V1

V6

HRA Figure 1-7

S S S 4.15 sec sinus pause

Hisprox

Hismid

Hisdist

RV
1 sec

In Fig. 1-7, pacing is repeated for 1 min at the same cycle length as shown in the
prior figure to stress the sinus node. Upon cessation of pacing, a prolonged sinus pause
(4.15 seconds) is observed; a junctional escape complex occurs after 3 seconds. This is
another potential cause of syncope (sinus node dysfunction).
6 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Ventricular Pacing
∗
1

V1

V6
Sinus Sinus
Figure 1-8 HRA
A A A

Hisprox

Hismid
H
H H H
Hisdist

RV S S S S S S
400 ms

Turning to the ventricles (Fig. 1-8), slow ventricular pacing again shows that there is retro-
grade conduction; the first and last atrial complexes are sinus in origin (HRA before His
atrial recordings) but the middle three complexes are retrogradely conducted. The first two
of these (blue arrows) are over the fast pathway, but after the fourth ventricular stimulus,
the ventriculoatrial interval suddenly increases, signifying a switch to a slow pathway (red
arrow). Immediately after this, there is a QRS complex that is not fully paced (asterisk); this
is because of fusion between the paced wavefront and one over the normal conduction
system (see His potential). This is the result of an atypical AV nodal echo (retrograde slow
pathway, anterograde fast—blue arrow). This is a common finding and, unless accompa-
nied by sustained atypical AV nodal reentrant SVT, has no relevance for the diagnosis of
syncope.

Ventricular Stimulation

V1

V6

Figure 1-9
HRA
SA SA

Hisprox

Hismid

H H H
Hisdist

RV S
1 400 ms S1 S2 S3 S4
 CHAPTER 1 | SINUS NODE AND ATRIOVENTRICULAR CONDUCTION DISEASE 7

The last part of the syncope evaluation consists of programmed ventricular stimulation. As
shown in Fig. 1-9, standard stimulation (here, with triple extrastimuli, S2 to S4) initiates a
rapid, hemodynamically unstable ventricular tachycardia (CL 250 ms) that stopped spon-
taneously after 15 seconds. Given the presence of a prior MI and “serious” syncope, this
arrhythmia was deemed a reasonable candidate for the cause of his syncope. He received a
dual-chamber ICD later that day. Note that a His potential is seen on occasion but not with
every complex—excluding bundle branch reentry as a possible cause of the tachycardia
(SA 5 atrial stimulus).

Summary
n This man had syncope in the presence of structural heart disease—which always needs
further evaluation.
n Multiple potential causes of syncope may be present in the same patient; in this case,
n Sinus node dysfunction
n His-Purkinje dysfunction
n Ventricular tachycardia
n Judgment must be used to determine which possible cause(s) of syncope should be
treated and how.
PA RT 2 Supraventricular Arrhythmias

SECTION 1 AV Junctional Arrhythmias

Typical (“Slow-Fast”)
Atrioventricular Nodal Reentry 2
Case Presentation
A 48-year-old woman had a history of palpitations for ~5 years. Her episodes started and
stopped suddenly, lasted 1 to 2 minutes, and were associated with lightheadedness. She
came to a local emergency room with a prolonged episode: ECG showed a narrow QRS
tachycardia (by report; no ECG available) that was terminated with adenosine. She was
treated with oral diltiazem and metoprolol but continued to have supraventricular tachy-
cardia (SVT) episodes. She had a normal physical exam; non-invasive evaluation showed
no structural heart disease. She was referred for catheter ablation of her SVT.

Baseline ECGs and Intracardiac Recordings

Baseline ECG

aVR

aVL

aVF
Figure 2-1
V1

V2

V3

V4

V5

V6
1 sec

Fig. 2-1 demonstrates normal sinus rhythm without delta waves, fractionation, or prolon-
gation of the P wave or QRS and normal QT. ECG is normal.

9
10 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Baseline Intracardiac Recording

1
2
3
V1
V6
HRA
Hisprox
A
Hisdist
H V
Figure 2-2 CSprox

CSmid

CSdist
RV
200 ms

Fig. 2-2 shows normal intracardiac intervals (AH, HV); there is no evidence of preexcita-
tion on intracardiac recordings. Normal progression of atrial activation is seen from right
atrium to His to coronary sinus proximal to distal.

Ventricular Pacing
Ventricular Pacing (600 ms)

1
2
3
V1
V6
HRA
Hisprox

Hisdist
CSprox
Figure 2-3

CSmid

CSdist
RV
S 200 ms S S

In Fig. 2-3, with ventricular pacing at 600 ms, retrograde conduction is present with a
concentric activation pattern; a retrograde His potential (arrow) is seen between stimulus
artifact and local ventricular electrogram.
 CHAPTER 2 | TYPICAL (“SLOW-FAST”) ATRIOVENTRICULAR NODAL REENTRY 11

Ventricular Pacing (470-460 ms)

1
2
3
V1
V6
HRA
Hisprox

Hisdist
CSprox
Figure 2-4

CSmid

CSdist
RV
S 200 ms S S S

With more rapid ventricular pacing (470–460 ms) the same activation sequence is seen in
Fig. 2-4, with a longer VA interval—most consistent with AV nodal conduction.

Ventricular Pacing (280 ms)

1
2
3
V1
V6
HRA
Hisprox

Hisdist
CSprox
Figure 2-5

CSmid

CSdist
RV S S S S S S S S
400 ms

In Fig. 2-5, with the sudden onset of ventricular pacing (280 ms), a His “out the back”
(arrow) is seen after second stimulus, with atrial activation dependent on His (ie, no bypass
tract). Retrograde block occurs after the third stimulus likely because of block in the
His-Purkinje system, which recovers by the fourth stimulus (after which 1:1 retrograde
conduction resumes).
12 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

ECGs Compared

ECGs Compared
SVT Sinus Rhythm

1 1

2
2
3
3
aVR aVR

aVL aVL
aVF
Figure 2-6 aVF
V1
V1

V2 V2

V3 V3

V4 V4

V5 V5

V6 V6
1 sec 1 sec

SVT was induced ((left); sinus rhythm is shown at right in Fig. 2-6. A superimposed sinus
complex (red) overlaid on SVT shows no clear difference, implying that the P wave must be
hidden within the QRS complex.

