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Interpreting ECGs 3e
A Practical Approach
Third Edition

©rivetti/Getty Images
Interpreting ECGs 3e
A Practical Approach
Third Edition

©rivetti/Getty Images

Bruce Shade
EMT-P, EMS-I, AAS
INTERPRETING ECGs

Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2019 by McGraw-Hill
Education. All rights reserved. Printed in the United States of America. No part of this publication may be
reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the
prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic
storage or transmission, or broadcast for distance learning.

Some ancillaries, including electronic and print components, may not be available to customers outside the
United States.

This book is printed on acid-free paper.

1 2 3 4 5 6 7 8 9 LMN 21 20 19 18

ISBN 978-1-260-09293-6
MHID 1-260-09293-3

Cover Image: PIXOLOGICSTUDIO/Getty Images

All credits appearing on page or at the end of the book are considered to be an extension of the copyright page.

The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does
not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not
guarantee the accuracy of the information presented at these sites.

mheducation.com/highered
About the Author
Bruce Shade is currently employed as the EMS Educator for
Cleveland Clinic Hillcrest Hospital in Northeast Ohio. He is
also a paramedic instructor at Cuyahoga Community College
Courtesy Bruce Shade

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

Ohio Emergency Medical Services Board and just recently
retired as a part-time firefighter for the City of Willoughby.

Bruce has been involved in emergency services since

1972. He started as a volunteer firefighter/EMT for
Granger Township and then served as paramedic, educational supervisor, paramedic
training program director, and commissioner for the City of Cleveland’s Division of
Emergency Medical Service for the next 25 years. During those years, he also worked
as a part-time firefighter/paramedic for Willowick Fire Department and the para-
medic faculty at Lakeland Community College. For the remainder of his career with
Cleveland, he served as an ­Assistant ­Public Safety Director. Since retiring, Bruce
worked as a Homeland Security Consultant, Operations Director for Community
Care Ambulance, and Assistant Safety-Service Director for the City of Elyria, all in
Northeast Ohio.

Bruce is past President, Vice President, and Treasurer of the National Association
of EMTs and chairperson of the Instructor Coordinator Society. He has served as
president of several local associations and chairperson of many committees and task
forces. Bruce has authored several EMS textbooks and written many EMS-related
articles. He has lectured at local, regional, state, and national EMS conferences.

Dedication
This book is dedicated to my father, Elmer Shade, Jr. He recently passed
away at the age of 97. He grew up during the depression, served in
France during the Second World War, and worked hard his entire life.
He was still mowing 20 acres of property each week at 96 years of age.
A lifelong Cleveland sports fan, he had a keen sense of humor and a
strong set of values and work ethic. He was known for his ability to tell
stories and recall his life experiences. I can say, with great pride, that
I acquired many of his traits. My ability to communicate information
through textbooks can be directly attributed to what I learned from him.

v
Contents
Preface xxii
Features to Help You Study and Learn xxiv

Section 1: Preparatory
Chapter 1 Anatomy and Electrophysiology of the Heart 2
The Electrocardiogram 4
How It Works 5
The Circulatory System 6
Anatomy of the Heart 6
Shape and Position of the Heart 7
The Pericardial Sac 8
The Heart Wall 9
The Internal Heart 10
Cells of the Heart 12
Myocytes 12
Pacemaker and Electrical Conducting Cells 14
The Heart’s Conductive Pathway 14
SA Node 14
AV Node 14
Bundle of His and Right and Left Bundle Branches 16
Purkinje Fibers 16
The Heart’s Blood Supply 16
Right Coronary Artery 16
Left Main Coronary Artery 17
Coronary Veins 17
Physiology of the Heart and Circulation 18
The Cardiac Cycle 18
Cardiac Output 18
Blood Pressure 19
Blood Flow through the Atria 19
Initiation of Impulse in the SA Node 20
Atrial Depolarization and Contraction 21
Conduction through the AV Node 21
Conduction through the His-Purkinje System 22
Ventricular Depolarization and Contraction 22
Atrial and Ventricular Repolarization 24
Alternate Pacemaker Sites 24
vi
 Influences on the Heart and Circulatory System 25
The Autonomic Nervous System 26
Sympathetic Nervous System 26
Parasympathetic Nervous System 27
Increased Myocardial Oxygen Needs 27
Nerve Impulse Generation and Muscle Contraction 28
Polarized State 28
Depolarization 29
Repolarization 30
Refractory Periods 31
Impulse Generation of the SA Node 31
Depolarization and Repolarization of the Myocytes 33

Chapter 2 The Electrocardiogram 44

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

Section 2: The Nine-Step Process

Chapter 3 Analyzing the Electrocardiogram 86
Characteristics of the Normal ECG 88
Analyzing the Electrocardiogram Using the
Nine-Step Process 88
Step 1: Heart Rate 89
Step 2: Regularity 89
Step 3: P Waves 90
Step 4: QRS Complexes 91
Step 5: PR Intervals 91
Step 6: ST Segments 92
Step 7: T Waves 93

vii
 Step 8: QT Intervals 94
Step 9: U Waves 94
Flexibility in the Nine-Step Process 95
Dysrhythmia and Cardiac Condition Characteristics 95
Analyzing the ECG 98
Analyzing the Rhythm Strip 98
Analyzing the 12-Lead Tracing 99
Calibrating the ECG 100
Artifact 102

Chapter 4 Heart Rate 108

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

Chapter 5 Regularity 122

Importance of Determining Regularity 124
Quick Check of Regularity 124
Methods of Determining Regularity 125
Paper and Pen Method 126
Caliper Method 127
Counting the Small Squares Method 128
Using a Rate Calculator 128
Types of Irregularity 129
Occasionally or Very Irregular 130
Slightly Irregular 132
Irregularity Caused by Sudden Changes in the Heart Rate 133
Irregularly (Totally) Irregular 133
Patterned Irregularity 135
Irregularity Caused by Varying Conduction Ratios 136

viii
Chapter 6 P Waves 142
Importance of Determining the P Waves 143
Examining the P Waves 144
Normal P Waves 144
Identifying and Characterizing Abnormal P Waves 146
Peaked, Notched, or Enlarged Sinus P Waves 146
Atrial P Waves 147
Varying Atrial P Waves 148
Flutter and Fibrillatory Waves 150
Inverted and Absent P Waves 151
More P Waves than QRS Complexes 153

Chapter 7 QRS Complexes 160

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

Chapter 8 PR Intervals 184

Importance of Determining the PR Intervals 185
Characteristics of Normal PR Intervals 186
Measuring the PR Intervals 187
PR Intervals That Are Different 188
Shorter PR Intervals 188
Longer PR Intervals 191
Varying PR Intervals 192
Absent or Not Measurable PR Intervals 194
Constant PR Intervals Seen with More P Waves 195

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

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

Chapter 10 Heart Disease 222

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

Section 3: Origin and Clinical Aspects of Dysrhythmias

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

Chapter 12 Sinus Dysrhythmias 276

Rhythms Originating from the Sinus Node 278
ECG Appearance of Sinus Rhythms 278

xi
 Normal Sinus Rhythm 279
Sinus Bradycardia 280
Description 280
Causes 280
Effects 282
ECG Appearance 282
Treatment 282
Sinus Tachycardia 283
Description 283
Causes 284
Effects 285
ECG Appearance 285
Treatment 285
Sinus Dysrhythmia 285
Description 285
Causes 286
ECG Appearance 287
Treatment 287
Sinus Arrest 287
Description 287
Causes 287
Effects 288
ECG Appearance 289
Treatment 289
Sinoatrial Exit Block 289
Description 289
Causes 289
Effects 290
ECG Appearance 290
Treatment 290
Sick Sinus Syndrome 291
Description 291
Causes 291
Effects 291
ECG Appearance 292
Treatment 292
Sinus Rhythm as the Underlying Rhythm 292
Practice Makes Perfect 294

Chapter 13 Atrial Dysrhythmias 314

Rhythms Originating in the Atria 316
Key Features of Atrial Dysrhythmias 316

xii
 P Wave Appearance 316
QRS Complex Appearance 316
Effects of Atrial Dysrhythmias 317
Premature Atrial Complexes 318
Description 318
Causes 318
Effects 319
ECG Appearance 319
Differentiating Blocked PACs from Sinus Arrest 322
Treatment 323
Wandering Atrial Pacemaker 323
Description 323
Causes 324
Effects 324
ECG Appearance 324
Treatment 324
Atrial Tachycardia 325
Description 325
Causes 325
Effects 326
ECG Appearance 326
Treatment 327
Multifocal Atrial Tachycardia 329
Description 329
Causes 330
Effects 330
ECG Appearance 330
Treatment 330
Supraventricular Tachycardia 330
Atrial Flutter 331
Description 331
Causes 331
Effects 332
ECG Appearance 332
Treatment 333
Atrial Fibrillation 333
Description 333
Causes 334
Effects 334
ECG Appearance 335
Treatment 335
Practice Makes Perfect 336

xiii
 Chapter 14 Junctional Dysrhythmias 356
Dysrhythmias Originating in the Atrioventricular Junction 358
Key Features of Junctional Dysrhythmias 358
P Wave Appearance 358
PR Interval 359
QRS Complex Appearance 359
Effects 360
Premature Junctional Complex 360
Description 360
Causes 361
Effects 361
ECG Appearance 361
Treatment 362
Junctional Escape Rhythm 362
Description 362
Causes 363
Effects 363
ECG Appearance 363
Treatment 363
Accelerated Junctional Rhythm 364
Description 364
Causes 365
Effects 365
ECG Appearance 365
Treatment 365
Junctional Tachycardia 366
Description 366
Causes 367
Effects 367
ECG Appearance 367
Atrioventricular Nodal Reentrant Tachycardia 367
Description 367
ECG Appearance 368
Effects 369
Preexcitation 369
Wolff-Parkinson-White Syndrome 370
Lown-Ganong-Levine Syndrome 370
Atrioventricular Reentrant Tachycardia 372
Description 372
Appearance 372
Effects 373
Treatment of Supraventricular Tachycardia 373
Practice Makes Perfect 375

