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Interpreting ECGs 3e
A Practical Approach
Third Edition
©rivetti/Getty Images
Third Edition
Bruce Shade
EMT-P, EMS-I, AAS
INTERPRETING ECGs
Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2019 by McGraw-Hill
Education. All rights reserved. Printed in the United States of America. No part of this publication may be
reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the
prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic
storage or transmission, or broadcast for distance learning.
Some ancillaries, including electronic and print components, may not be available to customers outside the
United States.
This book is printed on acid-free paper.
1 2 3 4 5 6 7 8 9 LMN 21 20 19 18
ISBN 978-1-260-09293-6
MHID 1-260-09293-3
Cover Image: PIXOLOGICSTUDIO/Getty Images
All credits appearing on page or at the end of the book are considered to be an extension of the copyright page.
The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does
not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not
guarantee the accuracy of the information presented at these sites.
mheducation.com/highered
About the Author
Bruce Shade is currently employed as the EMS Educator for
Cleveland Clinic Hillcrest Hospital in Northeast Ohio. He is
also a paramedic instructor at Cuyahoga Community College
Courtesy Bruce Shade
(Tri-C) in Cleveland. Bruce is also a past Chairperson of the

Ohio Emergency Medical Services Board and just recently
retired as a part-time firefighter for the City of Willoughby.
Bruce has been involved in emergency services since

1972. He started as a volunteer firefighter/EMT for
Granger Township and then served as paramedic, educational supervisor, paramedic
training program director, and commissioner for the City of Cleveland’s Division of
Emergency Medical Service for the next 25 years. During those years, he also worked
as a part-time firefighter/paramedic for Willowick Fire Department and the para-
medic faculty at Lakeland Community College. For the remainder of his career with
Cleveland, he served as an Assistant Public Safety Director. Since retiring, Bruce
worked as a Homeland Security Consultant, Operations Director for Community
Care Ambulance, and Assistant Safety-Service Director for the City of Elyria, all in
Northeast Ohio.
Bruce is past President, Vice President, and Treasurer of the National Association
of EMTs and chairperson of the Instructor Coordinator Society. He has served as
president of several local associations and chairperson of many committees and task
forces. Bruce has authored several EMS textbooks and written many EMS-related
articles. He has lectured at local, regional, state, and national EMS conferences.
Dedication
This book is dedicated to my father, Elmer Shade, Jr. He recently passed
away at the age of 97. He grew up during the depression, served in
France during the Second World War, and worked hard his entire life.
He was still mowing 20 acres of property each week at 96 years of age.
A lifelong Cleveland sports fan, he had a keen sense of humor and a
strong set of values and work ethic. He was known for his ability to tell
stories and recall his life experiences. I can say, with great pride, that
I acquired many of his traits. My ability to communicate information
through textbooks can be directly attributed to what I learned from him.
v
Contents
Preface xxii
Features to Help You Study and Learn xxiv
Section 1: Preparatory
Chapter 1 Anatomy and Electrophysiology of the Heart 2
The Electrocardiogram 4
How It Works 5
The Circulatory System 6
Anatomy of the Heart 6
Shape and Position of the Heart 7
The Pericardial Sac 8
The Heart Wall 9
The Internal Heart 10
Cells of the Heart 12
Myocytes 12
Pacemaker and Electrical Conducting Cells 14
The Heart’s Conductive Pathway 14
SA Node 14
AV Node 14
Bundle of His and Right and Left Bundle Branches 16
Purkinje Fibers 16
The Heart’s Blood Supply 16
Right Coronary Artery 16
Left Main Coronary Artery 17
Coronary Veins 17
Physiology of the Heart and Circulation 18
The Cardiac Cycle 18
Cardiac Output 18
Blood Pressure 19
Blood Flow through the Atria 19
Initiation of Impulse in the SA Node 20
Atrial Depolarization and Contraction 21
Conduction through the AV Node 21
Conduction through the His-Purkinje System 22
Ventricular Depolarization and Contraction 22
Atrial and Ventricular Repolarization 24
Alternate Pacemaker Sites 24
vi
Influences on the Heart and Circulatory System 25
The Autonomic Nervous System 26
Sympathetic Nervous System 26
Parasympathetic Nervous System 27
Increased Myocardial Oxygen Needs 27
Nerve Impulse Generation and Muscle Contraction 28
Polarized State 28
Depolarization 29
Repolarization 30
Refractory Periods 31
Impulse Generation of the SA Node 31
Depolarization and Repolarization of the Myocytes 33
Chapter 2 The Electrocardiogram 44

The Electrocardiogram and ECG Machines 46
ECG Lead Wires and Electrodes 48
Lead Wires 48
Electrodes 49
Heart’s Normal Electrical Activity 52
ECG Leads 53
Bipolar/Unipolar Leads 54
Planes of the Heart and Lead Placement 56
Frontal Plane 56
Horizontal Plane 57
Putting the Views Together 73
15- and 18-Lead ECGs 74
Displays and Printouts 76
Reading Printouts 77
Section 2: The Nine-Step Process

Chapter 3 Analyzing the Electrocardiogram 86
Characteristics of the Normal ECG 88
Analyzing the Electrocardiogram Using the
Nine-Step Process 88
Step 1: Heart Rate 89
Step 2: Regularity 89
Step 3: P Waves 90
Step 4: QRS Complexes 91
Step 5: PR Intervals 91
Step 6: ST Segments 92
Step 7: T Waves 93
vii
Step 8: QT Intervals 94
Step 9: U Waves 94
Flexibility in the Nine-Step Process 95
Dysrhythmia and Cardiac Condition Characteristics 95
Analyzing the ECG 98
Analyzing the Rhythm Strip 98
Analyzing the 12-Lead Tracing 99
Calibrating the ECG 100
Artifact 102
Chapter 4 Heart Rate 108

Importance of Determining the Heart Rate 110
Quick Check of the Heart Rate 110
Heart Rates Seen with Various Dysrhythmias 111
Methods of Determining Heart Rate 111
6-Second Interval ×10 Method 112
300, 150, 100, 75, 60, 50 Method 113
1500 Method 116
Rate Calculators 118
Counting Both the Atrial and Ventricular Rates 118
Normal, Slow, and Fast Rates 119
Slow Rates—Bradycardia 119
Fast Rates—Tachycardia 119
Stable or Unstable, Narrow or Wide 119
Chapter 5 Regularity 122

Importance of Determining Regularity 124
Quick Check of Regularity 124
Methods of Determining Regularity 125
Paper and Pen Method 126
Caliper Method 127
Counting the Small Squares Method 128
Using a Rate Calculator 128
Types of Irregularity 129
Occasionally or Very Irregular 130
Slightly Irregular 132
Irregularity Caused by Sudden Changes in the Heart Rate 133
Irregularly (Totally) Irregular 133
Patterned Irregularity 135
Irregularity Caused by Varying Conduction Ratios 136
viii
Chapter 6 P Waves 142
Importance of Determining the P Waves 143
Examining the P Waves 144
Normal P Waves 144
Identifying and Characterizing Abnormal P Waves 146
Peaked, Notched, or Enlarged Sinus P Waves 146
Atrial P Waves 147
Varying Atrial P Waves 148
Flutter and Fibrillatory Waves 150
Inverted and Absent P Waves 151
More P Waves than QRS Complexes 153
Chapter 7 QRS Complexes 160

Importance of Examining the QRS Complexes 162
Examining the QRS Complexes 162
Measuring QRS Complexes 164
Variations in the QRS Configuration 165
QRS Complexes in Different Leads 166
Where We See Normal QRS Complexes 167
Abnormal QRS Complexes 167
Tall and Low-Amplitude QRS Complexes 168
Wide QRS Complexes of Supraventricular Origin 168
Wide, Bizarre-Looking QRS Complexes of Ventricular Origin 172
Absent QRS Complexes 178
Chapter 8 PR Intervals 184

Importance of Determining the PR Intervals 185
Characteristics of Normal PR Intervals 186
Measuring the PR Intervals 187
PR Intervals That Are Different 188
Shorter PR Intervals 188
Longer PR Intervals 191
Varying PR Intervals 192
Absent or Not Measurable PR Intervals 194
Constant PR Intervals Seen with More P Waves 195
Chapter 9 ST Segments, T Waves, QT Intervals, and U Waves 202

Analyzing the Specific Waveforms, Segments, and Intervals 204
Normal and Abnormal ST Segments 204
Normal Characteristics 205
Measuring the ST Segments 205
Abnormal ST Segments 206
ix
Normal and Abnormal T Waves 207
Measuring the T Waves 208
Abnormal T Waves 208
Normal and Abnormal QT Intervals 210
Measuring the QT Interval 210
Abnormal QT Intervals 211
Normal and Abnormal U Waves 212
Abnormal U Waves 212
Section 2 Practice Makes Perfect 217
Chapter 10 Heart Disease 222

Defining Heart Disease 223
Risk Factors of Heart Disease 224
Age, Gender, and Family History 224
Smoking and Alcohol Intake 224
Poor Diet, Obesity, and Physical Inactivity 224
High Blood Pressure 224
High Blood Cholesterol Levels 225
Diabetes 225
Stress and “Type A” Personalities 225
Poor Hygiene 225
Complications of Heart Disease 226
Dysrhythmias 226
Angina 226
Myocardial Infarction 226
Dilation and Hypertrophy 226
Heart Failure 226
Cardiogenic Shock 228
Stroke 228
Aneurysm 228
Peripheral Artery Disease 229
Pulmonary Embolism 229
Sudden Cardiac Arrest 229
Types of Heart Disease 230
Coronary Artery Disease 230
Myocardial Ischemia 231
Myocardial Injury 232
Myocardial Infarction 232
Cardiomyopathy 233
Arrhythmogenic Right Ventricular Dysplasia 236
Heart Infection 237
x
Rheumatic Fever 239
Valvular Heart Disease 239
Congenital Heart Defects 242
Section 3: Origin and Clinical Aspects of Dysrhythmias

