Electrocardiography of Arrhythmias-A

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Mithilesh Kumar Das
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Electrocardiography
of Arrhythmias
A COMPREHENSIVE REVIEW
 Electrocardiography
of Arrhythmias
A COMPREHENSIVE REVIEW
A COMPANION TO CARDIAC ELECTROPHYSIOLOGY: FROM CELL TO BEDSIDE

SECOND EDITION

MITHILESH K. DAS, MD
Professor of Clinical Medicine
Director, Electrophysiology Service
Cardiovascular Institute
Indiana University Health
Indianapolis, Indiana

DOUGLAS P. ZIPES, MD
Distinguished Professor
Professor Emeritus of Medicine, Pharmacology,
and Toxicology
Director Emeritus, Division of Cardiology and
the Krannert Institute of Cardiology
Indiana University School of Medicine
Editor, Practice Update Cardiology and Trends in
Cardiovascular Medicine
Indianapolis, Indiana
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ELECTROCARDIOGRAPHY OF ARRHYTHMIAS:
A COMPREHENSIVE REVIEW, SECOND EDITION ISBN: 9780323680509
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 To our wives and families,
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and my children, Awaneesh, Ruchi, Mohineesh, Kriti, and Avyukt
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 PREFACE

Clinical cardiac electrophysiology continues to play a critically important role in the care of patients
of all ages. Being able to interpret the electrocardiogram (ECG) accurately is vital for their evaluation
and treatment. As more people live to older ages, arrhythmias become an ever-increasing component
to their health and well-being. We have thoroughly revised and updated this second edition to
facilitate learning the fundamental aspects of arrhythmia interpretation. Similar to the first edition,
we have designed the book for learners at all levels of training, including internists with an interest
in cardiology, trainees in cardiology and electrophysiology, and experienced cardiologists. This
volume also continues as a companion to the well-known text, Cardiac Electrophysiology: From
Cell to Bedside, soon in its eighth edition. We hope you find it a useful addition to help with your
ECG reading skills.
Mithilesh K. Das, MD
Douglas P. Zipes, MD

vii
 CONTENTS
1 Important Concepts, 1
2 Sinus Node Dysfunction, 37
3 Atrioventricular Conduction Abnormalities, 61
4 Junctional Rhythm, 99
5 Atrioventricular Nodal Reentrant Tachycardia, 125
6 Atrioventricular Reentrant Tachycardias, 151
7 Atrial Tachycardia, 179
8 Atrial Flutter, 223
9 Atrial Fibrillation, 273
10 Wide Complex Tachycardia, 297
11 Ventricular Tachycardia in the Absence of Structural Heart
Disease, 329
12 Ventricular Tachycardia in Structural Heart Disease, 361
13 Polymorphic Ventricular Tachycardia and Ventricular Fibrillation in
the Absence of Structural Heart Disease, 411