Ventricular Pacing in SVT

Ventricular Pacing

1
2
3
V1
V6
HRA
Hisprox
A
Hisdist
Figure 2-7 CSprox
V V

CSmid

CSdist
RV
S S S S S 400 ms

In Fig. 2-7, ventricular pacing during SVT conducts retrogradely to atrium with the same
activation pattern as during SVT. During SVT that resumes on cessation of pacing, atrial
activation appears concentric and within (even before) the QRS complex, excluding ortho-
dromic SVT. The long pause after pacing suggests conduction down an AV nodal slow
pathway. The “VAV” response is consistent with typical atrioventricular nodal reentry
(AVNRT), not atrial tachycardia (AT).
 CHAPTER 2 | TYPICAL (“SLOW-FAST”) ATRIOVENTRICULAR NODAL REENTRY 13

Ventricular Pacing

1
2
3
V1
V6
HRA
Hisprox

Hisdist
A
CSprox Figure 2-8
V V

CSmid

CSdist
RV
S S 200 ms

Fig. 2-8 is a faster sweep speed of Fig. 2-7, showing the same findings.

Para-Hisian Pacing

Para-Hisian Pacing

1
2
3
V1
V6 HA 90 ms

HRA
Hisprox

Hisdist S S H
CSprox Figure 2-9
SA 90 ms SA 210 ms

CSmid

CSdist
RV
200 ms

The complex at right of Fig. 2-9 shows a normal sinus complex. The complex in middle
has a wide QRS suggesting pure ventricular capture. Retrograde conduction is evident.
The complex at left is relatively narrow, indicating some element of His capture, though
not pure His capture (His 1 V capture); retrograde conduction is evident with the same
pattern as during the wider complex and S-A interval is 90 ms; in the wide complex
(V capture only), the S-A interval is 210 ms, indicating conduction only over AV node.
The retrograde His is visible (H), with HA still 90 ms.
14 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Ventricular Extrastimuli in Sinus Rhythm

Ventricular Extrastimuli

1
2
3
V1
V6
HRA
Hisprox

Hisdist
Figure 2-10 CSprox

CSmid

CSdist
RV
S1 200 ms S1 S2

A single ventricular extrastimulus at a drive of 600 ms is shown in Fig. 2-10. A retrograde

His (blue arrow) is seen before the local ventricular electrogram on drive complexes,
whereas the His is “out the back” (red arrow) after the extrastimulus complex, as a result of
block in the right bundle branch with transseptal conduction to and then up the left bundle
to the His. If this relationship (atrial activation dependent on prior His activation) remains
constant over a range of coupling intervals, a bypass tract is excluded.

Ventricular Extrastimuli in SVT

PVC in SVT

1
2
3
V1
V6
370 ms 370 ms 350 ms 370 ms 370 ms
HRA
Hisprox

Hisdist
Figure 2-11 CSprox

CSmid

CSdist
RV
200 ms S2

In Fig. 2-11, a ventricular extrastimulus is given during SVT. The A-A interval surrounding the
extrastimulus is shorter than the rest of the A-A intervals, but the His was not refractory (blue arrow
 CHAPTER 2 | TYPICAL (“SLOW-FAST”) ATRIOVENTRICULAR NODAL REENTRY 15

shows where it would be expected if not for the extrastimulus). Advancement of the timing of
atrial activation surrounding a His-refractory ventricular extrastimulus demonstrates the existence
of a path of conduction extrinsic to the normal conduction system (bypass tract). If the extra-
stimulus occurs at a time when the His is not refractory (as here), it is feasible that conduction
could occur through the His to the AV node and atrium, and would not implicate a bypass tract.

Atrial and Ventricular Pacing and Extrastimuli During SVT

Atrial Overdrive During SVT

350 ms 370 ms
1
2
3
V1
V6
HRA S S S
Hisprox

Hisdist
CSprox Figure 2-12

PCL 350 ms

CSmid

CSdist
RV
200 ms

Overdrive atrial pacing during SVT is shown in Fig. 2-12. At first glance, the third QRS complex
appears to result from the third stimulus. On closer inspection, it is clear that the third stimulus
causes the fourth QRS complex because the V-V interval there is the same as the paced cycle
length (350 ms). This indicates the presence of slow AV nodal conduction (no surprise, because
this type of AV nodal reentry uses an anterograde slowly conducting pathway).
16 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Atrial Extrastimuli During SVT

1
2
3
V1
V6
S2
HRA
Hisprox

Hisdist
Figure 2-13 H-H 370 ms 370 ms 370 ms 370 ms 370 ms
CSprox

CSmid

CSdist
RV 200 ms

In Fig. 2-13, a single atrial extrastimulus is given during SVT. His-His intervals are as indi-
cated; the His immediately after the extrastimulus (blue arrow) is on time and unaffected
by the stimulus. Thus, if this were a focal junctional tachycardia, it would have already
“fired” for that complex and its next occurrence should be right on time. Although this is
exactly what happens—the next His (red arrow) occurs on time—this finding is also con-
sistent with AV nodal reentry or even AT conducting over a slow AV nodal pathway (the
impulse is already on its way down the slow pathway and is unaffected by the atrial extra-
stimulus). Thus this finding by itself is not diagnostic of focal junctional tachycardia.

Atrial Extrastimuli During SVT

1
2
3
V1
V6 S2 S3
HRA
Hisprox
Hisdist H-H 370 ms 370 ms 370 ms 350 ms 370 ms
Figure 2-14 CSprox

CSmid

CSdist
RV 200 ms

Double atrial extrastimuli are now given during SVT (Fig. 2-14). The His potential after second
extrastimulus (blue arrow) is on time (370 ms), unaffected by the first atrial stimulus (S2). How-
ever, the next His (red arrow), driven by the second atrial stimulus (S3) is advanced by 20 ms. This
shows that focal junctional tachycardia cannot be the diagnosis, because a focal discharge from
the His at the red arrow cannot be advanced by an atrial stimulus that did not affect the prior His.
 CHAPTER 2 | TYPICAL (“SLOW-FAST”) ATRIOVENTRICULAR NODAL REENTRY 17

Atrial Overdrive During SVT

1
2
3
V1
V6
HRA S S S
Hisprox

Hisdist
CSprox Figure 2-15
AH 362 ms AH 330 ms

CSmid

CSdist
RV
200 ms

Atrial overdrive pacing during SVT is performed again, as shown in Fig. 2-15; the AH in-
terval with pacing (362 ms) exceeds the AH in SVT (330 ms); this is consistent with AV
nodal reentry and inconsistent with right AT (in which case the AH intervals should be
similar between pacing and SVT).

