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2015v1.0
The
ECGMade Practical
This page intentionally left blank
The
ECGMade Practical
SEVENTH EDITION

JOHN HAMPTON DM MA DPhil FRCP FFPM FESC

Emeritus Professor of Cardiology, University of Nottingham, UK
DAVID ADLAM BA BM BCh DPhil FRCP FESC
Associate Professor of Acute and Interventional Cardiology and Honorary
Consultant Cardiologist, University of Leicester, Leicester, UK

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY 2019

© 2019 Elsevier Ltd. All rights reserved.

First edition 1986

Second edition 1992
Third edition 1997
Fourth edition 2003
Fifth edition 2008
Sixth edition 2013
Seventh edition 2019

The right of John Hampton and David Adlam to be identified as author(s) of this work has been asserted by them in
accordance with the Copyright, Designs and Patents Act 1988.

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
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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
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences,
in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no
responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as
a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or
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Contents
Preface vii
12-lead ECGs ix

1. The ECG in healthy people 1

2. The ECG in patients with palpitations and syncope:
initial assessment 57
3. The ECG in patients with palpitations and syncope:
ambulatory ECG monitoring 85
4. The ECG when the patient has a tachycardia 93
5. The ECG when the patient has a bradycardia 147
6. The ECG in patients with chest pain 195
7. The ECG in patients with breathlessness 255
8. The effects of other conditions on the ECG 283
9. Conclusions: four steps to making the most of the
ECG 313

Index 317

v
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Preface
What to expect of this book understand them so there is a series of changes in the
text compared with previous editions: for example,
This book is the seventh edition of The ECG in Practice,
there is more focus on ambulatory monitoring and
but we have changed the title to The ECG Made Practical
newer monitoring devices and developments in pacing
to emphasize its relationship to The ECG Made Easy
systems and defibrillators are described. We have made
We assume that the reader of this book will have the
a clearer link between the ECGs of myocardial infarc-
level of knowledge of the ECG that is contained in The
tion, coronary anatomy and the site of myocardial
ECG Made Easy. The ECG is indeed easy in principle, but
injury. To make room for these changes, and to give
the variations in pattern seen both in normal people and
more space to ECG interpretation, there is now less
in patients with cardiac and other problems can make the
focus on patient management.
ECG seem more complex than it really is. This book con-
The new edition of the third title in the series is being
centrates on these variations, and contains several exam-
published simultaneously and again we have changed the
ples of each abnormality. It is intended for anyone who
title, from 150 ECG Problems to 150 ECG Cases to empha-
understands the basics, but now wants to use the ECG to
size the central place of the patient rather than the ECG.
its maximum potential as a clinical tool.
This new edition is divided into two sections, one con-
The ECG is not an end in itself, but is an extension of
taining numerous examples of ‘everyday’ ECGs which are
the history and physical examination. Patients do not visit
suitable for those who have mastered The ECG Made Easy,
the doctor wanting an ECG, but come either for a health
and the other including more esoteric and difficult ECGs
check or because they have symptoms. Therefore this
which provides more examples than can be included the
book is organized according to clinical situations, and the
this new edition of The ECG Made Practical. Those who
chapters cover the ECG in healthy subjects and in patients
want to practice their skills after reading The ECG Made
with palpitations, syncope, chest pain, breathlessness or
Practical will find their challenge in the fifth edition of 150
non-cardiac conditions. To emphasize that the ECG is
ECG Cases.
part of the general assessment of a patient, each chapter
begins with a brief section on history and examination.
This seventh edition continues the philosophy of What to expect of the ECG
its predecessors in that the patient is considered more The ECG has its limitations. Remember that it provides a
important than the ECG. However, the ECG is a vital picture of the electrical activity of the heart, but gives only
part of diagnosis and, increasingly, influences treat- an indirect indication of the heart’s structure and func-
ment. Electrical devices of various sorts are standard tion. It is, however, invaluable for assessing patients whose
treatment in cardiology, and patients with such devices symptoms may be due to electrical malfunction in the
commonly present with non-cardiological problems. heart, especially patients with conduction problems and
Those who are not specialists in cardiology need to those with arrhythmias.

vii
Preface
In healthy people, finding an apparently normal
ECG may be reassuring. Unfortunately, the ECG can be
totally normal in patients with severe coronary disease.
Conversely, the range of normality is such that a healthy
subject may quite wrongly be labelled as having heart
disease on the basis of the ECG. Some ECG patterns
that are undoubtedly abnormal (e.g. right bundle branch
block) are seen in perfectly healthy people. It is a good
working principle that it is the individual’s clinical state
that matters, not the ECG.
When a patient complains of palpitations or syncope,
the diagnosis of a cardiac cause is only certain if an ECG
is recorded at the time of symptoms – but even when
the patient is symptom-free, the ECG may provide a
clue for the prepared mind. In patients with chest pain
the ECG may indicate the diagnosis, and treatment can
be based upon it, but it is essential to remember that
the ECG may remain normal for a few hours after the
onset of a myocardial infarction. In breathless patients a
totally normal ECG probably rules out heart failure, but
viii
it is not a good way of diagnosing lung disease or pul-
monary embolism. Finally it must be remembered that
the ECG can be quite abnormal in a patient with a variety
of non-cardiac conditions, and one must not jump to
the conclusion that an abnormal ECG indicates cardiac
pathology.
Acknowledgements
In this seventh edition of The ECG Made Practical we have
been helped by many people. In particular, we are grate-
ful to our development editor, Fiona Conn, for her enor-
mous attention to detail that led to many improvements
in the text. We are also grateful to Laurence Hunter and
his team at Elsevier for their encouragement and patience.
As before, we are grateful to many friends and colleagues
who have helped us to find the wide range of examples
of normal and abnormal ECGs that form the backbone of
the book.
JH, DA
12-lead ECGs
AAI pacing Fig. 5.31
Accelerated idionodal rhythm Fig. 1.47
Accelerated idioventricular rhythm Fig. 1.28
Anorexia nervosa Fig. 8.24
Aortic stenosis, severe, left ventricular hypertrophy
with Fig. 7.8
Aortic stenosis and left bundle branch block
Fig. 7.6
Atrial fibrillation Fig. 4.21, Fig. 4.22, Fig. 5.10
Atrial fibrillation, uncontrolled Fig. 7.1
Atrial fibrillation and anterior ischaemia Fig. 6.26
Atrial fibrillation and coupled ventricular
extrasystoles Fig. 7.2
Atrial fibrillation and inferior infarction Fig. 4.37
Atrial fibrillation and left bundle branch block
Fig. 4.26, Fig. 4.27
Atrial fibrillation and right bundle branch block
Fig. 4.32
Atrial fibrillation and Wolff–Parkinson–White
syndrome Fig. 4.45
Atrial flutter and 1 : 1 conduction Fig. 4.20
Atrial flutter and 2 : 1 block Fig. 4.17
Atrial flutter and 4 : 1 block Fig. 4.19
Atrial flutter and intermittent VVI pacing Fig. 5.27
Atrial flutter and variable block Fig. 5.9
Atrial flutter in hypothermia Fig. 8.2
Atrial septal defect and right bundle branch
block Fig. 8.9
Atrial tachycardia Fig. 4.16
Atrioventricular nodal re-entry tachycardia (AVNRT)
and anterior ischaemia Fig. 4.14, Fig. 6.27
Bifascicular block Fig. 2.22
Biventricular pacing Fig. 7.22
Broad complex tachycardia of uncertain origin
Fig. 4.34, Fig. 4.35
Brugada syndrome Fig. 2.14, Fig. 2.15
Chronic lung disease Fig. 7.19
Complete heart block Fig. 5.13
Complete heart block and Stokes–Adams attack
Fig. 5.15
Congenital long QT syndrome Fig. 2.12
DDD pacing, atrial tracking Fig. 5.34
DDD pacing, atrial and ventricular pacing Fig. 5.33
DDD pacing, intermittent Fig. 5.35
Dextrocardia Fig. 1.11
Dextrocardia, leads reversed Fig. 1.12
Digoxin effect Fig. 8.17
Digoxin effect and ischaemia Fig. 6.41
Digoxin toxicity Fig. 8.18
Ebstein’s anomaly, right atrial hypertrophy and right
bundle branch block Fig. 8.8
Ectopic atrial rhythm Fig. 1.8
ix
12-lead ECGs
Electrical alternans Fig. 8.12
Exercise-induced ischaemia Fig. 6.44
Exercise-induced ST segment depression Fig. 6.46
Exercise testing, normal ECG Fig. 6.43, Fig. 6.45
Fallot’s tetralogy, right ventricular hypertrophy
in Fig. 8.7
Fascicular tachycardia Fig. 4.33
First degree block and left bundle branch block
Fig. 2.20
First degree block and right bundle branch
block Fig. 2.21, Fig. 5.7, Fig. 5.14
Friedreich’s ataxia Fig. 8.26
His pacing Fig. 5.31
Hyperkalaemia Fig. 8.13
Hyperkalaemia, corrected Fig. 8.14
Hypertrophic cardiomyopathy Fig. 2.6, Fig. 7.11
Hypokalaemia Fig. 8.16
Hypothermia Fig. 8.3
Hypothermia, atrial flutter Fig. 8.2
Hypothermia, re-warming after Fig. 8.4
Intermittent VVl pacing Fig. 5.26
Ischaemia, anterior Fig. 6.24
Ischaemia, anterior and atrial fibrillation Fig. 6.26
Ischaemia, anterior and AV nodal re-entry
tachycardia Fig. 6.27
Ischaemia, anterior and inferior infarction and right
bundle branch block Fig. 6.21
Ischaemia, anterior and possible old inferior
infarction Fig. 6.23
Ischaemia, anterior and right bundle branch
block Fig. 6.20
Ischaemia, anterolateral Fig. 6.25
x
Ischaemia, digoxin effect and Fig. 6.41
Ischaemia, exercise-induced Fig. 6.44
Ischaemia, ?left ventricular hypertrophy
Fig. 7.10
Ischaemia, probable Fig. 7.9
Junctional tachycardia with right bundle branch
block Fig. 4.33
Left anterior hemiblock Fig. 7.12
Left atrial hypertrophy Fig. 2.7
Left atrial hypertrophy and left ventricular
hypertrophy Fig. 7.3
Left bundle branch block Fig. 2.3, Fig. 6.17
Left bundle branch block and aortic stenosis
Fig. 7.6
Left ventricular hypertrophy Fig. 2.2, Fig. 6.34,
Fig. 6.39, Fig. 7.5, Fig. 7.7, Fig. 8.6
Left ventricular hypertrophy and ?ischaemia
Fig. 7.10
Left ventricular hypertrophy and left atrial
hypertrophy Fig. 7.3
Left ventricular hypertrophy and severe aortic
stenosis Fig. 7.8
Limb lead switch Fig. 1.3
Lithium treatment Fig. 8.22
Long QT syndrome, congenital Fig. 2.12
Long QT syndrome, drug toxicity Fig. 4.43
Malignant pericardial effusion Fig. 8.11
Mediastinal shift Fig. 1.22
Mitral stenosis and pulmonary hypertension
Fig. 7.4
Myocardial infarction, acute anterior and old
inferior Fig. 6.16