Chapter 11 Overview of Dysrhythmias 250
The Heart’s Normal Electrical Activity 252
Dysrhythmias 252
The Effects of Dysrhythmias 253
Types of Dysrhythmias 255
Bradycardia 255
Tachycardia 255
Early (Premature) Beats 257
Dropped Beats or QRS Complexes 257
Irregularity 258
Causes and Mechanisms of Dysrhythmias 258
Increased Parasympathetic Tone 258
Myocardial Hypoxia, Injury, and Infarction 258
Increased Automaticity 258
Reentry 260
Triggered Beats 260
Proarrhythmia 260
Site of Origin 261
Sinus Dysrhythmias 261
Atrial Dysrhythmias 262
Junctional Dysrhythmias 262
Ventricular Dysrhythmias 262
AV Heart Block 262
Identifying Dysrhythmias 263
Patient Assessment 264
Primary Assessment (ABCDEs) 264
Secondary Assessment 265
Ongoing Assessment 267
Treatment of Dysrhythmias 267
Physical Maneuvers 267
Electrical Therapy 268
Medications 268
Chapter 12 Sinus Dysrhythmias 276

Rhythms Originating from the Sinus Node 278
ECG Appearance of Sinus Rhythms 278
xi
Normal Sinus Rhythm 279
Sinus Bradycardia 280
Description 280
Causes 280
Effects 282
ECG Appearance 282
Treatment 282
Sinus Tachycardia 283
Description 283
Causes 284
Effects 285
ECG Appearance 285
Treatment 285
Sinus Dysrhythmia 285
Description 285
Causes 286
ECG Appearance 287
Treatment 287
Sinus Arrest 287
Description 287
Causes 287
Effects 288
ECG Appearance 289
Treatment 289
Sinoatrial Exit Block 289
Description 289
Causes 289
Effects 290
ECG Appearance 290
Treatment 290
Sick Sinus Syndrome 291
Description 291
Causes 291
Effects 291
ECG Appearance 292
Treatment 292
Sinus Rhythm as the Underlying Rhythm 292
Practice Makes Perfect 294
Chapter 13 Atrial Dysrhythmias 314

Rhythms Originating in the Atria 316
Key Features of Atrial Dysrhythmias 316
xii
P Wave Appearance 316
QRS Complex Appearance 316
Effects of Atrial Dysrhythmias 317
Premature Atrial Complexes 318
Description 318
Causes 318
Effects 319
ECG Appearance 319
Differentiating Blocked PACs from Sinus Arrest 322
Treatment 323
Wandering Atrial Pacemaker 323
Description 323
Causes 324
Effects 324
ECG Appearance 324
Treatment 324
Atrial Tachycardia 325
Description 325
Causes 325
Effects 326
ECG Appearance 326
Treatment 327
Multifocal Atrial Tachycardia 329
Description 329
Causes 330
Effects 330
ECG Appearance 330
Treatment 330
Supraventricular Tachycardia 330
Atrial Flutter 331
Description 331
Causes 331
Effects 332
ECG Appearance 332
Treatment 333
Atrial Fibrillation 333
Description 333
Causes 334
Effects 334
ECG Appearance 335
Treatment 335
xiii
Chapter 14 Junctional Dysrhythmias 356
Dysrhythmias Originating in the Atrioventricular Junction 358
Key Features of Junctional Dysrhythmias 358
PR Interval 359
Effects 360
Premature Junctional Complex 360
Description 360
Causes 361
Effects 361
ECG Appearance 361
Treatment 362
Junctional Escape Rhythm 362
Description 362
Causes 363
Effects 363
ECG Appearance 363
Treatment 363
Accelerated Junctional Rhythm 364
Description 364
Causes 365
Effects 365
ECG Appearance 365
Treatment 365
Junctional Tachycardia 366
Description 366
Causes 367
Effects 367
ECG Appearance 367
Atrioventricular Nodal Reentrant Tachycardia 367
Description 367
ECG Appearance 368
Effects 369
Preexcitation 369
Wolff-Parkinson-White Syndrome 370
Lown-Ganong-Levine Syndrome 370
Atrioventricular Reentrant Tachycardia 372
Description 372
Appearance 372
Effects 373
Treatment of Supraventricular Tachycardia 373
xiv
Chapter 15 Ventricular Dysrhythmias 394
Dysrhythmias Originating in the Ventricles 396
Key Features of Ventricular Dysrhythmias 397
Effects 398
Premature Ventricular Complexes 398
Description 398
Causes 399
Effects 399
ECG Appearance 400
Treatment 404
Ventricular Escape Beats 404
Description 404
Causes 405
Effects 405
ECG Appearance 406
Treatment 406
Idioventricular Rhythm 407
Description 407
Causes 408
Effects 408
ECG Appearance 408
Treatment 408
Accelerated Idioventricular Rhythm 409
Description 409
Causes 409
Effects 410
ECG Appearance 410
Treatment 410
Ventricular Tachycardia 410
Description 410
Causes 410
Effects 410
ECG Appearance 412
Treatment 412
Polymorphic Ventricular Tachycardia 413
Description 413
Causes 413
Effects 414
ECG Appearance 414
Treatment 414
xv
Ventricular Fibrillation 414
Description 414
Causes 415
Effects 415
ECG Appearance 416
Treatment 416
Asystole 417
Description 417
Causes 417
Effects 417
ECG Appearance 417
Treatment 418
Pulseless Electrical Activity 419
Description 419
Causes 420
Effects 420
ECG Appearance 420
Treatment 420
Chapter 16 AV Heart Blocks 440

Block of the Atrioventricular Node 442
1st-Degree Atrioventricular Heart Block 443
Description 443
Causes 444
Effects 444
ECG Appearance 444
Treatment 444
2nd-Degree Atrioventricular Heart Block, Type I 445
Description 445
Causes 446
Effects 446
ECG Appearance 446
Treatment 447
2nd-Degree Atrioventricular Heart Block, Type II 447
Description 447
Causes 447
Effects 448
ECG Appearance 448
Treatment 448
3rd-Degree Atrioventricular Heart Block 449
Description 449
Causes 449
xvi
Effects 450
ECG Appearance 450
Treatment 450
Atrioventricular Dissociation 451
Description 451
Causes 451
Effects 452
ECG Appearance 452
Treatment 452
Chapter 17 Pacemakers and Implanted Cardioverter-Defibrillators 470

Pacemakers and Implantable Defibrillators 472
Temporary Pacemakers 472
Epicardial Pacing 472
Transvenous Pacing 472
Permanent Pacemakers 472
Uses 473
Permanent Pacemaker Components 473
Generator 473
Lead Wire(s) 474
Function of Permanent Pacemakers 475
Pacing Modes 475
Output 475
Sensitivity 475
Refractory Period 476
Rate Adaptation 476
Coding System 476
Cardiac Resynchronization Therapy 477
Appearance of the Paced ECG 478
Unipolar vs. Bipolar Systems 479
Pacemaker Failure and Complications 479
Failure to Capture 479
Failure to Pace 480
Failure to Sense 481
Oversensing 482
Pacemaker-Mediated Tachycardia 482
Complications of Pacemakers 483
Implantable Cardioverter-Defibrillators 483
Pulse Generator 484
Electrode Wires 484
Recognition of Ventricular Dysrhythmias 484
xvii
Therapies Provided by the ICD 485
Provider Safety 486
Section 4: 12-Lead ECGs

Chapter 18 Overview of 12-Lead ECGs and Electrical Axis 498
The 12-Lead ECG 500
Views 500
Limb Leads 500
Leads I, II, and III 500
Leads aV R, aV L, and aVF 502
Precordial Leads 502
Leads V1, V2, V3 503
Leads V4, V5, V6 504
ECG Views of the Heart 505
Contiguous Leads 505
Analyzing the 12-Lead ECG 506
Electrical Axis and the ECG 508
Vectors 508
Mean Instantaneous Vector 509
Waveform Direction 509
Ventricular Depolarization and Mean QRS Axis 509
Determining the Electrical Axis 512
Hexaxial Reference System 512
Altered QRS Axis 518
Causes of Altered Electrical Axis 519
Chapter 19 Myocardial Ischemia, Injury, and Infarction 532

Coronary Circulation 534
Right Coronary Artery (RCA) 534
Left Coronary Artery (LCA) 536
The ECG Waveforms 538
Q Waves 538
Normal ST Segments 539
Normal T Waves 540
ECG Indicators of Ischemia, Injury, and Infarction 541
T Wave Changes 541
ST Segment Changes 544
STEMI and NSTEMI 548
xviii
Q Wave Changes 550
Left Bundle Branch Block 551
Reciprocal Changes 552
ECG Evolution during Myocardial Infarction 553
MI—Age Indeterminate 554
Criteria for Diagnosing Myocardial Infarction 555
Clinical History 555
Serum Cardiac Markers 556
ECG Findings 556
Identifying the Myocardial Infarction Location 556
Septal Wall Infarction 557
Anterior Wall Infarction 558
Lateral Wall Infarction 559
Anterolateral Wall Infarction 559
Extensive Anterior Wall Infarction 560
Inferior Infarction 561
Posterior Wall Infarction 561
Right Ventricular Infarction 562
Treatment of Myocardial Infarction 566
Right Ventricular Infarction Treatment 567
Chapter 20 Bundle Branch Block 580

Ventricular Conduction Disturbances 582
The Bundle Branches 582
Bundle Branch Block 582
ECG Leads Used to Identify Ventricular Conduction Disturbances 585
Right Bundle Branch Block 585
Left Bundle Branch Block 588
Incomplete Bundle Branch Block 590
Nonspecific Intraventricular Conduction Defect 590
Fascicular Block 591
Left Anterior Fascicular Block 591
Left Posterior Fascicular Block 592
Bifascicular and Trifascicular Blocks 593
Identifying MI and/or Hypertrophy in the Presence of Bundle Branch
Block 594
Treatments of Bundle Branch Block 595
Inherited Conditions That Mimic Right Bundle Branch Block 596
Brugada Syndrome 596
Arrhythmogenic Right Ventricular Dysplasia (AVRD) (ARVC) 597
xix
Chapter 21 Atrial Enlargement and Ventricular Hypertrophy 610
ECG Changes Used to Identify Enlargement and Hypertrophy 612
Atrial Enlargement 612
Right Atrial Enlargement 612
Left Atrial Enlargement 613
Ventricular Hypertrophy 615
Right Ventricular Hypertrophy 615
Left Ventricular Hypertrophy 617
ST Segment and T Wave Changes 619
Hypertrophic Cardiomyopathy 620
Chapter 22 Other Cardiac Conditions and the ECG 626

