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ELSEVIER
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St. Louis, Mbsouri 63043

ECGt MADE EASY, SIXTH EDITION ISBN: 978-0-32340130-2

Copyright c 2018, lllsevier IDe. All r!pta raene4.

Prnloue e4itloall copyrlpted 2013,2011, 2006, 2002, uull995.

No part ofthil publication may be reproduced or transmitted in any form or by any mean1, electronk or mechani-
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This book and the lndlvldual contributl01111 contained In It are protected Wlder copyright by the Publilher (other
than u may be noted herein).

Notices

Knowledge and best practice in this field aR constantly changing. N new research and experience broaden
our undemanding, changes in research method.t, profesrional practices, or medical treatment may become
neceuary.
Practitioner~ and researchers must alwaya rely on their own aperlence and knowledge In evaluating and
uaing any Information, methods, compound&, or aperlmentl described herein. In usiDg tuc.h information or
method. they should be mindful of their own takty and the takty of others, including parties fur whom they
have a professional Rtpoll8ibility.
With respect. to any drug or pharmaceutical pmduct& ident:ified. reader• are adviled to check the mo1t
cun~nl information provided (i) on procedURS fealuRd or (ii) by the manufacturer of each product to be
administered. to verify the .recommended dose or formula, the method and duration of adminiltration, and
contnindlcatiOIIJ. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnose~, to determine doaget and the belt t.reatment for each individual patienl, and
to take all appropriate sarety precautionl.
To the fulli:st ment of the law, neither the Publisher nor the alrthon, contributors, or editor1, UNme
any liability fur any injury and/or damage to peraom or property u a matter of produculiabllity, nesJigence
or otherwile, or from any uae or operation of any method&, product., imtruction1, or ideu contained in the
m:rterial herein.

Name.: Aehlert, Barbara, author.

Title: ECGa made easy I Barbara Aehlert, MSEd, BSPA, RN.
Description: Sixth edition. I Phoenix, Arizona : Southwest EMS Education,
Inc., [2018liindudes blhllographical refuences and lnda. I
Identifiers: LCCN 2017015081 (print) I LCCN 2017026543 (ebook) I ISBN
9780323479059 () I ISBN 9780323401302 (pbk. : a1k. paper)
Subjecu: LCSH: Electrocardiography--Handboob. manuals. etc.
Cl.ulifi.c:ation: LCC RC683.5.F.5 (ebook) I LCC RC683.5.E5 A39 2018 (print) I
DDC 616.1/207547--dc23
LC record available at httpt:!/ka1loc.gov/2017015081

Executive Contel!t Stmteglst: Sandra Clark

Content Developmettt SpeclalUU: Laura SeltlrtiMelissa. Kinsey
Publishing Semcu Manager. Deepthi Unni
SenWr Project MaMpr. Umarani Na1arajan
~ Dirmton: Brian Saliabury
Worktng together
to grow l!b-r.arLC'~ Li1
Printed in Canada
de•n:l oping: cnuntrm(:~

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

Many ye.ars ago, as a green but enthusiastic nurse preparing to shift from medical-surgical nursing
to critical care, I signed up for a course in basic ECG recognition. It was an intimidating experi-
ence. My i.nst:ructor was extremely knowledgeable and kind. and I studied diligently throughout
the course, yet I struggled to crack the code of heart rhythm interpretation. To make matters
worse, I couldn't find any resources in which these complex concepts were presented in a practi-
cal, useful way. Although I passed the course. I decided to repeat it a few months later because I
simply coulchlt recall and apply the infonnation I needed to help my patients.
After successfully completing the second course, I promised myself that I would someday
present these concepts in a simpler way. 'Ihat promise became my life's work. Ever since then,
I have been looking for better ways in which to present the skill of basic ECG recognition to those
who will apply that knowledge every working day:
• Paramedics
• Nursing and medical students
• ECG monitor technicians
• Nurses and other allied health personnel world.ng in emergency departments, critical care
units, postanesthesia care units, operating rooms, and telemetry units
'!his book can be used alone or as part of a formal course of instruction in basic dysrhyth-
mia recognition. 1he book'• content focuses on the essentials of ECG interpretation. Each ECG
rhythm is described and accompanied by a sample rhythm strip. 1hen the discussion turns to
possible signs and symptoms related to each rhythm and. where appropriate, current recom-
mended treatment. At the end of each chapter, additional rhythm strips and their description.s are
provided for practice. (All rhythm strips shown in this text were recorded in lead n unless other-
wise noted.) 1he Stop 8c Review exerci!es at the end of each chapter are self-usessment activities
that allow you to check your learning.
In addition, resources to aid the in.stru.ctor in teaching this content can be found on Evolve at
http://evolve.elsevier.com/Aehlert/ecgl. 1hese resources include:
• Image Collection
• PPTSlide.
• PPT Practice Slides
• TEACH2.4
• Test Bank
I have made every attempt to supply content consistent with current literature, including cur-
rent resuscitation guidelines. However, medicine is a dynamic field. Recommendations change as
medical research evolves, technology improves, and new medications, procedures, and devices
are developed. As a result, be •ure to learn and follow local protocols as defined by your medi-
cal advisors. Neither I nor the publisher can assume responsibility or liability for loss or damage
resulting from the use of information contained within.
I genuinely hope this book is helpful to you, and I wish you success in your studies and clinical
practice.
Best regards,
Barbara Aehlert

iii
I would like to thank the manuscript reviewers foc their commenb and suggestiom. Areu of this
text were rewritten, reorganized, and clarified because of your effom.
I would also like to thank the following health care professionals, who provided many of the
rhythm strips used in this book: Andrew Baird, CEP; James Bratcher; Joanna Burgan, CEP; Holly
Button, CEP; Gretchen Chalmers, CEP; 'Ihomas Cole, CEP; Brent Haines, CEP; Paul Honeywell,
CEP; Timothy Klatt. RN; Bill Loughran. RN; Andrea Lowrey, RN; Joe Martinez, CEP; St.ephanos
Orphanidis, CEP; Jason Payne, CEP; Steve Ruehs, CEP; Patty Seneski, RN; David Stockton, CEP;
Jason Stodghill, CEP; Dionne Socie, CEP; Kristina Tellez, CEP; and Fran Wojculewicz, RN.
A special thanks to Melissa Kinsey for her humor, guidance, advice, and impeccable attention
to detail throughout this project.

iv
 To

Deepak C. Patel, MD

whose knowledge, humor, and genuine compassion for his

patients are unparalleled.
Krlaten Bon:IWt, llN, MSN, PNP, Nll-P, CPN BiB Miller
Care Coordinator Paramedic Crew Chief
Cincinnati Childrms Hospital Medical Center St. Louis Fire Department-HEMS
Cincinnati, Ohio St. Louis, Missouri

Joshua BorkoU:.y, BS, pp.c Mark.Nootena, MD, PACC

EMS Education Manager Cardiologist. Private Practice
University of Cincinnati College of Medicine Munster, Indiana
Cincinnati, Ohio
Ruth C. Tamulonis, MS, RN
Angela McConachie, DNP, MSN-PNP, RN Nursing Professor
Assistant Professor Yuba College
Goldfarb School ofNursing at Barnes-Jewish College Marysville, California
St Louis, Missouri

vi
Barbara Aehlert, MSBd, BSPA, RN, has been a registered nurse for more than 40 years. with
clinical experience in medicallsurgical nursing. critical care nursing, prehotpital education, and
nursing education. Barbara i.s an active CPR and Advanced Cardiovascular Life Support (ACLS)
instructor with a special interest in teaching basic dysrhythmia recognition and ACLS to nurses
and paramedics.