Ventricular Pacing vs SVT

1
2
3
V1
V6
HRA
Hisprox

Hisdist
CSprox HA 92 ms HA 80 ms
Figure 2-16

CSmid

CSdist
RV
S 200 ms S

The HA interval with ventricular pacing at the SVT cycle length (92 ms) is always the same
as or longer than HA in SVT (80 ms), when measured as shown in Fig. 2-16 (end of His to
A during pacing, onset of His to A during SVT, with standard 5-mm interelectrode record-
ing catheters). This is not found with very closely spaced, very proximal His recordings,
however, where the difference between HA intervals with pacing and SVT narrows as the
point of turnaround between anterograde slow and retrograde fast pathways occurs.
18 CASE STUDIES IN CLINICAL CARDIAC ELECTROPHYSIOLOGY

Ventricular Overdrive During SVT

1
2
3
V1

V6
HRA
Hisprox

Hisdist
Figure 2-17 CSprox

CSmid

SA 166 ms VA 46 ms
CSdist
RV PPI 544 ms
S PCL 320 ms S 200 ms TCL 344 ms

Ventricular overdrive pacing during SVT is shown in Fig. 2-17, with intervals as indicated;
the SA-VA difference (120 ms) exceeds 85 ms, and the postpacing interval (PPI)–tachycardia
cycle length (TCL) difference (200 ms) exceeds 115 ms; both indices indicate AV nodal
reentry rather than orthodromic SVT.

Cartoons and Ladder Diagrams of Pacing

Orthodromic reentry
SVT

Atrium

AV node

Ventricle

Entrained ventricular pacing

Figure 2-18 SAVpacing VASVT

Atrium

AV node

Ventricle

PPI TCL
SAVpacing - VASVT > 85 ms

PPI - TCL > 115 ms

Fig. 2-18 displays entrained ventricular pacing during orthodromic SVT; the bypass tract
shown here (connecting left atrium and left ventricle) is indicated in the ladder diagrams
as a dotted line.
Exploring the Variety of Random
Documents with Different Content
receptacles. But Matthew, after his former discoveries,
cared little for these in comparison with the contents of one
of these pockets, which attracted his glistening eyes.

"Bank notes! One, two, three. Ten! Twenty! Fifty!"

gasped the covetous old man, as he unfolded and held them
up to the light. "Who would have thought of this, now!"

Who shall tell the force of the temptation that whirled

through that sordid brain, and quickened the sluggish
pulses Of that throbbing heart?—The temptation which
whispered to his grasping thoughts and desires that his son,
being dead, needed money no longer; that no one knew of
his having that amount of portable wealth about his person,
that his grand-daughter was of course well provided for, and
that, at all events, he himself was the proper person to take
care of this property—till it was claimed, if it ever should
be; and if not claimed—well, what then?

His trembling hands had closed upon these notes, and

he was about to—no, not to replace them in the pocket-
book, when suddenly the chamber door was thrown open,
and his daughter stood before him, flushed with fear and
anger.

"For shame, father! Oh, father, father! What is it you

are doing? Put them back, put them back, put them back!"
she cried, in tones of terror. "And thank God for having
saved you from this sin."

"Elizabeth, woman! How dare you speak to me like

that? What is it you mean? What business have you to be
prying into what doesn't concern you?" stammered the
miserable old man, in broken sentences, as he sprang to his
feet, the bank paper still in his grasp.
 "Put them back! Put them back!" repeated the daughter,
in yet stronger tones of desperation. "Strike me if you will,
father," she cried, as she thought she detected a
threatening gesture in the clenched hand. "Strike me, and
kill me, if you will, and let me be laid along with poor Walter
—oh, I wish I could be! I wish I could be!—But don't rob the
dead and the living as well. Father, dear father," she went
on, in more imploring accents; "put them back; oh, father,
put them back!"

"How came you here, girl?" demanded the old man,

hoarsely.

"God sent me, I think," said she; "oh, father, I heard

you come in, and knew that you came up here, and I
followed, and have seen it all from that little window—" and
she pointed to a single pane of glass in a corner of the room
near the ceiling, which dimly lighted a narrow dark staircase
to the attic above—"and God has sent me to keep you from
doing a great sin. Oh, father, father, put them back!"

Slowly and silently the old man cast his eyes on to the
floor, stooped, picked up the pocket-book, put the notes in
their former position, then passionately threw the book
down again, muttering, "I shall remember this, Elizabeth. I
shan't forget it, you may make sure of that," and then he
shuffled out of the room.

It was a fine, soft, sunny day on the afternoon of which

Walter Wilson was buried. There was but little pomp at that
funeral, though there were many to follow him to his grave.

There was Helen as chief mourner, and the ceremonious

undertaker said that it was the right and proper thing for
her, as the only child, to walk first and alone, behind the
coffin, all the way from Low Beech Farm to the church—for
it was a walking funeral, as was the fashion then in those
parts; but Helen pleaded so earnestly and tearfully that
Sarah might accompany her and support her, and so put
strength into her to bear the last scene in her father's
history on earth, that it was yielded.

And so Walter's old discarded lover, and his daughter by

another and perhaps more highly-prized wife than Sarah
would ever have been, followed him together and stood side
by side at the open grave, and were the last to depart when
the solemn ceremony was over.

And if the tears which ran down Sarah's cheek then,

sprang, some of them, from old remembrances revived,
there was no treason in them against God or man. In that
world whither the words just uttered over the dead
transported the thoughts of the living, "they neither marry
nor are given in marriage, but are as the angels of God in
heaven."

Old Matthew and his wife followed their first-born to the

grave, and in their train came Walter's sister and his
brothers and their wives. And then John Tincroft and the
lawyer came after. And the Grigsons were there too.

It was "a fine funeral," one of the onlookers said to

another. But it was soon over, and then the family, with
Tincroft and the lawyer, returned to Low Beech to transact
business, for there was Walter's will to be read, as Mr.
Fawley had taken care to inform them all.

Helen would fain have stayed away, but it was needful

she should be there; and, still under Sarah's wing, but
supported and comforted now by John Tincroft also, she
entered, for almost the first time, the home of her father's
childhood and youth.

The will, when it came to be read, was not very prolix.