Pericarditis 628
ECG Changes 628
Pericardial Effusion 628
ECG Changes 630
Pulmonary Embolism 631
ECG Changes 632
Electrolyte Imbalance 632
Hyperkalemia 632
Hypokalemia 634
Calcium Disorders 635
Drug Effects and Toxicity 635
Digoxin 636
Other Medications 638
Section 5: Review and Assessment

Chapter 23 Putting It All Together 648
Using the Nine-Step Process and Deductive Analysis 650
Step 1: Heart Rate 650
Slow Rate 650
Normal Rate 651
Fast Rate 651
Step 2: Regularity 651
Regular Rhythms 651
Irregular Rhythms 652
xx
Step 3: P Waves 653
Normal P Waves 653
Abnormal P Waves 654
Step 4: QRS Complexes 655
Normal QRS Complexes 655
Abnormal QRS Complexes 656
Step 5: PR Intervals 656
Normal PR Intervals 656
Abnormal PR Intervals 657
Step 6: ST Segments 658
Normal ST Segments 658
Abnormal ST Segments 658
Step 7: T Waves 658
Normal T Waves 658
Abnormal T Waves 661
Step 8: QT Intervals 661
Normal QT Intervals 661
Abnormal QT Intervals 661
Step 9: U Waves 663
So Why Do It? 663
Practice Ruling Out Dysrhythmias and Conditions 664
Appendix A 696
Glossary 716
Index 723
xxi
Preface
This book presents information similar to how an instructor delivers it in the class-
room, with lots of illustrations, solid practical content, plentiful reinforcement of
material, questions to prompt critical thinking, case presentations, and plentiful
practice ECG tracings to promote the application of skills.
One of the first things readers will notice about this text is it is more of a “how-to
book” than a “theoretical book.” Although there is plenty of detail, the coverage is
to the point, telling you and then showing you what you need to know. The breadth
of information ranges from simple to complex, but regardless of how advanced
the material, the explanations and visuals make the concepts easy to understand.
Another aspect of this book is that it truly covers both dysrhythmia and 12-lead
analysis and interpretation. It reinforces those core concepts from the beginning
to the end using lots of repetition. This book includes plentiful pictures and figures
to help readers see what is being discussed in actual use. We have also included
coverage of the treatments used to manage the various dysrhythmias and cardiac
conditions to give readers a broader perspective and better prepare them for apply-
ing what they have learned.
Structure of This Book

This book is divided into five sections:
• Section 1, Preparatory, looks at the underlying concepts of the anatomy and
electrophysiology of the heart and the electrocardiogram itself.
• Section 2, The Nine-Step Process, comprises Chapters 3 through 9 and presents
the Nine-Step Process of ECG interpretation. Each chapter provides an in-depth
look at one of the steps and introduces the reader to the variances seen with that
step.
• Section 3, Origin and Clinical Aspects of Dysrhythmias, comprises Chapters
10 through 17 and leads readers through an overview of heart disease and a
thorough discussion regarding dysrhythmias. The section covers the origin of
dysrhythmias, including the sinus node, the atria, the atrioventricular junction,
the ventricles, atrioventricular heart blocks, and pacemakers. And it covers the
clinical aspects of each dysrhythmia.
• Section 4, 12-Lead ECGs, introduces the concept of 12-lead ECGs in Chapter 18.
Then Chapters 19 through 22 cover interpretation and recognition of myocardial
ischemia, injury and infarction, bundle branch block and atrial enlargement and
ventricular hypertrophy, and a host of other cardiac conditions and their effect
on the ECG.
• Section 5, Review and Assessment, wraps it all up with the chapter “Putting It All
Together” and more practice tracings.
xxii
Changes to the Book
Among the changes in this book is that we have retitled it to better reflect its com-
prehensive nature. While it is still easy to learn to interpret ECGs using this book,
its volume and breadth of coverage make it difficult to read from cover to cover in
a fast way. The third edition of Fast & Easy ECGs: A Self-Paced Learning Program
by Bruce Shade is thorough, innovative, and greatly enhanced. We have changed
the title to better reflect the comprehensive nature of this book. While we strive to
make our approach fast and easy, there are many complicated aspects of learning
how to analyze and interpret ECG tracings. For this reason, we cover the material
in sufficient depth to provide the reader with everything they need to know in order
to be proficient with this important skill.
Whereas the second edition had 22 chapters, this book is expanded and includes
23 chapters. The following chapter is brand new to this edition:
Chapter 10 provides an overview of heart disease, including what it is, the risks for
developing it, and its causes and complications. Then we review the common types
of heart disease. This chapter is designed to provide the reader with an understand-
ing of how dysrhythmias and cardiac conditions occur. This will make it easier for
the reader to understand the characteristics associated with each dysrhythmia and
cardiac condition.
In addition to the expanded content, this book has more than 300 figures and close
to 400 practice ECG tracings. It also introduces the reader to the treatment modal-
ities for the various dysrhythmias and medical conditions.
We hope this book is beneficial to both students and instructors. Greater under-
standing of ECG interpretation will lead to better patient care everywhere.
Instructor Resources
Instructors, are you looking for additional resources? Be sure to visit www.mhhe
.com/shade3e for answer keys, an Electronic Testbank, and accessible PowerPoint
Presentations. Access is for instructors only and requires a user name and pass-
word from your McGraw-Hill Learning Technology Representative. To find your
McGraw-Hill representative, go to www.mheducation.com and click “Contact,”
then “Contact a Sales Rep.”
Need help? Contact the McGraw-Hill Education Customer Experience Group

(CXG). Visit the CXG website at www.mhhe.com/support. Browse our freasked
questions (FAQs) and product documentation and/or contact a CXG representative.
xxiii
Features to Help You Study and Learn
Preview the Chapter Content

1 Anatomy and Electrophysiology
of the Heart
Study the Chapter Outline to get an
Chapter Outline overview of the subjects to be covered in
The Electrocardiogram
The Circulatory System
The Heart’s Conductive
Pathway
Physiology of the Heart
and Circulation
Nerve Impulse
Generation and the chapter.
The Heart’s Blood Influences on the Heart Muscle Contraction
Anatomy of the Heart
Supply and Circulatory System
Cells of the Heart
©McGraw-Hill Education/Rick Brady
Learning Outcomes
LO 1.1 Define the term electrocardiogram, list its uses, and describe how
it works.
LO 1.2 List the components of the circulatory system.
LO 1.3 Describe the anatomy of the heart.
LO 1.4 Identify and contrast the structure and function of the different types Learning Outcomes
of heart cells. LO 1.1 Define the term electrocardiogram, list its uses, and describe how
it works.
LO 1.5 Identify the structures of the heart’s conduction system and describe
what each does. LO 1.2 List the components of the circulatory system.
LO 1.3 Describe the anatomy of the heart.

LO 1.6 Identify how the heart receives most of its blood supply.
LO 1.4 Identify and contrast the structure and function of the different types
LO 1.7 Recall how the heart and circulatory system circulates blood throughout of heart cells.
Review the the Learning
body. Outcomes LO 1.5 Identify the structures of the heart’s conduction system and describe
to seeLOwhat
1.8 Describe the influence Note
you will learn. of the autonomic nervous system on the heart
what each does.
LO 1.6 Identify how the heart receives most of its blood supply.
that the Learning Outcomes
and circulatory system.
LO 1.7 Recall how the heart and circulatory system circulates blood throughout
numbers
LO 1.9are keyed
Recall to the
how nerve text
impulses are generated and muscles contract the body.
in the heart.
and learning assessments. LO 1.8 Describe the influence of the autonomic nervous system on the heart
and circulatory system.
LO 1.9 Recall how nerve impulses are generated and muscles contract
in the heart.
Case History
Emergency medical services responds to the home of a 65-year-old man complaining Case History
of a dull ache in his chest for the past two hours which came on while mowing his Read the Case History for a real-world
Emergency medical services responds to the home of a 65-year-old man complaining
lawn. He also complains of a “fluttering” in his chest and “shortness of breath.” He
scenario that features the type of
of a dull ache in his chest for the past two hours which came on while mowing his
lawn. He also complains of a “fluttering” in his chest and “shortness of breath.” He
has a history of hypertension, elevated cholesterol, and a one-pack-a-day smoking
habit. dysrhythmia covered in the chapter.
has a history of hypertension, elevated cholesterol, and a one-pack-a-day smoking
habit.
After introducing themselves, the paramedics begin their assessment, finding the After introducing themselves, the paramedics begin their assessment, finding the
patient’s blood pressure to be 160/110, pulse 120 and irregular, respirations 20, and patient’s blood pressure to be 160/110, pulse 120 and irregular, respirations 20, and
oxygen saturation 92% on room air. The patient is awake and alert, his airway is open,
oxygen saturation 92% on room air. The patient is awake and alert, his airway is open,
his breathing is slightly labored, and his pulses are strong.
his breathing is slightly labored, and his pulses are strong.
xxiv
Visualize the Content Chapter 14 Junctional Dysrhythmias 359
300 Full-Color Figures show you in detail

Inverted P’ wave may
precede the QRS
complex with a P ' R
interval shorter
than normal
where each dysrhythmia originates and P

T
P
P
T
P
T
teaches you step by step how to read the QRS QRS QRS QRS
Premature junctional complex (PJC) is a single early electrical impulse that
originates in the AV junction
ECGs that demonstrate each dysrhythmia.