vii
1 ANATOMY AND PHYSIOLOGY, 1
Location. SJu, and Shape of the Heart. 2
Surfaca of the Heart. 2
Coverinp of the Heart, 2
Structure of the Heart, 5
Layers of the Heart WalL 5
Heart Chambers, 6
Heart Valves, 8
The Heart's Blood Supply, 11
The Heart's Nerve Supply, 16
The Heart aa a Pump, 19
Cardiac Cycle, 19
Blood PreS3Ul't, 20
R£ferenca, '1.7
2 BASIC ELECTROPHYSIOLOGY, 28
Cardiac Cella, 30
Types of Cardiac Cells, 30
Propertia of Cardiac Cells, 30
Cardiac Action Potmtial, 30
Polarization, 31
Depolarization, 31
Repolarization, 32
Phases of the Cardiac Action Potential, 32
Refractory Periods, 34
Conduction Syatem, 35
Sinoatrial Node, 35
Atrioventricular Node and Bundle, 37
Right and Left Bundle Branches, 38
Purkinje Fibers, 38
Cauaea of Dyarhythmiaa, 39
Disorders of Impulse Formation, 39
Disorders of Impulse Conduction, 39
The Ela:trocardiogr, 41
Electrodes, 41
Leads, 42
Ambulatory Cardiac Monitoring, 46
Blectrocanliopaphy Paper, 47
Waveforms, 48
Segments, 53
Intervals, 55
Artifact. 56
Symmatic Rhythm J:nterpretation. 57
Asseas Regularity, 57
Asseas Rate, 58
Identify and Examine Waveforms, 60
Asseaslntervals and Examine Segments, 60
Interpret the Rhythm, 60
Re&renca, 74
viii
3 SINUS MECHANISMS, 78
Introdudlon. 76
Sinua Rhythm, 77
How Do I Recognize It? 77
Sinua Bradycardia. 78
How Do I Recognize It? 78
What Causes m 78
What Do I Do About It? 79
Sinua Tadlyardia, 80
How Do I Recognize It? 80
What Causes It? 80
What Do I Do About It? 81
Sinua Arrbytbmia, 81
How Do I Recognize It? 81
What Causes It! 81
What Do I Do About It? 82
Sinoatrial Block. 82
How Do I Recognize It? 82
What Causes It? 82
What Do I Do About It? 83
Sinua Arrest, 83
How Do I Recognize It? 83
What Causes It? 83
What Do I Do About It? 84
Referencea,IOI
4 ATRIAL RHYTHMS, 102
Introduction, 103
Atrial Dyar.bythmiaa: Mech.aDi~ms, 103
Abnormal Automaticity, 103
Tnggered Activity, 103
Reentry, 104
Premature Atrial Compleea, 104
How Do I Recognize It? 104
Noncompensatory versus Compensatory Pause, 105
Aberrantly Conducted Premature Atrial
Complexes, 106
Nonconducted Premature Atrial Complexes, 106
What Do I Do About Them? 107
Wuuleriq Atrial Pacemaker, 107
How Do I Recognize It? 107
What Causes It? 107
What Do I Do About It? 107
Mal.tifoc:al Atrial Tachycanlia, 108
How Do I Recognize It? 108
What Causes It? 108
What Do I Do About It? 108
 Contents

Supraventricular 'Thchycardia, 108 What Causes It? 177

Atrial Tachycardias, 109 What Do I Do About It? 177
Atrioventricular Nodal Reentrant Tachycardia, 113 ~(CanUa~S~).177
Atrioventricular Reentrant Thchycardia, 114 How Do I Recognize It? 177
Atrial Flutter, 117 What Causes It? 178
How Do I Recognize It? 117 What Do I Do About It? 178
What Causes It? 118 References, 193
What Do I Do About It? 118
Atrial Fibrillation, 119
How Do I Recognize It? 119 7 ATRIOVENTRICULAR BLOCKS, 194
What Causes It? 121
What Do I Do About It? 121 Introduction, 194
References, 140 First-Degree Atrioventricalar Block, 195
How Do I Recognize It? 195
What Causes It? 196
5 ~UNCTIONAL RHYTHMS, 141 What Do I Do About It? 197
Second-Degree Atrioventricular Blocks, 197
Introduction, 141 Second-Degree Atrioventricular Block Type I, 197
Premature Juncticmal Compleus, 142 How Do I Recognize It? 197
How Do I Recognize 1hem~ 142 What Causes It? 198
What Causes 1hem? 143 What Do I Do About It? 199
What Do I Do About Them? 143 Second-Degree Atrioventricular Block Type ll, 199
Junctional Escape Beau or Rhythm, 144 How Do I Recognize It? 199
How Do I Recognize It? 144 What Causes It? 200
What Causes It? 145 What Do I Do About It? 200
What Do I Do About It? 146 2:1 Atriovmtricalar moa, 200
Accelerated Junctional Rhythm, 146 How Do I Recognize It? 200
How Do I Recognize It? 146 Advanced Second-Degree Atriovent:rkular Block. 201
What Causes It? 146 'Ihird-Degree Atrioventricu1ar Block, 202.
What Do I Do About It? 146 How Do I Recognize It? 202
Junctional Tachyardia. 146 What Causes It? 203
How Do I Recognize It? 146 What Do I Do About It? 203
What Causes It? 147 Reference8, 221
What Do I Do About It? 147
References, 164
B PACEMAKER RHYTHMS, 222

6 VENTRICULAR RHYTHMS, 165 Pacemaker Systema. 223

Permanent Pacemakers and hnplantable Cardioverter-
Introductlon,166 Defibrillators, 223
Premature Ventricular Complexes, 166 Temporary Pacemakers, 224
How Do I Recognize 1hem~ 166 Pacing Lead Symms, 225
What Causes 1hem? 170 Padng Chamben and Modes, 226
What Do I Do About Them? 170 Single-Chamber Pacemakers, 226
Ventricular .Escape Beats or Rhythm,170 Dual-Chamber Pacemakers, 227
How Do I Recognize It? 170 Biventricular Pacemakers, 227
What Causes It? 172 Fixed-Rate Pacemakers, 227
What Do I Do About It? 172 Demand Pacemakers, 227
Accelerated Idlovmtrl<:Ular :Rhythm. 172 Pacemaker Codes, 228
How Do I Recognize It? 172 Pacemaker Malfunction.l28
What Causes It? 172 Failure to Pace, 228
What Do I Do About It? 173 Failure to Capture, 229
Ventricnlar Tachycardia, 173 Failure to Sense, 230
How Do I Recognize It? 173 Analyzing Pacemaker Fund:ion on the ECG, 230
Ventricular Fibrillation, 176 Reference., 240
How Do I Recognize It? 176
 Contents