Myocardial infarction, acute anterolateral, with left
axis deviation Fig. 6.8
Myocardial infarction, acute inferior Fig. 6.2
Myocardial infarction, acute inferior and anterior
ischaemia Fig. 6.13
Myocardial infarction, acute inferior infarction
(STEMI) and anterior NSTEMI Fig. 6.15
Myocardial infarction, acute inferior and old
anterior Fig. 6.14
Myocardial infarction, acute inferior and right bundle
branch block Fig. 6.18
Myocardial infarction, acute lateral Fig. 6.6
Myocardial infarction, anterior Fig. 6.5
Myocardial infarction, anterior NSTEMI Fig. 6.22
Myocardial infarction, anterolateral, ?age Fig. 6.9
Myocardial infarction, evolving inferior Fig. 6.3,
Fig. 6.4
Myocardial infarction, inferior and atrial
fibrillation Fig. 4.37
Myocardial infarction, inferior and right bundle
branch block Fig. 6.18
Myocardial infarction, inferior and right bundle
branch block and ?anterior ischaemia Fig. 6.21
Myocardial infarction, inferior and right ventricular
infarction Fig. 6.12
Myocardial infarction, inferior and ventricular
tachycardia Fig. 4.38
Myocardial infarction, lateral (after 3 days) Fig. 6.7
Myocardial infarction, old anterior Fig. 6.10
Myocardial infarction, old anterolateral NSTE-
ACS Fig. 6.40
Myocardial infarction, old inferior (possible) and
anterior ischaemia Fig. 6.23
Myocardial infarction, old posterior Fig. 6.35
Myocardial infarction, posterior Fig. 6.11
12-lead ECGs
Normal ECG Fig. 1.10, Fig. 1.13, Fig. 6.43, Fig. 6.45
Normal ECG, accelerated idionodal rhythm Fig. 1.47
Normal ECG, people of African origin Fig. 1.41,
Fig. 1.42
Normal ECG, child Fig. 1.50
Normal ECG, ectopic atrial rhythm Fig. 1.8
Normal ECG, exercise testing Fig. 6.44, Fig. 6.46
Normal ECG, high take-off ST segment Fig. 1.32
Normal ECG, junctional escape beat Fig. 1.6
Normal ECG, left axis deviation Fig. 1.49
Normal ECG, ‘leftward’ limit of normality Fig. 1.17
Normal ECG, notched S wave (V2) Fig. 1.27
Normal ECG, P wave inversion Fig. 1.8, Fig. 1.35
Normal ECG, P wave inversion (lead VR, VL) Fig. 1.35
Normal ECG, partial right bundle branch block
pattern Fig. 1.34
Normal ECG, pre-exercise Fig. 6.47
Normal ECG, R wave dominance (lead II) Fig. 1.14
Normal ECG, R wave dominance (V1) Fig. 1.23,
Fig. 7.17
Normal ECG, R wave dominance (V3) Fig. 1.21
Normal ECG, R wave dominance (V4) Fig. 1.19
Normal ECG, R wave dominance (V5) Fig. 1.20,
Fig. 1.25
Normal ECG, R wave size Fig. 1.14, Fig. 1.15
Normal ECG, right axis deviation Fig. 1.16
Normal ECG, ‘rightward’ limit of normality
Fig. 1.15
Normal ECG, R–R interval variation Fig. 1.4
Normal ECG, RSR1 pattern Fig. 1.26
Normal ECG, RSR1S1 pattern Fig. 1.27
Normal ECG, S wave dominance (V3) Fig. 1.19
Normal ECG, S wave dominance (V4) Fig. 1.20
Normal ECG, septal Q wave Fig. 1.29, Fig. 1.49
Normal ECG, small Q wave Fig. 1.30, Fig. 1.37
xi
12-lead ECGs
Normal ECG, ST segment, isoelectric and sloping
upward Fig. 1.31
Normal ECG, ST segment depression Fig. 1.34
Normal ECG, ST segment depression
(nonspecific) Fig. 1.35
Normal ECG, ST segment elevation Fig. 1.33
Normal ECG, T wave, peaked Fig. 8.15
Normal ECG, T wave, tall peaked Fig. 1.44
Normal ECG, T wave flattening Fig. 1.43
Normal ECG, T wave inversion (lead III) Fig. 1.37
Normal ECG, T wave inversion (lead V1) Fig. 1.37
Normal ECG, T wave inversion (lead V2) Fig. 1.40
Normal ECG, T wave inversion (lead V3) Fig. 1.41
Normal ECG, T wave inversion (lead VR) Fig. 1.36
Normal ECG, T wave inversion (lead VR, V1–V2)
Fig. 1.39
Normal ECG, T wave inversion in people of African
origin Fig. 1.41, Fig. 1.42
Normal ECG, U wave, prominent/large Fig. 1.45,
Fig. 1.46, Fig. 1.48
Pericardial effusion, malignant Fig. 8.11
Pericarditis Fig. 6.33
Pre-exercise normal ECG Fig. 6.47
Prolonged QT interval due to amiodarone Fig.
2.13, Fig. 8.20
Pulmonary embolus Fig. 6.29, Fig. 6.30, Fig. 6.31,
Fig. 6.32, Fig. 7.20
Pulmonary hypertension and mitral stenosis Fig. 7.4
Pulmonary stenosis Fig. 8.5
Re-warming after hypothermia Fig. 8.4
Right atrial hypertrophy Fig. 7.14
Right atrial hypertrophy and right bundle branch
block, in Ebstein’s anomaly Fig. 8.8
xii
Right atrial hypertrophy and right ventricular
hypertrophy Fig. 7.15
Right bundle branch block and acute inferior
infarction Fig. 6.18
Right bundle branch block and anterior
infarction Fig. 6.19
Right bundle branch block and anterior
ischaemia Fig. 6.20
Right bundle branch block and atrial septal
defect Fig. 8.9
Right bundle branch block and inferior infarction,
?anterior ischaemia Fig. 6.21
Right bundle branch block and right atrial
hypertrophy, in Ebstein’s anomaly Fig. 8.8
Right ventricular hypertrophy Fig. 2.4, Fig. 7.18
Right ventricular hypertrophy, marked Fig. 7.16
Right ventricular hypertrophy in Fallot’s
tetralogy Fig. 8.7
Right ventricular hypertrophy and right atrial
hypertrophy Fig. 7.15
Right ventricular outflow tract ventricular tachycardia
(RVOT-VT) Fig. 4.3, Fig. 4.41
RSR1 pattern Fig. 1.26, Fig. 2.14
RSR1S1 pattern Fig. 1.27
Second degree block (2 : 1) Fig. 5.12
Sick sinus syndrome Fig. 5.2
Sinus arrhythmia Fig. 1.4
Sinus bradycardia Fig. 1.6, Fig. 5.1, Fig. 5.2
Sinus rhythm, after cardioversion Fig. 4.18,
Fig. 4.36
Sinus rhythm, in Wolff–Parkinson–White syndrome
type A Fig. 4.12
Sinus rhythm and left bundle branch block Fig.
4.25