It contained an inventory of investments, and all was left in
trust—after the payment of a legacy of a thousand pounds
to his dear cousin Sarah Tincroft—to John Tincroft, of
Tincroft House, and so forth, for the benefit of the testator's
dear and only child, Helen. The property thus bequeathed
amounted, at a rough calculation, to something over twenty
thousand pounds. The will also constituted John Tincroft
sole executor of the testator's estate and effects, and the
guardian of his daughter until she should be of age. In case
of her decease before she had reached twenty-one, the
property was to be distributed among certain charities
which were named.

No mention was made in this will of any other family

connections than John and Sarah. Evidently it had been
prepared at a time when the fire of resentment in Walter's
mind against his family had not yet died out.

Matthew 'Wilson looked furiously across the room at

John Tincroft and Sarah. He understood it all now, he
thought; and before he had composed himself, the lawyer
was reading the codicil which had been drawn up and
signed and witnessed so lately in the sick-chamber at High
Beech.

In this instrument was revoked so much of the original

will as related to the disposal of the property in case of
Helen's death, and a fresh disposition was made of it. It was
to be divided in equal parts between the several members
of the testator's family, or their survivors.
 Old Matthew smiled ghastlily at this. Little hope that he
should ever see any of his son's money, he probably
thought.

But there was something else more interesting.

After an expression of regret that there had been so

long an alienation or distance of feeling between the
testator and his family, certain legacies were to be paid to
them out of the estate, amounting altogether to a thousand
pounds—namely two hundred pounds each to the brothers,
to Old Matthew, and to the sister. In addition to this, there
were some bank notes which would be found in his pocket-
book—(old Matthew broke out into a visible perspiration
here)—amounting to eighty pounds. This sum the testator
willed to be placed without deduction into the hands of his
dear sister Elizabeth, in remembrance of their old love,
which had been afresh stirred up (the document went on to
say) by what passed in the last walk they took together.

This was nearly all. The funeral expenses were, of

course, to be paid out of the estate, and the necessary legal
powers were to be placed in John Tincroft's hands to
administer to the will.

There was a short silence when Mr. Fawley had finished

reading; and he and his friends from the Manor House were
about to depart, when Old Matthew arose. Hoarsely, he
spoke.

He had never known such trickery—never. Here was his

son Walter, who had come home from Australia a rich man,
making believe to be a poor man. Or if he didn't make-
believe that, he never said he wasn't, and didn't seem as if
he had got a pound to bless himself with. And then, instead
of coming to his proper home in England, as he ought to
have done, and to his old father and mother, he had been
putting up with his old lover and her husband, which was
most improper; but, of course, Mr. Tincroft had made it
answer his purpose. And though he had pretended to him
that he did not know whether Walter was rich or poor,
anybody could see now what a pretence that was. And he
was to be executor too, and Helen's guardian, when, by
rights, he, the grandfather, ought to have been. A good deal
more fit, he was, though he said it, to take care of money
(having been used to business all his life) than a college
gentleman who had never added up a sum since he went to
school, he dared to say. And he said now that it was an
unnatural thing, and wicked, to be taking his poor grand-
daughter from her proper sheltering-place; and he wanted
to know if Mr. Tincroft meant to come between relations like
that. Wasn't Helen Wilson his own flesh and blood?

And then there was the money that was left to Elizabeth
over and above her share of that paltry thousand pounds—

"You shall have it all, father, if you will," said Elizabeth,

"only if you won't go on talking like this," she added, her
cheeks mantling with shame.

"And if your grand-daughter prefers making her home

at Low Beech, she has only to say so, and her will shall be
law to me," said John Tincroft.

We need not give Helen's reply. And as little need is

there to tell how the sombre party soon broke up. Our next
chapter will open on other scenes and circumstances.
 CHAPTER XXXI.
YOUNG TOM GRIGSON.

THE record of every man's life is necessarily mixed up

and interwoven with that of many other lives; and to
discourse on the one with any degree of interest, not to say
intelligibly and coherently, it is absolutely necessary to
include some portions of those other histories. For instance,
how could my readers have known anything worth knowing
of John Tincroft, apart from his friend Tom Grigson?

And our introduction to Tom led us in the most natural

way to the bachelor brother at the Manor House. Then we
could not have followed out our friend's matrimonial
adventures unless we had accompanied him to High Beech
Farm, and seen how he became engulfed or influxed, so to
speak, in the vortex of that great maelstrom of which I
have elsewhere spoken. High Beech led us to Low Beech,
just as the Manor House and its surroundings conducted us
to the Mumbles.

Then, without intending it in the first instance, a needs-

be gradually forced itself upon the present chronicler to
lightly sketch certain other characters and scenes, so as to
make, as far as lay in his power, a harmonious and
congruous whole, of which, as a matter of course, John
Tincroft should be the central point of interest, but without
which other characters and scenes the picture would have
presented an unpleasant confusion of impalpable shadows.

Above all, it has been the writer's design and study and
earnest labour to give the colouring of truth to every
subordinate as well as principal character in this picture of
life, so that, in the end, at least one useful lesson may have
been presented to each reader of this story, who, without
intending it, or even expecting to be instructed, has taken
up these pages to pass away an idle day or to amuse a
leisure hour.

Not many more chapters remain to be written; and this

immediate one must be given up to one or more of those
subordinate actors to whom I have referred.

A few days after that which witnessed the funeral of

Walter Wilson, and also the reading of his will, Tom Grigson
and his son took their departure homewards, John Tincroft
and Sarah and the young Helen accompanying them—Mr.
Fawley, the lawyer, having already taken his leave of the
hospitable master of the Manor House, and the woodland
glades of which he had become enamoured.

Tincroft and his following passed a day or two at their

friend's villa on the banks of the Thames, and then returned
to their home near Trotbury, where he and his Sarah
devoted themselves to comforting their darling ward, and to
puzzling themselves in laying plans for her unknown future.
Thus occupied we must at present leave them, our business
being, in the first place, with Tom Grigson the younger.

It was not, after all, an uncongenial life on which he was

about to enter. It may be thought, at first sight, perhaps,
that an active, enterprising lad of sixteen could find little
interest in the monotonous and wearying details of a
London house of business, especially if he should be the
possessor of what is called a correct and classical taste,
improved by education. I take leave to say, however, to
those who argue thus, that they are very little acquainted
with the subject on which they think themselves competent
to pass a judgment.