Index, 463

ix

A normal 12-lead electrocardiogram (ECG) includes P, QRS, T, and
sometimes the U waves (Fig. 1.1). The P wave is generated by activation
of the atria, the P-R segment represents the duration of atrioventricular
(AV) conduction, the QRS complex is produced by the activation of
the two ventricles, and the ST-T wave reflects ventricular recovery.
Normal values for the various intervals and waveforms of the ECG are
shown in Table 1.1. The range of normal values of these measurements
reflects the substantial interindividual variability related to (among
other factors) differences in age, sex, body habitus, heart orientation,
and physiology. In addition, significant differences in electrocardio-
graphic patterns can occur in an individual’s ECGs recorded days,
hours, or even minutes apart. These intraindividual variations may be
caused by technical issues (e.g., changes in electrode position) or the
biologic effects of changes in posture, temperature, autonomics, or eat-
ing habits, and may be sufficiently large to alter diagnostic evidence for
conditions, such as chamber hypertrophy.
P WAVE
Normal P waves (duration equal to ,110 ms and amplitude ,0.25 mV)
are generated in the sinus node, which depolarizes in the direction from
right to left atria and superior to inferior. P wave patterns in the precor-
dial leads correspond to the direction of atrial activation wave fronts in
the horizontal plane. Atrial activation early in the P wave is over the
right atrium and is oriented primarily anteriorly; later, it shifts poster-
iorly as activation proceeds over the left atrium. Therefore P waves are
positive in lead I and inferior in leads. The P wave in the right precordial
leads (V1 and, occasionally, V2) is upright or, often, biphasic, with an
initial positive deflection followed by a later negative deflection. In the
more lateral leads, the P wave is upright and reflects continual right to
left spread of the activation fronts. Variations in this pattern may reflect
differences in pathways of interatrial conduction.
P waves with prolonged duration usually denote atrial conduction
abnormalities and occur in atrial enlargement or myopathy, which can
be a substrate for reentrant atrial tachycardia (Fig. 1.2 and Table 1.2).
Negative P waves in lead I represent lead arm reversal or dextrocardia
(Fig. 1.3). Isolated dextrocardia is not a precursor for arrhythmias, but
when dextrocardia is associated with congenital heart disease, atrial
arrhythmias caused by atrial myopathy or scarring related to cardiac
surgery can occur. An abnormal P wave axis denotes an ectopic atrial
rhythm, and intermittently changing P wave morphology from sinus to
nonsinus represents wandering atrial pacemakers (Fig. 1.4). Frequent
premature atrial complexes can provoke atrial tachyarrhythmia (atrial
tachycardia, atrial fibrillation, and atrial flutter). Paroxysmal atrial fibril-
lation often is triggered by premature atrial complexes generated in the
muscle sleeves of one or more pulmonary veins. Electrical isolation of
these veins prevents the recurrence of atrial fibrillation (Fig. 1.5). P
waves can enlarge in right and left atrial hypertrophy or enlargement.
1
Important Concepts
Sinus P waves have prolonged duration and generally have a low ampli-
tude after a maze surgery for atrial fibrillation (Fig. 1.6).
P-R INTERVAL AND P-R SEGMENT
The P-R segment is usually the isoelectric region beginning with the
end of the P wave to the onset of the QRS complex. The P-R interval is
measured from the onset of the P wave to the onset of the QRS com-
plex. The P-R interval represents the initiation of atrial depolarization
to the initiation of ventricular depolarization. It is the time taken by the
sinus impulse to travel to the ventricles by way of the atrium, AV node,
bundle of His, and bundle branches. A delay in any part of the conduc-
tion will prolong the P-R interval. Prolonged P-R interval results
mostly from AV nodal disease and His-Purkinje disease but can occur
due to atrial myopathy causing prolonged intra- or interatrial conduc-
tion. His-Purkinje disease is almost always associated with a bundle
branch block (BBB). PR prolongation (.200 ms) caused by AV nodal
disease or severe His-Purkinje disease represents a potential substrate
for various degrees of heart block (see Chapter 3). A short P-R interval
(,120 ms) can result from enhanced AV nodal conduction (Fig. 1.7),
ventricular preexcitation (Fig. 1.8), or an atrial rhythm. Isorhythmic
AV dissociation can also falsely appear as short P-R interval (Fig. 1.9).
QRS WAVE
Normal QRS complexes represent the depolarization of both ventricles
(normal QRS duration 5 60
120 ms). This is represented by the
beginning of the Q wave and end of the S wave. Ventricular depolariza-
tion begins at the left side of the interventricular septum near the AV
junction and progresses across the interventricular septum from left to
right. The impulse then travels simultaneously to both the ventricles
endocardially by way of the right and left bundle branches. It also pro-
gresses from the endocardial surface through the ventricular wall to the
epicardial surface. The normal Q wave is the first negative deflection of
the QRS, which is not preceded by any R wave and represents interven-
tricular depolarization. The R wave is the first positive deflection in the
QRS complex. Subsequent positive deflection in the QRS above the base-
line represents a bundle branch delay or bundle branch block (BBB)
called R0 (R prime). The S wave is the first negative deflection (below the
baseline) after an R wave. The QS wave is a QRS complex that is entirely a
negative wave without any positive deflection (R wave) above the baseline.
The larger waves that form a major deflection in QRS complexes are
usually identified by uppercase letters (QS, R, S), whereas smaller waves
with amplitude less than the half of the major positive (R wave) or
negative (S wave) deflection are denoted by lowercase letters (q, r, s).
Therefore notches in R, S, or QS waves can be defined as qR, Rs, RSR,
QrS, or rS patterns. The QRS morphology on a particular ECG lead
depends on the sum vector of depolarization toward or away from that
1
2 CHAPTER 1 Important Concepts