360 Section 3 Origin and Clinical Aspects of Dysrhythmias 362 Section 3 Origin and Clinical Aspects of Dysrhythmias
Inverted P’ wave may precede each QRS complex
with P'R intervals shorter than normal
in the ventricular muscle. This results in the QRS complexes usually being within nor- PJCs intermingled between normal beats are named depending on how frequent
In addition, algorithms and tables present

mal limits of 0.06 to 0.10 seconds. However, in any dysrhythmia where the QRS com- they occur. When every other beat is a PJC, it is called bigeminal PJCs, or junctional
plexes should be normal, they can instead be wide or unusual looking if there P
is
T bigeminy. If every third beat is a PJC, it is called trigeminal PJCs, or junctional
intraventricular conduction disturbance, aberrancy, or ventricular preexcitation. trigeminy. Likewise, if a PJC occurs every fourth beat, it is called quadrigeminal
QRS PJCs, or junctional quadrigeminy. Regular PJCs at greater intervals than every fourth
content visually to help you memorize the Effects

If the atria are depolarized at the same time or after the ventricles, the atria are
Junctional escape rhythm arises from a single site in AV
beat have no special name. Remember, bi = 2, tri = 3, and quad = 4.
junction at a rate of between 40 and 60 beats per minute
P’ wave may be buried

Treatment
most important elements of each type of
forced to pump against the contracting ventricles, which contract with muchingreater
the QRS complex
force. This can result in a loss in atrial kick, decreased stroke volume, and, ulti- PJCs generally do not require treatment. PJCs caused by the use of caffeine,
mately, decreased cardiac output. Decreased cardiac output can also Toccur with tobacco, or alcohol, or with anxiety, fatigue, or fever can be controlled by eliminat-
P
slow or fast junctional dysrhythmias. ing the underlying cause.
dysrhythmia and condition. As a reminder, dysrhythmias arising from the SA node, atria, or AV junction
QRS
can bejunctional rhythm arises from a single site in the
Accelerated
AV junction at a rate of between 60 and 100 beats per minute
collectively called supraventricular dysrhythmias.
P’ wave may follow
14.4 Junctional Escape Rhythm
each QRS complex
Description
14.3 Premature Junctional Complex
P Junctional escape rhythm is slow, steady rhythm (40 to 60 beats per minute) with
Description QRS
narrow QRS complexes, inverted or absent P9 waves, and shorter than normal P9R
intervals (when the P9 wave precedes the QRS complex). It typically occurs when
A PJC is a single early electrical impulse that originates Junctional
in the tachycardia arises from a single site in the AV
AV junction
junction at a rate of between 100 and 180 beats per minute the rate of the primary pacemaker (SA node) falls below that of the AV junctional
(Figure 14-2). It occurs before the next expected sinus impulse, interrupting the tissue (Figure 14-3). Remember, if the SA node fails to fire or slows down, the AV
regularity of the underlying rhythm. Because theFigure 14-1arises from the middle of
impulse junction (or ventricles) in their role as backup pacemakers, should initiate the heart-
Junctional dysrhythmias originate from the AV junction.
the heart, the atria are depolarized in a retrograde fashion. This causes the P9 wave
PR Interval Junctional escape rhythm arises from a single site in the AV junction.
PR
Premature junctional complex arises from somewhere in the AVintervals
junction. seen with premature junctional complexes or junctional rhythms are
shorter than normal (less than 0.12 seconds in duration) or absent if the P wave is
buried in the QRS complex. If the P’ wave follows the QRS complex, it is referred
to as the RP’ interval and is usually less than 0.20 seconds.
QRS Complex Appearance

In junctional rhythms, whereas the atria are depolarized in an abnormal way, the ven-
tricles depolarize normally. Electrical impulses travel in a normal pathway from the AV
junction through the bundle of His and bundle branches to the Purkinje fibers, ending
Rate P’ waves QRS complexes

between 40 and Rhythm of normal duration
inverted; may appear before, during, or after
60 BPM regular QRS complex, may be hidden in QRS and all look alike*
Rate Rhythm P’ waves QRS complexes
depends on irregular due to PJC is inverted; may appear before, during or after of normal duration
underlying rhythm premature beat QRS complex, may be hidden in QRS complex and all look alike* P’R intervals ST segments T waves QT intervals U waves
If present will be shorter normal and normal shape within normal limits of may or may
than normal isoelectric and upright 0.36 to 0.44 second not be present
ST segments T waves QT intervals U waves
P'R intervals
normal and normal shape within normal limits of may or may
shortened if seen
isoelectric and upright 0.36 to 0.44 second not be present
Junctional escape rhythm Accelerated junctional rhythm Junctional tachycardia
40 to 60 beats per minute 60 to 100 beats per minute 100 to 180 beats per minute
*unless aberrantly conducted in which case they may be wider than normal and bizarre-looking
*unless aberrantly conducted in which case they may be wider than normal and bizarre-looking
Figure 14-2
Premature junctional complex. Figure 14-3
Junctional escape rhythm.
Review the Content

Practice Makes Perfect
Practice Makes Perfect strips at the end
of chapters and sections give you over 400 For each of the tracings on the following pages, practice the Nine-Step Process for analyz-
ing ECGs. To achieve the greatest learning, you should practice assessing and interpretating
the ECGs immediately after reading Chapter 23. Below are questions you should consider
opportunities to interpret ECG strips using your

as you assess each tracing. Your answers can be written into the area below each ECG
marked “ECG Findings.” Your findings can be compared to the answers provided in Appen-
dix A. All dysrhythmia tracings are 6 seconds in length.
new knowledge. 1. Determine the heart rate. Is it slow? Normal? Fast? What is the ventricular rate? What
is the atrial rate?
2. Determine if the rhythm is regular or irregular. If it is irregular, what type of
irregularity is it? Occasional or frequent? Slight? Sudden acceleration or slowing in
heart rate? Total? Patterned? Does it have a variable conduction ratio?
3. Determine if P waves are present. If so, how do they appear? Do they have normal
height and duration? Are they tall? Notched? Wide? Biphasic? Of differing
morphology? Inverted? One for each QRS complex? More than one preceding some
or all the QRS complexes? Do they have a sawtooth appearance? An indiscernible
chaotic baseline?
Key Points 4. Determine if QRS complexes are present. If so, how do they appear? Narrow with
proper amplitude? Tall? Low amplitude? Delta wave? Notched? Wide? Bizarre-
looking? With chaotic waveforms?
LO 1.1 • The electrocardiogram is a graphic representation of the heart’s electrical activity. 5. Determine the presence of PR intervals. If present, how do they appear? Constant? Of
It is used to identify irregularities in the heart rhythm and to reveal the presence of normal duration? Shortened? Lengthened? Progressively longer? Varying?
injury, death, or other physical changes in the heart muscle. 6. Evaluate the ST segments. Do they have normal duration and position? Are they
• The electrocardiograph detects the electrical activity occurring in the heart through elevated? (If so, are they flat, concave, convex, arched?) Depressed? (If so, are they
electrodes attached to the patient’s skin. normal, flat, downsloping, or upsloping?)
7. Determine if T waves are present. If so, how do they appear? Of normal height and
• When an impulse occurring in the heart moves toward a positive electrode of the
duration? Tall? Wide? Notched? Inverted?
ECG, it produces a positive waveform. When it moves away from the positive
electrode (or toward a negative electrode), it produces a negative waveform. 8. Determine the presence of QT intervals. If present, what is their duration? Normal?
Shortened? Prolonged?
LO 1.2 • The heart, blood, and blood vessels are the chief components of the circulatory system. 9. Determine if U waves are present. If present, how do they appear? Of normal height
• The circulatory system circulates enough blood to deliver needed oxygen and and duration? Inverted?
nutrients to the tissues and to remove waste products. 10. Identify the rhythm, dysrhythmia, or condition.
LO 1.3 • The heart is the pump; each time it contracts, it pushes blood throughout the body. 1.
• The heart is located between the lungs in the mediastinum behind the sternum, and it
rests on the diaphragm with a front-to-back (anterior-posterior) orientation.
• It is surrounded by a double-walled closed sac called the pericardium. The pericardium
allows the heart to contract and expand within the chest cavity with minimal friction.
• The heart wall consists of three layers: the myocardium, endocardium, and epicardium.
• The heart consists of two upper chambers, the atria, and two lower chambers, the
ventricles.
ECG Findings:
• A muscular wall, the septum, separates the right side from the left side of the heart.
• The right side of the heart receives blood from the systemic venous circulation and
pumps it into the pulmonary circulation.
Key Points cover all of the

• The left side of the heart receives blood from the pulmonary circulation and pumps it Practice Makes Perfect 677
into the systemic circulation.
• The skeleton of the heart provides firm support for the AV and semilunar valves and
acts to separate and insulate the atria from the ventricles.
• The four heart valves permit blood to flow through the heart in only one direction.
pertinent content in the chapter.
LO 1.4 • There are two basic types of cells in the heart: the myocardial cells (also referred to
as the working cells), which contract to propel blood out of the heart’s chambers,
and the specialized cells of the electrical conduction system, which initiate and carry
impulses throughout the heart.
• The structure of the myocardial cells permits the rapid conduction of electrical
impulses from one cell to another. This results in the cardiac muscle cells acting as a
single unit, permitting coordinated contraction of a whole group of cells.
LO 1.5 • Depolarization of the myocardium progresses from the atria to the ventricles in an
orderly fashion. The electrical stimulus causes the heart muscle to contract.
• The wave of depolarization is carried throughout the heart via the heart’s conduction
system. The conduction system is a grouping of specialized tissues that form a
network of connections, much like an electrical circuit.
• The key structures of the conduction system are the SA node, intraatrial conductive
pathway, internodal pathways, AV node, bundle of His, right and left bundle
branches, and Purkinje fibers.
Chapter 1 Anatomy and Electrophysiology of the Heart 37
xxv
• Five of the small boxes represent 0.20 seconds in duration and make up the larger
boxes denoted by a heavier line. Fifteen larger boxes equal a three-second interval.
You can use the horizontal measurements to determine the heart rate.
• Vertically on the ECG paper, the distance between the lines, or boxes, represents
amplitude in mm or electrical voltage in mV. Each small square represents 1 mm or
0.1 mV while the larger boxes, made up of five small squares, represent 5 mm or
0.5 mV.
• The flat line that precedes the electrical impulses is called the isoelectric line.
Assess Your Understanding

The following questions give you a chance to assess your understanding of the
material discussed in this chapter. The answers can be found in Appendix A.
1. An electrocardiogram is a/an (LO 2.1)
a. graphic record of the heart’s electrical activity.
b. device that measures and records the ECG.
c. irregular rhythm.
d. device that measures the heart’s mechanical activity.
Assess Your Understanding quizzes, with 2. The electrocardiograph can be used to do all the following
EXCEPT (LO 2.1)
answers in Appendix A, help you recall

a. detect cardiac dysrhythmias.
b. determine cardiac output.
c. identify the presence of myocardial ischemia and/or infarction.
the material and test your knowledge. 3.