The details of business, in London or elsewhere, are

neither monotonous nor wearying to properly constituted
minds; nor are they inconsonant with good taste and good
education. There are men, old and young, and in every
proper sense of the word true gentlemen, who belong to
houses of business all the world over, and who yet have
more true taste for the beautiful in nature and art, more
cultivation of mind, and greater scientific and literary
acquirements, than are to be found in one half of the
frequenters of fashionable salons. And yet these same
persons are energetic men of business, and possess talents
which, if need were, would qualify them for conducting the
affairs of a nation almost as easily, and quite as
successfully, as those of a mercantile firm.

Such a person as this was the principal partner in the

house with which Elliston and Grigson were connected; and
this gentleman—who had by this time become a member of
Parliament—took a strong fancy to young Tom, almost on
his first entrance into the house. Under his auspices, the lad
was not only pushed forward in the higher departments Of
business, but was introduced to some circles in society,
intercourse with which gave a zest to the everyday and
more prosaic details of London life.

It is scarcely to be wondered at, therefore, that, after a

short time, the young man was sufficiently satisfied with his
present position to desire no change. In other words, his
visions of university life gradually faded away, and nothing
more was said or thought of entering him at Oxford.

To compensate—if compensation were needed—for this

deprivation, which cannot be called a disappointment, Tom
was indulged, at the end of his second year's experience in
business life, with a long holiday ramble on the Continent,
whence he returned full of enthusiastic admiration for Alpine
scenery and adventures, but with more energy than ever
for the common concerns and ordinary duties of his worldly
calling.

Nor were the attractions of home very feeble for young

Grigson. A pleasant villa, a good-tempered father, who did
not draw the cords of discipline over tightly, an indulgent
mother, a tolerably harmonious brood of younger brothers
and sisters, a select circle of friends, occasional visitors,
serviceable domestics, a horse to ride when he pleased, a
sailing-boat on, if not one of the loveliest rivers in the
world, yet a very passable one as rivers go, and time
enough to enjoy these luxuries of existence, and not too
much, so as to breed ennui. If with all these acquisitions
any young fellow overflowing with bodily health and animal
spirits could not be reasonably happy, that young fellow was
not our young Tom.

There was only one little ingredient in this cup of

happiness which now and then gave a slight flavour to it
which was not altogether to young Grigson's taste.

"I wish they had left me to choose for myself," said

Tom, one day, to his sister Catherine, who was only a year,
or a little more, younger than himself.

They were having a quiet sail on the river one summer's

evening, and were seated side by side at the stern, Tom
with the sail under his management.

"But you like Blanche, don't you, Tom?"

"Oh, don't I?" Tom rejoined, lightly.

 "Well, but you do, you know, Tom."

"Oh yes; Cousin Blanche is so charming, you know,

Kitty, that I ought to be the happiest young fellow in the
world. Everybody tells me so; and what everybody says
must be true. But for all that, Kitty—" and then Kitty's
brother came to a full stop.

"Well, Tom?" This after a long pause.

"Suppose we change the subject, Kitty."

"With all my heart; only we have not begun it yet, and

mamma wanted me to say just a word—may I? She thinks I
can do it better than she can."

"Say away, then, darling; but wait a bit: I'll just hitch
this line round the bolt, and take the rudder strings, There—
so; now."

It is as well to say that two years had passed away

since we fell in with Tom the younger at the Manor House.
He is consequently eighteen years old, or a little over, and a
strange sensation sometimes creeps over him, when he
reminds himself that in three years' time he is to be a
married man, will-he, nil-he; and the "nil-he" is at present
uppermost in his mind.

"And now," said he, settling himself soberly to hear

what his sister (who at seventeen is, in some respects,
older than her brother at eighteen) has to say.

"Mamma thinks you don't pay quite proper attentions to

Blanche."

"Pho! Pho! Kitty. Not proper attentions! Why, don't I go

to see her once a week? If that is not often enough, I don't
know what would be."

"I shouldn't think so, Tom, if I were Blanche. Besides,

when you do go to see her—or, rather, when you go to
dinner at Uncle Elliston's—you stay so long in the dining-
room that Blanche has very little of your company, she
says."

"I wonder what she would have," grumbled Tom. "She'll

have enough of it by-and-by, I'll be bound," he added.

"That depends. Do you know, mamma is afraid—" It

was Catherine's turn to come to a full stop now.

"Well, Kitty?" This after another pause.

"Mamma is afraid that you are running a risk of losing

Blanche, after all."

"You don't say so, Kitty?" cried Tom, with an odd

expression of alarm, too readily put on to be quite real, his
sister thought.

"Mamma says so," answered Kitty, demurely; adding,

"She says she is mistaken if—if somebody else, never mind
who—"

"Oh, I don't mind. Well?"

"Isn't trying to step into your shoes. That's what

mamma says, Tom."

"I hope the old shoes won't pinch the feet," said Tom,
laughing.

"But seriously, Tom."

 "To be sure; yes, seriously, Kitty," returned the brother,
composing his countenance.

"You don't want to lose Cousin Blanche, do you?"

"I have never thought much about it, Kitty. What do you
think about it?"

"I think, Tom, that you will be sorry to lose her."

"Um! Well?"

"You know it was all settled so long ago."

"That's true enough," said Tom.

"And then when you marry you are to come into a

partnership."

"Nobody ever married without coming into that," said

Tom.

"Tom, you are incorrigible. A partnership in the house, I

mean. You know what I mean."

"Yes, I know what you mean, darling Kitty; and it will all
come right, don't be afraid; and tell mamma not to worry
herself about it. I am agreeable. Only I wish it hadn't been
all planned out so nicely. If only they had left it for me to
choose for myself," he added, returning to his starting-
point.

"And if they had, you would have chosen Blanche, don't

you think?"

"Possibly. Blanche is a charming girl, of course. Oh,

Kitty, Kitty! Why didn't they leave me and Cousin Blanche to
set about it in the good old fashion? As it is, I feel as if
Blanche had been my wife and I her husband ever since we
were babies; and that I am an old married man."

"An old married man of eighteen!" and Kitty laughed

merrily.

"Just so," said Tom, grimly. "I wonder whether anybody

took the trouble to plan in this way for father and mother
before they were really married."

"Their case was different," argued the sister; "but what

does that signify? You say you are fond of Blanche, don't
you?"

"Why, of course. What a young infidel you are, Kitty."

"Then you should be a good boy, and take care she

doesn't slip through your fingers. That's what mamma
says."

"Tell mamma, then, that I will behave better in future.