9 INTRODUCTION TO THE 12-LEAD 10 POSlTEST, 278

ECG, 241
Introduction, 141
Layout of the 12-Lead Electrocardiogram, 242 INDEX, 321
Vedors,242
Axis,243
.Acute Coronary Syndromes, 244
Anatomic Location of a Myocardial Infarction, 246
Intraventricular Conduction Delays, 254
Structures of the Intraventricular Conduction
System,254
Bundle Branch Activation, 254
How Do I Recognize It? 254
What Causes It? 257
What Do I Do About It? 257
Chamber Enlargement, 257
Atrial .Abnormalities, 258
Ventricular Abnormalities. 259
Electrolyte Disturbances, 260
Sodium, 261
Potassium, 261
Calcium, 262
Magnesium, 263
ADalyzing the 12-Lead EledJ:ocanUogram, 263
References, 277
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Describe the location of the heart.
2. Identify the surfaces of the heart.
3. Describe the structure and function of the coverings of the heart.
4. Identify the three cardiac muscle layers.
5. Identify and describe the chambers of the heart and the vessels that
enter or leave each.
6. Identify and describe the location of the atrioventricular and semilunar
valves.
7. Explain atrial kick.
8. Name the primary branches and areas of the heart supplied by the
right and left coronary arteries.
KEY TERMS
acute coronary syndrome (ACS): A term used to referto distinct
conditions caused by a similar sequence of pathologic events-
a temporary or permanent blockage of a coronar_y artery. These
conditions are characterized by an excessive dem nd or inadequate
supply of oxygen and nutrients to the heart muscle associated
with plaque disruption, thrombus formation, and vasoconstriction.
ACSs consist of three major syndromes: unstable angina, non-
ST-elevation myocardial infarction, and ST elevation myocardial
infarction.
afterload: The pressure or resistance against which the ventricles must
pump to eject blood.
angina pectoris: Chest discomfort or other related symptoms of sudden
onset that may occur because the increased oxygen demand of the
heart temporarily exceeds the blood supply.
apex of the heart: Lower portion of the heart that is formed by the tip of
the left ventricle.
atria: Two upper chambers of the heart (singular, atrium).
atrial kick: Blood pushed into the ventricles because of atrial contraction.
atrioventricular (AV) valve: The valve located between each atrium
and ventricle; the tricuspid separates the right atrium from the right
ventricle, and the mitral (bicuspid) separates the left atrium from the
left ventricle.
atypical presentation: Uncharacteristic signs and symptoms perceived
by some patients experiencing a medical condition, such as an ACS.
9. Define and explain acute coronary syndromes.
10. Discuss myocardial ischemia, injury, and infarction, indicating which
conditions are reversible and which are not.
11. Compare and contrast the effects of sympathetic and parasympathetic
stimulation of the heart.
12. Identify and discuss each phase of the cardiac cycle.
13. Beginning with the right atrium, describe blood flow through the
normal heart and lungs to the systemic circulation.
14. Identify and explain the components of blood pressure and cardiac
output.
base of the heart: Posterior surface of the heart.
blood pressure: Force exerted by the blood against the walls of the arter-
ies as the ventricles of the heart contract and relax.
cardiac output (CO): The amount of blood pumped into the aorta each
minute by the heart; defined as the stroke volume multiplied by the
heart rate.
chordae tendineae (tendinous cords): Thin strands of fibrous connec-
tive tissue that extend from the AV valves to the papillary muscles that
prevent the AV valves from bulging back into the atria during ventricular
systole (contraction).
chronotropy: A change in (heart) rate.
diastole: Phase of the cardiac cycle in which the atria and ventricles relax
between contractions and blood enters these chambers. When the term
is used without reference to a specific chamber of the heart, ventricular
diastole is implied.
dromotropy: Refers to the speed of conduction through the AV junction.
dysrhythmia: Any disturbance or abnormality in a normal rhythmic pat-
tern; any cardiac rhythm other than a sinus rhythm.
ejection fraction: The percentage of blood pumped out of a heart cham-
ber with each contraction.
endocardium: Innermost layer of the heart that lines the inside of the
myocardium and covers the heart valves.
epicardium: Also known as the visceral pericardium; the external layer of
the heart wall that covers the heart muscle.
1
 Chapter 1 Anatomy and Physiology
hBart failure: Acondition In whlctl the heart Is unable tD pump enough
blood to meet the metabolic needs of the body; It may result from any
cond~ion that impairs preload, afterload, cardiac contractility, or heart
rare.
inDtropy: Refers to a change in myocardial contractility.
ischemia: Decreased supply of oxygena1ed blood tn a body part or organ.
mediastinum: Middle area of the thoracic cavity; contains the heart, great
vessels, trachea, and esophagus, among other structures; extends from
the sternum to the vertebral column.
mltochondrta: The energy-producing parts of a cell.
mvocardlallnfarctlon (M~: Death of some mass of the heart muscle
caused by an Inadequate blood supply.
mvocardlum: Middle and thickest layer of the heart; contains the cardiac
muscle fibers that cause contraction of the heart and contal ns the
conduction system and blood supply.
myofibril: Slender striated strand of muscle tissue.
papillary muscles: Muscles attached to the chordae mndineae of the AV
valves and the ventricular muscle of the heart that help prevent the AV
valves from bulging too far intn the abia.
pericardium: A double-walled sac thai erdoses the heart and helps
protect It from trauma and Infection.
peripheral resistance: Resistance to the flow of blood determined by
blood vessel diameter and the tone of the vascular musculature.
preload: Force exerted by the blood on the walls of the venb1cles at the
end of diastole.
LOCATION, SIZE, AND SHAPE
OFTHEHEART
[Oblectlve 1]
The heart is a hollow muscular organ that lies in the space
between the lungs (i.e., the mediastinum) in the middle of
the chest (Pig. 1.1). It sits behind the stemwn and just above
the diaphragm. About two thirds of the heart lies to the left
of the midline of the stemwn. The remaining third lies to the
right of the sternum.
The adult heart is about 5 inches ( 12 an) long, 3.5 inches
(9 em) wide, and 2.5 inches (6 em) thick (Fig_ 1.2). It typically
weighs between 250 and 350 g (about 11 oz) and is about
the size of its owner's fist The weight of the heart is about
0.4596 ofa man's body weight and about 0.40% ofa woman's,
A person's heart size and weight are influenced by his or her
age, body weight and build. frequency of physical exercise,
and heart disease.
SURFACES OF THE HEART
[Obiactiva 2]
The base, or posterior surface, of the heart is formed by the
left atrium, a small portion of the right atrium, and proxi-
mal portions of the superior and inferior venae cavae and
the pulmonary veins (Fig. 1.3). The front (anterior) surface
of the heart lies behind the sternum and costal cartilages. It is
pi'Oldmal: Location nearer to the midline of the body or the point of
attachment than something else Is.
sarcolemma: Membrane that covers smooth, striated, and cardiac
muscle fibers.
sarcomere: Smallest functional un~ of a myofibril.
sarcoplasm: SemWiuid cytnplasm of muscle cells.
sarcoplasmic reticulum: Network of tubules and sacs that plays an
important role in muscle contraction and relalration by releasing and
storing calcium Ions.
semilunar (SL) valves: Valves shaped like half-moons that separate the
ventricles from the aorta and pulmonary artery.
septum: An lntBmal wall of connective tissue.
stroke volume {SV): The amount of blood e]eclBd from a ventricle with
each heartbeat
sulcus: Groove.
systole: Contraction of the heart (usually refarri ng to ventricular contrac-
tion), during which blood is propelled intn the pulmonary artery and
aorta; when the tenn is used without reference to a specific chamber of
the heart, ventricular systole is implied.
tone: A term that may be used when referring to the normal state of bal-
anced tension In body tissues.
venous return: Amount of blood flowing lntn the right atrium each minute
from the syslemlc c1rculatlon.
venb1cles: The two lower chambers of the heart
formed by portions of the right atrium and the left and right
vmtrides (Fig. 1.4). However, because the heart is tilted
slightly toward the left in the chest, the right ventricle is the
area of the heart that lies most directly behind the sternum.
The apa, or lower portion, of the heart is formed by the tip
of the left ventricle. The apex lies just above the diaphragm
at about the level of the fifth intercostal space in the midcla-
vicular line.
The heart's left side (i.e., left lateral surface) faces the
left lung and is made up mostly of the left ventricle and a
portion of the left atrium. The right lateral surface faces
the right lung and consists of the right atrium. The heart's
bottom (i.e., inferior) surface is formed primarily by the
left ventricle, with small portions of the right ventricle
and right atrium. The right and left ventricles are sepa-
rated by a groove containing the posterior interventricu-
lar vessels. Because the inferior surface of the heart rests
on the diaphragm, it is also called the diaphragmatic sur-
face (Fig. 1.5).
COVERINGS OF THE HEART
[Obiactive 3)
The periQU'dium is a double-walled sac that encloses the
heart and helps protect it from trauma and infection. The
tough outer layer of the pericardia! sac is called the fibrous
parietal pericardium (Fig. 1.6). It anchors the heart to some

Mldclavlcular
line
Fig. 1.1 Antar1or v1aw of tha chest wall of a man lhM!rg skslalal structullls and
the surface projactlon of the heart (From Draka R, Vogl AW, Mlb:hall AWM: Gtay's
8II8JDmy for studsnts, ed 3, New York, 2015, Churchill LMngstooe.)
Fig. 1.3 The base af the heart. (Ffm1 Drake R, 'ql A.W, Milcrell A."WM: &ay's
anaiDmy for stJJdents, ed 3, New York, 2015, Churchill Uvingslune~
The right and left phrenic nerves, which innervate the dia-
phragm, pass through the fibrous pericardium as they
descend to the diaphragm. Because these nerves sup-
ply sensory fibers to the fibrous pericardium, the parietal
serous pericardium, and the mediastinal pleura, discomfort
related to conditions affecting the pericardium may be felt
In the areas above the shoulders or lateral neck.
of the structures around it. such as the sternum and dia-
phragm, by means of ligaments. This helps prevent exces-
sive movement of the heart in the chest with changes in
body position.
If the pericardium becomes Inflamed (pericarditis), excess
pericardia! fluid can be quickly generated in response to the
inflammation. Pericarditis can result from a bacterial or viral
infection, rheumatoid arthritis, tumors, destruction of the
heart muscle in a heart attack, among other causes.
Chapter 1 Anatomy and Physiology
Fig. 1.2 Appean~nca of 1h& heart. This pho!Dgraph shows a living human heart
p111pered for transplan1al!on Into a paUent. NoiB liB slza llllaUveiD 1he hands that Rill
hading 1t. (From PaiiDn KT, Thlbolil&u GA: Anatomy& physiology. &d 9, St. Louis.
2016, Mosby.)
Anlartor
lntervent~wer
branch of left
coronary artery
Greal canlac vein
Obtuee mergln
Fig. 1.4 Th& ant:&r1or surface of the haart. (From Drake R, Vogl AW, Mitchell
AWM: Gray's anatomy frJr stJJd6nts, &d 3, Naw York, 2015, Churchill L.Mrgstona.)
The inner layer of the pericardium, the serous pericar-
dium, consists of two layers: parietal and visceral (Fig. 1.7).
the parietal. layer lines the inside of the fibrous pericardium.
The visceral layer attaches to the large vessels that enter and
exit the heart and covers the outer surface ofthe heart muscle
(ie., the epicardium).
Between the visceral and parietal layers is a space (the
pericardia! space) that normally contains about 20 mL of
serous (pale yellow and transparent) fluid. This fluid acts as a
lubricant, preventing friction as the heart beats.
Heart surgery or trauma to the heart, such as a stab wound,
can cause a rapid buildup of blood in the pericardia! space. The
buildup of excess blood or fluid in the pericardia! space com-
presses the heart. This can affect the heart's abiily to relax and
fill with blood between heartbeats. Ifthe heart cannot adequately
 Chapter 1 Anatomy and Physiology

fill with blood, the amount of blood the ventricles can pump out
to the body (cardi~ output) will be decreased. As a result, the
amount of blood returning to the heart is also decreased. These
changes can result in a life-threatening cond~ion called C8ldiac
temponade. The amount of blood or fluid in the pericardia!
space needed to impair the heart's ability to fill depends on the
rate at which the buildup of blood or fluid occurs and the ability
of the pericardium to stretch and accommodate the increased
volume of fluid.
The rapid buildup of as little as 100 to 150 ml of fluid or
blood can be enough to result in signs and symptoms of
shock. Conversely, 1000 mL of fluid may build up over a lon-
ger period without any significant effect on the heart's ability
to fill. This is because the pericardium accommodates the
increased fluid by stretching over time.
The symptoms of cardiac tamponade can be relieved
by removing the excess fluid from the pericardia! sac.
Pericardiocentesis is a procedure in which a needle is
inserted into the pericardia! space and the excess fluid
is sucked out (aspirated) through the needle. If scarring is
the cause of the tamponade, surgery may be necessary to
remove the affected area of the pericardium.