d. evaluate the function of artificial implanted pacemakers.
positioned on the patient’s skin detect the heart’s
electrical activity. (LO 2.2)
a. Electrodes
b. Lead wires
c. Tracings
d. Leads
4. Describe the three phases of ventricular depolarization. (LO 2.3)
5. Impulses that travel toward a positive electrode and away from a negative elec-
trode are recorded on the electrocardiogram as deflections.
(LO 2.4)
a. downward
b. perpendicular
c. neutral
d. upward
Chapter 2 The Electrocardiogram 81
First, I would like to thank Claire Merrick, the editor on the first edition of this
textbook. It was her vision for the project that led to the original signing and
publishing of Fast & Easy ECGs. Next, I would like to thank Melinda Bilecki, the
Freelance Product Developer for this edition. Melinda maintained a steady hand
to get the chapters rewritten and figures redone despite my many delays. Even with
these obstacles, she displayed incredible patience and helped guide completion of
the book. Further, her hard work and attention to detail helped ensure the accuracy
of the content.
Many thanks go to, Michelle Flomenhoft, the Senior Product Developer, and
William Lawrensen, the Executive Portfolio Manager with the Health Professions
team at McGraw-Hill. They allowed me to significantly restructure the order of
chapters, add more content and practice ECG tracings, and increase the footprint of
the textbook. These features make a good book even better. They also convinced me
of the need to rename the book to better reflect its comprehensive nature. As hard
as it was for me to give up the former title, I recognize the importance of doing so.
Bruce Shade
xxvi
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“Oh, I could not choose but go
Into the woodlands hoar.
“Into the blithe and breathing air,

Into the solemn wood,
Solemn and silent everywhere!
Nature with folded arms seem’d there,
Kneeling at her evening prayer!
Like one in prayer I stood.
“Before me rose an avenue

Of tall and sombrous pines;
Abroad their fanlike branches grew,
And where the sunshine darted through,
Spread a vapour soft and blue.
In long and sloping lines.
“And falling on my weary brain,

Like a fast falling shower,
The dreams of youth came back again;
Low lispings of the summer rain,
Dropping on the ripen’d grain,
As once upon the flower.”
He told her of his happy progress, from that first dawning of hope to the full
joy of steadfast faith. He ran over the history of the past year, in which from
day to day he had looked forward to this meeting; and he told with what joy
he had slowly added coin to coin, until he had saved a sufficient sum to
carry him home. Then, when he had finished, the sister and brother mingled
their thanksgivings and happiness together, and Christian’s heart swelled
full and overbrimming: she could have seated herself upon the floor, like
Ailie, and poured out her joy as artlessly. But it is Halbert’s turn now to ask
questions. When will little Mary be home? how long she stays. Halbert
wearies to see his little sister, but he is bidden remember that she is not little
now, and Christian sighs, and the dark cloud, that she fears is hanging over
Mary’s fate, throws somewhat of its premonitory gloom upon her heart and
face. Halbert, unnoticing this, is going about the room, almost like a boy,
looking lovingly at its well-remembered corners, and at the chairs and
tables, at the books, and last his eye falls on a card lying in a little basket,
and he starts as if he had encountered a serpent, and his eye flashes as he
suddenly cries out, almost sternly, as he lifts it and reads the name.
“Christian, what is this—what means this? Mr. Walter Forsyth a visitor
of yours; it cannot be. Tell me, Christian, what does it mean?”
“It is Mr. Forsyth’s card,” said Christian gravely; “an acquaintance, I am
afraid I must say a friend of ours. Indeed, Halbert, now that you are home
with us again, this is my only grief. I fear we shall have to give our little
Mary into his keeping, and he is not worthy of her.”
Halbert is calmed by his long trial, but his natural impetuosity is not
entirely overcome, and he starts up in sudden excitement and disorder.
“Walter Forsyth the husband of my sister Mary! Walter Forsyth, the infidel,
the profligate; better, Christian, better a thousand times, that we should lay
her head in the grave, great trial as that would be, and much agony as it
would cause us all, than permit her to unite herself with such a reptile.”
“Halbert,” said Christian, “the name misleads you; this cannot be the
man—the Forsyth who wrought you so much unhappiness and harm, and
has caused us all such great grief and sorrow; he must be much older, and
altogether a different person. This one is not even a scoffer, at least so far as
I have seen.”
“Christian,” cried Halbert vehemently, “I feel assured it is the same. Do
not tell me what he pretends to be, if he has any end to serve he can be
anything, and put on the seeming of an angel of light even. I tell you,
Christian, that I am sure, quite sure, that it is he. I met him as I came here,
and I shuddered as I saw him, and even felt myself shrinking back lest his
clothes should touch me; but little did I suspect that he was about to bring
more grief upon us. Does Mary, do you think, care for him?”
Christian could not but tell him her fears; but she said also that Mary had
always avoided speaking to her on the subject. What could they do? What
should be done to save Mary? Halbert, in his impatience, would have gone
to seek her out at once, and have pointed out to her the character of her
lover; but Christian only mournfully shook her head, such a plan was most
likely to do harm and not good.
“You must be calm, Halbert,” she said, “this impetuosity will be
injurious—we must save Mary by gentler means, she is far too like yourself
to be told in this outspoken manner—the shock would kill her.”
But old Ailie is stealing the door of the room open timidly, to break in on
the first hour of Christian’s joy, and when she entered she did it with a look
of sober cheerfulness, widely different from her late joyful frenzy.
“Miss Mary came in a while since,” she said, “and ran straight up to her
own room, without speaking, or waiting till I telled her of Mr. Halbert’s
home coming, and she looked pale and ill like; would you not go up, Miss
Christian, and see?”
The Melvilles are Ailie’s own children, and she has a mother’s care of
them in all their troubles, bodily or mental. So at her bidding Christian rose
and went softly to Mary’s room: the door was closed, but she opened it
gently, and standing hidden by the curtains of Mary’s bed, was witness to
the wild burst of passionate sorrow and disappointed affection in which
Mary’s breaking heart gushed forth, when she found herself once more
alone. Herself unseen, Christian saw the scalding tears welling out from her
gentle sister’s dim and swollen eyes, she saw the convulsive motions of her
lithe and graceful figure, as she rocked herself to and fro, as if to ease or
still the burning grief within: and she heard her broken murmurs.
“Had he but died before I knew this, I would have mourned for him all
my life, even as Christian mourns, but now—but now!—such as he is”—
and her burst of sobbing checked the voice of her sorrow. A moment after
she started up and dashed the tears from her eyes, with some vehemence.
“Should I not rather thank God that I have been saved from uniting myself
with a godless man—with my poor brother’s seducer?” and she sank on her
knees by the bedside. Poor Mary’s grief was too great for silent
supplications, and Christian stood entranced, as that prayer, broken by many
a gush of weeping, rose through the stillness of the quiet room. She had
never, she thought, heard such eloquence before of supplicating sorrow, had
never seen the omnipotence of truth and faith till then; gradually they
seemed to subdue and overcome the wildness of that first grief, gradually
attuned that sweet young sobbing, struggling voice, to sweetest resignation,
and ere Christian echoed the solemn “Amen,” Mary had given thanks for
her deliverance, though still natural tears, not to be repressed, broke in on
her thanksgiving, and silent weeping followed her ended prayer. But when
she bent her head upon her hands again, Christian’s kind arm was around
her, Christian’s tears were mingled with her own, Christian’s lips were
pressed to her wet cheek in tender sympathy, and the voice of Christian, like
a comforter, whispered,
“I know all, Mary, I know all; may God strengthen you, my dear sister—
you have done nobly, and as you should have done; may God bless you,
dearest Mary.”
And Mary’s head, as in her old childish sorrows, nestles on Christian’s
bosom, and Mary’s heart is relieved of half its heavy and bitter load. Poor
Mary! the days of childhood have indeed come back again, and, as the
violence of the struggle wears away, she weeps herself to sleep, for sorrow
has worn out the strength of her delicate frame, already exhausted by the
varied and contending emotions of the day, and now the tears slide slowly
from beneath her closed eyelids even in her sleep.
But Halbert is at the door anxiously begging for admittance, and
Christian leads him in to look at little Mary’s sleep. It was a child’s face, the
last time he looked upon it, a happy girlish face, where mirth and quick
intelligence rivalled each other in bringing out its expressive power; he sees
it now, a woman’s, worn with the first and sorest struggle that its loving
nature could sustain, and a kind of reverence mingled with his warm
affection as he bent over his sleeping sister; he had yielded to temptations,
oh, how much weaker, since his heart was not enlisted on the tempter’s
side; he had made shipwreck of his faith and of his peace, for years,
fascinated by attractions a thousand times less potent than those which this
girl, her slight figure still trembling with her late emotions, still weeping in
her sleep, had withstood and overcome; and Halbert bent his head, humility
mingling with his rejoicing. Had he only been as steadfast as Mary, how
much sorrow and suffering would they all have been saved.
They have left the room awhile with quiet footsteps, and there is much
gladness in those two hearts, though trembling still mingles with their joy;
for, if Christian fears the effect of this terrible shock on Mary’s health, at
least she is delivered; there is great happiness in that certainty, she has
found out Forsyth’s true character, though it passes all their guessing and
conjectures to tell how.
And now Halbert is asking about his father, and James and Robert, and
expressing his fears as to how they will receive him, the truant son. His
brothers will be rejoiced; but Christian shakes her head half doubtful, half
smiling, when Halbert, “and my father”—she cannot say, but an hour or two
more will bring that to the proof.
“Do you know, Christian, I feel myself like one of the broken men of the
old ballads, and I am in doubt, in perplexity, and fear, about this meeting.”
“If you are broken, if your ship has been cast ashore, we will get it
mended again,” said Christian, with more of humour and lightheartedness
than she had either felt or used for many a day. “But no more of that,
Halbert, just now. Tell me, will you go to see James to-night?”
“No, I can’t; it would be unseemly besides.”
Halbert will not leave his sister the first night of his return, and Christian
feels relieved; after a pause, he continues:
“How do you like Elizabeth now, Christian; are James and she happy
together?”
“I have no doubt they are,” said Christian, evasively; “why should they
not be?”
“But you don’t like her.”
“I never said so, Halbert.”
“Well, that’s true enough; but I inferred it.”
“Nay, you must make no inferences. Elizabeth can be very pleasant and
lovable; if she is not always so, it is but because she does not choose to
exercise her powers of pleasing.”
“So she can be lovable when she likes. But it was she, was it not, that
introduced Mary to Forsyth?” said Halbert, his brow darkening.
“You must forgive her that, Halbert; she was not aware of his character
when she received him as her cousin’s friend,” and Christian looked
distressed and uneasy, and continued; “and Halbert, you must not cherish a
vindictive feeling even against Forsyth, bad as he is, and great as is the
mischief he did you; promise me that, Halbert, promise me, now.”
“Well, I do promise you; I could not, if I would; and I now pity him
much more than hate him.”
They sat together conversing, till the shadows began to lengthen, when
Christian, compelled by domestic cares and preparations for the evening,
left her new found brother for a time.
CHAPTER IV.
Bear a lily in thy hand;