xiv
Chapter 15 Ventricular Dysrhythmias 394
Dysrhythmias Originating in the Ventricles 396
Key Features of Ventricular Dysrhythmias 397
P Wave Appearance 397
QRS Complex Appearance 398
Effects 398
Premature Ventricular Complexes 398
Description 398
Causes 399
Effects 399
ECG Appearance 400
Treatment 404
Ventricular Escape Beats 404
Description 404
Causes 405
Effects 405
ECG Appearance 406
Treatment 406
Idioventricular Rhythm 407
Description 407
Causes 408
Effects 408
ECG Appearance 408
Treatment 408
Accelerated Idioventricular Rhythm 409
Description 409
Causes 409
Effects 410
ECG Appearance 410
Treatment 410
Ventricular Tachycardia 410
Description 410
Causes 410
Effects 410
ECG Appearance 412
Treatment 412
Polymorphic Ventricular Tachycardia 413
Description 413
Causes 413
Effects 414
ECG Appearance 414
Treatment 414

xv
 Ventricular Fibrillation 414
Description 414
Causes 415
Effects 415
ECG Appearance 416
Treatment 416
Asystole 417
Description 417
Causes 417
Effects 417
ECG Appearance 417
Treatment 418
Pulseless Electrical Activity 419
Description 419
Causes 420
Effects 420
ECG Appearance 420
Treatment 420
Practice Makes Perfect 421

Chapter 16 AV Heart Blocks 440

Block of the Atrioventricular Node 442
1st-Degree Atrioventricular Heart Block 443
Description 443
Causes 444
Effects 444
ECG Appearance 444
Treatment 444
2nd-Degree Atrioventricular Heart Block, Type I 445
Description 445
Causes 446
Effects 446
ECG Appearance 446
Treatment 447
2nd-Degree Atrioventricular Heart Block, Type II 447
Description 447
Causes 447
Effects 448
ECG Appearance 448
Treatment 448
3rd-Degree Atrioventricular Heart Block 449
Description 449
Causes 449

xvi
 Effects 450
ECG Appearance 450
Treatment 450
Atrioventricular Dissociation 451
Description 451
Causes 451
Effects 452
ECG Appearance 452
Treatment 452
Practice Makes Perfect 453

Chapter 17 Pacemakers and Implanted Cardioverter-Defibrillators 470

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

xvii
 Therapies Provided by the ICD 485
Provider Safety 486
Practice Makes Perfect 487

Section 4: 12-Lead ECGs

Chapter 18 Overview of 12-Lead ECGs and Electrical Axis 498
The 12-Lead ECG 500
Views 500
Limb Leads 500
Leads I, II, and III 500
Leads aV R, aV L, and aVF 502
Precordial Leads 502
Leads V1, V2, V3 503
Leads V4, V5, V6 504
ECG Views of the Heart 505
Contiguous Leads 505
Analyzing the 12-Lead ECG 506
Electrical Axis and the ECG 508
Vectors 508
Mean Instantaneous Vector 509
Waveform Direction 509
Ventricular Depolarization and Mean QRS Axis 509
Determining the Electrical Axis 512
Hexaxial Reference System 512
Altered QRS Axis 518
Causes of Altered Electrical Axis 519
Practice Makes Perfect 522

Chapter 19 Myocardial Ischemia, Injury, and Infarction 532

Coronary Circulation 534
Right Coronary Artery (RCA) 534
Left Coronary Artery (LCA) 536
The ECG Waveforms 538
Q Waves 538
Normal ST Segments 539
Normal T Waves 540
ECG Indicators of Ischemia, Injury, and Infarction 541
T Wave Changes 541
ST Segment Changes 544
STEMI and NSTEMI 548

xviii
 Q Wave Changes 550
Left Bundle Branch Block 551
Reciprocal Changes 552
ECG Evolution during Myocardial Infarction 553
MI—Age Indeterminate 554
Criteria for Diagnosing Myocardial Infarction 555
Clinical History 555
Serum Cardiac Markers 556
ECG Findings 556
Identifying the Myocardial Infarction Location 556
Septal Wall Infarction 557
Anterior Wall Infarction 558
Lateral Wall Infarction 559
Anterolateral Wall Infarction 559
Extensive Anterior Wall Infarction 560
Inferior Infarction 561
Posterior Wall Infarction 561
Right Ventricular Infarction 562
Treatment of Myocardial Infarction 566
Right Ventricular Infarction Treatment 567
Practice Makes Perfect 568

Chapter 20 Bundle Branch Block 580

Ventricular Conduction Disturbances 582
The Bundle Branches 582
Bundle Branch Block 582
ECG Leads Used to Identify Ventricular Conduction Disturbances 585
Right Bundle Branch Block 585
Left Bundle Branch Block 588
Incomplete Bundle Branch Block 590
Nonspecific Intraventricular Conduction Defect 590
Fascicular Block 591
Left Anterior Fascicular Block 591
Left Posterior Fascicular Block 592
Bifascicular and Trifascicular Blocks 593
Identifying MI and/or Hypertrophy in the Presence of Bundle Branch
Block 594
Treatments of Bundle Branch Block 595
Inherited Conditions That Mimic Right Bundle Branch Block 596
Brugada Syndrome 596
Arrhythmogenic Right Ventricular Dysplasia (AVRD) (ARVC) 597
Practice Makes Perfect 599

xix
 Chapter 21 Atrial Enlargement and Ventricular Hypertrophy 610
ECG Changes Used to Identify Enlargement and Hypertrophy 612
Atrial Enlargement 612
Right Atrial Enlargement 612
Left Atrial Enlargement 613
Ventricular Hypertrophy 615
Right Ventricular Hypertrophy 615
Left Ventricular Hypertrophy 617
ST Segment and T Wave Changes 619
Hypertrophic Cardiomyopathy 620
Practice Makes Perfect 621

Chapter 22 Other Cardiac Conditions and the ECG 626

Pericarditis 628
ECG Changes 628
Pericardial Effusion 628
ECG Changes 630
Pulmonary Embolism 631
ECG Changes 632
Electrolyte Imbalance 632
Hyperkalemia 632
Hypokalemia 634
Calcium Disorders 635
Drug Effects and Toxicity 635
Digoxin 636
Other Medications 638
Practice Makes Perfect 639

Section 5: Review and Assessment

Chapter 23 Putting It All Together 648
Using the Nine-Step Process and Deductive Analysis 650
Step 1: Heart Rate 650
Slow Rate 650
Normal Rate 651
Fast Rate 651
Step 2: Regularity 651
Regular Rhythms 651
Irregular Rhythms 652

xx
 Step 3: P Waves 653
Normal P Waves 653
Abnormal P Waves 654
Step 4: QRS Complexes 655
Normal QRS Complexes 655
Abnormal QRS Complexes 656
Step 5: PR Intervals 656
Normal PR Intervals 656
Abnormal PR Intervals 657
Step 6: ST Segments 658
Normal ST Segments 658
Abnormal ST Segments 658
Step 7: T Waves 658
Normal T Waves 658
Abnormal T Waves 661
Step 8: QT Intervals 661
Normal QT Intervals 661
Abnormal QT Intervals 661
Step 9: U Waves 663
So Why Do It? 663
Practice Ruling Out Dysrhythmias and Conditions 664
Practice Makes Perfect 677
Appendix A 696
Glossary 716
Index 723

xxi
 Preface
This book presents information similar to how an instructor delivers it in the class-
room, with lots of illustrations, solid practical content, plentiful reinforcement of
material, questions to prompt critical thinking, case presentations, and plentiful
practice ECG tracings to promote the application of skills.

One of the first things readers will notice about this text is it is more of a ­“how-to
book” than a “theoretical book.” Although there is plenty of detail, the coverage is
to the point, telling you and then showing you what you need to know. The breadth
of information ranges from simple to complex, but regardless of how advanced
the material, the explanations and visuals make the concepts easy to understand.
Another aspect of this book is that it truly covers both dysrhythmia and 12-lead
analysis and interpretation. It reinforces those core concepts from the beginning
to the end using lots of repetition. This book includes plentiful pictures and figures
to help readers see what is being discussed in actual use. We have also included
coverage of the treatments used to manage the various dysrhythmias and cardiac
conditions to give readers a broader ­perspective and better prepare them for apply-
ing what they have learned.

Structure of This Book

This book is divided into five sections:
• Section 1, Preparatory, looks at the underlying concepts of the anatomy and
electrophysiology of the heart and the electrocardiogram itself.
• Section 2, The Nine-Step Process, comprises Chapters 3 through 9 and presents
the Nine-Step Process of ECG interpretation. Each chapter provides an in-depth
look at one of the steps and introduces the reader to the variances seen with that
step.
• Section 3, Origin and Clinical Aspects of Dysrhythmias, comprises Chapters
10 through 17 and leads readers through an overview of heart disease and a
thorough discussion regarding dysrhythmias. The section covers the origin of
dysrhythmias, including the sinus node, the atria, the atrioventricular junction,
the ventricles, atrioventricular heart blocks, and pacemakers. And it covers the
clinical aspects of each dysrhythmia.
• Section 4, 12-Lead ECGs, introduces the concept of 12-lead ECGs in Chapter 18.
Then Chapters 19 through 22 cover interpretation and recognition of myocardial
ischemia, injury and infarction, bundle branch block and atrial enlargement and
ventricular hypertrophy, and a host of other cardiac conditions and their effect
on the ECG.
• Section 5, Review and Assessment, wraps it all up with the chapter ­“Putting It All
Together” and more practice tracings.

xxii
Changes to the Book
Among the changes in this book is that we have retitled it to better reflect its com-
prehensive nature. While it is still easy to learn to interpret ECGs using this book,
its volume and breadth of coverage make it difficult to read from cover to cover in
a fast way. The third edition of Fast & Easy ECGs: A Self-Paced Learning Program
by Bruce Shade is thorough, innovative, and greatly enhanced. We have changed
the title to better reflect the comprehensive nature of this book. While we strive to
make our approach fast and easy, there are many complicated aspects of learning
how to analyze and interpret ECG tracings. For this reason, we cover the material
in sufficient depth to provide the reader with everything they need to know in order
to be proficient with this important skill.