Right Rbrous
ventricle pericardium
{cut;)
Postertor
lnt8r-
ventrlcu lar
art8ly Left verrtricla
and vein
Right Coronary
sulcus
atrium
Inferior
vena cava

Fig. 1.15 The Inferior surface ot the heart The lnfe~or part ot the fibrous pe~card urn has been removed v.tlh the dla-
pluagm. (From Gosling JA: Human anaJDmy: color atlas and text. ad 4, L..ordcn, 2002, Mosby.)

Laft brachl~ Left

oaphalil: Aortic vagus
vein arch narve

Lung
roots

Left
phrenic
nerve

•.· ... Cenlral

""""~- tendon of
diaphragm

Fig. 1 .& The fibrous pericanium and phrenic nerves revealed after reiTlCJ\Iill of the lungs. {From Gosling J&.: Human
anafDmy: color afias and text. ed 4, Lllndon, 2002, Mosby.)
 Chapter 1 Anatomy and Physiology

Left and llgtrt

phrenic Alcendng
aorta

Pulmonary
trunk

Fibrous
pert-
cardium
(cut)

V-.1
~--+-:ft-.,_;.;..- MI'OUS
pert-
cardium

Fig. 1.7 The fbrous pericardium has been opened to expose the visceral pericardium ~ring lhe anterior surface of the
heart. (From Gosling JA: HumaiJ anatomy: color atlas and tert; eel 4, London, 2002, Mosby.)

STRUCTURE OF THE HEART

Layers of the Heart Wall
[Oblactlve 4]
lhe walls of the heart are made up of three tissue layers: the
endocardium, myocardium, and epicardium (Fig. 1.8 and
Table 1.1). The heart's innennost layer, the endocardium, is Endocardium -~~=-~
made up of a thin, smooth layer of epithelium and connec-
Myocardium
tive tissue and Unes the heart's inner chambers, valves, chor-
dae tendineae (tendinous cords), and papillary muscles. The VIsceral
terminal components of the heart's specialized conduction pericardium
(epicardium)
system can be found within this layer (Anderson & Roden.
2010). The endocardium is continuous with the innennost Perlcardlal
apace
layer of the arteries, veins, and capillaries ofthe body, thereby
creating a continuous, closed circulatory system.
1he .myocarclium (middle layer) is a thick. muscular layer
Abrous
that consists of cardiac muscle fibers (cells) responsible for the layer
pumping action of the heart The myocardium makes up about
Flf. 1.8 The parlcardlal sac Is aJIIliOSIId af 1:\W layn separaiBd by a narrow
30% ofthe total left. ventrkular mass (Anderson & Roden, 2010). ftuld-fllled Sjlllllll. The v1scaral part:anllum (aplcmdklm) Is attached dlractly 1D 1ha
lhe innermost halfofthe myocardium is called the subendocar- heart's surface, and the parlelal pertardlum fcnns the llJIEr layer af the sac. (from
1&1 area. The outermost halfis called the subepicardial area. 1he ~-l<lrlitx:Jm L, Blnlslk JL: PBthoplrys/rJ/o ad 5, PhiBde~hla, 2013, Elakr.)
muscle fibers of the myocardium are separated by connective
tissues that have a rich supply ofcapillaries and nerve fibers.
The heart's outennost layer is called the epicardium. The
Did You Know?- - - - - - - epicardium is continuous with the inner lining of the peri-
cardium at the heart's apex. The epicardium contains blood
The thickness of a heart chamber is related to the amount of
pressure or resistance that the muscle of the chamber must capillaries, lymph capillaries, nerve fibers, and fat. 1he main
overcome to eject blood. coronary arteries lie on the epicardial surface of the heart.
 Chapter 1 Anatomy and Physiology
lrJ:ll¥81 Layers of the Heart Wall
Heart Layer Description
Epicardium • External layer of 1he heart
• Coronary arteries, blood capillaries,
lymph capillaries, nerve fibers, and fat
are found in this layer
Myocardium • Middle and thickest layer of the heart
• Muscular component of the heart;
responsible for the heart's pumping
action
Endocardium • Innermost layer of the heart
• Lines heart's inner chambers, valves,
chordae tendineae, and papillary
muscles
• Continuous with the innermost layer
of arteries, veins. and capillaries of the
body
They feed this area first before entering the myocardium and
supplying the heart's inner layers with oxygenated blood.
Ischemia is a decreased supply of oxygenated blood to a
body part or organ. The heart's subendocardial area is at the
greatest risk ofischemia because this area has a high demand
for oxygen and it is fed by the most distal branches of the
coronary arteries.
CARDIAC MUSCLE
Cardiac muscle fibers make up the walls of the heart.
These fibers have striations, or stripes, similar to that of
skeletal muscle. Each muscle fiber is made up of many
muscle cells (Fig. 1.9). Each muscle cell is enclosed in
a membrane called a sarcolemma. Within each cell (as
with all cells) are mitocho.odria, the energy-producing
parts of a cell, and hundreds of long, tube-like structures
called myoflbrlls. Myofibrils are made up of many sar~o­
merea, the basic protein units responsible for contraction.
The process of contraction requires adenosine triphos-
phate (ATP) for energy. The mitochondria that are inter-
spersed between the myofibrils are important sites of ATP
production.
The sarcolemma has holes in it that lead into tubes called
T (transverse) tubules. T tubules are extensions of the cell
membrane. Another system of tubules, the sarcoplasmic:
reticulum (SR), stores calcium. Muscle cells need calcium
in order to contract. Calcium is moved from the sarco-
plasm of the muscle cell into the SR by means of "'pumps"
in the SR.
There are certain places in the cell membrane where
sodium (Na+), potassium (K+), and calcium (Ca++) can
pass. These openings are called pores or channels. There
are specific channels for sodium (sodium channels},
I
L------
lrrtercalallld dlskB
- Mltllchandrlon
Fig. 1.8 cardiac muscle filar. lklllke ather types a! muscle fibers, 1he cardiac
muscle flbar Is t)Pically branchoo and foiTI'IS junc1!oos, called lntaroalllled dis~. with
adjacent cardiac muscle fibers. (From PatiDn KT, Thltxxfeau GA: Anthony's IIJXtbook
of 8fi/J/Dmy & phys/okJgy, ad 20, St Louis, 2013, Mooby~
potassium (potassium channels), and calcium (calcium
channels). When the muscle is relaxed, the calcium chan-
nels are closed. As a result, calcium cannot pass through
the membrane of the SR. This results in a high concen-
tration of calcium in the SR and a low concentration in
the sarcoplasm, where the muscle cells (sarcomeres) are
found. If the muscle cells do not have calcium available to
them, contraction is inhibited (the muscle stays relaxed).
The force of cardiac muscle contraction depends largely
on the concentration of calcium ions in the extracellular
fluid.
0 ECG Pear1 _ _ _ _ _ _ _ __
The heart consists of two syncytia: atrial and ventricular.
The atrial syncytium consists of the walls of the right and
left atria. The ventricular syncytium consists of the walls of
the right and left ventricles. Normally, impulses can be con-
ducted from the atrial syncytium into the ventricular syncy-
tium only by means of the atrioventricular (AV) junction. The
AV junction is a part of the heart's electrical system. This
allows the atria to contract a short time before ventricular
contraction.
Heart Chambers
The heart has four chambers, two atria and two ventri-
cles. The outside surface of the heart has grooves called
sulci. The coronary arteries and their major branches lie
in these grooves. The coronary sulcus (groove) encircles
the outside of the heart and separates the atria from the
ventricles. It contains the coronary blood vessels and
epicardial fat.
 Chapter 1 Anatomy and Physiology

,....,_-- Pulmonary tnlnk

Right atrium
·~~=---;;::::..:....:.-.- Openings to
coronary arteries
Aortic (SL) valve
Laftatrlum

F1g. 1.10 lntartor of the heart. This Illustration shows the heart as It would appear If It were a.Jt along a lronllll plane and
opened Ilks a book. The fnlnt portion of the heart lies ID 1hll reader's ~ght; the back portion of the heart lias ID the reader's
Iaft. ThB four chambers Ill 1hll heart-two a~a and two van~des--an~ easily seen. A~ Abtlvant~cular; st.. semilunar. [From
Patton KT, Thllodeau GA: Anatomy & physiology, ad 9, St. llluls, 2016, Mosby.)