Gates of brass cannot withstand
One touch of that magic wand.
Bear through sorrow, wrong and ruth,

In thy heart the dew of youth,
On thy lips the smile of truth.—Longfellow.
HE day wore away, and now the evening darkened fast, and old
Ailie’s beaming face, illuminated by the lights she carries,
interrupts brother and sister, again seated in the cheerful fire-light,
which, ere the candles are set upon the table, has filled the room
with such a pleasant flickering half-gloom, half-radiance. And there, too, is
Mr. Melville’s knock, which never varies, at the door. Halbert knows it as
well as Christian, and grows pale and involuntarily glides into a corner—as
he had done of old when he had transgressed—but Christian has met her
father at the door, and whispered that there is a stranger newly arrived in the
room. It fortunately so happens to-night that Mr. Melville has come home
more complacent and willing to be pleased than he has done for many a
day. Some speculation suggested by James, and agreed to with sundry
prudent demurring by the heads of the house, has turned out most
successfully, and Mr. Melville has taken the credit of James’s foresight and
energy all to himself, and is marvellously pleased therewith. “A stranger,
aye, Christian, and who is this stranger?” he says most graciously, as he
divests himself of his outer wrappings; but Christian has no voice to answer
just then, and so he pushes open the half-shut door, and looks curiously
about the room; his son stands before him, his eyes cast down, his cheeks
flushed, his heart beating.
“Halbert!”
The human part of Mr. Melville’s nature melts for the moment, the
surprise is pleasurable; but he soon grows stern again.
“Where have you been, sir? what have you been doing? and why have
you never written to your sister?”
Halbert’s trial has taught him meekness, and his answers are in words
which turn away wrath, and his father turns round to seek his easy-chair on
the most sheltered and cosiest side of the glowing fire.
“Humph!” he says; “well, since you are home, I suppose it’s no use
making any more enquiries now, but what do you intend to do?”
Halbert looks astonished; it is a question he is not prepared to answer; he
feels that he ought not and cannot ask his father to enable him to carry out
the plan he has been dreaming of for the past twelve months, and he is
silent.
“There is plenty of time for answering that, father,” said Christian
briskly; “we can consult about that afterwards, when we have all recovered
ourselves a little from this surprise which Halbert has given us; and here
comes Robert.”
Robert came merrily into the room as Christian spoke, and not alone, he
had a companion with him whom he brought forward to introduce to
Christian, when his eye caught his brother. What! are we going to have old
Ailie’s extravagances over again. Poor Robert’s laugh is hysterical as he
tumbles over half a dozen chairs, and lays hold of Halbert, and his shout
electrifies the whole household, wakening poor sleeping Mary in her lonely
chamber. “Halbert! Halbert”—Robert is a fine fellow for all his
thoughtlessness, and is almost weeping over his recovered brother, and
Halbert’s newly acquired composure has forsaken him again, and he sobs
and grasps Robert’s hands, and thanks God in his heart. This is truly a
prodigal’s welcome, which Halbert feels he deserves not.
Robert’s companion hangs back bashfully, unwilling to break in upon,
lest he mar this scene of heartfelt family joy, which a good brother like
himself fully appreciates; but Christian’s kind and watchful eye is upon
him, and has marked him, and she comes forward to relieve him from the
awkward position in which he is placed, Marked him! yes, but what a
startled agitated look it is with which she regards him, and seems to peruse
every lineament of his countenance with eager earnestness. What can it be
that comes thus in the way of Christian’s considerate courtesy, and makes
her retire again and gaze and wonder? What a resemblance! and Christian’s
heart beats quick. But Robert has at length recollected himself, and now
brings the young man forward and introduces him as his friend Charles
Hamilton. Christian returns his greeting, but starts again and exchanges a
hurried glance with Halbert, who also looks wonderingly on the stranger.
Christian soon leaves the room, she has Mary to seek after, and attend to;
but as she passes Halbert’s chair, she bends over it and whispers in his ear,
and her voice trembles the while,—
“Is not the resemblance most striking—and the name?”
“It is most extraordinary,” answered Halbert aloud, gazing again on the
mild ingenuous face of the stranger. Christian glided away.
“What is most extraordinary, Halbert?” asked Robert, with a slight
impatience in his tone.
“Oh, nothing; at least only Mr. Hamilton’s great resemblance to an old
friend of ours long since dead.”
The young man looked towards him and smiled. Can that picture still be
hanging in its old place in Christian’s room?
Our poor Mary has slept long and calmly, and when Robert’s shout
awoke her, she started up in astonishment. She was lying in the dark room
alone, with silence round about her, and her pillow was wet with tears.
Mary raised herself in her bed, and throwing back the disordered hair which
hung about her face tried to collect her bewildered thoughts. The memory
of her grief has left her for the moment, and she is wondering what the
sound could be that came indistinctly to her ears; it sounded, she fancied,
very like “Halbert.” Who could be speaking of him, and as she repeats his
name the full knowledge of what has passed, all the momentous events and
misery of this day come upon her like a dream. Poor Mary! a heavy sigh
breaks from her parted lips, and she presses her hand over her painful eyes.
She does not see the approaching light which steals into the little room; she
does not hear the light footstep of its gentle bearer, but she feels the kind
pressure of Christian’s arm, and most readily and thankfully rests her head
on Christian’s supporting shoulder.
“I have news to tell you,” whispers Christian, “which you will be glad of
and smile at, though you are sighing now. You remember Halbert, Mary?”
Remember him! but Mary’s only answer is a sigh. Halbert’s name has
terrible associations for her to-night; she has remembered him and his
fortunes so well and clearly this day.
“Mary, Halbert has come home, will you rouse yourself to see him?”
“Come home, Halbert come home!” and the poor girl lifted up her head.
“Forgive me, Christian, forgive me, but I have done very wrong, and I am
very, very unhappy;” and the tears flowed on Christian’s neck again more
freely than before.
“You have done nobly, dear Mary—only rouse yourself, shake off this
grief; you have done well, and God will give you strength. Let me bathe
your temples—you will soon be better now,” said Christian, parting the
long dishevelled hair, and wiping away the still streaming tears. “That man
is not worthy one tear from you, Mary: be thankful rather, dearest, for your
deliverance from his cunning and his wiles.”
A deep blush flitted over Mary’s tear-stained face, as she raised herself
and began with Christian’s tender assistance to remove the traces of her
grief. Christian wondered as she saw her begin to move about the little
room again; there was a still composure gathering about her gentle features,
which the elder sister, accustomed to think of Mary as still little more than a
child, could only marvel at in silence. Her eyes were almost stern in their
calmness, and her voice was firmer than Christian could have believed
possible as she turned to speak.
“Yes, Christian, I am thankful—thankful beyond anything I can say; but
do not ask me about anything just now,” she continued, hurriedly, as
Christian looked up to her as if about to speak. “I will tell you all
afterwards, but not to-night—not to-night, dear Christian.”
“Would you not like to see Halbert, Mary?” said Christian, taking the
cold hands of her sister in her own. “Do you care or wish to see Halbert
now, Mary?”
“Yes, yes,” was the answer, and Mary’s eye assumed a kinder and more
natural glow. “I forgot, tell him to come here Christian, I would rather see
him, I cannot meet him down stairs.”
Halbert was speedily summoned, and when his step paused at the door,
Mary ran forward to meet him with pleasure in her eyes. True, Halbert’s
tone of affectionate sympathy brought the remembrance of that scene of the
morning, and with it the tears to Mary’s eyes; but Christian rejoiced to see
how gently they fell, and hoped that the sorest and bitterest part of the
struggle was past; and so it was, for Mary went down with untrembling step
and entered the room where her father, brother, and the stranger sat with a
sweet and settled calmness, which allayed all Christian’s fears.
It seemed now that however strange the stranger was to Christian, he
was no stranger to Mary Melville. Mr. Charles Hamilton was in truth well
known to Mary—yea, that Robert looked arch and intelligent, and his
young friend blushed as he rose to greet her on her entrance. This
acquaintanceship was soon explained, Mary had met him several times at
Mrs. James’s parties, and the casual mention which Robert and Mary had
made of him among the host of Elizabeth’s visitors had not been sufficiently
marked to attract the attention of Christian, engrossed as she was then with
such great anxiety regarding poor Mary’s unfortunate attachment.
Charles Hamilton’s qualities of head and heart were much too large for
Mrs. James Melville, and, accordingly, though she received him as a guest,
and was even glad to do so, from his social position and prospects—she
regarded him with much the same feeling which prompted her attacks on
Christian, and having noticed what poor Mary was too much occupied to
notice, the bashful attention with which the young man hovered about her
fair sister-in-law, Mrs. James had decided upon entirely crushing his hopes
by exhibiting to him this evening, at her party, the crowning triumph of her
friend Forsyth. Poor Mrs. James! how completely she had over-reached and
outwitted herself. That evening found her accomplished friend the rejected
—rejected with scorn and loathing, too—of simple Mary Melville, in no
humour for contributing to the amusement of her guests, and Charles
Hamilton in a far fairer way of success than even he himself had ever
dreamt of, for Christian’s eyes are bent on him from time to time, and there
is wonder blended with kindness in her frequent glances on his face, and
her pleasant voice has an unconscious tone of affection in it as she speaks to
him, as though she were addressing a younger brother. But the time has
come when they must prepare for Mrs. James’s party; Christian will not go,
Mary will not go, how could she? Halbert will not go, and the young
stranger’s face grows suddenly clouded, and he moves uneasily on his chair,
and at last rises reluctantly. Mr. Melville and Robert must go for a time at
least, to excuse the others that remain at home, and tell James of Halbert’s
return, and Charles Hamilton in vain hunts through every recess of his
inventive powers to find some reason that will excuse him for sitting down
again. But all fail, he can find nothing to offer as an excuse; he is intruding
on the family this night, sacred as it is—the evening of the wanderer’s
return—and when he may suppose they all so much desire to be alone; and
so he must take his leave, however loth and reluctant so to do. But while so
perplexed and disappointed Christian takes him aside, Christian bids him sit
down and speak to her a moment when Robert and his father have gone
away, and he does so gladly. Mary wonders what Christian can have to say
to him, a stranger to her till the last hour, and looks over, with interest every
moment increasing, towards the corner where they are seated side by side,
and so does Halbert too; but there is no astonishment in his face, though
there is compassionate affection beaming from his eyes. Their conversation
seems to be most interesting to both, and the look of sad recollection on
Christian’s gentle face seems to have been communicated to the more
animated features of her companion, and at length he suddenly starts and
clasps her hand.
“Christian Melville!” he exclaims, “Oh that my mother were here!”
The tears stand in Christian’s eyes—some chord of old recollection has
been touched more powerfully than usual, and Christian’s cheeks are wet,
and her eyes cast down for a moment. Mary can only gaze in astonishment,
and before she recovers herself Christian has led the young man forward to
them, and then she hurries from the room, while Halbert extends his hand to
him cordially. What is the meaning of this? both the young men join in
explanations, but Charles Hamilton’s voice is broken, half with the
recollection of his dead brother, and half with the pleasure of discovering
such a tie already existing with Mary’s family. Yes, Charles’s brother was
the original of that saint-like portrait which hangs within reach of the
glories of sunset on the wall of Christian’s room. The grave where Christian
had buried her youthful hopes was the grave of William Hamilton, and that
one name made the young man kindred to them all; and when Christian
after a time came down stairs again, she found him seated between Halbert
and Mary as though he had been familiar with that fireside circle all his
days, and was indeed a brother.
It was a happy night that to the group in this bright room, a night of great
cheerfulness and pleasant communion, just heightened by the saddening
tinge which memory gave it, and Mary, our sweet Mary, marvels at herself,
and is half disappointed that there is so little of romance in the fading of her
sorrow; but marvel as she likes, the unwitting smile plays on her lips again,
and you could scarce believe that those clear eyes have shed so many tears
to-day. She feels easier and happier even, now the weight of concealment,
which disturbed and distressed her in Christian’s presence of late, is
removed from the spirit; and she is the same open, single-minded,
ingenuous girl as heretofore; the secret consciousness that it was not right to
yield to Forsyth’s fascinating powers is gone now, and Mary Melville is
herself once more, aye, more herself than she has been for months past,
notwithstanding the bitter suffering of that very day. God has graciously
tempered the fierceness of his wind to the tender and trembling lamb, and
Christian’s confidence is restored, and she feels sure that time will make
Mary’s heart as light as ever, and efface from her memory the image of that
evil man, and blot out the traces of this day’s agony; and a smile flits over
Christian’s cheerful face as she fancies the substitution of another image in
the precious entablature of Mary’s heart. Who can tell but Charles Hamilton
may gain a right to the name of brother, which she already hesitates not to
accord, better than his present claim, precious to her mind as it is.
Mrs. James Melville’s party is sadly shorn of its lustre this year, when
we compare it with its last predecessor, only a short twelvemonth since; and
already, in spite of all the attractions of gossip, music, and flirtation, her
guests are beginning to yawn and look weary. Mrs. James was never so
annoyed in her life, all seems this night to have gone wrong. Her very
husband had deserted her—she had seen him fly down stairs three steps at a
time, and skim away through the cold street towards his father’s house.
Mrs. James was enraged to be left alone at such a time for any Halbert of
them all.
“A nice fuss was made about him, as much nonsense when he went
away as if there wasn’t another in the whole country, and now when he
thought fit and had come home——”
Mrs. James could not finish the sentence, for spite and vexation
overmastered her. Forsyth was not there, her chief attraction; Mary was not
there, and even Christian’s absence, little as she liked her, was another
source of annoyance; and this flying off of James was the finishing stroke.
We hardly think, however, that even Mrs. James would not have melted had
she seen her husband in the middle of yon cheerful group, with his beaming
joyous face, shaking Halbert’s hands over and over again, to the imminent
danger of bone and joint. We really think she could not but have helped
him.
There was a voice of thanksgiving in Mr. Melville’s house that night, of
thanksgiving which told in its earnest acknowledgment of many mercies;
thanksgiving whose voice was broken by the sobbings of one and
accompanied by the happy tears of all, for Halbert led their devotions, and
when his earnest tones rose up among them there was not a dry cheek in the
kneeling family, not James, though it might be thought his heart was
alienated from the overflowing affection of home, by the remembrance of
his own; not Charles Hamilton, permitted, nay requested, to stay, for who so
well as Halbert could give thanks for that double deliverance.
There are dreams to-night hovering with drowsy wing about the
dwelling, dreams which alight on Charles Hamilton’s young head as he
hastens home, his heart full of the last scene of the evening, and his voice
repeating—
“In dwellings of the righteous