Whereas the second edition had 22 chapters, this book is expanded and includes
23 chapters. The following chapter is brand new to this edition:

Chapter 10 provides an overview of heart disease, including what it is, the risks for
developing it, and its causes and complications. Then we review the common types
of heart disease. This chapter is designed to provide the reader with an understand-
ing of how dysrhythmias and cardiac conditions occur. This will make it easier for
the reader to understand the characteristics associated with each dysrhythmia and
cardiac condition.

In addition to the expanded content, this book has more than 300 figures and close
to 400 practice ECG tracings. It also introduces the reader to the treatment modal-
ities for the various dysrhythmias and medical conditions.

We hope this book is beneficial to both students and instructors. Greater under-
standing of ECG interpretation will lead to better patient care everywhere.

Instructor Resources
Instructors, are you looking for additional resources? Be sure to visit www.mhhe
.com/shade3e for answer keys, an Electronic Testbank, and accessible PowerPoint
­Presentations. Access is for instructors only and requires a user name and pass-
word from your McGraw-Hill Learning Technology Representative. To find your
McGraw-Hill representative, go to www.mheducation.com and click “Contact,”
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xxiii
Features to Help You Study and Learn

Preview the Chapter Content

1 Anatomy and Electrophysiology
of the Heart
©rivetti/Getty Images
Study the Chapter Outline to get an
Chapter Outline overview of the subjects to be covered in
The Electrocardiogram
The Circulatory System
The Heart’s Conductive
Pathway
Physiology of the Heart
and Circulation
Nerve Impulse
Generation and the chapter.
The Heart’s Blood Influences on the Heart Muscle Contraction
Anatomy of the Heart
Supply and Circulatory System
Cells of the Heart

©McGraw-Hill Education/Rick Brady

Learning Outcomes
LO 1.1 Define the term electrocardiogram, list its uses, and describe how
it works.

LO 1.2 List the components of the circulatory system.

LO 1.3 Describe the anatomy of the heart.

LO 1.4 Identify and contrast the structure and function of the different types Learning Outcomes
of heart cells. LO 1.1 Define the term electrocardiogram, list its uses, and describe how
it works.
LO 1.5 Identify the structures of the heart’s conduction system and describe
what each does. LO 1.2 List the components of the circulatory system.

LO 1.3 Describe the anatomy of the heart.

LO 1.6 Identify how the heart receives most of its blood supply.
LO 1.4 Identify and contrast the structure and function of the different types
LO 1.7 Recall how the heart and circulatory system circulates blood throughout of heart cells.
Review the the Learning
body. Outcomes LO 1.5 Identify the structures of the heart’s conduction system and describe

to seeLOwhat
1.8 Describe the influence Note
you will learn. of the autonomic nervous system on the heart
what each does.

LO 1.6 Identify how the heart receives most of its blood supply.
that the Learning Outcomes
and circulatory system.
LO 1.7 Recall how the heart and circulatory system circulates blood throughout
numbers
LO 1.9are keyed
Recall to the
how nerve text
impulses are generated and muscles contract the body.
in the heart.
and learning assessments. LO 1.8 Describe the influence of the autonomic nervous system on the heart
and circulatory system.

LO 1.9 Recall how nerve impulses are generated and muscles contract
in the heart.

Case History
Emergency medical services responds to the home of a 65-year-old man complaining Case History
of a dull ache in his chest for the past two hours which came on while mowing his Read the Case History for a real-world
Emergency medical services responds to the home of a 65-year-old man complaining
lawn. He also complains of a “fluttering” in his chest and “shortness of breath.” He
scenario that features the type of
of a dull ache in his chest for the past two hours which came on while mowing his
lawn. He also complains of a “fluttering” in his chest and “shortness of breath.” He
has a history of hypertension, elevated cholesterol, and a one-pack-a-day smoking
habit. dysrhythmia covered in the chapter.
has a history of hypertension, elevated cholesterol, and a one-pack-a-day smoking
habit.

After introducing themselves, the paramedics begin their assessment, finding the After introducing themselves, the paramedics begin their assessment, finding the
patient’s blood pressure to be 160/110, pulse 120 and irregular, respirations 20, and patient’s blood pressure to be 160/110, pulse 120 and irregular, respirations 20, and
oxygen saturation 92% on room air. The patient is awake and alert, his airway is open,
oxygen saturation 92% on room air. The patient is awake and alert, his airway is open,
his breathing is slightly labored, and his pulses are strong.
his breathing is slightly labored, and his pulses are strong.

xxiv
Visualize the Content Chapter 14 Junctional Dysrhythmias 359

300 Full-Color Figures show you in detail

Inverted P’ wave may
precede the QRS
complex with a P ' R
interval shorter
than normal

where each dysrhythmia originates and P

T
P
P
T
P
T

teaches you step by step how to read the QRS QRS QRS QRS
Premature junctional complex (PJC) is a single early electrical impulse that
originates in the AV junction

ECGs that demonstrate each dysrhythmia.

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

In addition, algorithms and tables present

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

content visually to help you memorize the Effects

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

P’ wave may be buried

Treatment
most important elements of each type of
forced to pump against the contracting ventricles, which contract with muchingreater
the QRS complex
force. This can result in a loss in atrial kick, decreased stroke volume, and, ulti- PJCs generally do not require treatment. PJCs caused by the use of caffeine,
mately, decreased cardiac output. Decreased cardiac output can also Toccur with tobacco, or alcohol, or with anxiety, fatigue, or fever can be controlled by eliminat-
P
slow or fast junctional dysrhythmias. ing the underlying cause.

dysrhythmia and condition. As a reminder, dysrhythmias arising from the SA node, atria, or AV junction
QRS
can bejunctional rhythm arises from a single site in the
Accelerated
AV junction at a rate of between 60 and 100 beats per minute
collectively called supraventricular dysrhythmias.
P’ wave may follow
14.4 Junctional Escape Rhythm
each QRS complex
Description
14.3 Premature Junctional Complex
P Junctional escape rhythm is slow, steady rhythm (40 to 60 beats per minute) with
Description QRS
narrow QRS complexes, inverted or absent P9 waves, and shorter than normal P9R
intervals (when the P9 wave precedes the QRS complex). It typically occurs when
A PJC is a single early electrical impulse that originates Junctional
in the tachycardia arises from a single site in the AV
AV junction
junction at a rate of between 100 and 180 beats per minute the rate of the primary pacemaker (SA node) falls below that of the AV junctional
(Figure 14-2). It occurs before the next expected sinus impulse, interrupting the tissue (Figure 14-3). Remember, if the SA node fails to fire or slows down, the AV
regularity of the underlying rhythm. Because theFigure 14-1arises from the middle of
impulse junction (or ventricles) in their role as backup pacemakers, should initiate the heart-
Junctional dysrhythmias originate from the AV junction.
the heart, the atria are depolarized in a retrograde fashion. This causes the P9 wave

PR Interval Junctional escape rhythm arises from a single site in the AV junction.

PR
Premature junctional complex arises from somewhere in the AVintervals
junction. seen with premature junctional complexes or junctional rhythms are
shorter than normal (less than 0.12 seconds in duration) or absent if the P wave is
buried in the QRS complex. If the P’ wave follows the QRS complex, it is referred
to as the RP’ interval and is usually less than 0.20 seconds.

QRS Complex Appearance

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

Rate P’ waves QRS complexes

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

Review the Content

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

opportunities to interpret ECG strips using your

as you assess each tracing. Your answers can be written into the area below each ECG
marked “ECG Findings.” Your findings can be compared to the answers provided in Appen-
dix A. All dysrhythmia tracings are 6 seconds in length.

new knowledge. 1. Determine the heart rate. Is it slow? Normal? Fast? What is the ventricular rate? What
is the atrial rate?
2. Determine if the rhythm is regular or irregular. If it is irregular, what type of
irregularity is it? Occasional or frequent? Slight? Sudden acceleration or slowing in
heart rate? Total? Patterned? Does it have a variable conduction ratio?
3. Determine if P waves are present. If so, how do they appear? Do they have normal
height and duration? Are they tall? Notched? Wide? Biphasic? Of differing
morphology? Inverted? One for each QRS complex? More than one preceding some
or all the QRS complexes? Do they have a sawtooth appearance? An indiscernible
chaotic baseline?