ATRIA
[Obiactive 5]
The two upper chambers of the heart are the right and
left atria (singular, atrium) (Fig. 1.10). An earlike flap
called an auricle (meaning "little ear·) protrudes from
each atrium.
The purpose of the atria is to receive blood. The right
atrium receives blood low in oxygen from the superior vena
cava (which carries blood from the head and upper extremi-
ties), the inferior vena cava (which carries blood from the
lower body), and the coronary sinus (which is the largest
vein that drains the heart). The left atrium receives freshly
oxygenated blood from the lungs via the right and left pul-
monary veins.
1he four chambers of the heart vary in muscular wall
thickness, reflecting the degree of pressure each chamber
must generate to pump blood. For example, the atria encoun-
ter little resistance when pumping blood to the ventricles. As
a result, the atria have a thin myocardial layer. The wall of
the right atrium is about 2 mm thick. and the wall of the left
atrium is about 3 m.m thick. Blood is pumped from the atria
through an atrioventricular (AV) valve and into the ventri-
cles. The valves ofthe heart are discussed later in this chapter.
Q ECG Pearl _ _ _ _ _ _ _ _ __
Think of the atria as holding tanks or reservoirs for blood.
VENTRICLES
(Obiactive 5]
The heart's two lower chambers are the right and left ven-
tricles. Their purpose is to pump blood. The right ventricle
pumps blood to the lungs. The left ventricle pumps blood
out to the body. Because the ventricles must pump blood
either to the lungs (the right ventricle) or to the rest of the
body (the left ventricle), the ventricles have a much thicker
myocardial layer than the atria. Because the right ventricle
moves blood only through the blood vessels of the lungs and
then into the left atrium, it has one sixth of the muscle mass
and one third of the wall thickness of the left ventricle, which
must propel blood to most vessels of the body (Hutchison &:
Rudakewich, 2009) (Fig. 1.11).
When the left ventricle contracts, it normally produces an
impulse that can be felt at the apex of the heart (apical
impulse). This occurs because as the left ventricle con·
tracts, it rotates forward. In a normal heart, this causes the
apex of the left ventricle to hit the chest wall. You may be
able to sea the apical impulse in thin individuals. The api-
cal impulse is also called the point of maximal impulse
because it is the site where the left ventricular contraction
is most strongly felt.
 Chapter 1 Anatomy and Physiology

Antarlor lntarvenb1cuJar Right vantrk:ular

artery wall

/
Left Papillary Intel'" Trabeculae Marginal
ventricular mUICia Y811lrtcular camaae arl8ry
-11 saptum
Fig. 1.11 Section through the heart shi7Mng 1he &Peal porUn of the left and ~ghl venll1clas. (From Gosling JA: Human
anatumy: oo1or atlas and t8Xt, ed 4, London, 2002, Mosby.)

Heart Valves
The heart has a skeleton, which is made up of four rings
of thick connective tissue. This tissue surrounds the bases
of the pulmonary trunk, the aorta, and the heart valves.
The inside of the rings provides secure attachments for
the heart valves. The outside of the rings provides for the
attachment of the cardiac muscle of the myocardium (Fig.
1.12). The heart's skeleton also helps form the partitions
(septa) that separate the atria from the ventricles.
There are four one-way valves in the heart: two sets of AV
valves and two sets of&emilUIW' (SL) valves. The valves open
and close in a specific sequence and assist in producing the
pressure gradient needed between the chambers to ensure
a smooth :flow of blood through the heart and prevent the
bacldl.ow of blood.
Fig. 1.12 Skeleton of the heart. This IX)Stel1or view shows part of the venll1cular
ATRIOVENTRICULAR VALVES myooardlum with 1he heart valves 81111 attached. The rim of each heart valve Is sup-
ported by a fibrous structure, called the sk8/stonofth6 h6art, which encircles all four
[Oblectlves 6, 7] valves. AV. Atrlovenll1cular. (From PatiDn KT, Thibodeau GA: Anatmny&ph~
Atrioventricular valves separate the atria from the ventricles. ed 9, St Louis, 201 6, Mosby.)
The two AV valves consist of tough. fibrous rings (annuli
:6.brosi); :flaps (lea11.ets or cusps) of endocardium; chordae
tendineae; and papillary muscles. left atrium and left ventricle (Fig. 1.14). The mitral valve is
1he tricuspid valve is the AV valve that lies between the so named because of its resemblance to a miter, which is a
right atrium and right ventricle. It consists of three separate double-cusp bishop's hat, when open.
cusps or flaps (Fig. 1.13). It is larger in diameter and thinner The AV valves open when a forward pressure gradi-
than the mitral valve. The mitral valve, which is also called ent forces blood in a forward direction. They close when
the bicuspid valve, has only two cusps and lies between the a ba.ck.ward pressure gradient pushes blood backward. The
 Chapter 1 Anatomy and Physiology

Superior vena

Right

TrtcuspldG Anterior cusp Septal papllluy miiiiCie

Septal cusp
valve Posterior cusp
Septom•rgln•l trabecul•

Fig. 1.13 Internal view of 1he right venll1cle. (From Drake R, Vogl AW, Mitchell AWM: Gmy~ snatrHny frJr si1Jdenls. ed 3,
New Yorll, 2015, Churchill Uvlngstone.)