Sinus rhythm and normal conduction, post-
cardioversion Fig. 4.36
Sinus tachycardia Fig. 1.5
ST segment, nonspecific changes Fig. 6.1
ST segment depression, exercise-induced Fig.
6.46
Subarachnoid haemorrhage Fig. 8.25
Supraventricular extrasystole Fig. 1.7, Fig. 4.7
Supraventricular tachycardia Fig. 4.11
T wave, nonspecific changes Fig. 6.1
T wave, nonspecific flattening Fig. 6.42
T wave, unexplained abnormality Fig. 6.38
Thyrotoxicosis Fig. 8.10
Torsade de pointes Fig. 2.11
Trauma Fig. 8.23
Trifascicular block Fig. 2.23
Ventricular extrasystole Fig. 1.9, Fig. 4.8
Ventricular extrasystoles, coupled and atrial
fibrillation Fig. 7.2
12-lead ECGs
Ventricular fibrillation Fig. 4.50
Ventricular tachycardia Fig. 4.29, Fig. 4.30, Fig.
4.31
Ventricular tachycardia, fusion and capture
beats Fig. 4.39
Ventricular tachycardia and inferior infarction
Fig. 4.38
Ventricular tachycardia torsade de pointes Fig. 2.11
VVl pacing, bipolar Fig. 5.24
VVl pacing, intermittent Fig. 5.26
VVl pacing, unipolar Fig. 5.25
VVl pacing in complete block Fig. 5.28
Wolff–Parkinson–White syndrome and atrial
fibrillation Fig. 4.45
Wolff–Parkinson–White syndrome type A Fig. 2.8,
Fig. 2.9, Fig. 4.12, Fig. 4.44, Fig. 6.36, Fig. 7.13
Wolff–Parkinson–White syndrome type B Fig. 2.10,
Fig. 6.37
xiii
This page intentionally left blank
The ECG in healthy people

Types of ECG 1
1
The ECG is frequently used as a screening tool whether
from a truly asymptomatic, apparently ‘healthy’, subject
The ‘normal’ ECG 2
(e.g. for an employment medical) or as part of the battery
The normal cardiac rhythm 2 of initial investigations in patients presenting with new
symptoms of uncertain significance or cause. ECG find-
The heart rate 2
ings should always be interpreted in the clinical context
Extrasystoles 5 in which it was taken. Over-interpretation of normal
variations in the ECG may lead to misdiagnosis and risk
The P wave 9
initiation of unnecessary investigations and inappropri-
The PR interval 13 ate management. Understanding variations in the ECG
that we can expect to find in completely healthy people is
The QRS complex 15
therefore a key prerequisite to the accurate interpretation
The ST segment 35 of ECGs that appear ‘abnormal’.
The T wave 39
The QT interval 47
TYPES OF ECG
The ECG in athletes 49
ECG traces come in many guises including continuous
The ECG in pregnancy 52
single channel heart monitoring, 3-lead rhythm assess-
The ECG in children 52 ment, and even internal electrograms obtained from
implanted devices or during cardiac procedures. The most
What is a ‘normal ECG’? 53
‘complete’ external ECG is the traditional 12-lead trace
What to do 55 (Fig. 1.1). Accurate lead position (Fig. 1.2) is key as mis-
placed leads change the appearances of the trace and may
Further investigations 55
lead to misinterpretation. For example, limb lead switches
Treatment of asymptomatic ECG abnormalities 55 can resemble abnormalities of the cardiac axis (Fig. 1.3),

1
1 The ECG in healthy people
whilst alterations of chest lead position, for example due
to displacement in obese patients or by breast tissue, may
resemble cardiac rotation with delayed anterior R-wave
progression (see Fig. 1.20).
THE ‘NORMAL’ ECG
The normal cardiac rhythm
Sinus rhythm is the only normal sustained rhythm (see
Fig. 1.1). In young people the R–R interval is reduced (i.e.
the heart rate is increased) during inspiration, and this is
called sinus arrhythmia (Fig. 1.4). When sinus arrhythmia
is marked, it may mimic an atrial arrhythmia. However, in
sinus arrhythmia each P–QRS–T complex is normal, and
it is only the interval between them that changes.
Sinus arrhythmia becomes less marked with increas-
ing age of the subject, and is lost in conditions such as
Fig. 1.1
Normal ECG
I VR
II VL
III VF
2
diabetic autonomic neuropathy due to impairment of
vagus nerve function.
The heart rate
There is no such thing as a normal heart rate, and the
terms ‘tachycardia’ and ‘bradycardia’ should be used
with care. There is no point at which a high heart rate
in sinus rhythm has to be called ‘sinus tachycardia’ and
there is no lower limit for ‘sinus bradycardia’. Nev-
ertheless, unexpectedly fast or slow rates do need an
explanation.
Sinus tachycardia
The ECG in Fig. 1.5 was recorded from a young woman
who complained of a fast heart rate. She had no other
symptoms, but was anxious. There were no other abnor-
malities on examination, and her blood count and thyroid
function tests were normal.
V1 V4
V2 V5
V3 V6
 Fig. 1.2

R Y

VR VL

I
V1 V2 V3 V4 V5 V6

6 chest leads looking at heart from the front

B
G

III II

VF
6 limb leads looking at heart
from the sides and from below
ECG lead positions for the chest and upper limb leads. Correct positioning of the lower limb leads is also required for
a 12-lead ECG (not shown here).
1 The ECG in healthy people

Fig. 1.3
I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

II

Fig. 1.4
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

4
 The ‘normal’ ECG 1

BOX 1.1 Possible Causes of Sinus Rhythm With a Fast

Limb lead switch Heart Rate
NOTE • Pain, fright, exercise
• Prominent R wave in a VR • Hypovolaemia
• Inverted limb lead complexes • Myocardial infarction
• Normal chest leads • Heart failure
• Pulmonary embolism
• Obesity
• Lack of physical fitness
• Pregnancy
• Thyrotoxicosis
• Anaemia
• CO2 retention
• Autonomic neuropathy
• Drugs:
• sympathomimetics
• salbutamol (including by inhalation)
• caffeine
• atropine

Box 1.1 shows possible causes of sinus rhythm with a

Sinus arrhythmia
fast heart rate.
NOTE
• Marked variation in R–R interval Sinus bradycardia
• Constant PR interval
The ECG in Fig. 1.6 was recorded from a young profes-
• Constant shape of P wave and QRS complex
sional footballer. His heart rate was 44 bpm, and at one
point the sinus rate became so slow that a junctional
escape beat appeared.
The possible causes of sinus rhythm with a slow heart
rate are summarized in Box 1.2.

Extrasystoles
Supraventricular extrasystoles, either atrial or junctional
(atrioventricular [AV] nodal), occur commonly in normal
people and are of no significance. Atrial extrasystoles (Fig.
1.7) have an abnormal P wave; in junctional extrasystoles
either there is no P wave or the P wave may follow the
QRS complex.

5
1 The ECG in healthy people

Fig. 1.5
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.6
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

6

Sinus tachycardia
NOTE
• Normal P–QRS–T waves
• R–R interval 500 ms
• Heart rate 120 bpm
Sinus bradycardia
NOTE
• Sinus rhythm
• Rate 44 bpm
• One junctional escape beat
Junctional escape beat
The ‘normal’ ECG 1
BOX 1.2 Possible Causes of Sinus Rhythm With a
Slow Heart Rate
• Physical fitness
• Vasovagal attacks
• Sick sinus syndrome
• Acute myocardial infarction, especially inferior
• Hypothyroidism
• Hypothermia
• Obstructive jaundice
• Raised intracranial pressure
• Drugs:
• beta-blockers (including eye drops for glaucoma)
• calcium channel blockers (e.g. verapamil)
• digoxin
• ibabradine
In healthy people, normal sinus rhythm may be
replaced by what are, in effect, repeated atrial extrasysto-
les. This is sometimes called an ‘ectopic atrial rhythm’ and
it is of no particular significance (Fig. 1.8).
Ventricular extrasystoles are also commonly seen in
normal ECGs (Fig. 1.9). Ventricular extrasystoles are
almost universal, but when very frequent they indicate
populations at increased risk and may merit further inves-
tigation (see Ch. 4, p. 101).
7
1 The ECG in healthy people

Fig. 1.7
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

Fig. 1.8
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

8
 The ‘normal’ ECG 1

Supraventricular extrasystole
NOTE
• In supraventricular extrasystoles the QRS complex and the
T wave are the same as in the sinus beat
• The fourth beat has an abnormal P wave and therefore an
atrial origin
The P wave
In sinus rhythm, the P wave is normally upright in all leads
except VR. When the QRS complex is predominantly down-
ward in lead VL, the P wave may also be inverted (Fig. 1.10).
In patients with dextrocardia the P wave is inverted
in lead I (Fig. 1.11). In practice this is more often seen if
the limb leads have been wrongly attached (Fig. 1.3), but
dextrocardia can be recognized if leads V5 and V6, which
normally ‘look at’ the left ventricle, show a predominantly
downward QRS complex.