Key Points 4. Determine if QRS complexes are present. If so, how do they appear? Narrow with
proper amplitude? Tall? Low amplitude? Delta wave? Notched? Wide? Bizarre-
looking? With chaotic waveforms?
LO 1.1 • The electrocardiogram is a graphic representation of the heart’s electrical activity. 5. Determine the presence of PR intervals. If present, how do they appear? Constant? Of
It is used to identify irregularities in the heart rhythm and to reveal the presence of normal duration? Shortened? Lengthened? Progressively longer? Varying?
injury, death, or other physical changes in the heart muscle. 6. Evaluate the ST segments. Do they have normal duration and position? Are they
• The electrocardiograph detects the electrical activity occurring in the heart through elevated? (If so, are they flat, concave, convex, arched?) Depressed? (If so, are they
electrodes attached to the patient’s skin. normal, flat, downsloping, or upsloping?)
7. Determine if T waves are present. If so, how do they appear? Of normal height and
• When an impulse occurring in the heart moves toward a positive electrode of the
duration? Tall? Wide? Notched? Inverted?
ECG, it produces a positive waveform. When it moves away from the positive
electrode (or toward a negative electrode), it produces a negative waveform. 8. Determine the presence of QT intervals. If present, what is their duration? Normal?
Shortened? Prolonged?
LO 1.2 • The heart, blood, and blood vessels are the chief components of the circulatory system. 9. Determine if U waves are present. If present, how do they appear? Of normal height
• The circulatory system circulates enough blood to deliver needed oxygen and and duration? Inverted?
nutrients to the tissues and to remove waste products. 10. Identify the rhythm, dysrhythmia, or condition.
LO 1.3 • The heart is the pump; each time it contracts, it pushes blood throughout the body. 1.
• The heart is located between the lungs in the mediastinum behind the sternum, and it
rests on the diaphragm with a front-to-back (anterior-posterior) orientation.
• It is surrounded by a double-walled closed sac called the pericardium. The pericardium
allows the heart to contract and expand within the chest cavity with minimal friction.
• The heart wall consists of three layers: the myocardium, endocardium, and epicardium.
• The heart consists of two upper chambers, the atria, and two lower chambers, the
ventricles.
ECG Findings:
• A muscular wall, the septum, separates the right side from the left side of the heart.
• The right side of the heart receives blood from the systemic venous circulation and
pumps it into the pulmonary circulation.

Key Points cover all of the

• The left side of the heart receives blood from the pulmonary circulation and pumps it Practice Makes Perfect 677
into the systemic circulation.
• The skeleton of the heart provides firm support for the AV and semilunar valves and
acts to separate and insulate the atria from the ventricles.
• The four heart valves permit blood to flow through the heart in only one direction.
pertinent content in the chapter.
LO 1.4 • There are two basic types of cells in the heart: the myocardial cells (also referred to
as the working cells), which contract to propel blood out of the heart’s chambers,
and the specialized cells of the electrical conduction system, which initiate and carry
impulses throughout the heart.
• The structure of the myocardial cells permits the rapid conduction of electrical
impulses from one cell to another. This results in the cardiac muscle cells acting as a
single unit, permitting coordinated contraction of a whole group of cells.
LO 1.5 • Depolarization of the myocardium progresses from the atria to the ventricles in an
orderly fashion. The electrical stimulus causes the heart muscle to contract.
• The wave of depolarization is carried throughout the heart via the heart’s conduction
system. The conduction system is a grouping of specialized tissues that form a
network of connections, much like an electrical circuit.
• The key structures of the conduction system are the SA node, intraatrial conductive
pathway, internodal pathways, AV node, bundle of His, right and left bundle
branches, and Purkinje fibers.
Chapter 1 Anatomy and Electrophysiology of the Heart 37

xxv
 • Five of the small boxes represent 0.20 seconds in duration and make up the larger
boxes denoted by a heavier line. Fifteen larger boxes equal a three-second interval.
You can use the horizontal measurements to determine the heart rate.
• Vertically on the ECG paper, the distance between the lines, or boxes, represents
amplitude in mm or electrical voltage in mV. Each small square represents 1 mm or
0.1 mV while the larger boxes, made up of five small squares, represent 5 mm or
0.5 mV.
• The flat line that precedes the electrical impulses is called the isoelectric line.

Assess Your Understanding

The following questions give you a chance to assess your understanding of the
material discussed in this chapter. The answers can be found in Appendix A.
1. An electrocardiogram is a/an (LO 2.1)
a. graphic record of the heart’s electrical activity.
b. device that measures and records the ECG.
c. irregular rhythm.
d. device that measures the heart’s mechanical activity.

Assess Your Understanding quizzes, with 2. The electrocardiograph can be used to do all the following
EXCEPT (LO 2.1)

answers in Appendix A, help you recall

a. detect cardiac dysrhythmias.
b. determine cardiac output.
c. identify the presence of myocardial ischemia and/or infarction.

the material and test your knowledge. 3.

d. evaluate the function of artificial implanted pacemakers.
positioned on the patient’s skin detect the heart’s
electrical activity. (LO 2.2)
a. Electrodes
b. Lead wires
c. Tracings
d. Leads

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

5. Impulses that travel toward a positive electrode and away from a negative elec-
trode are recorded on the electrocardiogram as deflections.
(LO 2.4)
a. downward
b. perpendicular
c. neutral
d. upward

Chapter 2 The Electrocardiogram 81

First, I would like to thank Claire Merrick, the editor on the first edition of this
textbook. It was her vision for the project that led to the original signing and
publishing of Fast & Easy ECGs. Next, I would like to thank Melinda Bilecki, the
Freelance Product Developer for this edition. Melinda maintained a steady hand
to get the chapters rewritten and figures redone despite my many delays. Even with
these obstacles, she displayed incredible patience and helped guide completion of
the book. Further, her hard work and attention to detail helped ensure the accuracy
of the content.

Many thanks go to, Michelle Flomenhoft, the Senior Product Developer, and
William Lawrensen, the Executive Portfolio Manager with the Health Professions
team at McGraw-Hill. They allowed me to significantly restructure the order of
chapters, add more content and practice ECG tracings, and increase the footprint of
the textbook. These features make a good book even better. They also convinced me
of the need to rename the book to better reflect its comprehensive nature. As hard
as it was for me to give up the former title, I recognize the importance of doing so.

Bruce Shade

xxvi
Interpreting ECGs 3e
A Practical Approach
Third Edition

©rivetti/Getty Images
 section 1
Preparatory

©rivetti/Getty Images

Chapter 1: Anatomy and Electrophysiology of the Heart

Chapter 2: The Electrocardiogram

1
1 Anatomy and Electrophysiology
of the Heart
©rivetti/Getty Images

Chapter Outline
The Electrocardiogram The Heart’s Conductive Physiology of the Heart Nerve Impulse
The Circulatory System Pathway and Circulation Generation and
The Heart’s Blood Influences on the Heart Muscle Contraction
Anatomy of the Heart
Supply and Circulatory System
Cells of the Heart

©McGraw-Hill Education/Rick Brady

Learning Outcomes
LO 1.1 Define the term electrocardiogram, list its uses, and describe how
it works.

LO 1.2 List the components of the circulatory system.

LO 1.3 Describe the anatomy of the heart.

LO 1.4 Identify and contrast the structure and function of the different types
of heart cells.

LO 1.5 Identify the structures of the heart’s conduction system and describe
what each does.

LO 1.6 Identify how the heart receives most of its blood supply.

LO 1.7 Recall how the heart and circulatory system circulates blood throughout
the body.

LO 1.8 Describe the influence of the autonomic nervous system on the heart
and circulatory system.

LO 1.9 Recall how nerve impulses are generated and muscles contract
in the heart.

Case History
Emergency medical services responds to the home of a 65-year-old man complaining
of a dull ache in his chest for the past two hours which came on while mowing his
lawn. He also complains of a “fluttering” in his chest and “shortness of breath.” He
has a history of hypertension, elevated cholesterol, and a one-pack-a-day smoking
habit.

After introducing themselves, the paramedics begin their assessment, finding the
­patient’s blood pressure to be 160/110, pulse 120 and irregular, respirations 20, and
oxygen saturation 92% on room air. The patient is awake and alert, his airway is open,
his breathing is slightly labored, and his pulses are strong.

3
 The paramedics apply oxygen by nasal cannula and attach the patient to a cardiac mon-
itor by applying electrodes to his chest. The monitor shows a fast, narrow complex
rhythm with frequent wide and bizarre-appearing extra complexes. On the basis of what
they observe, the paramedics obtain a 12-lead electrocardiogram (ECG) to determine if
signs of a heart attack are present. The 12-lead ECG confirms their suspicions. The
patient is having a myocardial infarction.

The paramedics then administer aspirin, nitroglycerin, and medication for pain relief to
the patient and transport him to the nearest appropriate facility. En route to the hospi-
tal, the patient states his pain is less and the paramedics notice that the extra complexes
are gone from his heart rhythm.

1.1 The Electrocardiogram

In order for the muscles of the body to contract, they must first be stimulated by
electrical impulses generated and conducted by the nervous system. The electrocar-
diogram, often referred to as an ECG or EKG, is a tracing or graphic representation
of the heart’s electrical activity over time. The device that detects, measures, and
records the ECG is called an electrocardiograph. The name e­ lectrocardiogram is
derived of different parts: electro, because it’s related to electricity, cardio, a Greek
word for heart, and gram, a Greek root meaning “to write.”

The ECG provides healthcare professionals with valuable information (­ Figure 1-1).
It is used to identify irregularities in the heart rhythm (called dysrhythmias); detect

Figure 1-1
The electrocardiogram
provides valuable information
in a host of clinical settings.

(All Photos) Courtesy Philips Healthcare

4
 Chapter 1 Anatomy and Electrophysiology of the Heart   5

electrolyte disturbances and conduction abnormalities; and reveal the presence of

injury, death, or other physical changes in the heart muscle. It is also used as a
screening tool for ischemic heart disease during a cardiac stress test. It is occasion-
ally helpful with diagnosing noncardiac conditions such as pulmonary embolism or
hypothermia.