MHral val¥8 antartor cuep

Pulmonary arteries

Pulmonary veins

Coronary sinus

valve poeterlor cuap

Fig. 1.14 Internal view of 1he left ventriCle. (From Drake R, Vcgl AW, MitChell AWM: !#a~ anatomy for students, ed 3, New
Ya'k, 2015, Chu I'Ch ill Livingstone.)
 Chapter 1 Anatomy and Physiology
AV valves require almost no backflow to cause closure
(Hall, 2016).
The flow of blood from the superior and inferior venae
cavae into the atria is normally continuous. About 70%
of this blood flows directly through the atria and into the
ventricles before the atria contract; this is called passi'o'e
filling. & the atria fill with blood, the pressure within the
atrial chamber rises. This pressure forces the tricuspid
and mitral valves open, and the ventricles begin to fill,
gradually increasing the pressure within the ventricles.
When the atria contract, an additionallO% to 30% of the
returning blood is added to filling of the ventricles. This
additional contribution of blood resulting from atrial
contraction is called atrial kick. On the right side of the
heart, blood low in oxygen empties into the right ventri-
cle. On the left side of the heart, freshly oxygenated blood
empties into the left ventricle. When the ventricles then
contract (i.e., systole), the pressure within the ventricles
rises sharply. The tricuspid and mitral valves completely
close when the pressure within the ventricles exceeds that
of the atria.
Chordae tendineae (tendlnoua cords) are thin strands
of connective tissue. On one end, they are attached to the
underside of the AV valves. On the other end, they are
attached to small mounds of myocardium called papillary
maades. Papillary muscles project inward from the lower
portion ofthe ventricular walls. When the ventricles contract
and relax, so do the papillary muscles. The papillary muscles
adjust their tension on the chordae tendineae, preventing
them from bulging too far into the atria. For example, when
the right ventricle contracts, the papillary muscles of the
right ventricle pull on the chordae tendineae. 1he chordae
tendineae prevent the flaps of the tricuspid valve from bulg-
ing too far into the right atrium. 1hus, the chordae tendineae
and papillary muscles serve as anchors. Because the chordae
tendineae are thin and string-like, they are sometimes called
"heart strings."
SEMILUNAR VALVES
[OIJiactlve B]
The pulmonic and aortic valves are SL valves. 1he SL valves pre-
vent the bacldlow ofblood from the aorta and pulmonary arter-
ies into the ventricles. 1he SL valves have three cusps shaped
like half-moons. 1he openings of the SL valves are smaller than
the openings of the AV valves, and the flaps of the SL valves are
smaller and thicker than the AV valves. Unlike the AV valves,
the SL valves are not attached to chordae tendineae.
When the ventricles contract, the SL valves open, allow-
ing blood to flow out of the ventricles. When the right
ventricle contracts, blood low in oxygen flows through
the pulmonic valve into the pulmonary trunk. which
divides into the right and left pulmonary arteries. When
the left ventricle contracts, freshly oxygenated blood flows
through the aortic valve into the aorta and out to the body
(Fig. 1.15). The SL valves close as ventricular contraction
ends and the pressure in the pulmonary artery and aorta
exceeds that of the ventricles.
Improper valve function can hamper blood flow through the
heart. Valvular heart disease is the term used to describe
a malfunctioning heart valve. Types of valvular heart dis-
ease include the following:
• vaJvular prolapse. If a valve flap inverts, it is said to have
prolapsed. Prolapse can occur if one valve flap is larger
than the other. It can also occur if the chordae tendin-
eae stretch markedly or rupture.
• vaJvutar regurgitation. Blood can flow backward, or
regurgitate, if one or more of the heart's valves does
not close properly. Valvular regurgitation Is also known
as valvular incompetence or valvular insufficiency.
• Valvular stenosis. If a valve narrows, stiffens, or thick-
ens, it is said to be stenosed. The heart must work
harder to pump blood through a stenosed valve.
Papillary muscles receive their blood supply from the
coronary arteries. If a papillary muscle ruptures because
of an inadequate blood supply (as in myocardial infarc-
tion), the attached valve cusps will not completely
close and may result in a murmur. If a papillary muscle
in the left ventricle ruptures, the leaflets of the mitral
valve may invert Q.e., prolapse). This may result in blood
leaking from the left ventricle into the left atrium (e.g.,
regurgitation} during ventricular contraction. Blood flow
to the body o.e., cardiac output) could decrease as a
result.
HEART SOUNDS
Heart sounds occur because of vibrations in the tissues
of the heart caused by the closing of the heart's valves.
Vibrations are created as blood flow is suddenly increased
or slowed with the contraction and relaxation of the
heart chambers and with the opening and closing of the
valves.
Normal heart sounds are called Sl and S2. 1he first heart
sound ("lubb,.) occurs during ventricular contraction when
the tricuspid and mitral (AV) valves are closing. The second
heart sound ("dupp) occurs during ventricular relaxation
as the pulmonic and aortic (SL) valves close. A third heart
sound is produced by ventricular filling. In those younger
than 40 years ofage, the left ventricle normally permits rapid
filling. The more rapid the ventricular filling, the greater
the likelihood of hearing a third heart sound. A third heart
sound (S3) heard in people older than 40 years ofage is con-
sidered abnormal An abnormal third heart sound is fre-
quently associated with heart failure. An Sl-S2-S3 sequence
is called a ventricular gallop or gallop rhythm. It sounds like
"Kentucky"-Ken (Sl) -tuck (S2) -y (S3). The location of the
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place at the quaint beauty of the edifice, and lastly intense and wild
admiration takes entire possession of you, and all is forgotten in the
glorious nearness of the great Golden Pagoda.
On either side of the rugged steps there are rows of most
picturesque little stalls, at which are sold endless offerings to be
made to Buddha—flowers of every shade and hue, fruit, glowing
bunches of yellow plantains and pepia, candles, wondrous little
paper devices and flags, and, lastly, the gold leaf, which the faithful
delight to place upon the beloved pagoda. It is looked upon as a
great act of merit to expend money in thus decorating the much
loved and venerated shrine....
As you mount slowly up the steep uneven steps of the pagoda,
turn for a moment and glance back at the scene. It is a pagoda feast,
and the place is crowded with the faithful from all parts, who have
come from far and near to present offerings and perform their
religious observances. It is an entrancing picture, a marvel of colour
and picturesqueness—see, the stalls are laid out with their brightest
wares, and the crowd is becoming greater every moment. Look at
that group of laughing girls, they have donned their most brilliant
tamehns, and dainty shawls, and the flowers in their hair are
arranged with infinite coquettishness; behind them are coming a
dazzling company of young men in pasohs of every indescribable
shade; perchance they are the lovers of the girls whom they are
following so eagerly, and they are bearing fruit and flowers to present
to Buddha. Beyond them again are some yellow-robed Pohn-gyees;
they are supposed to shade their eyes from looking upon women
with their large lotus-shaped fans, but to-day they are gazing about
them more than is permitted, and are casting covert glances of
admiration on some of those dainty little maidens. Behind them
again are a white-robed company, they are nuns, and their shroud-
like garments flow around them in long graceful folds. Their hair is
cut short, and they have not so joyous an expression upon their
faces as the rest of the community, and they toil up the steep steps a
trifle wearily. Behind them again are a little toddling group of children,
with their little hands full of bright glowing flowers and fruits.
 Shall we follow in the crowd and see where the steps lead? It is
a wondrous study, the effects of light and shade; look at that
sunbeam glinting in through the roof and laying golden fingers on the
Pohn-gyees’ yellow robes, and turning the soft-hued fluttering silks
into brilliant luminous spots of light.
At last we have arrived at the summit! Let us pause and take
breath morally and physically before walking round the great open-
paved space in the centre of which rises the great and glorious
pagoda. There it stands towering up and up, as though it would fain
touch the blue heaven; it is surrounded by a galaxy of smaller
pagodas, which seem to be clustering lovingly near their great high
priest; around these again are large carved kneeling elephants, and
deep urn-shaped vessels, which are placed there to receive the
offerings of food brought to Buddha. The crows and the pariah dogs
which haunt the place will soon demolish these devout offerings, and
grow fat upon them as their appearance testifies; but this, curiously,
does not seem in the least to annoy the giver. He has no objection to
seeing a fat crow or a mangy dog gorging itself upon his offering, as
the feeding of any animal is an act of merit, which is the one thing of
importance to a Burman. The more acts of merit that he can
accomplish in this life, the more rapid his incarnations will be in the
next.
There are draped about the small golden pagodas and round the
base of the large one endless quaint pieces of woven silk; these are
offerings from women, and must be completed in one night without a
break.
On the outer circle of this large paved space are a multitude of
shrines, enclosing hundreds of images of Buddha. You behold
Buddha standing, you behold him sitting, you behold him reclining;
you see him large, you see him small, you see him medium size; you
see him in brass, in wood, in stone, and in marble. Many of these
statues are simply replicas of each other, but some differ slightly,
though the cast of features is always the same, a placid, amiable,
benign countenance, with very long lobes to the ears, which in
Burmah are supposed to indicate the great truthfulness of the person
who possesses them. Most of the images have suspended over
them the royal white umbrella, which was one of the emblems of
Burma, and only used in Thebaw’s time to cover Buddha, the king,
and the lord white elephant.

Among Pagodas and Fair Ladies (London, 1896).

 THE CATHEDRAL OF SIENA.
JOHN ADDINGTON SYMONDS.

QUITTING the Palazzo, and threading narrow streets, paved with

brick and overshadowed with huge empty palaces, we reach the
highest of the three hills on which Siena stands, and see before us
the Duomo. This church is the most purely Gothic of all Italian
cathedrals designed by national architects. Together with that of
Orvieto, it stands to show what the unassisted genius of the Italians
could produce, when under the empire of mediæval Christianity and
before the advent of the neopagan spirit. It is built wholly of marble,
and overlaid, inside and out, with florid ornaments of exquisite
beauty. There are no flying buttresses, no pinnacles, no deep and
fretted doorways, such as form the charm of French and English
architecture; but instead of this, the lines of party-coloured marbles,
the scrolls and wreaths of foliage, the mosaics and the frescoes
which meet the eye in every direction, satisfy our sense of variety,
producing most agreeable combinations of blending hues and
harmoniously connected forms. The chief fault which offends against
our Northern taste is the predominance of horizontal lines, both in
the construction of the façade, and also in the internal decoration.
This single fact sufficiently proves that the Italians had never seized
the true idea of Gothic or aspiring architecture. But, allowing for this
original defect, we feel that the Cathedral of Siena combines
solemnity and splendour to a degree almost unrivalled. Its dome is
another point in which the instinct of Italian architects has led them to
adhere to the genius of their ancestral art rather than to follow the
principles of Gothic design. The dome is Etruscan and Roman,
native to the soil, and only by a kind of violence adapted to the
character of pointed architecture. Yet the builders of Siena have
shown what a glorious element of beauty might have been added to
our Northern cathedrals, had the idea of infinity which our ancestors
expressed by long continuous lines, by complexities of interwoven
aisles, and by multitudinous aspiring pinnacles, been carried out into
vast spaces of aërial cupolas, completing and embracing and
covering the whole like heaven. The Duomo, as it now stands, forms
only part of a vast original design. On entering we are amazed to
hear that this church, which looks so large, from the beauty of its
proportions, the intricacy of its ornaments, and the interlacing of its
columns, is but the transept of the old building lengthened a little,
and surmounted by a cupola and campanile. Yet such is the fact.
Soon after its commencement a plague swept over Italy, nearly
depopulated Siena, and reduced the town to penury for want of men.
The Cathedral, which, had it been accomplished, would have
surpassed all Gothic churches south of the Alps, remained a ruin. A
fragment of the nave still stands, enabling us to judge of its extent.
The eastern wall joins what was to have been the transept,
measuring the mighty space which would have been enclosed by
marble vaults and columns delicately wrought. The sculpture on the
eastern door shows with what magnificence the Sienese designed to
ornament this portion of their temple; while the southern façade rears
itself aloft above the town, like those high arches which testify to the
past splendour of Glastonbury Abbey; but the sun streams through
the broken windows, and the walls are encumbered with hovels and
stables and the refuse of surrounding streets. One most remarkable
feature of the internal decoration is a line of heads of the Popes
carried all round the church above the lower arches. Larger than life,
white solemn faces, they lean, each from his separate niche,
crowned with the triple tiara, and labelled with the name he bore.
Their accumulated majesty brings the whole past history of the
Church into the presence of its living members. A bishop walking up
the nave of Siena must feel as a Roman felt among the waxen
images of ancestors renowned in council or in war. Of course these
portraits are imaginary for the most part; but the artists have
contrived to vary their features and expression with great skill.
 CATHEDRAL OF SIENA