Heigh-ho! And now let us talk about something else. Aren't
you sorry you have left school for good?"

"No, I don't think I am. There's only one thing makes

me sorry. Helen Wilson is to stay at Miss G—'s another half,
and she is my dearest friend. Poor dear Helen! You have
heard me speak of her, Tom?"

"I should think so. Where were my ears else?"

"And you remember her, don't you?"

"Yes; of course. I remember her—down at Uncle Dick's

when I was there, and came home with us—she and dear
old Tincroft and Mrs. T. Yes, I remember her."
 "I like her so much," continued Kitty; "and I wanted to
bring her home with me these holidays, but Mr. Tincroft
wouldn't hear of it. He couldn't spare her, he said. Ill-
natured, wasn't it?"

And then from this topic of conversation, the brother

and sister passed on to another, till it was time to finish
their cruise.

Tom did "behave better in future." That is to say, he

begun from this time to pay greater attentions to the young
lady, who, without any choice on his part, or hers either,
was marked out to be his future wife; that is to say, he
went twice a week instead of once to her father's house at
Camberwell, and devoted more time when he was there to
her special society.

And, not to flatter Blanche, she was not unworthy of

these attentions. She had made good use of her time since,
two years before, our friend Tincroft had passed, in his own
mind, so unfavourable a judgment respecting her. The
rather pert and conceited and affected schoolgirl had
changed into an attractive and well-behaved young woman;
while her pale face and unformed figure had ripened, if not
into a perfect Hebe, yet into a sufficiently blooming and
graceful piece of humanity. Whether or not it was wise in
this instance—or whether it is wise in any instance—for
such an alliance as has been spoken of to be contracted by
other parties as sponsors for those most deeply interested,
remains to be proved.

The wisdom of this arrangement, however, seemed

manifest to one, at any rate, of these contracting parties,
when a certain event of importance occurred.
 "Did you ever know anything like this?" Mrs. Tom
Grigson wished to be told, holding up her hands in sheer
astonishment, when she had made herself acquainted with
the purport of a letter which her husband had handed to her
across the breakfast-table.

"Yes, my dear, I have known a good many things so

exactly like it as to be identically the same," responded our
old friend Tom.

"What a—what a—moon-calf he must be, Tom," the lady

went on.

"Rather tough to digest, Kate," returned the husband,

drily.

"But they do say there's no fool like an old fool,"

continued Mrs. Grigson.

"My dear!" remonstrated Tom.

"To think that he should ever think of doing such a

thing!" said the lady. "'Tis dreadful!" she added.

"Is it so dreadful, Kate?" asked the gentleman, looking

up. "That's a new light cast on the subject," he added.

"Nonsense, Tom! You know what I mean. Of course it

isn't always dreadful, nor yet dreadful in itself; but, as you
say sometimes, 'circumstances alter cases.'"

"Alters, you should say, Kate, to give the proper roll to

the aphorism."

"That isn't grammar, Tom."

 "Never mind about grammar when you want to produce
effect. And I say, circumstances alters cases. And then,
again—"

"There's no accounting for opinions;

Some likes apples, some likes inions."

"And Dick likes matrimony, it seems. Why shouldn't

he?"

"Wasn't he always railing against it?"

"None the less likely to fall into it, for all that, Kate. And
when he had our example set before him to follow, with the
benefit of our experience—"

"Nonsense, Tom! Why, we have been man and wife any

time these twenty years."

"Is it so long, Kate?" Tom asked.

"Of course it is; and here's Dick pretty near old enough
to be your father—"

"Which he isn't," interposed the gentleman.

"You put me out, and make me forget what I was going

to say, Tom, when you interrupt me like that," remonstrated
the lady. "But what I mean is that at his age your brother
Richard ought to be above such folly."

"Ought not to be above such wisdom, you should say,

Kate. He sees his folly, no doubt, and argues that it is never
too late to mend."
 "To mend, indeed! An old man like him to be marrying a
girl of twenty! He ought to be ashamed of himself."

It was quite true that Mr. Richard Grigson had so far

committed himself. Having lived a single life till his hair had
turned grey, and all the while declaring against matrimony,
he had suddenly and violently become enamoured of a
young lady from London who, while visiting a friend in the
country, not far from the Manor House, accidentally fell in
with and was introduced to the Manor House's owner.

It was a storm of wind and rain that brought about the

introduction. The young lady and the old gentleman, in
whose house she was a guest were out walking one fine
May day, when suddenly the sky became overcast, and a
heavy dark cloud from the west began to discharge its
contents. The old gentleman was two or three miles away
from his own house; he was afraid of rheumatism; he had
not an umbrella; and the nearest shelter was the Manor
House, whose gates he and his young friend were passing
as the shower came on. He was slightly acquainted with
Richard Grigson, though on no familiar terms with him. But,
driven by the exigencies of the case, the storm-attacked
pedestrians rushed at once through the gateway, scudded
across the lawn, and presented themselves at the
hospitable doors of the Manor House, suppliants for shelter.

They received shelter and something more; and the

next day Richard bethought himself that it would be only
proper for him to ride over to the old gentleman's house to
give expression to his hope that the young lady had not
taken cold.

The young lady had not taken cold, thanks to Mr.

Grigson; but the old gentleman had, and was confined to
his chamber by its effects. And so, perforce, the elderly
bachelor and the juvenile maiden had to entertain each
other in the drawing-room. The entertainment lasted longer
than was calculated on; for, strange to say, while they were
thus engaged, another heavy shower came on; and Richard,
who never till now had minded being wet to the skin, felt an
unconquerable repugnance to facing the rain. Before the
shower was over, he had secretly made up his mind to pay
another visit—which he did, and this time it was to Miss
Hardcastle.

There is no need to multiply words in describing the

progress of a rapid thaw of frozen-up passions. It is enough
to say that before three weeks had passed away, Mr.
Richard's determination never to marry had melted away
beneath the influence of Miss Hardcastle's charms. In
another week, he was her accepted lover.

It was rather awkward—at least, kind-hearted Richard

Grigson felt it to be so—to make known to his brother the
change which had come over him, and the engagement on
which he had entered.

"It will be a little hard upon brother Tom," he thought

within himself, "and if not upon brother Tom, it will fall
heavy upon nephew Tom (bless his young heart!) to know
that the old family estate may have to keep in a straight
line after all. But they are good fellows, both of them, and I
am sure they won't make a quarrel of it, and I must make it
as easy for young Tom as I can. And, after all, it may come
to him all the same," he added, by way of salvo, or salve to
his conscience.