due to scarring from a myocardial infarction. Noninfarction Q waves

(pseudoinfarction pattern) are also encountered in ventricular
hypertrophy, fascicular blocks, preexcitation, cardiomyopathy, pneu-
QRS mothorax, pulmonary embolus, amyloid heart disease, primary and
metastatic tumors of the heart, traumatic heart disease, intracranial
hemorrhage, hyperkalemia, pericarditis, early repolarization, and car-
diac sarcoidosis.
T
P Q J point
U
INTRAVENTRICULAR CONDUCTION
ABNORMALITIES
P-R interval QRS prolongation can be because of the conduction system abnormal-
ity resulting from a right bundle branch block (RBBB) or a left bundle
QRS interval branch block (LBBB). When the QRS duration is prolonged, often
called wide ( . 120 ms), and its morphology does not qualify for a BBB,
then it is called an interventricular conduction defect (IVCD). IVCD
can result from myocardial disease, such as coronary artery disease or
Q-T interval
cardiomyopathy. IVCD can also result from electrolyte abnormalities,
such as hypokalemia or antiarrhythmic drug therapy, mainly with the
Fig. 1.1 Normal QRS waves and baseline intervals. use of class I drugs (sodium channel blockers), which prolong the
conduction velocity of the myocardial depolarizing waves (Fig. 1.10).
IVCD can represent a substrate for ventricular arrhythmias. Other
TABLE 1.1 Normal Electrocardiogram causes of a wide QRS include premature ventricular complexes, ventri-
Parameters cular preexcitation, or a paced ventricular rhythm.
Electrocardiogram Waves
or Intervals Duration in MS FRAGMENTED QRS COMPLEXES
P wave duration ,110 Fragmented QRS is defined as the presence of one or more notches in
P-R interval 120 to ,200 ms the R wave or S wave without any BBB in two contiguous leads.
Fragmented wide QRS is defined as QRS duration greater than 120 ms
QRS duration ,100 ms with 2 or more notches in the R wave or the S wave in two contiguous
QTc (corrected Q-T interval) a
#460 for men and #470 for women leads. QRS fragmentation and Q waves represent myocardial infarction
scarring and can indicate a substrate for reentrant ventricular arrhyth-
b
U wave N/A mias (Figs. 1.11
1.14).
N/A, Not applicable.
a
The QTc is traditionally reported in units of ms; however, the units of the BUNDLE BRANCH BLOCK AND FASCICULAR BLOCKS
QTc will vary with the formula used for the rate correction. The commonly
applied Bazett formula is a ratio of Q-T interval in ms to the square root of Conduction block or delay in one of the bundle branches results in the
R-R interval in seconds. Fridericia formula: QTc 5 QT/3 ORR. depolarization of the corresponding ventricle by way of the contralat-
eral bundle (Table 1.3). The RBBB has rSR0 pattern in lead V1-V2,
b
U waves may normally be present in midprecordial leads in a few
individuals. The normal range of amplitude and duration is not well whereas LBBB has rSR0 pattern in lead V6 and lead I (Figs. 1.15
1.17).
defined. The QRS duration between 100 ms and less than 120 ms is called
incomplete BBB, and greater than 120 ms is called a complete BBB.
lead. Usually, the R waves are upright in limb leads and augmented limb Narrow QRS at baseline and a physiologic delay in one of the bundle
leads except for lead aVR. A QS pattern in lead V1-V2 may represent nor- branches at higher heart rates can cause BBB and is called ventricular
mal myocardial depolarization, but a Q wave in lead V3 represents myo- aberrancy (see Chapter 6). A wide complex tachycardia is more com-
cardial scarring, usually caused by a septal myocardial infarction. QRS monly a ventricular tachycardia but can also be a supraventricular
transition is seen in lead V3-V4 with R wave amplitude larger than S tachycardia with BBB or ventricular aberrancy.
wave amplitude. R waves are upright in lead V5-V6 because of a positive
net vector toward these precordial leads. Poor progression of R wave
MULTIFASCICULAR BLOCK
amplitude across the precordial leads represents severe myocardial dis-
ease. It is seen in severe nonischemic and ischemic cardiomyopathy with Conduction delay in any two fascicles is called a bifascicular block, and
severely reduced left ventricular ejection fraction. delay in all three fascicles is termed a trifascicular block (Table 1.4). The
term bilateral bundle branch block has been used to refer to concomi-
tant conduction abnormalities in both the left and right bundle branch
Q WAVES
systems. Trifascicular block involves conduction delay in the right bun-
The normal Q wave duration is less than 40 ms with amplitude less dle branch plus delay in the main left bundle branch or in both the left
than one-fourth of the amplitude of the succeeding R wave. Q waves in anterior and the left posterior fascicles.
the baseline ECG of a patient with palpitations can be a clue to Rate-dependent conduction block or ventricular aberrancy, BBB,
reentrant ventricular arrhythmias. Q waves more than 40 ms may be fascicular block, or IVCD can occur with changes in the heart rate.
 CHAPTER 1 Important Concepts 3