The ECG is used in the prehospital, hospital, and other clinical settings as both an
assessment and diagnostic tool. It can also provide continuous monitoring of the
heart’s electrical activity, for instance, during transport to the hospital or in the
coronary care unit. The ECG does not, however, tell us how well the heart is pump-
ing. The presence of electrical activity on the cardiac monitor does not guarantee
that the heart is contracting or producing a blood pressure. To determine that, we
must assess the patient’s pulse and blood pressure, as well as perform an ­appropriate
physical examination.

How It Works
In simple terms, the electrocardiograph, or ECG machine, detects the electrical
current activity occurring in the heart (Figure 1-2). It does this through electrodes
placed on the patient’s skin. The ECG electrode must be in good contact with the
skin to properly detect the heart’s electrical currents. Tips for achieving effective
contact will be discussed further in Chapter 2. These impulses, which appear as a
series of upward (positive) and downward (negative) deflections (waveforms), are
then transferred to the ECG machine and displayed on a screen (called the oscillo-
scope or monitor), or they are printed onto graph paper (often referred to as an
ECG tracing or strip).

As the impulse moves toward a positive electrode of the ECG, it produces a positive
waveform (upright deflection). Refer to Figure 1-2. In this ECG tracing, all the
waveforms (P, QRS, and T) are positive, meaning the impulses are traveling toward

Figure 1-2
The ECG detects electrical
activity in the heart.
Courtesy Physio-Control
6  Section 1 Preparatory

a positive electrode. When it moves away from a positive electrode or toward a neg-
ative electrode, it produces a negative waveform (downward deflection). The sites
for the placement of the electrodes vary depending on which area of the heart’s
­activity is being viewed. Different sites provide different views. We discuss this
­information in more depth in the next chapters.

This book is designed to teach you how to interpret what you see on an ECG.
To do this, it is important for you to understand the anatomy and physiology of
the circulatory system and the heart. We begin by reviewing the role of the
circulatory system and discussing the location and structure of the heart. Then
we talk about how the generation and conduction of nerve impulses leads to
contraction of the heart chambers, which then pump blood throughout the
body. Finally, we discuss the influence of the autonomic nervous system on
the heart.

1.2 The Circulatory System

In order to achieve and maintain homeostasis in the body, the circulatory system
performs a number of vital functions: It carries nutrients, gases, and wastes to
and from the body’s cells; it helps fight diseases; and it helps stabilize body tem-
perature and pH. The term perfusion describes the circulatory system’s delivery
of oxygen and nutrients to the tissues and the removal of waste products from
those tissues. Perfusion is necessary for the body’s cells to function and survive.
The body’s cells die if there is insufficient blood supply to meet their needs. The
chief elements of the circulatory system are the heart, blood, and blood vessels
(Figure 1-3).

The circulatory system includes the pulmonary circulation, a “loop” through the
lungs, and the systemic circulation, a “loop” through the rest of the body to provide
oxygenated blood to the body’s cells. The arteries of the systemic circulation carry
oxygenated blood, whereas the veins carry deoxygenated blood. The reverse is true
in the pulmonary circulation, where the pulmonary artery carries deoxygenated
blood to the lungs and the pulmonary veins carry oxygenated blood back to the
heart. The circulatory system of an average adult contains roughly 4.7 to 5.7 L of
blood, which consists of plasma that contains red blood cells, white blood cells, and
platelets.

1.3 Anatomy of the Heart

The heart is an amazing organ. It is the pump of the circulatory system. Each time
it contracts, it pushes blood throughout the body. The typical adult heart beats an
average of 75 times a minute, 24 hours a day, 365 days a year, never stopping to
take a rest. In an average day it pumps between 7000 and 9000 liters (L) of blood!
This circulates enough blood to deliver needed oxygen and nutrients to the tissues
and to remove waste products. Depending on the requirements of the body, the
heartbeat can either be sped up (during exercise) or slowed down (while resting or
sleeping). Try this experiment: count your pulse rate while sitting or lying comfort-
ably reading this book. Then, if you are physically able, go for a brisk walk (or per-
haps run) and then recheck your pulse rate. Your heart should be beating faster;
 Chapter 1 Anatomy and Electrophysiology of the Heart   7

CO2 Figure 1-3

Blood flow through the heart
and systemic and pulmonary
circulations.
Pulmonary
circuit

O2-poor,
CO2-rich O2-rich,
blood CO2-poor
blood

Systemic circuit

CO2 O2

Superior and Right Pulmonary

Right Tricuspid Pulmonary Pulmonary
inferior vena ventricle semilunar
atrium valve trunk arteries
cava valves

Body tissues Lung tissue

(systematic (pulmonary
circulation) circulation)

Aortic
Aorta semilunar Left Bicuspid Left Pulmonary
valves ventricle valve atrium veins

you may even feel the sensation of it pounding in your chest. Your body increases
the heart rate and strength of contractions to circulate more blood (and oxygen
and nutrients) to your cells and to remove the waste products that have been pro-
duced by those working cells.

Shape and Position of the Heart

Make a fist. Your heart is about the same size as your closed fist (Figure 1-4A).
It is shaped like an inverted blunt cone. Its top (called the base) is the larger,
flat part whereas its inferior end (called the apex) tapers to a blunt, rounded
point. The heart is located between the lungs in the mediastinum behind the
sternum (Figure 1-4B). It lies on the diaphragm in front of the trachea, esopha-
gus, and thoracic vertebrae. About two-thirds of the heart is situated in the left
side of the chest cavity. Its base is directed posteriorly and slightly superiorly at
the level of the second intercostal space. Its apex is directed anteriorly and
slightly inferiorly at the level of the fifth intercostal space in the left midclavic-
ular line. This gives it a front-to-back (anterior-posterior) orientation. In this
position the right ventricle is closer to the front of the left chest whereas the
left ventricle is closer to the side of the left chest (Figure 1-4C). This informa-
8  Section 1 Preparatory

Base of the 2nd rib

heart
Sternum
Apex of the
heart 5th rib

Diaphragm

Lungs

Thoracic
vertebra Left ventricle
Base of Apex of
the heart the heart
Sternum Right ventricle
A C

Figure 1-4
(A) The heart is about the size of a closed fist. (B) The position of the heart in the chest.
(C) Cross section of the thorax at the level of the heart.

tion will be particularly useful to you when we discuss placement of the various
leads in later chapters.

Knowing the position and orientation of the heart will help you to understand why
certain ECG waveforms appear as they do when the electrical impulse moves
toward a positive or negative electrode. The location of the various ECG leads
­permits us to look at the heart from several different directions.

The Pericardial Sac

The heart is surrounded by the pericardial sac (also called the pericardium), a
double-walled closed sac (Figures 1-5 and 1-6). The tough, fibrous, outer layer is
called the fibrous pericardium whereas the inner, thin, transparent lining is called
the serous pericardium. Above the heart, the fibrous pericardium is continuous
with the connective tissue coverings of the great vessels, and below, the heart is
attached to the surface of the diaphragm. This anchors the heart within the me-
diastinum. The serous pericardium has two parts: the parietal pericardium,
which lines the fibrous pericardium; and the visceral pericardium, which covers
the surface of the heart. The pericardial cavity, located between the parietal
­pericardium and the visceral pericardium, holds a small amount of clear lubri-
cating fluid that allows the heart to contract and expand within the chest cavity
with minimal friction.

The accumulation of additional fluid in the pericardial space can restrict the heart’s
ability to contract. This leads to a condition called pericardial tamponade. Pericar-
dial tamponade can be life-threatening.
 Chapter 1 Anatomy and Electrophysiology of the Heart   9

Figure 1-5
The pericardium is the
protective sac that surrounds
the heart.
Aorta
Superior
vena cava Pulmonary
Right lung trunk

Parietal
pleura (cut)
Apex
of heart

Parietal
pericardium
Diaphragm
(cut)

Figure 1-6
This cross section shows the
structure of the heart. The
Pericardial enlarged section shows that
cavity the wall of the heart has three
distinct layers of tissue: the
Fibrous endocardium, myocardium,
layer Parietal
pericardium
and epicardium. Also note its
Serous relationship to the
layer pericardium.
Visceral
pericardium (epicardium)
Myocardium
Endocardium

Myocardium

Endocardium
Epicardium
(visceral pericardium)
Parietal
pericardium

The Heart Wall

The heart wall is comprised of three layers (see Figure 1-6). The middle layer, the
muscular layer, is called the myocardium. Myo means muscle whereas cardia means
heart. It is the thickest of the three layers and is composed of cylindrical cells that
look similar to skeletal muscle.
10  Section 1 Preparatory

The innermost layer of the heart wall is called the endocardium. The endocardium
is a serous membrane that lines the four chambers of the heart and its valves. It has
a smooth surface and is continuous with the lining of the arteries and veins. It is
watertight to prevent leakage of blood into the other layers.

The outermost layer is the epicardium. It is a thin serous membrane that constitutes
the smooth outer surface of the heart. The outer layer of the heart wall is called the
epicardium when someone is referring to the layers of the heart but is called the
visceral pericardium when someone is referring to the pericardium.

The Internal Heart

The heart is a muscular, hollow organ (Figure 1-7). It has two upper chambers, the
atria, and two lower chambers, the ventricles. You can think of the heart as having
two upper pumps (the atria) and two lower pumps (the ventricles). The thin-walled
atria serve as low-pressure containers that collect blood from the systemic and pul-
monary circulation and deliver it to the ventricles. The larger, more muscular ven-
tricles pump blood to the pulmonary and systemic circulation. The left ventricle is
thicker and more muscular because it pumps blood through the larger, higher-­
pressure systemic circulation. The left ventricle can be thought of as the workhorse
of the heart.