Early abnormal P wave

Normal variant: ectopic atrial rhythm

NOTE
• Sinus rhythm
• Inverted P wave in leads II–III, VF, V4–V6
• Constant PR interval

Inverted P waves in lead II

9
1 The ECG in healthy people

Fig. 1.9
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

Fig. 1.10
I VR V1 V4

II VL V2 V5

III VF V3 V6

10
 The ‘normal’ ECG 1
If the ECG of a patient with dextrocardia is repeated
with the limb leads reversed, and the chest leads are
Ventricular extrasystole placed on the right side of the chest instead of the left, in
NOTE corresponding positions, the ECG becomes like that of a
• Sinus rhythm, with one ventricular extrasystole normal patient (Fig. 1.12).
• Extrasystole has a wide and abnormal QRS complex and A notched or bifid P wave (P mitrale) is the hallmark of
an abnormal T wave left atrial hypertrophy, and peaked P waves (P pulmonale)
indicate right atrial hypertrophy – but bifid or peaked P
waves can also be seen with normal hearts (Fig. 1.13) and
are not particularly clinically useful features.

Ventricular extrasystole

Normal ECG
NOTE
• In both leads VR and VL the P wave is inverted, and the
QRS complex is predominantly downward

Inverted P wave in lead VL

11
1 The ECG in healthy people

Fig. 1.11
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.12
I VR V1 V4

II VL V2 V5

III VF V3 V6

12
 The ‘normal’ ECG 1

The PR interval
Dextrocardia In sinus rhythm, the PR interval is constant and its
NOTE normal range is 120–200 ms (3–5 small squares of ECG
• Inverted P wave in lead I paper) (see Fig. 1.1). In atrial extrasystoles, or ectopic
• No left ventricular complexes seen in leads V5–V6
atrial rhythms, the PR interval may be short, and a PR
interval of less than 120 ms suggests pre-excitation (see
Figs 2.8, 2.9, 2.10).
A PR interval of longer than 220 ms may be due to
first degree block, but the ECGs of healthy individuals,
especially athletes, may have PR intervals of slightly longer
than 220 ms – which can be ignored in the absence of any
other indication of heart disease.

Inverted P wave and Persistent S

dominant S wave in lead I wave in lead V6

Dextrocardia, leads reversed

NOTE
• Same patient as in Fig. 1.11
• P wave in lead I upright
• QRS complex upright in lead I
• Typical left ventricular complex in lead V6

Upright P wave Normal QRS

and QRS complex complex in lead
in lead I V6

13
1 The ECG in healthy people

Fig. 1.13
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

Fig. 1.14
I VR V1 V4

II VL V2 V5

III VF V3 V6

14
 The ‘normal’ ECG 1

The QRS complex

The cardiac axis
Normal ECG
NOTE There is a fairly wide range of normality in the direction of
• Sinus rhythm the cardiac axis. In most people the QRS complex is tallest
• Bifid P waves, best seen in leads V2–V4 in lead II, but in leads I and III the QRS complex is also
• Peaked T waves and U waves, best seen in leads V2–V3 – predominantly upright (i.e. the R wave is greater than the
normal variants S wave) (Fig. 1.14).

Bifid P wave in lead V3

Normal ECG
NOTE
• QRS complex upright in leads I–III
• R wave tallest in lead II

15
1 The ECG in healthy people

Fig. 1.15

I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.16
I VR V1 V4

II VL V2 V5

III VF V3 V6

16
 The ‘normal’ ECG 1
The cardiac axis is still perfectly normal when the R
wave and S wave are equal in lead I: this is common in tall
Normal ECG people (Fig. 1.15).
NOTE When the S wave is greater than the R wave in lead
• This record shows the ‘rightward’ limit of normality of the I, right axis deviation is present. However, this is very
cardiac axis common in perfectly normal people. The ECG in Fig. 1.16
• R and S waves equal in lead I is from a professional footballer.
It is common for the S wave to be greater than the R
wave in lead III, and the cardiac axis can still be consid-
ered normal when the S wave equals the R wave in lead
II (Fig. 1.17). These patterns are common in obese people
and during pregnancy.
When the depth of the S wave exceeds the height of the
R wave in lead II, left axis deviation is present (see Figs
2.22 and 2.23).
Limb lead switches can sometimes be misinterpreted
as abnormalities of cardiac axis (see Fig. 1.3).

Normal ECG
NOTE
• Right axis deviation: S wave greater than R wave in lead I
• Upright QRS complexes in leads II–III

Dominant S wave
in lead I

17
1 The ECG in healthy people

Fig. 1.17
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.18
I VR V1 V4

II VL V2 V5

III VF V3 V6

18
 The ‘normal’ ECG 1

Normal ECG
NOTE
• This shows the ‘leftward limit’ of normality of the cardiac
axis
• S wave equals R wave in lead II
• S wave greater than R wave in lead III

S wave = R S wave > R

wave in lead II wave in lead III

Normal ECG The size of R and S waves in the chest leads

NOTE In lead V1 there should be a small R wave and a deep S
• Lead V1 shows a predominantly downward complex, with wave, and the balance between the two should change
the S wave greater than the R wave progressively from V1 to V6. In lead V6 there should be a
• Lead V6 shows an upright complex, with a dominant R tall R wave and no S wave (Fig. 1.18).
wave and a tiny S wave Typically the ‘transition point’, when the R and S waves
are equal, is seen in lead V3 or V4 but there is quite a lot of
variation. Fig. 1.19 shows an ECG in which the transition
point is somewhere between leads V3 and V4.
Fig. 1.20 shows an ECG with a transition point between
leads V4 and V5, and Fig. 1.21 shows an ECG with a transi-
tion point between leads V2 and V3.
The transition point is typically seen in lead V5 or even
S wave > R wave in lead V1 Dominant R wave in lead V6 V6 in patients with chronic lung disease (see Ch. 7), and
this is called ‘clockwise rotation’. In extreme cases, the
chest leads need to be placed in the posterior axillary line,
or even further round to the back (leads V7–V9) before the
transition point is demonstrated. A similar ECG pattern

19
1 The ECG in healthy people

Fig. 1.19
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.20
I VR V1 V4

II VL V2 V5

III VF V3 V6

20

Normal ECG
NOTE
• In lead V3 there is a dominant S wave
• In lead V4 there is a dominant R wave
• The transition point is between leads V3 and V4
Normal ECG
NOTE
• Dominant S wave in lead V4
• R wave just bigger than S wave in lead V5
The ‘normal’ ECG 1
may be seen in patients with an abnormal chest shape,
particularly when depression of the sternum shifts the
mediastinum to the left. The patient from whom the ECG
in Fig. 1.22 was recorded had mediastinal shift. An appar-
ent ‘clockwise rotation’ ECG pattern can sometimes arise
from lateral displacement of the ECG chest leads, particu-
larly in larger patients or by breast tissue.
Occasionally the ECG of a totally normal subject will
show a ‘dominant’ R wave (i.e. the height of the R wave
exceeds the depth of the S wave) in lead V1. There will
thus, effectively, be no transition point, and this is called
‘counterclockwise rotation’. The ECG in Fig. 1.23 was
recorded from a healthy footballer with a normal heart.
However, a dominant R wave in lead V1 is usually due to
either right ventricular hypertrophy (see Ch. 7) or a true
posterior infarction (see Ch. 6).
Excessive R wave voltages may be an indication of left
ventricular hypertrophy (see page 263). Provided that the
ECG is properly calibrated (1 mV causes 1 cm of vertical
deflection on the ECG), the limits for the sizes of the R
and S waves in normal subjects are usually said to be:
• 25 mm for the R wave in lead V5 or V6
• 25 mm for the S wave in lead V1 or V2
• Sum of R wave in lead V5 or V6 plus S wave in lead V1
or V2 should be less than 35 mm.
However, R waves taller than 25 mm are commonly seen
in leads V5–V6 in fit and thin young people, and are per-
fectly normal. Thus, once again, interpretation of these
‘limits’ depends on the clinical context. The ECGs in Figs
1.24 and 1.25 were both recorded from fit young men with
normal hearts.
21
1 The ECG in healthy people