Is heard the melody
Of joy and health: the Lord’s right hand
Doth ever valiantly;”—
dreams which enter Halbert Melville’s long shut chamber, welcoming its
old dreamer back again—dreams which float about Christian’s resting-place
—above the fair head laid on Christian’s shoulder, calm as in the happy
days of childhood; sweet, hopeful, cheering dreams, that open up long
vistas of indistinct and dazzling brightness, all the brighter for their glad
uncertainty before their eyes, and fill the hearts which tremble in their joy
with a sweet assurance that calms their fears into peace. Even Ailie
dreamed, and her visions were of a gay complexion, fitting the nature of her
doings through this eventful day, and had various anticipations of bridal
finery floating through them. Nay, the very wind which whistled past Mr.
Melville’s roof-tree had a language of its own, and admirable gleesome
chuckle, which said plain as words could speak that happy as this night had
been beneath it, there would be merrier, happier doings here next new
year’s day.
CHRISTIAN MELVILLE.
EPOCH V.
Sweet is the sunshine lacing with its light,

The parting storm-cloud after day of sadness;
That ere the even darkens into night
O’erflows the world with glory and with gladness;
But sweeter is the flood of pleasantness,
That breaks at noonday through the clouds of morning,
While yet the long glad hours have power to bless,
And the earth brightens ’neath its warm adorning
Of scattered sunbeams. So their fate excels
In blessedness, upon whose noonday story
The heavenly sunshine of God’s favour dwells,
While yet their tongues are strong to speak His glory;
And blessed they, O Lord! who, saved and free,
Stretch out compassionate hands to draw men near to thee!
CHAPTER I.
They thicken on our path,
These silent witness years;
A solemn tenantry, that still land hath
Wherein were spent our bygone smiles and tears;
Graven on their secret tablets silently,
Stand deed, and thought, and word,
Beyond the touch of change or soft decay,
’Stablished perpetually before the Lord!
* * * * *
Season of labour, time of hope and fear,
Kind to our households let thy varyings be;
With thee we give a sigh to the Old year,
And do rejoice us in the New with thee.—Y.S.P.
EN years have passed away, and again it is a fireside scene that