Two Functional Pumps

The heart is separated into two functional units by the septum (see ­Figure 1-7).
The word septum comes from the Latin word saeptum, meaning a “dividing wall
or enclosure.” The interatrial septum is a thin membranous wall that separates
the two atria whereas the more muscular wall, the interventricular septum,
­separates the two ventricles. For this reason the heart is referred to as a double
pump. The ventricular septum consists of an inferior muscular and superior
membranous portion and is extensively innervated with heart cells capable of
conducting nerve impulses. The septum also provides strength to the walls of
the heart.

Figure 1-7
Internal anatomy of the heart.

Left pulmonary artery

Aorta
Pulmonary trunk
Right pulmonary
artery Pulmonary valve
Superior vena cava
Right pulmonary Left pulmonary veins
veins
Left atrium
Right atrium Aortic valve
Left AV (bicuspid) valve
Left ventricle
Right AV
(tricuspid) valve Papillary muscle
Chordae tendineae Interventricular septum
Myocardium
Right ventricle
Inferior vena cava Epicardium
 Chapter 1 Anatomy and Electrophysiology of the Heart   11

Figure 1-8
Pulmonary Superior view of the heart
valve with the atria removed and
Openings to four heart valves exposed. In
coronary the superior view, the top of
arteries the heart represents the
Aortic anterior aspect whereas the
valve
bottom of the heart
represents the posterior
aspect.
Bicuspid
(mitral) valve

Tricuspid valve

Heart Valves
Two atrioventricular (AV) valves are located between the atria and ventricles,
whereas two semilunar valves are located between the ventricles and major arter-
ies (Figure 1-8). The two AV valves include the tricuspid valve, situated between
the right atrium and right ventricle, and the bicuspid (or mitral) valve, located
between the left atrium and left ventricle. These valves prevent blood from flow-
ing backward into the atria when the ventricles contract, resulting in the ejection
of blood forward from the ventricles and into the pulmonary and systemic circu-
lation. The mitral valve has two cusps whereas the tricuspid valve has three. The
cusps are connected to papillary muscles in the floor of the ventricle by thin,
strong strings of connective tissue called chordae tendineae. These cords prevent
the cusps from bulging (prolapsing) backward into the atria during ventricular
contraction.

The two semilunar valves include the pulmonic valve, found at the base of the pul-
monary artery, and the aortic valve, situated at the base of the aorta, just as they
arise from the right and left ventricles, respectively. They prevent the backward flow
of blood after the ventricles have contracted and propelled blood into the pulmo-
nary arteries and aorta. Each valve has three cusps that look somewhat like shirt
pockets.

Skeleton of the Heart

Between the atria and ventricles is a plate of fibrous connective tissue called the
skeleton of the heart (Figure 1-9). This plate forms fibrous rings around the AV and
semilunar valves, providing firm support. It also acts to separate the atria from the
ventricles, functioning in two important ways.

First, it allows the top and bottom parts of the heart to act as separate, sequential
pumps. Second, it electrically insulates the atria from the ventricles. This insulation
allows the atria to be depolarized without depolarizing the ventricles and allows the
ventricles to be depolarized without depolarizing the atria.

The cardiac muscles are attached to the fibrous connective tissue and arranged in
such a way that, when the ventricles contract, they do so in a wringing motion,
which shortens the distance between the base and the apex of the heart. This results
in the most efficient ejection of blood out of the ventricles.
Exploring the Variety of Random
Documents with Different Content
a stone roller for threshing rice and a shovel for winnowing. Manure,
consisting of horse and cow droppings, night soil and ashes, was
bought in the city at the rate of threepence per donkey load, and
used freely on the land, which was a rich alluvial loam; the frequent
storms also deposited layers of dust which were regarded as good
for the crops.
The house, which Isa Haji owned and had built room by room as he
could afford it, at a total cost (including the land) of £50, covered a
square of sixty feet. The guest-room, in which he lived during the
summer and in which the meals were cooked and served, was about
twenty feet square and was lighted by a hole in the roof. A mud
platform covered with felts, on which the family slept, occupied a
prominent position, and the chief piece of furniture was a carved box,
which held clothes and served as a bedstead. Above it was a shelf
full of Russian teapots. Off this room opened the store-room, in
which grain was kept for winter consumption and which served as
the living-room in winter. There was also a courtyard partly roofed in
with matting during the summer, in which grew a shady tree, and this
was the chief working room of the wife and daughters-in-law at that
season. Here we noticed a cradle, a spinning-wheel and various
pans. Two small rooms belonged to two unmarried sons, and the
rest of the square contained stabling, an oven and a store for dry
fodder.
 THE SONS OF ISA HAJI PLOUGHING.
Page 304.

The home was managed by the wife and her three daughters-in-law,
who cooked the food, looked after the children and made the
clothes. They did not work in the fields, but spun the cotton into yarn,
which they wove into the rough white calico of which most of the
clothing of the poorer classes is fashioned.
The staple food of the family was bread made from millet, a grain
that is held to be more sustaining than wheat or rice. Isa Haji’s large
family consumed all his share of the crops, except the lucerne and
some of the melons, turnips, carrots and linseed, which were sold.
The oil of the linseed was used for cooking and lighting.
The chief meal of these peasant-farmers was eaten at sunset and
consisted of suyukash, a soup prepared from pieces of paste-like
macaroni and vegetables boiled in water. In the morning they took
tea with cream and salt, and fruit and bread were eaten at odd
hours. Meat, generally beef, appeared on their table only once a
week. There was plenty of this rude fare, supplemented by slices of
pumpkin eaten hot and by other delicacies; and Isa Haji’s sons
appeared healthy, their teeth being noticeably fine and sound. They
said that they suffered a good deal from lack of warmth in the winter,
as charcoal was dear and had to be used sparingly. They placed a
bowl of lighted charcoal under a wooden frame, over which a quilt
was thrown, and the family sat by day and slept by night under this
covering, with their feet towards the centre.
Isa Haji had been the tenant of the farm for more than ten years. It
included three small properties belonging to three Kashgar
merchants. Two-thirds of the lucerne, amounting in value to about
five pounds, and one half of the other crops, were paid over as rent.
He had no security of tenure, and could be turned out at will, but the
prospect of this appeared to him unlikely, and he expressed
satisfaction with his lot.
The farm paid revenue to the extent of 105 lbs. of wheat, a similar
quantity of millet and 2100 lbs. of chopped straw, Isa Haji and his
landlords each paying one half of the whole. There had also to be
met the demand of the Chinese authorities for forced labour on
public works and transport, but this was compounded for in money
and might come to the equivalent of two shillings per annum.
Nothing was paid for the use of irrigation water, and the taxation
represented less than 5 per cent of the two main crops. In the case
of villages situated at some distance from the city double this amount
may be taken by the tax collectors, who are more exacting in
proportion to their distance from headquarters.
To sum up, we have an oasis in which agriculture is not affected by
the rainfall, but depends entirely on the rivers. The peasants have
enough to eat, a good climate and neighbours in abundance. There
are few parts of the world where the people are so contented, and,
although discontent might perhaps bring an improvement of their lot,
it is pleasant to see such cheerful, friendly tillers of the soil leading a
healthy agricultural life, and to meet them returning home at night
singing their tuneful songs:

How happy he who crowns in shades like these

A youth of labour with an age of ease;
Who quits a world where strong temptations try,
And, since ’tis hard to combat, learns to fly.
 CHAPTER XVII
MANNERS AND CUSTOMS IN CHINESE TURKESTAN

Straight and slender-waisted are the maids of Kashgar,

Short, with sack-like figures, are the maids of Yangi Hissar.
A goitre above and fat below are the maids of Yarkand.
Arranging apples on saucers are the maids of Khotan-Ilchi.
Wearing felt caps, with foreheads high, are the maids of Sarikol.

The Maids of Turkestan. (From an old ballad.)