Not less peculiar to Siena is the pavement of the Cathedral. It is

inlaid with a kind of tarsia work in stone, not unlike that which Baron
Triqueti used in his “Marmor Homericum”—less elaborately
decorative, but even more artistic and subordinate to architectural
effect than the baron’s mosaic. Some of these compositions are as
old as the cathedral; others are the work of Beccafumi and his
scholars. They represent, in the liberal spirit of mediæval Christianity,
the history of the Church before the Incarnation. Hermes
Trismegistus and the Sibyls meet us at the doorway: in the body of
the church we find the mighty deeds of the old Jewish heroes—of
Moses and Samson and Joshua and Judith. Independently of the
artistic beauty of the designs, of the skill with which men and horses
are drawn in the most difficult attitudes, of the dignity of some single
figures, and of the vigour and simplicity of the larger compositions, a
special interest attaches to this pavement in connection with the
twelfth canto of the “Purgatorio.” Did Dante ever tread these stones
and meditate upon their sculptured histories? That is what we cannot
say; but we read how he journeyed through the plain of Purgatory
with eyes intent upon its storied floor, how “morti i morti, e i vivi
parean vivi,” how he saw “Nimrod at the foot of his great work,
confounded, gazing at the people who were proud with him.” The
strong and simple outlines of the pavement correspond to the few
words of the poet. Bending over these pictures and trying to learn
their lesson, with the thought of Dante in our mind, the tones of an
organ, singularly sweet and mellow, fall upon our ears, and we
remember how he heard the Te Deum sung within the gateway of
repentance.

Sketches in Italy and Greece (London, 1874).

 THE TOWN HALL OF LOUVAIN.
GRANT ALLEN.

LOUVAIN IS in a certain sense the mother city of Brussels. Standing

on its own little navigable river, the Dyle, it was, till the end of the
Fourteenth Century, the capital of the Counts and of the Duchy of
Brabant. It had a large population of weavers, engaged in the cloth
trade. Here, as elsewhere, the weavers formed the chief bulwark of
freedom in the population. In 1378, however, after a popular rising,
Duke Wenseslaus besieged and conquered the city; and the
tyrannical sway of the nobles, whom he re-introduced, aided by the
rise of Ghent, or later, of Antwerp, drove away trade from the city.
Many of the weavers emigrated to Holland and England, where they
helped to establish the woollen industry....
As you emerge from the station, you come upon a small Place,
adorned with a statue (by Geefs) of Sylvain van de Weyer, a
revolutionary of 1830, and long Belgian minister to England. Take the
long straight street up which the statue looks. This leads direct to the
Grand’ Place, the centre of the town, whence the chief streets
radiate in every direction, the ground-plan recalling that of a Roman
city.
 TOWN HALL OF LOUVAIN

The principal building in the Grand’ Place is the Hôtel de Ville,

standing out with three sides visible from the Place, and probably the
finest civic building in Belgium. It is of very florid late-Gothic
architecture, between 1448 and 1463. Begin first with the left façade,
exhibiting three main storeys, with handsome Gothic windows.
Above come a gallery, and then a gable-end, flanked by octagonal
turrets, and bearing a similar turret on its summit. In this centre of the
gable is a little projecting balcony of the kind so common on Belgic
civic buildings. The architecture of the niches and turrets is of very
fine florid Gothic, in better taste than that at Ghent of nearly the
same period. The statues which fill the niches are modern. Those of
the first storey represent personages of importance in the local
history of the city; those of the second, the various mediæval guilds
or trades; those of the third, the Counts of Louvain and Dukes of
Brabant of all ages. The bosses or corbels which support the
statues, are carved with scriptural scenes in high relief. I give the
subjects of a few (beginning Left): the reader must decipher the
remainder for himself. The Court of Heaven: The Fall of the Angels
into the visible Jaws of Hell: Adam and Eve in the Garden: The
Expulsion from Paradise: The Death of Abel, with quaint rabbits
escaping: The Drunkenness of Noah: Abraham and Lot: etc.
The main façade has an entrance staircase, and two portals in
the centre, above which are figures of St. Peter (Left) and Our Lady
and Child (Right), the former in compliment to the patron of the
church opposite. This façade has three storeys, decorated with
Gothic windows, and capped by a gallery parapet, above which rises
the high-pitched roof, broken by several quaint small windows. At
either end are the turrets of the gable, with steps to ascend them.
The rows of statues represent as before (in four tiers), persons of
local distinction, mediæval guilds and the Princes who have ruled
Brabant and Louvain. Here again the sculptures beneath the bosses
should be closely inspected. Among the most conspicuous are the
Golden Calf, the Institution of Sacrifices in the Tabernacle, Balaam’s
Ass, Susannah and the Elders, etc.
The gable-end to the Right, ill seen from the narrow street,
resembles in its features the one opposite it, but this façade is even
finer than the others.
The best general view is obtained from the door of St. Pierre, or
near either corner of the Place directly opposite.
Cities of Belgium (London, 1897).
 THE CATHEDRAL OF SEVILLE.
EDMONDO DE AMICIS.

THE Cathedral of Seville is isolated in the centre of a large square,

yet its grandeur may be measured by a single glance. I immediately
thought of the famous phrase in the decree uttered by the Chapter of
the primitive church on July 8, 1401, regarding the building of the
new Cathedral: “Let us build a monument which shall cause posterity
to think we must have been mad.” These reverend canons did not
fail in their intention. But to fully appreciate this we must enter. The
exterior of the Cathedral is imposing and magnificent; but less so
than the interior. There is no façade: a high wall encloses the
building like a fortress. It is useless to turn and gaze upon it, for you
will never succeed in impressing a single outline upon your mind,
which, like the introduction to a book, will give you a clear idea of the
work; you admire and you exclaim more than once: “It is immense!”
but you are not satisfied; and you hasten to enter the church, hoping
that you may receive there a more complete sentiment of admiration.
On entering you are stunned, you feel as if you are lost in an
abyss; and for several moments you can only let your glance wander
over these immense curves in this immense space to assure
yourself that your eyes and your imagination are not deceiving you.
Then you approach a column, measure it, and contemplate the
others from a distance: they are as large as towers and yet they
seem so slender that you tremble to think they support the edifice.
With a rapid glance you look at them from pavement to ceiling and it
seems as if you could almost count the moments that it takes the
eye to rise with them. There are five naves, each one of which might
constitute a church. In the central one another cathedral could easily
lift its high head surmounted by a cupola and bell-tower. Altogether
there are sixty-eight vaults, so bold that it seems to you they expand
and rise very slowly while you are looking at them. Everything in this
Cathedral is enormous. The principal altar, placed in the centre of
the great nave, is so high that it almost touches the vaulted ceiling,
and seems to be an altar constructed for giant priests to whose
knees only would ordinary altars reach; the paschal candle seems
like the mast of a ship; and the bronze candlestick which holds it, is a
museum of sculpture and carving which would in itself repay a day’s
visit. The chapels are worthy of the church, for in them are lavished
the chefs d’œuvre of sixty-seven sculptors and thirty-eight painters.
Montanes, Zurbaran, Murillo, Valdes, Herrera, Boldan, Roelas, and
Campaña have left there a thousand immortal traces of their hands.
St. Ferdinand’s Chapel, containing the sepulchres of this king and of
his wife Beatrice, of Alphonso the Wise, the celebrated minister
Florida Blanca, and other illustrious personages, is one of the richest
and most beautiful. The body of King Ferdinand, who delivered
Seville from the dominion of the Arabs, clothed in his military dress,
with the crown and the royal mantle, reposes in a crystal casket
covered with a veil. On one side is the sword which he carried on the
day of his entrance into Seville; and on the other his staff, the symbol
of command. In this same chapel a little ivory wand which the king
carried to the wars, and other relics of great value are preserved. In
the other chapels there are large marble altars, Gothic tombs and
statues in stone, in wood and silver, enclosed in large caskets of
silver with their bodies and hands covered with diamonds and rubies;
and some marvellous pictures, which, unfortunately, the feeble light,
falling from the high windows, does not illuminate sufficiently to let
the admirer see their entire beauty.
 THE CATHEDRAL OF SEVILLE.