"Besides," continued he, in his thoughts, "there's no law

that I know of, in the Bible or out of it, to keep a man from
marrying because he has a fair estate on the one hand, and
a fair nephew on the other."
 The result of this soliloquy was the letter which had so
disturbed the equanimity of Mrs. Tom Grigson at the
breakfast-table; and, to tell the truth, it also took Mr. Tom a
little aback. But he soon recovered himself.

"Dick has as much right to please himself by taking a

wife as ever I had," said he; "and I'll go down to his
wedding," he added.

It could not be denied, however, that this new move (as

it was called) of Dick's sent all, or a good many, previous
calculations to the right-about. And our friend Tom
congratulated himself more than ever on having brought up
his son to business instead of sending him to Oxford.

"As it isn't at all likely our boy will come to the estate
now," he said to his wife, when they were by themselves, "it
is a good thing to have put him in the way of being
independent without it, which he mightn't have been if we
had made a scholar of him."

There was another source of congratulation also—

namely, that the young fellow's match with his cousin had
been made so long ago, and was progressing without any
palpable hitch.

"I wish Tom was a little more in earnest about it," the
father went on; "but, as he says, it will come on in time.
And then, when they are married, Tom will have got a snug
nest, anyhow."

Tom the elder did go down to his brother's wedding, and

so did Tom the younger. Mrs. Tom Grigson was also
prevailed upon to dispose of her chagrin and go also.
Richard Grigson was profoundly touched by this almost
unlooked-for kindness on their part.
 "I always knew you were a good fellow, dear old Tom!"
said Dick. "But I was half afraid you would turn rusty."

"Nonsense, Richard! The world's wide enough for us all,

isn't it? And there's no one wishes you all sorts of happiness
in your married life more heartily than I do. All sorts of
happiness, mind," he added.

CHAPTER XXXII.
IN THE FLOWER GARDEN.
 IT is high time we returned to Tincroft House, and our
friends there, whom we left puzzling themselves how best
to fulfil the new duties laid upon them. After many
consultations, and weighing all sorts of pros and cons, it
was finally decided—with the young lady's consent—that
Helen's education should be carried on and completed at a
boarding school. There were several reasons that led to this
conclusion.

Among others, it was wisely propounded by John that,

being an heiress, some accomplishments, in which Helen
was acknowledged to be deficient, were necessary for her
future establishment in life, whenever that event might
occur. Internally, John also reflected that neither from Sarah
nor himself were these accomplishments likely to be
obtained. Moreover (and here he spoke out again), the best
they could do for Helen by way of dissipating the grief of
her recent bereavement, was to provide her with a change
of scene and companionship, which, as far as he could see,
could be done only by the plan proposed.

In this emergency, John's friend Grigson came to his

help. His daughter Catherine was at a highly respectable
boarding school in a certain town on the coast, not far from
Trotbury. Tom spoke very highly of this school (which had
the additional virtue of not being called an "establishment
for young ladies"). And accordingly, after a brief interval
devoted to due preparations, Helen Wilson was placed
under the care of Miss G—.

How pleasantly the time passed there; how the young

Australian very soon became a favourite with all the girls
(some sixty or more) in the school; how, especially, she and
Catherine Grigson became bosom friends; and how she
made rapid progress towards those accomplishments in
which she had been held to be deficient—there is no need to
tell. Time passed quickly, and after an interval of some
three years, we find Helen Wilson once more at Tincroft
House, very dearly loved and cherished by the motherly
Sarah and dear old shy awkward John, both of whom
manifested their love in a variety of ways pleasant to
behold.

For instance, Helen's bower was replenished with a

bounteous store of treasures of art, literature, and science,
"calculated," as the advertisements have it, "to please the
eye and improve the taste." A new maid was hired for
Helen's especial behoof; but as she turned out a failure, and
the young lady declared herself quite capable of waiting on
herself, this adjunct was afterwards dispensed with.

To bring themselves and their old-fashioned ways more

into accord with the usages of modern society, moreover,
John and Sarah altered their dinner-hour from two to six,
greatly, it must be said, to the disgust of Mrs. Jane (now
exalted to the rank of housekeeper), who was to be
appeased only by the gift of a new dress and cap, which
outshone those of her contented mistress.

But the most admirable of all the wonders wrought by

affection when thus enlisted on the side of darling Helen,
was when dear old John set about witching the world with
his noble horsemanship. In our former account of Helen, we
noted that among the accomplishments she had learned in
her home in the bush was that of being an expert and
fearless rider. And if one ungratified wish, on her return to
Tincroft House, existed in her heart, it was for a wild gallop
across the country.

By accident this wish became known to John; and

before the world was a week older, the hitherto unused
stables of Tincroft House, and the chamber above, were
duly prepared for the reception of a horse fit for a lady's
use, a grey pony for John's own bestriding, and a groom to
keep them in proper condition. To what extent Tincroft was
compelled to draw his purse-strings, and how far he was
cheated in the bargain he made, no one probably knew at
the time—the honest horse-dealer only excepted.

But dear John, who had never in his life bestridden even
a rocking-horse! Well, well, he would have mounted a
hippogriff to please Walter Wilson's child, and his Sarah's
pet; and it was a sight worth seeing when, by Helen's side,
who gracefully reined in her steed to accommodate herself
to his more sober pace, John bumped up and down on his
saddle till the knobby chairs at High Beech Farm would have
been as downy pillows in comparison with it.

And so time wore on.

It has already been intimated that a strong attachment

sprung up between Helen Wilson and her school-fellow
Catherine Grigson. And this was continued after both young
ladies had left school. Their intercourse was kept up,
however, principally by writing; for, though Helen was often
invited to visit her friend on the banks of the Thames, some
unforeseen difficulty always started up to set the invitation
aside. I think our friend Tincroft could have given a rational
explanation of these unexpected hindrances if he had been
disposed to do so, which he was not.

There was nothing, however, to prevent Miss Grigson

paying a long-promised visit to Tincroft House one summer;
and when there, there was everything to invite its
prolongation. Dear Helen was so glad of her friend's
company, while Mr. and Mrs. Tincroft were so kind and so
hospitably inclined, that it would have been positive cruelty
—so Catherine wrote home—to deprive them of the
pleasure they coveted.