The inhabitants of Chinese Turkestan are divided by the

anthropologist into four distinct groups. The first consists of the
Sarikoli and Pakhpo mountaineers, who are pure Aryans. The
second is a desert group including the mass of the inhabitants of the
country, the basis of this population being Aryan with some Uighur
admixture, more especially at Aksu in the north. The third group is
formed of the Kirghiz, the Dulanis and the inhabitants of Aksu; the
fourth consists of the Chinese and Mongols, whose differentiation
from the Kirghiz is to be noted. The Aryan type has been best
preserved in the southern and south-western parts of the province,
with their rugged mountain areas which are difficult of access. In the
western districts Turkish influence is evident, in the northern the
Mongol zone begins, and this, as our survey moves eastwards, gives
place to the Chinese.
Throughout this work reference is constantly made to the people of
Chinese Turkestan, and here an attempt will be made to summarize
their character. They are distinctly to be classified as “tame,” in the
frontier officer’s sense of the word, being submissive, lacking in spirit
and ready to serve any master, provided that they can enjoy life in
their own way, with feasting, women and music. In their ballads they
complain of forced labour, with its separation from wife and family,
and they sing the praises of the home. But they are not faithful to
their wives: “Let every one follow his inclination and enjoy himself
with the woman he prefers. If the kings were just, every one would
have his beloved mistress at his side.” Lack of physical and moral
energy and dislike of hard, continuous work and, above all, of
discipline, are notable characteristics of these apathetic oasis-
dwellers; but against these imperfections, which they share, more or
less, with the neighbouring peoples of Russian Turkestan, must be
set many good qualities. Hospitality is found everywhere, strangers
are welcomed and the people are pleasant to deal with, their
politeness being especially marked. The Chinese rule, though
supported by few troops, is a living force, and this proves that the
people are law-abiding. Moreover, there is very little fanaticism, and
the inhabitants of Chinese Turkestan, although obedient to their
spiritual leaders, are not easily excited to rebellion. One inconsistent
trait in this home-loving race is the readiness they show to undertake
a journey, though travelling is generally hard and wearisome; but
perhaps the chief cause of this is curiosity, and, after all, relatively
few travellers leave their beloved province. “We love our festivals” is
the general refrain of this happy, but nonchalant, race of lotos-eaters.
During the months we spent in this little-known country, I employed
my spare time in collecting information regarding its manners and
customs, which, as is natural, bore strong traces of Chinese origin.
They were also influenced by the fact that the people were Buddhists
for many hundreds of years before their forcible conversion to Islam
in the tenth century, when they became Sunnis, looking up to the
Khan of Bokhara and, above him, to the Sultan of Turkey. Their holy
places remained unchanged so far as the sites were concerned, and
on them shrines in honour of Moslem saints have been erected.
Ancestor-worship, too, is inherited from the Chinese, with the result
that the tombs are visited with a frequency unknown elsewhere in
Central Asia.
Girls, when they reach a marriageable age, visit one of the shrines
and pray as follows: “O Allah, O Lord of the Shrine, grant me a
house with a kettle ready placed on the stove, and a spoon in the
kettle. May it be a house with its four sides decorated with cloth, with
carpets and druggets ready spread, and with towels hanging from
the pegs. Grant me a husband whose father and mother are dead;
and may he have no other wife!” When the saint vouchsafes to hear
this delightfully naïve petition and a suitor appears on the scene,
there is no formal betrothal, although in the case of the wealthy large
sums are paid by the bridegroom and the bride is richly dowered.
Costly gifts, too, are given to the bride by the bridegroom and by
relatives and friends. In the case of a poor man, a payment of merely
one or two pounds sterling is made to the parents, who defray the
bride’s outfit from the money. The next step taken is to obtain a
certificate from the Imam of the quarter, that the woman is free to
marry, and after the payment of a small fee a written permission for
the marriage is given by the local Beg.
Nowadays there is no special wedding-dress, and even the globular
wedding-cap of cloth of gold or silver has ceased to be worn. The
marriage ceremony is generally celebrated at the termination of a
feast which lasts until the evening. A mulla reads the fatiha or
opening chapter of the Koran, after which the agent of the bride goes
to the women’s apartment and asks her thrice whether she accepts
the bridegroom, and upon receiving her bashfully given consent, he
returns to the men to announce the success of his mission, thereby
completing the nikah or legal ceremony. Two pieces of bread soaked
in salt water are then given to the bridegroom and bride respectively,
and this, in popular opinion, is the most important act of the
marriage. Indeed many marriages are contracted by the observance
of this custom alone, bread and salt probably symbolizing the
inauguration of a new household, although the meaning has now
been forgotten.
As the bride leaves her old home, the mother laments: “O my black-
eyed darling! Alas, my child, my child! My sweet-voiced, soft-eyed
darling! My daughter leaves me, and I remain in an empty house.
Alas, my child, my child!”
When conducted to her new home, the people of the quarter bar her
path by means of a fire, and demand gifts in the shape of
handkerchiefs. The groom, too, will not allow her to dismount from
her horse until he is handsomely fee’d, and finally, when the bride
enters her husband’s house, flour and cotton are set before her and
given away to the poor. This ceremony is termed Ak-Yul-luk or
“White Road,” and symbolizes a happy journey through life. During
the lifetime of the older generation the bridegroom is called kiau oghli
or “son-in-law” by the parents, and the bride kelin or “daughter-in-
law,” but she is spoken of as a chaukan or married woman by her
neighbours.
There is an immense difference between the villagers and the
townspeople in Kashgar, both in the position of women and in their
morality. The villagers as a rule marry only one wife and rarely
practise divorce, and their wives take a high position inherited from
pre-Islamic days. For example, it is customary to agree, before the
reading of the nikah, that the wife shall be taken to the shrine of
Hazrat Apak for tawwuf or “circling” of the tomb when the apricots
are ripe, other stipulations being that the woman cannot be taken to
another town without her consent, and sometimes that the husband
shall not take another wife. The women may frequently be seen
riding to market on good horses and attending to business almost on
an equality with the men. In the city wives are constantly divorced,
so much so that the majority of them remarry many times. Temporary
marriages, resembling in effect sigheh marriages in Persia, are also
very common, and some women systematically indulge in divorces
in order to gain money. They cannot remarry until after the expiration
of the iddat of three months and ten days, but upon receiving two
letters of divorce—generally obtained in different towns—they can
remarry at once by using the older letter. It is an indication of the low
position held by women in the towns that a merchant, on starting off
to business, will sometimes return home if he first meets one of the
fair sex, this being looked upon as a bad omen.
Constant intermarriage, as in most Moslem countries, produces sad
results in the form of idiocy, deafness and dumbness in the offspring,
such visitations being especially noticeable among the rich, landed
classes, who intermarry generation after generation, in order to keep
the family property intact. So far is this policy pursued that in the
richest family of Kashgar many of the girls have perforce remained
single because there were not enough cousins to go round. It is
interesting to note that in this matter the Chinese go to the opposite
extreme, the whole nation being divided up into about one hundred
divisions, and no man being permitted to marry a woman of his own
division, although she be in no way related to him.
In Kashgar, marriage is not the chief event in a woman’s life, the
ceremony of chachbagh or “braiding of the hair” being far more
important, although held at no fixed time after marriage, and not
depending on the birth of a child. It is celebrated by a great feast,
with dancing, which sometimes lasts for three days. Gifts, far richer
than those given at marriage, are bestowed on the wife, the parents
in many cases handing over landed property. The culminating point
is the appearance of the woman, who, attired in her richest clothes,
takes the seat of honour in the room; and then, in the presence of all,
her hair, hitherto worn in four or five plaits, is formally and for the first
time braided in two plaits, and she becomes thereby a jawan. She is
now entitled to wear five red semicircular strips of embroidery on the
right side of the neck of her gown, one below the other, and
increasing successively in length. In the case of the rich, Indian cloth
of gold is generally used.
One day a woman was seen weeping at a shrine, and her prayer
was as follows: “O Holy One! What shall I do? How shall I live? I
have been left an orphan. I am become a stranger. What shall I do?
Am I to suffer the hardships of an orphan? Am I to remain lonely? I
have no father, no mother. Every one is oppressing me. O Allah, I
am lost among friends and foes. Alas, my stranger’s fate! Alas, my
orphan’s fate! O Holy One, put love into the heart of my husband and
make his mind just towards me. O Allah, grant me the wish of my
heart, give me a son, a son with a long life. I have become a
stranger. Thou hast left me an orphan. O Allah, help me and make
my enemies like dust.”
After this fervent prayer the suppliant, with her eyes shut, put her
hand into a hole in the tomb and drew forth a morsel of earth, which
she swallowed. Her faith was justified, and in due course of time she
began to make arrangements for an easy delivery, to ensure which a
visit was paid to a bakhshi or magician. He played upon a drum and
chanted some incoherent gibberish, the woman meanwhile holding a
rope that hung from the roof, and dancing round it until giddiness
ensued. After this ceremony she paid a fee, gave alms to the poor,
and returned home with her heart at ease. Later on she visited the
tombs of her ancestors, taking with her an offering of food, and
begged them to intercede for an easy delivery and, above all, for the
birth of a son. She laid the offering near the grave, praised her
ancestors, lamented her own failings, walked round the tomb seven
times and finally distributed the food to the beggars. About a month
before the event, she went on foot to a place where there were
seven water mills, and after slowly crossing the seven ducts that fed
them, returned home with happy confidence in the special efficacy of
the ceremony.
A MAGICIAN AND HIS DISCIPLE.
 Page 314.

When her hour was come, no one was allowed to leave the house
unless upon business that was urgent, in which case no harm was
anticipated, provided that some article of dress was left behind. The
women of the neighbourhood assembled to help, and during the
delivery cried out with the idea of keeping the birth a secret, a
custom adopted from the Chinese. The newly born infant, too, was
carefully concealed from visitors.
If former children belonging to the parents have all died, which is,
alas, a frequent occurrence, the father, dressed as a beggar, takes
the baby to the bazar and begs from the shopkeepers small pieces
of calico, which are made into a shirt, the idea being to avoid
misfortune by thus humbling himself. Special names signifying “solid”
or “stay” or “may he stay!” are in such cases given to the child when
he is named, between the third and seventh day, by a mulla, who
first whispers the azan or call to prayer into his ear. On the fortieth
day the head of the infant is shaved and the hair buried. A sheep is
sacrificed and eaten on this occasion, while its bones, which must
not be broken, are buried.
The rite of circumcision, one of the most important of the “five
foundations” of Islam, is performed between the third and eighth
years. The barber operates, and in the case of the rich the event is
celebrated by a feast lasting two or three days, at which the boy
receives presents including hard-boiled eggs, with which he plays a
game by knocking them together.
Children of both sexes are sent to school very young, the idea being
that they will gradually pick up their letters. Education in Kashgar
merely consists of learning by heart a chapter of the Koran and its
Turki equivalent. The letters are taught, penmanship is encouraged,
and lessons are given in the forms of prayer and of ablution.
Geography, history (as distinct from legend), mathematics and
foreign languages are utterly neglected, and the girls leave school at
about ten and most of the boys a year or two later. The teachers are
narrow-minded bigots, and the parents are content to have it so, with
the result that there is not much progress in Kashgar.
We visited the chief boys’ school in Kashgar, where the master bade
his favourite pupils recite passages from the Koran. This they did in
a lugubrious sing-song, swaying backwards and forwards as if in
pain. The pedagogue and his scholars were then photographed,
holding imposing leather-bound and silver-embossed books, which
on enquiry proved to be commentaries on the Koran.

A KASHGAR SCHOOL.
Page 316.