Fig. 1.2 Biatrial enlargement in a 32-year-old patient with complex congenital heart disease with pulmonary atresia, double inlet ventricle, and
multiple cardiac shunts (A). Lead II shows tall P waves greater than 0.25 mV, and lead V1 shows deep inverted T waves. The patient suffered from
atrial arrhythmias. (B) Biatrial enlargement with left bundle branch block in a patient with nonischemic dilated cardiomyopathy with severely
reduced left ventricular systolic function.

TABLE 1.2 Right and Left Atrial Enlargement

Left Atrial Abnormality
P wave duration .120 ms in lead II
Prominent notching of P wave, usually most obvious in lead II, with
interval between notches of 0.40 ms (P mitrale)
Ratio between the duration of the P wave in lead II and duration of the
PR segment .1.6
Increased duration and depth of terminal-negative portion of P wave in
lead V1 (P terminal force) so that area subtended by .0.04 mm-sec
Leftward shift of mean P wave axis to between 230 and 245
Right Atrial Abnormality
Peaked P waves with amplitudes in lead II .0.25 mV (P pulmonale)
Prominent initial positivity in lead V1 or V2 .0.15 mV
Increased area under initial positive portion of the P wave in lead V1 to
.0.06 mm-sec
Rightward shift of mean P wave axis to more than 175
4 CHAPTER 1 Important Concepts
Fig. 1.3 Electrocardiogram showing inverted P and QRS waves in lead I along with poor progression of R wave. This is due to dextrocardia. The
arm lead reversal is also associated with similar P and QRS axis in lead I, but the QRS progression in precordial leads is unaffected.
1. Ashman phenomenon: The duration of the refractory period of the
ventricular myocardium is a function primarily of the immediately
preceding cycle length(s). If the preceding cycle length is long, the
refractory period of the subsequent QRS complex is long and may
conduct with BBB aberrancy (Ashman phenomenon) as part of a
long cycle
short cycle sequence, often when there is an abrupt
prolongation of the immediately preceding cycle. The RBBB
aberrancy is more common than LBBB aberrancy because the
refractory period of the right bundle is usually longer than that of
the left bundle at slower heart rates (Fig. 1.18).
2. Acceleration (tachycardia)-dependent block or conduction delay: It is
manifest as either RBBB or LBBB, which occurs when the heart rate
exceeds a critical value. At the cellular level, this aberration is the result
of encroachment of the impulse on the relative refractory period
(sometime during phase 3 of the action potential) of the preceding
impulse, which results in slower conduction (Figs. 1.19
1.23).
3. Deceleration (bradycardia)-dependent block or conduction delay: It
occurs when the heart rate falls below a critical level. It is thought to
be due to abnormal phase 4 depolarization of cells so that activation
occurs at reduced resting potentials. Deceleration-dependent block is
less common than acceleration-dependent block and usually occurs
in the setting of a significant conduction system disease (Fig. 1.23).
FASCICULAR BLOCK
Fascicular block is an abnormal delay or conduction block in one of the
fascicles of the LBBB. This alters ventricular activation, and therefore
the axis of the QRS is altered. Isolated fascicular block (without any
BBB) does not prolong the QRS significantly. Left anterior fascicular