"And why don't you run down for a day or two?" she
wrote to her brother Tom. "'Tis years and years since you
were here, you know; and you haven't been out for a
holiday all the summer."

"No more have I," said Tom to himself, when he read

the note, and the next morning he had deposited himself on
the box seat of the Trotbury coach.

"Just come to see how you are getting on in this part of

the world," was his first salutation to John, as he landed
himself unexpectedly at the gate of Tincroft House, on the
afternoon of the same day.

John was very pleased to see the son of his old friend,
and he told him so. And as to the inconvenience of
accommodating an unexpected guest, quoth Mrs. Tincroft,
when young Tom apologised for the abruptness of his
invasion, as he called it, she hoped Tincroft House was big
enough to accommodate a dozen such as Tom, if need
were. And so he might set his mind at rest on that subject.

And Tom did set his mind at rest. In fact, he found his
quarters so much to his liking, that he lengthened his visit
from day to day, under a variety of pretences, until he had
been more than a fortnight an inmate of the pleasant
mansion.

"You must stay with us over next week now," said

Sarah, one evening when Tom was seriously propounding
the propriety of returning to business. "It is Trotbury cricket
week, and we shall want a gentleman to take us on to the
ground two or three of the days at least; and John doesn't
like cricket at all—do you, John?"
 John didn't like cricket, and he said so. He had had
enough of cricket in his younger days, and what pleasure
there could be in standing up before three sticks stuck into
the ground to knock away a ball, with the chance of being
maimed for life, he couldn't for a moment conceive. But for
all that, if his dear Sarah had any pleasure in seeing what
was called "the noble game" played, or if he could be of any
use to the young ladies in procuring them good positions for
viewing "the noble game," he was very much at their
service.

So, if Tom must really return, or felt called upon by the

imperative claims of business to return to London, he
himself would not interpose an obstacle in the shape of
Trotbury cricket week. Indeed, he wasn't quite sure that it
wouldn't be as well for Tom to remember that there were
claims upon him elsewhere. What, for instance, would the
young lady at Camberwell think when she heard, if she
should hear, of Tom's being seen on Trotbury cricket ground
with another young lady? John asked, gravely.

Whereupon, Tom declared that the young lady at

Camberwell might think as she pleased. He hoped he wasn't
tied to any young lady's apron strings; there would be time
enough for that when another knot was tied. Tom shifted
rather uneasily in his chair as he said this, and, though he
did feign to laugh, he looked a little redder than usual,
especially when he saw that his host's gravity was not at, all
moved by his gaiety.

Perhaps it was to prove how much at liberty he felt

himself, that, later in the day, Tom left his host and hostess
and his sister in the drawing-room, and strolled into the
pretty flower garden already described, where Helen was
employing herself—as he very well knew—in tending her
plants. By the way, there is no feminine occupation more
adapted to innocent flirtation (if such a composite term, or
rather, contradiction in terms, may be used) than in this
kind of gardening. The sweet, enthralling tyranny displayed
by the head-gardeneress in ordering her enchanted slave,
who for the nonce is made to be a hewer of wood (with his
pocket-knife in preparing flower-sticks) and a drawer of
water (in filling the watering-pot any number of times from
the nearest pump, well, or pond), is something quite
instructive to witness (for it points back to Eden, evidently),
and delightful to endure.

Tom at least thought so, as he found himself (his

offered services accepted), making himself of some use, as
she said, to the fair Helen. For by this time a kind of
understanding seemed to have been tacitly entered into
that Master Tom, being already on the high road to
matrimony, and within sight, so to speak, of the goal, was
to consider Miss Wilson as a sort of twin-sister to his own
sister Catherine, and to be treated with frank unreserve
accordingly, for:

"What was Hecuba to him, or he to Hecuba?"

I am afraid, too, that dear old John Tincroft had by this

time, if the truth were known, rather spoiled darling Helen,
by making her see and believe how happy it made him to
be her humble servant; and perhaps she might have
thought that every gentleman she fell in with was like John.
But this by the way.

"There, that will do for all the watering we want to-

night," said the lady, looking round with admiration on her
revived flowers. "And now please help me tie up this
straggler, Tom."

In another moment TOM was on one knee, for the

convenience of the operation, and the young lady's slender
fingers were deftly fastening the string which was to confine
the flower-stalks to their supporting stick, when a hand, not
Helen's, was laid on Tom's shoulder.

"Very pleasantly employed, Tom," said Tincroft, quietly;

for he was the intruder.

Tom started to his feet.

"Don't hurry," said John; "but when Miss Wilson has

quite done with your services, I want a word or two."

The young lady graciously gave Tom permission to

retire; and the two gentlemen walked slowly down the path
together without speaking until they had reached the
farther end. Then John wheeled round (as also did Tom),
and stood looking from the distance towards the fair
gardeneress, who was now, as it seemed, occupied in
gathering a nosegay.

"Tom, don't you think it would be better for you to

return home to-morrow?" said Tincroft, after a rather
awkward pause.

Master Tom looked his elderly friend in the face, with

some surprise, as well he might, perhaps, for John Tincroft
was not usually anxious to get rid of his guests.

"Do you think so, sir?" the young fellow asked.

"I'll tell you presently what I think," said John, "and also
why I think it, if I do think it. You may be sure of one thing,
at any rate—I shall be very sorry to lose your good
company."

"Thank you, Mr. Tincroft. You are very kind," said young
Tom.

"You would like to stay over next week, it being the

grand cricket week?" continued John.

"Yes, I should," replied Tom, bluntly.

"No doubt, end not only because of its being the cricket
week?"

Tom again looked up into his friend's face, with a quick

gesture, not altogether of surprise; and then he turned
rather red in the face, I think, and looked down upon the
path. There was a broken twig upon it, which engrossed his
attention, perhaps; for he took great pains to turn it over
with his foot, so as to pass it under a kind of general
examination. He didn't speak.

Until now the two gentlemen had remained, as it

seemed, rooted to the spot, and the fair Helen was still
employed in filling her little flower basket. This completed,
she turned from the border and disappeared. Apparently
this broke the spell, for Tincroft now slipped his arm within
that of his young friend, and the two paced up and down
the long path as they communed together.

"My dear lad," said John, when they were thus in

motion, "your father and I were dear friends when we were
about your age. We were almost always together when we
were at Oxford. We never had a serious disagreement in our
lives; I received many a kindness from him; and though we
have not seen so much of each other of late years as
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