But after a detailed examination of these chapels, paintings, and

sculptures, you always return to admire the Cathedral’s grand, and, if
I may be allowed to say it, formidable aspect. After having glanced
towards those giddy heights, the eye and mind are fatigued by the
effort. And the abundant images correspond to the grandeur of the
basilica; immense angels and monstrous heads of cherubim with
wings as large as the sails of a ship and enormous floating mantles
of blue. The impression that this Cathedral produces is entirely
religious, but it is not sad; it creates a feeling which carries the mind
into the infinite space and silence where Leopardi’s thoughts were
plunged; it creates a sentiment full of desire and boldness; it
produces that shiver which is experienced at the brink of a precipice,
—that distress and confusion of great thoughts, that divine terror of
the infinite....
 It is needless to speak of the Feasts of Holy Week: they are
famous throughout the world, and people from all parts of Europe
still flock to them.
But the most curious privilege of the Cathedral of Seville is the
dance de los seises, which is performed every evening at twilight for
eight consecutive days after the Feast of Corpus Domini.
As I found myself in Seville at this time I went to see it. From
what I had heard I expected a scandalous pasquinade, and I entered
the church quite ready to be indignant at the profanation of a holy
place. The church was dark; only the large altar was illuminated, and
a crowd of women kneeled before it. Several priests were sitting to
the right and left of the altar. At a signal given by one of the priests,
sweet music from violins broke the profound silence of the church,
and two rows of children moved forward in the steps of a contre-
danse, and began to separate, interlace, break away, and again
unite with a thousand graceful turnings; then everybody joined in a
melodious and charming hymn which resounded in the vast
Cathedral like a choir of angels’ voices; and in the next moment they
began to accompany their dance and song with castanets. No
religious ceremony ever touched me like this. It is out of the question
to describe the effect produced by these little voices under the
immense vaults, these little creatures at the foot of this enormous
altar, this modest and almost humble dance, this antique costume,
this kneeling multitude, and the surrounding darkness. I went out of
the church with as serene a soul as if I had been praying....
The famous Giralda of the Cathedral of Seville is an ancient
Arabian tower, constructed, according to tradition, in the year one
thousand, on the plan of the architect Huevar, the inventor of
algebra; it was modified in its upper part after the expulsion of the
Moors and converted into a Christian bell-tower, yet it has always
preserved its Arabian air and has always been prouder of the
vanished standard of the conquered race than the Cross which the
victors have placed upon it. This monument produces a novel
sensation: it makes you smile: it is as enormous and imposing as an
Egyptian pyramid and at the same time as gay and graceful as a
garden kiosk. It is a square brick tower of a beautiful rose-colour,
bare up to a certain height, and then ornamented all the way up by
little Moorish twin-windows displayed here and there at haphazard
and provided with little balconies which produce a very pretty effect.
Upon the story, where formerly a roof of various colours rested,
surmounted by an iron shaft which supported four enormous golden
balls, the Christian bell-tower rises in three stories; the first
containing the bells, the second enclosed by a balustrade, and the
third forming a kind of cupola on which turns, like a weather-vane, a
statue of gilt bronze representing Faith, holding a palm in one hand
and in the other a standard visible at a long distance from Seville,
and which, when touched by the sun, glitters like an enormous ruby
imbedded in the crown of a Titan king who rules the entire valley of
Andalusia with his glance.

La Spagna (Florence, 1873).

 WINDSOR CASTLE.
WILLIAM HEPWORTH DIXON.

A STEEP chalk bluff, starting from a river margin with the heave and
dominance of a tidal wave is Castle Hill, now crowned and mantled
by the Norman keep, the royal house, the chapel of St. George, and
the depending gardens, terraces, and slopes.
Trees beard the slope and tuft the ridge. Live waters curl and
murmur at the base. In front, low-lying meadows curtsey to the royal
hill. Outward, on the flanks, to east and west, run screens of elm and
oak, of beech and poplar; here, sinking into clough and dell: there
mounting up to smiling sward and wooded knoll. Far in the rear lie
forest glades, with walks and chases, losing themselves in distant
heath and holt. By the edges of dripping wells, which bear the names
of queen and saint, stand aged oaks, hoary with time and rich in
legend: patriarchs of the forest, wedded to the readers of all nations
by immortal verse.
A gentle eminence, the Castle Hill springs from the bosom of a
typical English scene.
 WINDSOR CASTLE.

Crowning a verdant ridge, the Norman keep looks northward on

a wide and wooded level, stretching over many shires, tawny with
corn and rye, bright with abundant pasture, and the red and white of
kine and sheep, while here again the landscape is embrowned with
groves and parks. The stream curves softly past your feet,
unconscious of the capital, unruffled by the tide. Beyond the river
bank lie open meadows, out of which start up the pinnacles of Eton
College, the Plantagenet school and cloister, whence for twenty-one
reigns the youth of England have been trained for court and camp,
the staff, the mitre, and the marble chair. Free from these pinnacles,
the eye is caught by darksome clump, and antique tower, and distant
height; each darksome clump a haunted wood, each antique tower
an elegy in stone, each distant height a storied and romantic hill.
That darksome clump is Burnham wood; this antique tower is Stoke;
yon distant heights are Hampstead Heath and Richmond Park.
Nearer to the eye stand Farnham Royal, Upton park, and Langley
Marsh; the homes of famous men, the sceneries of great events.
Swing round to east or south, and still the eye falls lovingly on
household spots. There, beyond Datchet ferry, stood the lodge of
Edward the Confessor, and around his dwelling spread the hunting-
grounds of Alfred and other Saxon kings. Yon islet in the Thames is
Magna Charta Island; while the open field, below the reach, is
Runnymede.
The heights all round the Norman keep are capped with fame—
one hallowed by a saint, another crowned with song. Here is St.
Leonard’s hill; and yonder, rising over Runnymede, is Cooper’s hill.
Saints, poets, kings and queens, divide the royalties in almost equal
shares. St. George is hardly more a presence in the place than
Chaucer and Shakespeare. Sanctity and poetry are everywhere
about us; in the royal chapel, by the river-side, among the forest
oaks, and even in the tavern yards. Chaucer and Shakespeare have
a part in Windsor hardly less pronounced than that of Edward and
Victoria, that of St. Leonard and St. George.
Windsor was river born and river named. The stream is winding,
serpentine; the bank by which it rolls was called the “winding shore.”
The fact, common to all countries, gives a name which is common to
all languages. Snakes, dragons, serpentines, are names of winding
rivers in every latitude. There is a Snake river in Utah, another
Snake river in Oregon; there is a Drach river in France, another
Drach river in Switzerland. The straits between Paria and Trinidad is
the Dragon’s Mouth; the outfall of Lake Chiriqui is also the Dragon’s
Mouth. In the Morea, in Majorca, in Ionia, there are Dragons. There
is a Serpent islet off the Danube, and a Serpentaria in Sardinia. We
have a modern Serpentine in Hyde Park!
Windsor, born of that winding shore-line, found in after days her
natural patron in St. George.
With one exception, all the Castle builders were men and women
of English birth and English taste; Henry Beauclerc, Henry of
Winchester, Edward of Windsor, Edward of York, Henry the Seventh,
Queen Elizabeth, George the Fourth, and Queen Victoria; and these
English builders stamped an English spirit on every portion of the
pile—excepting on the Norman keep.
Ages before the Normans came to Windsor, a Saxon hunting-
lodge had been erected in the forest; not on the bleak and isolated
crest of hill, but by the river margin, on “the winding shore.” This
Saxon lodge lay hidden in the depths of ancient woods, away from
any public road and bridge. The King’s highway ran north, the Devil’s
Causeway to the south. The nearest ford was three miles up the
stream, the nearest bridge was five miles down the stream. A bridle-
path, such as may still be found in Spain or Sicily, led to that Saxon
lodge; but here this path was lost among the ferns and underwoods.
No track led on to other places. Free to the chase, yet severed from
the world, that hunting-lodge was like a nest. Old oaks and elms
grew round about as screens. Deep glades, with here and there a
bubbling spring, extended league on league, as far as Chertsey
bridge and Guildford down. This forest knew no tenants save the
hart and boar, the chough and crow. An air of privacy, and poetry,
and romance, hung about this ancient forest lodge.
Seeds of much legendary lore had been already sown. A builder
of that Saxon lodge had been imagined in a mythical king—Arthur of
the Round Table, Arthur of the blameless life—a legend which
endures at Windsor to the present day. There, Godwin, sitting at the
king’s board, had met his death, choked with the lie in his wicked
throat. There, Edward the Confessor had lisped his prayers, and
cured the halt and blind. There, too, the Saxon princes, Tosti and
Harold, were supposed to have fought in the king’s presence,
lugging out each other’s locks, and hurling each other to the ground.
Of later growth were other legends; ranging from the romance of the
Fitz-Warines, through the Romaunt of the Rose, down to the rhyme
of King Edward and the Shepherd, the mystery of Herne the Hunter,
and the humours of the Merry Wives.
William the Conqueror preserved his Saxon hunting-lodge by the
river-side, but built his Norman keep on the Castle Hill—perhaps on
the ruins of a Celtic camp, certainly round the edges of a deep and
copious well.