block is associated with qR pattern in lead aVL, QRS axis between
245 and 290 , and the time to peak R wave in aVL 45 ms or more.
Left posterior fascicular block is associated with a qR pattern in lead III
and aVF, rS pattern in lead I and aVL, and QRS axis between 190 and
1180 . Other causes of QRS wave changes similar to that of left poster-
ior fascicular block include right ventricular hypertrophy and lateral
wall myocardial infarction.
J POINT AND J WAVE
The J point is the junction between the end of QRS and initiation of the
ST segment. A J wave is a dome- or hump-shaped wave caused by J
point elevation. The amplitude of the normal J point and ST segment
varies with race, sex, autonomic input, and age. The upper limits of J
point elevation in leads V2 and V3 are 0.2 mV for men older than 40
years, 0.25 mV for men younger than 40 years, and 0.15 mV for
women. In other leads the accepted upper limit is 0.1 mV.
The J wave can be prominent as a normal variant called early repo-
larization (Figs. 1.24 and 1.25). However, the incidence of early repo-
larization abnormality in the inferolateral leads is higher in patients
who were resuscitated after sudden cardiac death, and therefore it may
not always be benign, as was previously believed. In addition, the J
wave can be seen in systemic hypothermia (Osborn wave), Brugada
pattern, coronary artery disease, and electrolyte abnormalities and dur-
ing vagal stimulation. Its origin has been related to a prominent notch
(phase 1) of the action potentials on the epicardium but not on the
endocardium (Figs. 1.26
1.28).
U WAVE
In some patients the T wave can be followed by an additional low-
amplitude wave known as the U wave. This wave, usually less than
0.1 mV in amplitude, normally has the same polarity as the preceding
T wave and is best seen in anterior precordial leads. It is most often
seen at slow heart rates. Its electrophysiologic basis is uncertain; it may
be caused by the late repolarization of the Purkinje fibers, by the long
action potential of midmyocardial M cells, or by delayed repolarization
in areas of the ventricle that undergo late mechanical relaxation.
Prominent U waves can be seen in hypokalemia (discussed later).
Inverted U waves are a sign of coronary ischemia.
ST-T WAVES
Normal ST segment is almost always isoelectric to the PR and TP seg-
ments. ST segment elevation can be defined morphologically as cov-
ing, concavity upward, or downsloping. ST horizontal or coving
segment elevation occurs in acute myocardial infarction, coronary
vasospasm, and left ventricular aneurysm (Box 1.1). ST segment ele-
vation with concavity upward is seen in acute pericarditis. Coved or
saddleback ST segment elevation with incomplete RBBB is called a
Brugada pattern ECG. Persistence of juvenile pattern of T wave
inversion in precordial adults is encountered in 1% to 3% of the
population.
 CHAPTER 1 Important Concepts 5

Fig. 1.4 Wandering atrial pacemaker. (A) Electrocardiogram depicts intermittent change in P wave morphology from sinus rhythm to low atrial
rhythm (inverted P waves in lead II, arrows). (B) Electrocardiogram shows P wave morphology and axis during sinus rhythm. Wandering atrial
pacemaker usually does not denote atrial pathology; however, this patient later developed atrial flutter with 2:1 atrioventricular block (C).