Fig. 1.21
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.22
I VR V1 V4

II VL V2 V5

III VF V3 V6

22
 The ‘normal’ ECG 1

Normal ECG
NOTE
• Dominant S wave in lead V2
• Dominant R wave in lead V3
• The transition point is between leads V2 and V3

V7 Mediastinal shift
NOTE
• ‘Abnormal’ ECG, but a normal heart
• Shift of the mediastinum means that the transition point is
under lead V6
• Ventricular complexes are shown in leads round the left
V8 side of the chest, in positions V7–V9

V9

23
1 The ECG in healthy people

Fig. 1.23
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.24
I VR V1 V4

II VL V2 V5

III VF V3 V6

24
 The ‘normal’ ECG 1

Normal ECG
NOTE
• Dominant R waves in lead V1

Dominant R wave
in lead V1

Normal ECG
NOTE
• S wave in lead V2 is 36 mm

S wave > 25 mm in lead V2

25
1 The ECG in healthy people

Fig. 1.25
I VR V1 V4

II VL V2
V5

III VF
V3
V6

Fig. 1.26
I VR V1 V4

II VL V2 V5

III VF V3 V6

26
 The ‘normal’ ECG 1

The width of the QRS complex

Normal ECG The QRS complex should be less than 120 ms in duration
NOTE (i.e. less than 3 small squares) in all leads. If it is longer
• R wave in lead V5 is 42 mm
than this, then either the ventricles have been depolarized
from a ventricular rather than a supraventricular focus (i.e.
a ventricular rhythm is present), or there is an abnormal-
ity of conduction within the ventricles. The latter is most
commonly due to bundle branch block. An RSR1 pattern,
resembling that of right bundle branch block (RBBB) but
with a narrow QRS complex, is sometimes called ‘partial
right bundle branch block’ and is a normal variant (Fig.
1.26). An RSRV pattern is also a normal variant (Fig. 1.27)
and is sometimes called a ‘splintered’ complex.
In perfectly normal hearts the normal rhythm may be
replaced by an accelerated idioventricular rhythm, which
looks like a run of regular ventricular extrasystoles, with
wide QRS complexes (Fig. 1.28).

R wave > 25 mm in lead V5

Normal ECG
NOTE
• RSR1 pattern in lead V2
• QRS complex duration 100 ms
• Partial right bundle branch block pattern

RSR1 pattern and QRS complex 100 ms in lead V1

27
1 The ECG in healthy people

Fig. 1.27
I VR V1 V4

II VL V2 V5

III VF V3 V6

Fig. 1.28
I VR V1 V4

II VL V2 V5

III VF V3 V6

II

28
 The ‘normal’ ECG 1

Normal ECG
NOTE
• RSR1S1 pattern in lead V1
• Notched S wave in lead V2
• QRS complex duration 100 ms
• Partial right bundle branch block pattern

RSR1S1 pattern in Notched S

lead V1 wave in lead V2

Accelerated idioventricular rhythm

NOTE
• Sinus rhythm
• First and last beats are ventricular extrasystoles
• The fifth beat starts a run of ventricular rhythm at about
80 bpm