The death ceremonies are in general those common to Islam

throughout Asia, but there are also some customs peculiar to
Kashgar. The body, after being washed and shrouded, is laid out
with the thumbs of the hands and the big toes tied together, while the
chin is also tied up. It is then carried out of the house and, at seven
paces from the door, a spoonful of rice water is poured on the
ground. At every seven steps this is repeated, and the following
verse recited:

Zir[16] has come, Zabar has come,

From the centre of the earth news has come.
 O swift dogs of the door of heaven,
Come, open the gates of paradise for this man.

This mention of dogs is due to Chinese influence; in Islam they

occupy a degraded position and are considered unclean. Contrary to
the general usage of Islam, white is the mourning colour, as in
China. The funeral procession to the grave is headed by professional
mourners, and accompanied by a mulla, who reads sentences from
the Koran on the way, and conducts the service at the grave.
Women do not attend at the graveside, but mourn at a neighbouring
mosque: “O my father! My brave father! My good father!” or “O my
mother! My beautiful mother with black eyebrows! Thou leavest us
and we are alone.” One curious custom is that of driving a stick into
the grave near the head of the corpse, which Grenard considers to
be a survival of the ancient practice of offering food to the dead. On
the third day a solemn feast is held in the house of the deceased.
The mourning lasts for forty days, and upon the termination of this
period a second feast is given, and the normal life is then resumed
by the mourners.
The system of medicine at Kashgar is based on the ancient Greek
theory as taught by Hippocrates, Galen and Plato, whose works
were translated into Arabic and Persian, especially by Abu Ali bin
Sina, known in Europe as Avicenna. Diseases are divided into the
categories of “hot” and “cold,” to be cured by medicines and food of
the opposite category. For instance, in the case of fever, cock’s flesh,
which is “cold,” is eaten, or fish. Hen’s flesh is considered “hot” in
Persia, but in Kashgar there is some difference of opinion among the
faculty.
The Kashgar doctors believe implicitly in giving pigeon’s or duck’s
blood in cases of poisoning, and, moreover, prescribe the flesh of a
nestling sparrow torn in two to ease swellings in the groin; they stop
bleeding by means of a pad composed of burnt felt, or a bit of leather
covered with mud or filth. Rheumatism and dropsy are treated by
burying the patient in hot sand or by wrapping him in the skin of a
recently killed sheep, and abdominal complaints by sticking several
lighted candles into a loaf and placing it on the patient’s stomach.
So much for the doctors of Kashgar; but, as their reputation is very
low, recourse is had to other means of curing sickness. Among the
most common is the female diviner, who, when called in, kneads
flour into a ball, recites some gibberish in which the names of the
archangels and of Solomon are mentioned, and solemnly buries the
ball under the fire, reciting the names of all the holy men who are
buried in the neighbourhood. Whichever of these saints is being
mentioned when the ball bursts has to be propitiated. Oil is taken to
his shrine, where it is boiled and the steam is inhaled by the patient,
after which it is mixed with food, part of which is distributed to the
poor and part eaten for seven days by the sufferer. This ceremony is
termed chachratku or “bursting of a ball of kneaded flour” and is
regarded as most efficacious.
The power of the evil eye is firmly believed in by all classes, and
children usually wear round their necks a little leather case
containing a verse of the Koran as a protection against it. If a child is
believed to be possessed, an old woman recites the following:
“Allah is sublime. Praise be to Allah! There is no god but Allah. If
thou art an evil eye depart, as this place is not for thee. Go to a
deserted watermill; go to a deserted house; go to a grave; go to the
house of the Kazi. These are the commands of Allah, of Solomon
and of the Saint.” The evil eye cannot withstand this invocation and
leaves the sufferer forthwith.
In cases of possession by the devil, a magician is called in, and
chants as follows: “Another head has come to the head; another
body has come to the body. Your master has come; a jade lamp and
blood sherbet are here. You will soon be like ashes, for I have an
iron knife to cut you with and coal bullets to shoot you with.” The
devil, hearing these threats from the magician, quits the patient
without more ado.
Among general remedies are the following: The eyes of sheep
sacrificed at the Id-i-Gurban at Mecca are dried and kept as powerful
charms for sickness. When used they are moistened and applied to
the forehead. Another remedy consists of bread and meat, collected
from seven bakers and butchers. The food, when prepared, is taken,
together with a doll, to the grave of a saint, after which some of it is
eaten and the remainder distributed to the poor. This effects the
cure. Yet another curious treatment is to cover up the patient’s head
while a man walks round him with lighted straw, uttering certain
special prayers during the fumigation.
As to children’s ailments: if a child cries too much, straw is swept up
from three roads, dust is taken from the footprints of passers-by and
Syrian rue is collected from the desert; the mixture is then lighted
and the child is cured by being held over the smoke. If a child suffers
from deafness, one method is to call in the services of a trumpeter,
who spits into the ear, while another plan is to cut seven small twigs,
wrap them up in cotton and, on market day, to tie the little bundle to
the ear of a donkey loaded with salt. For other ailments, seven coral
beads are thrown into a spring; or, again, copper pieces are begged
from seven men named Mohamed, others are added by the parents,
and a charm is made to hang round the child’s neck.
Finally, there are certain shrines famous for the cure of specific
diseases. For skin disease a shrine known as the Sigm is much
frequented. There mud is taken from a well outside and thrown at the
wall with a prayer to the saint, after which the suppliant walks away
without looking back.
A WOMAN THROWING MUD TO EFFECT A CURE.
 Page 320.

I conclude this brief account of the treatment of diseases in Kashgar

by a story entitled “The Clever Physician”:[17]
“Once upon a time there was a physician. When this physician
entered the room where the sick person was, he looked all about it,
and whatever met his eyes in the shape of an eatable, he looked at
the patient and said, ‘You have eaten such and such a thing and that
is what has done you harm.’ The physician had a pupil, and
wherever the physician went, there went his pupil with him. A rich
man had become paralysed, that is to say, unable to walk. Many
physicians had treated him, but his disease did not abate. At last,
having heard that the aforesaid physician’s pupil was a wonderful
medical adept, he summoned him to his house.
“When the physician’s pupil had entered the house and had carefully
looked round, he perceived that there was nothing at all in the shape
of an eatable in it, but in one corner of the room an old donkey-
saddle had been thrown down. When he saw this he exclaimed, ‘Oh,
rich man! you have eaten an old donkey-saddle, through which your
disease has increased and you have become paralysed.’ When he
said this, the rich man was very angry, and exclaiming, ‘Does one
who is called a human being eat donkey-saddles?’ sprang up in his
rage in order to beat him and—walked!
“The physician, poor fellow, was terrified and had fled away. The rich
man was struck with wonder and exclaimed, ‘This is a great man; for
my leg, which grew no better for any physician’s medicine, has now
become quite well through this person.’ He caused the physician’s
pupil to be summoned, apologized to him, and sent him away with
many valuable gifts.”
At the first fall of snow a man frequently calls on a friend with some
snow wrapped in an envelope, while in another are enclosed verses:

My dear friend with this document I throw you snow;

From joy of heart this game arose;
Cups and jugs we have collected and wooden trays;
And we have prepared sweetmeats.
 The mandoline, violin, zither and tambourine we have made ready.
When snow has fallen in winter, do not people give entertainments?
If there are friends living around do not people invite them?
If you are clever enough to seize the man who has brought the snow,
Powder his face, paint him like a girl, and beat him severely.

The visitor places his verses secretly in the house and then
decamps. If the owner of the house catches him he beats him, paints
his face like a girl and leads him through the streets calling out, “This
is the punishment for the man who throws snow”; and the visitor is
then bound to give an entertainment. But if the owner of the house
does not catch the visitor, he himself must prepare a banquet. If he
fails to do so within a week, bulrushes are tied on the top of his door,
and if this hint is not sufficient, the bier from the cemetery is placed
outside his house.
Owing to Chinese influence, there is no Moslem country where
respect for parents and for superiors is so strong as in Kashgar.
During the lives of the parents they are never referred to by name by
their children, but are always addressed as “My Lord.” A son will
never sit in the presence of his father without special permission, but
will stand with the head bowed and hands folded in token of humility.
He would never dream of retiring to sleep before his father, nor of
smoking in his presence. To superiors deference is shown by
dismounting from horseback, and by always prefacing an answer
with taksir or “fault,” which has come to be the equivalent of our “Sir.”
Upon receipt of a robe of honour, the recipient bows low, sweeping
the arms in a circle to stroke the beard. Women courtesy by bowing
low with folded hands.
The Kashgaris have few games, but kite-flying, an elementary form
of rounders, pitch-and-toss into a hole with walnuts or coins, and a
kind of tip-cat are favourite amusements. Grown-up men indulge in
ram-fighting and partridge-fighting, heavy bets being made on the
contests.
Music is extremely popular, the Kashgar peasants being distinctly
musical, and their refrains, sung in unison on returning from work,
are pleasing to the European ear. The usual instruments are the
tambourine, the mandoline and the four-stringed rubab. In Kashgar
dancing is regarded as improper, and is indulged in only by
professional women or boys; but in the Khotan oasis, among the
Dulanis of Merket, the Sarikolis and the Kirghiz, men and women
dance together at weddings. At entertainments the men and women
sit on opposite sides and, when the music commences, a woman
rises and places a handkerchief in front of a man, who thereupon
rises also, sings a song and returns the handkerchief. This is done
by all present, and men and women then dance together.
During my stay in Chinese Turkestan I sought for any custom which
might be a survival from the days of the Nestorian Christians. One
such is that horse-dealers, when a bargain is not concluded, make
the sign of the cross on the horse to avert the evil eye. It is
interesting to note that, owing to Chinese influence, black and dark
grey are the favourite colours for horses, whereas few people care to
buy a roan, whose colour is deemed unlucky.
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