we have to depict, and a fireside conversation we have to
chronicle. The room we now stand in is large and pleasant, and
bright with the radiance of merry faces—faces of every age and
size, but all marvellously alike in features, as in happiness, from the grave
seniors down to the crowing baby, through all the gradations of stature and
sobriety that crowd around that well-spread table. The assembly is too
large, and the children too near each other in age to allow you to think them
all members of one household; and two fathers half checked, half
encouraged the merry crowd, and two mothers took sweet counsel together,
praising each other’s little ones, and exchanging domestic experiences with
each other. We must try and find in these merry faces the traits of those we
have known before. Let us see whom we have before us. A man of goodly
presence is the elder; grave, it seems, habitually, but with a smile that is like
a sunbeam, and which has an electrical effect in the saddest house it beams
in; and many, many houses of sorrow does it see, and many mourners are
cheered by the words of hope and comfort that flow from these
sympathising lips; for you will see, if you look at his apparel, and mark his
manner, that he holds a high vocation, no less than a labourer about that
glorious vine which has the Eternal Father for its husbandman; a labourer,
one who, like the bee, seeks honey from every flower, and from his pulpit,
and standing by beds of suffering, and in the dark, close, and fœtid haunts
of sin, seeks to have souls for his hire as the labour of his life and the joy of
his existence. No mere Sabbath day worker in his pulpit, but one that never
tires, that is always ready, and almost always with his harness on his back;
like a good knight of the olden time, prompt to succour the distressed. The
lady too, who sits beside him, has about her a gentle dignity that is akin to
his; but with her blooming cheek and bright eye we can boast no old
acquaintance, though when she lays her white hand on his arm and calls
him “Halbert,” we are half ashamed to say so much of Halbert Melville’s
wife.
But on the other side of the fire sits a younger lady, with a calm air of
matronly self-possession, which almost sets our memory at defiance; it is
true that her face looks so youthful in its eloquent expressiveness that, but
for that copy of it that shines at her knee, through the fair straggling locks
of a little merry girl, you might fancy her still the Mary of ten years ago; but
in the silent depths of her dark eyes sits such serene and assured happiness,
at once so calm, and deep, and full, as makes one sure this cannot be the
disconsolate inhabitant of yon dim chamber, weeping in her sleep in the
first agony of womanly woe. Yet so it is, and lightly have these ten swift
years—long, oh, how long and dreary to many—flown over her, effacing so
entirely everything but the remembrance of those passages in her history
from her mind, that when she looks back now upon that troubled time, she
half smiles, half blushes for her old self, and reckons of her brief but
agonising trial, as sick men recall to their memories the terrible dreams of
some delirious fever fit. For Mary Melville has found entire and perfect
kindred in the heart of one whom then she little recked of and cared not for,
and she wonders now how she, ever the object of Charles Hamilton’s warm
and full affection, could have overlooked his nobler qualities, and preferred
instead Forsyth’s deceptive and hollow brilliancy, and the glitter of well-
displayed accomplishments, which threw the blushing youth into the shade.
And the blushing youth of our last chapter blushes no longer when he
speaks to Mary, nor has his bashfulness been seen, Halbert says, for nine
long years and more; never since one bright autumn evening, when Mary
and he surprised Christian in her solitude by the whispered communication
of an important agreement come to between them, and which was carried
into effect, ratified and sealed, on the following new year’s day, fulfilling,
in the most joyous manner, old Ailie’s dream. At this transaction Halbert’s
presence was indispensable, albeit he was again, after Christian’s kind
persuasions and James’s spirited remonstrances had shamed their father into
liberality, finishing the long forsaken studies so disastrously interrupted of
old, with a vigour and ardour that was unquenchable. True, he did not come
to James’s wedding when it took place; but Christian, and Mary, and
Charles Hamilton were each and all immovable in their demands; they
could not do without Halbert, and so he was present at the ceremony,
exciting Charles’s wrathful contradiction, and Christian and Mary’s
curiosity, by hinting merrily of another Mary, whose presence would throw
the bride of to-day into the shade, though no one at that blithe bridal looked
on Mary Melville with more affectionate admiration than her brother
Halbert. And lo! when the time of Halbert’s study and probations was over,
and Providence had so ordered that the place of his ministry should be the
same as that of his birth, and the dwelling-place still of his nearest and
dearest kindred, then came about another bridal, and the name of Mary
Melville was resuscitated, though Mrs. Charles Hamilton’s proud husband
would never allow that the old bearer of the name was equalled by the new.
But there is no rivalship between the sisters—sisters in affection as much
as in name—and the children, whose fair heads have sprung up like flowers
beside and about them, are like one family in their cordial intercourse. But
where is Christian? Our enquiry is echoed by half-a-dozen merry voices.
“Where can Aunt Christian be?” There will be no need to ask the question a
moment hence, if indeed we can discern our old friend through the pyramid
of children that are clustering about her; the little girl that stood by Mary’s
knee has left for Aunt Christian, and now stands on a chair beside her, with
her round arms about her neck, and her rosy face beaming on her shoulders;
the sturdy boy who leant on Halbert’s chair has left that place of honour for
Aunt Christian, and he stands proudly at her right hand as prime minister,
helping at the distribution of the great basketful of new year’s dainties—for
this is again the first night of another year—which she has brought to
gladden these youthful hearts. The whole host of her nephews and nieces,
absorbed a moment since in their various amusements, have left them all for
Aunt Christian, and are gathered about her, one clinging round her waist
and one hanging at either arm, greatly impeding the action of her gift-
dispensing hand. Sure enough here is Christian, how blithe! how happy!
Time has dealt gently with her, and though he has drawn a thread of silver
through the rich dark abundance of her plainly braided hair, there is not one
in this room that would not start up in indignant surprise, if you said that
Christian was either looking or growing old.
“Nay, nay,” said Halbert, not long ago, when some indifferent friend of
the family suggested this, “Christian will never grow old. When years come
upon her, she will glide away like a streamlet into a river, but she will not
fade. Christian’s spirit will always be young.”
And so it is; her soft clear voice stills all that little childish hubbub in a
moment. The very baby stays its scream of joy, as if it too would listen to
Aunt Christian, and little Mary on her shoulder, and strong Halbert at her
right hand, and every separate individual of their respective hosts of
brothers and sisters would dare in single-handed valour any full-grown
Goliath that would presume to interrupt the expression of Aunt Christian’s
pleasure, pleasant as it always is. It is a great day this, with these two united
families. A day of childish jubilee to the younger members, and of joyful
commemoration to the older, for Halbert looks back with glistening eyes,
and rejoices in the union of ten years ago, a beginning of happy, laborious
years to him; and Mary remembers her early trial, and thanks God most
earnestly for deliverance, and participates with her husband in the happier
recollections of their marriage day; and the other Mary, with generous
affection, sympathises with each and all; and Christian? Christian’s heart,
open at all times to generous impulses, seems to have its sluices of
overpouring and constant love thrown wide open for the free passage of its
swelling tides, each new year’s night, and if you heard her fervent
thanksgiving when she kneels before God alone, you would think that flood
of blessings had been all poured out upon her, not that its fulness had
flowed upon her friends, but that she herself was the individual recipient of
every separate gift. For Christian identifies herself with those dear ones so
entirely, that she looks upon their happiness as a peculiar blessing bestowed
upon herself. Christian has, however, now seated herself in the empty chair
waiting for her—jealously kept for her, indeed—at the brightest corner of
the cheerful fireside, and taking a little namesake of her own, a grave,
serious, thoughtful child, who has begun to lisp wisdom already with her
infant tongue, upon her knee, she joins in the conversation which her
entrance, and still more her equitable distribution of the basket of good
things had interrupted.
“Father,” questioned Halbert Melville, second bearer of the name, “do
you keep new year’s day because it is new year’s day?”
“Why do you ask, Halbert?” said his mother, smiling, as she drew the
boy towards her.
“Because, Mamma, nobody else cares about it here; and I’ve heard Aunt
Christian say how foolish it was for people to keep their birthdays, as if
they were glad that time was going away from them, people that don’t use
their time well either,” moralised Halbert, looking earnestly in his mother’s
face, “and isn’t new year’s day just the same as a birthday and—” the boy
hesitated and seemed unwilling or unable to say more.
“And what, Halbert,” said Christian, as the boy paused and looked down,
“and what—what was it you were going to say?”
“I don’t know, Aunt Christian,” hesitated Halbert, “I don’t know whether
it’s right or not, but shouldn’t we be rather sorry when the new year comes,
than glad that the old year has ended?”
“And why sorry, Halbert?” said his father, who had hitherto been
listening in silence, “why do you think we should be sorry?”
“Because, father,” said Halbert, quickly, raising his eyes, “because you
said in your sermon last Sabbath, that when once a year was gone, if we had
not spent it well, it was entirely lost for ever, for we could never bring a
minute back again.”
“And therefore you think we should be sorry, do you, Halbert?” rejoined
his father.
“Yes, father,” was the answer, and again young Halbert’s face was cast
down, “for you say often that nobody spends their time well, or as right as
they should do.”
The elder Halbert did not answer, but he took little Christian, who had
been gazing with her large eloquent eyes at every one that spoke in turn,
and had attended diligently and earnestly to the unusual conversation, upon
her aunt’s knees. “Well, little one, do you think we should be sorry when
the new year comes?”
“I think we should be both sorry and glad, papa,” was the prompt
answer.
“Well, Christian, Halbert has told us why we should be sorry; now do
you tell us what it is we should be glad for.”
There was a murmur among a little knot at a corner of the table, and a
half-suppressed laugh before Christian had time to answer her father’s
question.
“Who is that? what is it that makes you so merry?” said Halbert, smiling
and shaking his head at the merry urchins, who were congregated in a
group.
“It’s only our Halbert, uncle, it’s only our Halbert,” whispered little
Mary Hamilton, deprecatingly.
“Well, Mary, we are impartial to-night, so we must hear what our
Halbert has to say; come here, sir.”
And Halbert Hamilton, the wildest little rogue that ever kept nursery in
an uproar, or overcame nurse’s patience, or conquered her heart by his feats
of merry mischief, half hid himself below the table in pretended fear and
dismay at his uncle’s summons, and did not stir.
“Come, Halbert,” said Mary, his mother, as Charles drew his incorrigible
son into the middle of the little circle, “what did you say over there?”
Halbert the third looked down and blushed, and then laughed outright.
“He only said we should be glad when the new year comes, because we
have plenty of fun,” interposed Mary Melville, her wild cousin’s constant
defender and apologist.
“Quite right, my boy,” said the elder Halbert, laying his hand kindly on
the boy’s head, “the coming of plenty of fun is a very good and proper thing
to be glad for; but sit you down now, and let us hear what little Christian
has to say.” And Halbert sat down at his uncle’s feet to listen.
“Well now, Christian, what should we be glad for? Is it because there is
plenty of fun, as Halbert says?”
“No, papa,” said the little, grave girl, seriously, shaking her head
solemnly, “no, it is not that. I think it’s because we have another to be good
and do right in. Isn’t that it, Aunt Christian?”
And the little girl looked over to her aunt inquiringly, to see if her
childish conclusion was a correct one.
“Just so, my dear,” was Aunt Christian’s answer, as Halbert patted the
child’s soft cheek, and then permitted her to make her way over to her
accustomed seat.
The children were gathered now about their parents’ knees, and even
wild Halbert Hamilton was silent and attentive. “Yes, children,” said the
kind father and uncle, as he looked round upon them, “yes, children, there is
a better reason for being glad than even having plenty of fun. There is a new

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Computational Fluid Dynamics A Practical Approach 3rd

Cost Effectiveness Analysis in Health A Practical

Practical Management of Thyroid Cancer: A

Practical Pulmonary Pathology: A Diagnostic Approach: A

Process Control: A Practical Approach Myke King

Restaurant financial management a practical approach

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(Tri-C) in Cleveland. Bruce is also a past Chairperson of the

Bruce has been involved in emergency services since

Chapter 2 The Electrocardiogram 44

Section 2: The Nine-Step Process

Chapter 4 Heart Rate 108

Chapter 5 Regularity 122

Chapter 7 QRS Complexes 160

Chapter 8 PR Intervals 184

Chapter 9 ST Segments, T Waves, QT Intervals, and U Waves 202

Chapter 10 Heart Disease 222

Section 3: Origin and Clinical Aspects of Dysrhythmias

Chapter 12 Sinus Dysrhythmias 276

Chapter 13 Atrial Dysrhythmias 314

Chapter 16 AV Heart Blocks 440

Chapter 17 Pacemakers and Implanted Cardioverter-Defibrillators 470

Section 4: 12-Lead ECGs

Chapter 19 Myocardial Ischemia, Injury, and Infarction 532

Chapter 20 Bundle Branch Block 580

Chapter 22 Other Cardiac Conditions and the ECG 626

Section 5: Review and Assessment

Structure of This Book

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Preview the Chapter Content

©McGraw-Hill Education/Rick Brady

LO 1.2 List the components of the circulatory system.

LO 1.3 Describe the anatomy of the heart.

LO 1.3 Describe the anatomy of the heart.

300 Full-Color Figures show you in detail

where each dysrhythmia originates and P

ECGs that demonstrate each dysrhythmia.

In addition, algorithms and tables present

content visually to help you memorize the Effects

P’ wave may be buried

QRS Complex Appearance

Rate P’ waves QRS complexes

Review the Content

opportunities to interpret ECG strips using your

Key Points cover all of the

Assess Your Understanding

answers in Appendix A, help you recall

the material and test your knowledge. 3.

4. Describe the three phases of ventricular depolarization. (LO 2.3)

Chapter 2 The Electrocardiogram 81

“Into the blithe and breathing air,

“Before me rose an avenue

“And falling on my weary brain,