Idioventricular rhythm in lead II

29
Another random document with
no related content on Scribd:
leaves which had brought the pale-faced man to the luxurious sky
parlors of the “Elmleaf.” His merry face was soberly overshadowed.
With little formality, Jimmy Potter closed the door into the rooms
where the two women were engaged, and, not without a glance of
impelled admiration at the statuesque stenographer, broke into a
confidence which astounded Vreeland.
“Hear me out first, Vreeland,” he soberly said, “and then help me if
you can. I’m off on the steamer for Havre to-morrow. To join
Hathorn’s widow.”
Vreeland started, but Potter’s outstretched arm kept him in his chair.
“Poor Fred was drowned two days ago by the upsetting of a boat at
Cienfuegos. The fact is, the Cuban authorities were after him, and
so, he cleared out of Havana.”
“I’ve sent a good man down there to do all that may be done, in a
decent respect for his past. Mrs. Hathorn has just cabled for me. I
have had a long letter from her.
“Some damned traitor deliberately gave her the dead cross on the
‘Sugar Deal.’ She was trying to get Fred out of the Street. And so,
she plunged on fifty thousand shares of Sugar on this lying tip, came
out short, and has to pay, as Hathorn shoved all their customers’
money in to hold over his own huge, private gamble until the market
broke down to forty. It’s up to seventy-eight and there to stay. Now,
she wishes to make restitution to the men whom the firm robbed.
And I have to help her settle her own private losses.”
“Poor woman,” murmured Vreeland, with an agitation which did not
escape Potter. The little man was all broken up.
“See here, Vreeland!” cried Potter, “I have had a glimpse into a real
woman’s heart. This fatal quarrel with the Willoughby has wrecked
two lives. Hathorn believed Mrs. Willoughby to be invincible in the
Street.
“He tried to follow her game. She is reported to have dealt in Sugar
up to several millions.
“Do you suppose that she laid a trap for Hathorn’s wife to fall into?
Who gave her the false tips? I hope that the author of this misery will
roast in hell.”
“I know nothing. I am not in speculative stocks,” musingly said
Vreeland.
“Someone may have taken advantage of the Hathorns and lured
them on by pretending to give them Mrs. Willoughby’s game. I am
busied here now, half the day, with my own private matters.”
“It was soul-murder, whoever did it,” said Potter. “Alida Hathorn went
in nobly to help and save her husband. To aid him, to square him
with the Street and his firm, and then to take him forever out of the
turmoil and convoy him over to Europe. She has loads of money, you
know. But, the Ring was too much for him.
“He plunged, too, on her tip, and then came the crash, his flight, and
now his untimely death. It’s all due to the one who lured Alida
Hathorn on to ruin her husband. It was a fiend’s work.” A silence
reigned, a gloomy acquiescence.
Vreeland was moodily regarding the falling snow through the
darkened panes when Jimmy Potter sighed and said: “Well, it’s
good-by, old fellow. I’ve got an expert with Wolfe going over the real
honest debts.
“I shall stay over there, advise with Alida and see that the sufferers
get their money. For she has been a wifely sacrifice; she is high-
spirited and true, she outclassed Hathorn. Mrs. Willoughby set him
up, and then threw him down.
“His pride never got over her ruin of his firm’s reputation by drawing
all her business out.
“Of course, the society snakes who poisoned the young wife’s mind
brought on the social catastrophe. I would like to feel that Elaine
Willoughby did not betray that poor young woman. But I’ll square it
all by and by.”
“How?” eagerly demanded Vreeland. Potter was brave in a mad
resolve.
The young millionaire paused, hat and umbrella in hand. “I have
found a business in life at last. One that suits me.
“If Alida Hathorn has not money enough to square all the honest
claims, I have. For a year and a day from Hathorn’s death, I shall
marry her, and then give her a woman’s decent happiness.
“It was a false ambition that pushed Hathorn into her circle. He was
only a good-looking upstart, and never worthy of her.
“So, you can see all comes around to the man who waits.
“Now, I count on your sense of manliness to protect the name of
Fred Hathorn’s widow, the woman who will be my wife, for, with all
your money, you would not be in New York to-day, as you are, at the
top of the ladder but for Hathorn.
“You stand in his shoes up at Lakemere, here in the Circassia, and
you of all men, should be considerate to his memory.” The scheming
liar bowed his head in a speechless agitation.
Vreeland escorted his visitor to the stair. “If I need any private tip, I
may use you,” said Potter. “I’ll be at Hotel Vendôme, Paris, till I have
made her Mrs. Jimmy Potter, if we live.”
With a last touch of his old lightness, the champion of the absent
Alida whispered, “That’s a young goddess you have captured.”
Potter had observed the Bona Dea.
Vreeland frowned gravely as he followed the furtive gesture.
“Miss Garland has entire charge of all the books and records of my
private estate,” he coldly said.
“I am a man of system and order. The other little woman is my
private telegraph operator. She is a part of our ‘business force.’”
Vreeland affected the careworn millionaire.
“Ah, you don’t mix up the two affairs. Very good, very good,”
complacently said Potter as he disappeared, leaving Vreeland
startled. He bore away fruitful memories of Vreeland’s downcast
hesitation.
The hard-hearted schemer took a pull at the brandy bottle. “It was a
close shave,” he murmured.
“Alida Hathorn is game to the very last. She has not given him my
name, and now, as she will finally drift into this fortunate marriage,
the Lady of the Red Rose will be only a buried memory.
“I am safe, and he never will know. The lovely ‘Red Rose’ is only
another flower in le Jardin Secret.”
He realized, at last, that the daring imprudence of Alida Hathorn’s
visit was but a jealous wife’s device, at any risk, to break the lines of
her husband’s enemies.
“She got my secret far too easily,” he gloomily reflected, “and without
paying the price.
“I wonder if she was playing me as a lone fish,” he pondered—and
then a flash came to enlighten him.
“Could Elaine Willoughby fancy that the news of her plunging would
leak out and ruin them?
“By heaven! She may have crossed this gigantic trade by secret
orders to Endicott. Hathorn ruined, she may have no further use for
me.
“And if the Lady of the Red Rose should ever speak I would be
ruined, even held at arms length as I am.”
He shuddered under the curse of the burning words of that last
telegram.
“She believes me a liar and traitor to her, and I will never dare to
undeceive her.” He felt that he had missed the finest play of his life.
But the “special delivery” letter still stared him in the face. He
carelessly tore it open and then a smile wreathed his lips.
“To meet Senator Alynton, Senator Garston, and Miss Katharine
VanDyke Norreys at dinner.” He instantly wrote out and dispatched
his acceptance. A glow of joy lit up his anxious face.
“I must get Justine at work soon on my secret lines. I see it all.
These Senators are of the ‘Inner Guild,’ the true illuminati.
“Who the devil is this Garston—some Western fellow?”
A few moments’ reference gave him the news: “Senator-elect from
one of the newly knocked together Western States”—the “means to
an end” in balancing National elections. The trick of warring
plutocrats and democrats.
He paced the room in deep thought, after dispatching his reply. “The
battle will be on again soon. The Trust is reorganized and
conveniently removed to little Jersey. The courts have now done
their worst, and the small holders are all squeezed out.
“Now for a game of high ball. Yes, my lady, that’s your trick. A new
deal. And the beautiful Californian heiress is only a bright lay-figure.
“Your real hold on the Street is the secret chain linking these
statesmen, through you and Endicott, to the secret chiefs of the
Sugar Syndicate.
“I’ll get myself into your current, as a ‘transmitter,’ and you, Madame
Elaine, shall yet learn to bow and bend. The child, the secrets of this
dangerous partnership, the story of your past life, I can soon get it
all, bit by bit. And, then, marriage and ‘dominion over you.’ That’s my
game!”
There was an unpleasant menace lingering in the last words of the
departing Potter. Vreeland knew that should the generous-hearted
ex-banker, in time, marry Fred Hathorn’s widow, the few hundred
thousands lost in saving Hathorn’s personal honor would not in any
way impair their united estates. He lingered long on the subject. He
feared this new alliance.
“They might crush me, if they joined forces. The one danger is a
reconciliation with Mrs. Willoughby. I will see that this never occurs.”
And so, with a sense of defeat clinging to his past attempts, he
decided to use great care in approaching his proposed dupe, Miss
Romaine Garland.
For his patroness certainly was not wearing her heart upon her
sleeve now. Her private sorrows busied her more than the
confidential intimacy with her newest protégé.
“She could drop me, ruin me, or trap me as easily as she finished off
Hathorn,” he decided.
“And the hot-headed, daring young wife, desperate in her jealousy,
anxious to break Elaine Willoughby’s lines and guide her husband
into the heart of the Sugar forces, she had merely broken the
convenances, nothing more.
“For only a cur dare ever hint at the stolen visits. Club and coterie
would brand the man as a hound who dared to boast of such a
desperate confidence in a man’s honor.
“No. The Lady of the Red Rose, bright, daring and stormy-hearted
like many another fin de siècle New York wife, was safe.”
Safe by all the laws of manhood and honor. And, in all the gay life he
had led, he had only met the easy abandon of high life.
The loosening of restraint of a democratic luxury. He well knew that
the Dickie Doubledays and the Tottie Thistledowns did not weigh in
the scale against a real flesh and blood womanhood. They were only
bright, lurid beacons, warning signals on the seas of life, stranded on
the reefs of human weakness, and with shoals of foolish virgins
following on in their daring footsteps.
When he lifted his head, the stroke of twelve brought Miss Romaine
Garland, with bowed head, before him, awaiting her daily dismissal.
He had never dared to use the busy hours from nine to twelve for
any covert approach upon the stately girl’s confidence. There, too,
was the clear-eyed Mary Kelly.
The rapturous verdict of Jimmy Potter was confirmed as he glanced
at the young goddess, her brown hair rippling from a pure Greek
brow, her dark eyes dreaming under their lashes, and her pale,
proud face at rest, with all the untroubled peace of maidenhood.
In her plain, dark dress, her sculptured form was deliciously
intimated. Her voice, sweet and low as the breath of forest winds,
awoke his hungering curiosity. It was temps de relâche.
Here was the very chance to begin to mold her to his will. To awake
her latent love of luxury, to lead her out step by step into the
confidential delights of wine and song, and to find out the shady
places where Love lurks, an archer unawares. Yes. He would begin
to mold this woman to his will.
Vreeland desired to let the loneliness of a great city aid him in his
easy approach. And to hurry slowly and be wise. He had noted the
friendly cordiality of the two young women. “If the new assistant
would only play into his hands, and help to outwit the pale spy.
“If she can throw this little spy off her guard—if I can get them both to
begin to enjoy themselves a little, and then drop into an easy, hidden
intimacy with Miss Romaine, then my patroness’ little spy game here
will be useless.
“For, if that woman learned to love a man, she would go through fire
and water for him.”
The throbbing of his heart made his voice tremble, and the veiled
purpose of his crafty soul crept into his eyes, though they only rested
on her superbly molded arms and slender, delicate hands, when he
carelessly said: “If you would kindly leave me your private address,
Miss Garland, I might need it. There may be some extra call of duty. I
might wish to communicate with you.”
There was a slight flush upon her cheek as the delicate lips slowly
parted.
“I live at some distance, Mr. Vreeland, with private friends, and it
would be impossible for me to render you any other services than as
arranged. I have no one to escort me, and I never receive visitors.”
The voice was as cold as the glacier’s rills.
Her beauty shone out as pure as an Easter lily, when she simply
said: “Miss Kelly will, however, send any communication you might
have to make. I am an absolute stranger in New York. The
references which I gave Miss Marble are from old friends in Buffalo. I
can, however, at all times, stay as late as Miss Kelly does, on any
occasion when you may have overwork.”
The young Diana’s pure brow was loftily brave in its innocence.
Vreeland’s eyes hungrily followed her as she moved quietly away in
answer to his grave bow of dismissal.
“More time. More time,” he murmured. “If I could find some way to
gain her personal confidence. Flowers, books, little attentions, a
stray set of theatre or opera tickets. For she is, after all, only a
woman. Fit to reign, royal in youth, and serving without stooping.
“I must see Miss Marble. The ice once broken, perhaps—”
He mused long upon an ingenious plan to “brighten the life” of the
woman he would use as a tool. “Yes, it can be done, easily, through
the Marble.” And he knew that veteran traitress would aid him for
money.
The week before the day of Mrs. Willoughby’s ceremonial dinner was
wasted by Vreeland in some amateur detective work. Miss Justine
Duprez easily diagnosed the growing friendship of the two young
girls.
For Miss Garland’s sweet, tender face was already familiar in the
little household where Mary Kelly’s mother watched and wondered
from what fairyland this bright-faced nymph had descended.
A stout school lad of sixteen was an efficient home escort for the
young neophyte in New York, and pride filled the eyes of Mary
Kelly’s brother.
Vreeland felt all the growing charm of the steadfast girl’s influence,
her cultured manners, her dainty refinement and the rare delicacy of
her language and taste. He valued her as of superior clay.
“Not of common stock,” he murmured as he deftly trod along her
path, with a veiled impatience. He was deep now in the last details of
a plan which busied Justine Duprez, for the coming of the second
Senator, the open splendors of the grand dinner party as elaborated
by Justine warned him that if he would cut the secret channels so
vital to his success, he must bring the janitor and postal carriers of
the “Circassia” under control.
Justine, checking his headlong impatience, only smiled her velvety
smile and whispered, “Give me some money to hoodwink them a
little. Wait only for a few days, and trust to me. Have I ever failed
you?”
When the “rising and successful man,” Mr. Harold Vreeland, dressed
himself with unusual distinction for Mrs. Willoughby’s regal dinner
party of twenty, there was all the happiness of a new-born hope in
his heart. For he was nearly ready now “to move on the enemy’s
works.”
That experienced “broker in young womanly talent,” Miss Marble,
had earned herself a pretty diamond lace pin, and “an authorization
to proceed,” by her ingenious plan of drawing out “Miss Romaine
Garland.” The experienced lady had smiled at all his first crude
attempts.
“You were too abrupt. There is the awkward fact before her eyes
always, that you are her employer. She acts on the mere defensive.
“The proprieties you surely know. Now, you are far too young and
charming as a man,” she blushingly said, “to be a safe benefactor for
this glowing-hearted girl with her sweet, tender eyes.
“She is a rare beauty and frankly good, and untinged as yet with the
fires of Babylon. I have some showy friends of some influence, and,
as she trusts me blindly, I will ‘have warm-hearted civilities’ extended
to her.
“You will have her home address now, in return for my pretty pin.
Never go there. You would ruin all.
“But, sir, you shall be drawn in as a guest to our little friendly
coteries. She must be led into our allied camp gradually.
“You, by hazard, will appear as an old intimate, here and there, when
her shyness is worn off and, on that friendly and neutral ground, you
can soon warm the marble into life.” The Marble had a crafty and
glowing heart.
The sly woman smiled. “No lonely young woman can resist long-
continued and unobtrusive kindness. It always disarms. Let me have
the means to lead her along into little pleasures. Once the taste of
the easy evening outing life comes upon her, then, bit by bit, she will
be as wax in my hands. You can meet her, by chance, at the
theatres or operas when out with me. I will have a little supper given
at some friend’s home. We can drop off the friends one by one. I
cling to her.
“You can then drop me off, when we are sure that the taste of
pleasure is gently awakened, and you are free to then show her all
your generous liberality. Take her home to your daily life, then once
that the confidential relation is established—” Vreeland’s eyes
gleamed in a coming triumph. The way shone out, “straight and
sweet,” before him. “Miss Joanna, you are a good fairy, and a keen-
witted genius. I will give you carte blanche to lead her out along the
rosy path, step by step, and a path that leads always toward me.”
Mr. Harold Vreeland moved on serenely and laid his pitfalls for the
pure young girl, whom chance had thrown in his way, with no
compunction. In the blighted career of his own dishonored father, he
had only despised the weaknesses which led to failure.
He had seen the downfall of Hathorn without a throb of sympathy
and he resented the frank, honest predilection which was now
leading the warm-hearted Potter to screen Alida Hathorn from a mob
of cold-hearted “woman eaters” in honorable marriage.
Mean at heart, he even doubted the past life of the woman who had
lifted him up to luxury. He hated her now only that his charms of
person and manner had not brought her to his feet, a willing dupe.
“She seemed to be impressed at first,” he mused. “But the shock of
Hathorn’s cold abandonment in his little tiger cat wife’s jealous frenzy
seems to have turned her against man, for a time.
“But, let me only get a hold on her. I do not care to be the star actor
in a modern ‘Romance of a Poor Young Man.’ She shall not shake
me off.”
He plotted deliberately against her peace—his generous
benefactress. “First, the tapping of the private lines. Then, to mold
Romaine Garland to my will. If she does not yield to Joanna Marble’s
smooth ways, then out into the streets of New York.
“There are others, more complaisant; but to awaken those dark eyes
to pleasure’s glow. To have them quicken at my coming.”
It was with these “undreamed dreams” haunting him that Harold
Vreeland arrived, in sedate splendor, at the “Circassia,” where “the
feast was set” for Senator Alynton and that Western wonder of
recent occultation, Senator-elect James Garston.
In the kaleidoscopic splendors of the drawing-room, where manly
eyes gleamed upon the beauties of splendid womanhood, among
the fair daughters of Eve he missed that brilliant blonde heiress, Miss
Katharine VanDyke Norreys. A tap from Mrs. Volney McMorris’ fan
recalled him.
“I know that you are looking for her,” whispered the radiant duenna.
“Katharine is a sort of ward of Senator Garston. He is her trustee.
They all come together. I must have a word with you about poor—”
The entrance of Mrs. Elaine Willoughby brought the splendid circle
around her, there where gleaming lights and the breath of matchless
flowers, where diamonds and brightest eyes, where ivory bosoms
and shapely silver shoulders were mingling charms of a modern
Paradise of throbbing, hungry hearts.
Doctor Alberg’s gloved hand was resting in Vreeland’s palm—he was
whispering, “You and I and Justine must watch”—when the calm,
passionless face of Senator Alynton, with Miss Katharine Norreys on
his arm, appeared.
There was a hum of astonishment, of frank self-surrender to the
Occidental beauty’s charms as Alynton gravely presented a tall,
stately stranger, whose slightly silvered hair and chevalieresque
bearing recalled the “Silver King.”
“My friend, Senator James Garston,” began Alynton, but there was a
crowd of a dozen men eagerly stretching willing arms, as Elaine
Willoughby’s face contracted in a spasm of pain, and she fell
senseless into Doctor Alberg’s firm grasp. “Only the old heart
trouble. In five minutes madame will be herself,” suavely announced
the doctor. “Perhaps a bit too tightly laced,” he whispered to
Mrs. McMorris.
It was a stately function, the dinner, which proceeded in a solemn
splendor.
Senator James Garston was gravely attentive at the hostess’ left,
and only Vreeland knew when the lights were low that Garston had
whispered, “I must see you, at once.”
And with pale lips Elaine Willoughby had murmured, “At Lakemere,
and to-morrow.”
Justine had gained her long-needed clue.
 CHAPTER X.

AN INTERVIEW AT LAKEMERE—SOME INGENIOUS MECHANISM.

—“WHOSE PICTURE IS THAT?”

Harold Vreeland was seated in a blaze of light, in his own rooms at

four in the morning, anxiously awaiting a night visit from one who
might unravel the whole mystery while the lonely Elaine Willoughby
lay helpless in her secluded rooms, feebly struggling toward a return
of her self-control.
“What new devil’s jugglery is this?” muttered Vreeland, pausing in his
wolf stride. He carefully recalled every action of the newly-made
Senator and yet he was baffled at every turn. “Was the newcomer an
agent of a morose husband, an old lover, or an unwelcome
apparition from the clouded past?” He was baffled.
For, he began to realize how baseless were his meaner suspicions
of the past. There had been no unworthy love between Elaine and
Hathorn. The devil’s poison of slander alone had excited Alida’s
burning jealousy. She herself had only sought “a dead straight point”
in the daring visit to his rooms. Elaine’s record was clear so far. “Was
it only an old sorrow?” He pondered long. Even the pale-faced,
proud girl, whom he would trap, so far had hugged her honest
poverty to a stainless bosom.
“I’ve been dead wrong on Alynton’s game all along. There’s neither
an old love, nor a new intrigue, there,” he growled. “Justine has
clearly proved that. Their union is only to be termed, ‘strictly
business.’
“And the Senator’s frank, brotherly concern at Elaine’s sudden
illness went no farther than Colonel Barton Grahame’s sympathy,
Judge Endicott’s alarm, or my own undisguised interest. Here is a
new jack-in-the-box. I must watch Senator Garston.”
It had been a galling mortification to Vreeland in the past, that faintly
disguised disdain of Senator David Alynton, who had always
practically ignored him.
But, this new statesman, sturdy James Garston, had brought to their
meeting an unfeigned western bonhomie.
The newcomer had sought him out eagerly. He had drawn the
younger man aside, in a lull of the entertainment.
“We must meet and talk over western matters; we have the world’s
coming treasury out there,” largely remarked the new Senator-elect.
“I am housed at the Plaza, to be near Miss Norreys, who is at the
Savoy. I shall stay here a few days, and, we will have a luncheon
together.”
In fact the acute Mrs. Volney McMorris had very deftly arranged it,
for she was eager to matronize the resplendent Miss Norreys, to
bask in the smile of this rising financial sun, and to have her own
private chat with the young Fortunatus about the vanished Lady of
the Red Rose. Her prompt social fastening upon Mrs. Willoughby,
was only a grim proof that “the one who goes is happier than the one
that’s left behind.”
The new Senator’s round bullet-head, his curved beak-like nose, his
uncertain gray eye and unsmiling lips marked him as a man of
power.
He bore in every movement the badge of hard-won success.
His fifty-one years had marked him lightly, and, lawyer, mine owner,
and capitalist, he was riding into the Senate on a chariot with golden
wheels. It is the West that holds now the American sceptre.
Vreeland had watched Garston keenly at the dinner and noted his
poised manner, his brilliant flashes of silence, and the grave,
undisturbed courtesy of his demeanor toward the marble-faced
hostess. “A man of a level head,” was Vreeland’s verdict. And he
tried to read the secret of Garston’s imploring glances.
There had been no lingering cloud over the table, and no shade of
Banquo was evoked to chill the later merriment. Love, veiled and
unveiled, deftly footed it, among the revelers, and, only Doctor
Alberg’s steady eyes, anxiously fixed upon his “star” patient, proved
that but one, besides Vreeland, realized the desperate battle against
Time which Elaine Willoughby was fighting out to the last. The
egoistic revelers imagined their hostess’ seizure to be a mere
passing weakness. They all knew the strain of the exhausting New
York season.
“Charming woman, our hostess,” frankly remarked Senator Garston
to Vreeland. “Type all unknown to our modest Marthas of the
Occident. Here in America, our women will soon be crowned
queens, if I may trust to the ‘tiara’ bearing stories of the society
journals.” And a casual remark from Vreeland brought out the
admission that Senator Garston had never before met the hostess.
“It was to my colleague, Alynton, that I owe the honor of this
presentation,” said the newly-made toga wearer. “And, as
Mrs. Willoughby has been so kind to my ward, Miss Norreys, in this
new acquaintance, both pleasure and duty join hands.”
But, the startled Vreeland, pacing his silent room had several times
exclaimed, in his lonely rounds while waiting for Alberg, “James
Garston, you are a cool-headed, thorough-paced liar! I will trace you
back, my occidental friend, only to find ‘the wires crossed,’
somewhere in the past, and, from you, I will yet wrench the secret of
Elaine Willoughby’s early life. Her child! Yes,” he cried, “It might well
be.” He was thrilling in every fibre, for, in the dressing room, Justine
had stolen to his side whispering:
“Doctor Alberg has sent for a trained nurse to help me watch with her
to-night. Be on your guard.
“When this new Senator had made his adieu, I was hidden behind
the curtain in the long hall. I saw him neatly drop his glove, as if by
accident. Alynton and that tall golden-haired girl were waiting outside
as he stole back.” The French woman fairly hissed, “He is the man to
fear. I am sure they are old lovers. For, he caught her by both hands
and fairly devoured her with his eyes.
“‘To-morrow, alone, at Lakemere,’ she said. Voilà! Milady. Just a
woman, like the rest of us.”
“Justine, that paper, the one in her corset. A thousand dollars for a
copy of it.”
“I will get it to-night!” the velvet-eyed spy cried.
“Go now. You will hear from me soon. Don’t leave your room for a
moment, and, gare la Kelly. She reports daily on you to our full-blown
ingenue. Whatever turns up, you will surely hear from me. I’ll earn
your money yet.”
It was five o’clock when the haggard German physician crawled up
Vreeland’s stair. He was worn and exhausted.
“I’ve had a night of it,” he savagely cried, “give me a glass of real
brandy. No slops. That poor devil of a woman has had fainting fits
one after the other. I’ve now got Martha Wilmot, my only really
reliable nurse, watching her. The devil of it is, Madame will go up to
Lakemere at ten o’clock, and she vows she will, alone. The house
there is shut up. It is not even properly warmed. She will come back,
and have a relapse, but what can I do. She has an iron will.”
The angry Teuton drank a second dram and then relapsed into a
sullen silence.
“Alberg, my boy, you are a good doctor, but, you don’t know women,
only your blue-eyed, clumsy frauleins, over there. This American
woman is made of fire and flame. Tell me, what sort of a person is
your nurse, Wilmot?”
“She’s a good one—an ‘out and outer.’ She goes home to England
next week. She has some ideas of her own to work out over there.”
“Tell that smart woman to slip down here and see me before our
patient comes back. I’ll be here from four to seven to-day. And, mind
that you put her ‘dead on’ to me, as the holder of a hundred pound
note for her.”
“Good,” grunted Alberg.
“And, now, my son of Galen, what was it that upset
Mrs. Willoughby?” Vreeland was eagerly studying the German’s
face.
“The old thing. She has raved all night about her child. I only brought
her out of the attack with the strongest anti-spasmodics that man
dare to use, short of clear cold murder. It’s a terrible risk,” sighed
Alberg.
When Doctor Hugo Alberg left the Elmleaf, he was under the spell of
his lying coadjutor, and richer by a few hundred dollars. “This fellow
must never even lift the veil of the Temple,” muttered Vreeland. “Only
trust to Justine. Only Justine,” he cried, as he threw himself down to
sleep, after ordering the wondering Bagley to send Miss Kelly home
on her arrival, and also that dark-eyed enigma, Miss Garland. He
needed solitude.
“I am ill, and, must have a long sleep. You can take a day off
yourself. Clear out for the day and don’t let me hear a single footfall
about my rooms,” were the staccato injunctions of the excited
schemer.
“If that nurse only comes,” he murmured, as he closed his weary
eyes.
It was eleven o’clock when a light step echoed in Vreeland’s hall,
and the swishing sound of Justine Duprez’s robe made the banker
leap to his door. The French girl had her will at last. She stood amid
the splendors of Vreeland’s veiled Paradise—her lover’s home.
She cried out in glee, “Thank God! She is out of the way. I came
here from the train. She absolutely forbade me to go with her. I have
had the janitor’s boy watching all the trains. This Senator Garston
went up the road an hour ago. The smart boy helped us last night in
the cloak rooms, and, so, they are off alone together, up there, to-
day.”
Vreeland’s eyes blazed in a mighty triumph. “To-night, you must help
me, Justine,” cried the eager schemer.
“See here. I already have stolen what you want,” cried Justine. “You
said it was worth a thousand dollars. I copied even every mark on
the hidden papers, and, I went over it a dozen times, while the new
nurse was with her. Madame was insensible, and, I had time to work
in safety. What will you give me, now?”
She was not listened too, for with a ferocious joy, Vreeland leaped
up, crying, “My God! I have her now. They are all in the hollow of my
hand.”
He had glanced over the list of names written there, and a row of
figures with some characters added, which seemed to glow before
him in living flame.
He drew the Frenchwoman to his side, and there dashed off a check
to his own order and carefully indorsed it.
“There’s your money, you jewel,” he gasped. “Listen. To-night, when
she comes back, or to-morrow night, if she is again under the
nurse’s watch, you must steal that envelope again. I will be waiting
outside the Circassia, and stay all of both nights till I get the original
paper that you copied. Put a simple sheet of blank paper back in the
envelope and close it up. Sew it up again in the same place in her
corset.
“We will leave that to be stolen by the nurse, Martha Wilmot. She will
know what to do with it.
“She clears out of here for Europe in a few days. She will keep well
out of Mrs. Willoughby’s way. And, so the Madame will think that she
has been robbed by our sly, English friend. I will pay the nurse well
and help her away. But that original paper must come to me.
“Be sure to leave Mrs. Willoughby’s garments where the nurse could
easily reach them—no one shall suspect you. I’ll hold you safe—it is
our own secret. Alberg will, of course, raise a devil of a row about the
nurse clearing out, and robbing him, but only after she is gone.”
“And my mistress. Mon Dieu! But, how I fear her!” faltered the
trembling Justine.
“Nonsense. The woman comes down here to-day. She will get her
orders from me. You can put this blank envelope with its paper filling
back in the corset, so that Mrs. Willoughby will feel that something is
there. And, now, about tapping her telephone and telegraph wires.”
Justine had finished a glass of wine when she sprang to her feet.
“To-day is the day of days. The janitor, August Helms, is all ready to
tie on the wires to tap her telegraph and telephone. Come up to the
Circassia at noon. I will take you into his room by the back way. He
has arranged all with Mulholland, one of the two letter-carriers, to
always delay Mrs. Willoughby’s mail by one delivery. Mulholland can
hold them all for himself to handle. And, Helms, in his room, will then
open and copy any we need. He is a German adept in letter
opening.”
“You are a genius, Justine,” cried Vreeland. “You can bring Helms
down to your own room in South Fifth Avenue and there you and I
together can square up with him. We must be two to his one. This is
the very day of days while she is fondly lingering at Lakemere with
her own oldest lover.
“And now, my girl, take a good look around my den and then get out
of here. It is too dangerous for us.
“For, you must never come here again. The janitor has sharp eyes.”
“Yes, and, the new ‘Mees Gairland’ is many evenings now, with that
little Kelly devil. Look out for them both. You can only trust me,”
nodded Justine, as she fled away, whispering, “I will come down into
the court of the Circassia and meet you, in the entrance, as if by
hazard at noon precisely. All you have to do is to silently follow me. I
will have that paper by midnight if I live and the nurse shall have the
blame.”
The rooms echoed to the laughter of hell as Vreeland’s fiery devil
whispered, “Victory!” He had at last solved the mystery of a
“business syndicate” which made him tremble as he feared its name
might escape his lips. The copied paper gave a list of names whose
publication would shake a nation’s counsels, and Garston’s name
was there.
So, tiger-like and triumphant, he waited for the hour to go and
arrange for his secret stealing of his dupe’s messages.
And, far away, at lonely Lakemere, where the trees now gleamed like
ghastly silver skeletons of summer’s glories, the winds wailed around
the silent mansion where Elaine Willoughby stood face to face with
the man who had come out of her dead past, an apparition as grim
and awful to her as the rising of the sheeted dead.
It was the struggle to the death of two proud and world-hardened
hearts. The secret of her blighted youth was face to face with her
now. And, the shadow of a crime hung menacingly over James
Garston, the toga wearer. A statesman of a clouded past—a past
known only to the defiant woman facing him on her own battle-
ground.
“I find you here under a stolen name, facing the world, as a living lie.”
The woman’s scornful lips had lashed into his quivering heart.
Garston, bold-brave, reckless now with a mad tide of desire
sweeping over his reawakened heart, had seized her hands. He
cried, passionately: “And, I find my lost wife, the mother of our child,
here, a lovely, and a glowing truth.”
When he would have drawn her to him, she flung him off and
dropped, a shaken Niöbe, into a chair, with her stormy tears raining
over her beautiful, pallid face. That single word, “child,” had
disarmed her rising anger. For, she was facing one who knew all of
the sealed past.
“My child, my child,” she sobbed.