When ST segment or T wave changes (or both) occur without any
cardiac pathology or abnormal physiologic state, they are called non-
specific ST-T changes. This includes slight ST depression or T wave
inversion or T wave flattening.
Q-T INTERVAL
The Q-T interval extends from the onset of the QRS complex to the
end of the T wave. Thus it includes the total duration of ventricular
depolarization and repolarization. Ventricular depolarization, and there-
fore repolarization, does not occur instantaneously. Electrophysiologically,
the Q-T interval is therefore a summation of action potentials in
both ventricles. It is measured from the onset of the QRS to the
end of the T wave. The Q-T interval duration will vary from lead
to lead in a normal ECG by as much as 50 to 60 ms. The difference
between the longest and shortest Q-T interval is called Q-T
dispersion. Accurately measuring the Q-T interval is challenging for
several reasons, including identifying the beginning of the QRS
6 CHAPTER 1 Important Concepts

Sinus beat

APC Atrial fibrillation

Sinus rhythm

Fig. 1.5 Frequent atrial premature complexes (APCs) initiating atrial fibrillation in a 40-year-old male patient. Frequent APCs, mostly originating from
pulmonary veins, can trigger focal atrial fibrillation. (A) Electrocardiogram shows frequent monomorphic APCs with right bundle branch block
aberrancy initiating a short run of atrial tachycardia. The APC was mapped to be originating from the right superior pulmonary vein. (B) APC was
mapped by a circular decapolar catheter (Lasso 1,2 to Lasso 9,10) and an ablation catheter (Abl D and Abl P) placed at the ostium of the pulmonary
vein. (C) These APCs repeatedly initiated atrial fibrillation. All these rapid focal discharges in the right pulmonary veins do not reach the left atrium,
as shown by the coronary sinus recording (CS 1,2 [distal] to CS 9,10 [proximal]). Electrical isolation of the right superior pulmonary vein during
catheter ablation is confirmed because these focal discharges are still present in the pulmonary vein during the sinus rhythm but do not reach the
left atrium; therefore the initiation atrial fibrillation is prevented. Arrows indicate atrial premature complexes.
 CHAPTER 1 Important Concepts 7

Fig. 1.6 Low voltage and prolonged P waves in a patient with a history of maze procedure for atrial fibrillation (A). (B) Patient developed atrial
flutter 2 years after the procedure. Flutter waves are positive in inferior leads, negative in lead aVR and aVL, and isoelectric/negative in V1. Flutter
circuit was mapped at the right superior pulmonary vein ostium during electrophysiology study.

Fig. 1.7 Electrocardiogram showing short P-R interval with no evidence of preexcitation. This is called enhanced atrioventricular nodal conduction
because of the minimum normal delay at the atrioventricular nodal level for the atrial impulse to reach the ventricle by way of the His-Purkinje
system. This is not a precursor of arrhythmia but can conduct impulses rapidly from the atria to the ventricles during an atrial arrhythmia.
8 CHAPTER 1 Important Concepts

B
Fig. 1.8 Short P-R interval caused by preexcitation in a 19-year-old female patient. Electrocardiogram shows a short P-R interval of 80 ms resulting
from preexcitation (negative delta waves in lead V1 and inferior leads and positive delta waves in lead I and aVL) over a right posteroseptal
accessory pathway (A) that was successfully ablated. The P-R interval normalized after the ablation (B).

complex and end of the T wave; determining which lead(s) to use;
and adjusting the measured interval for rate, QRS duration, and
sex. The presence of U waves also complicates the measurement.
Q-T interval should be measured in the lead at which it is longest,
and without a prominent U wave. In automated electrocardio-
graphic systems, the interval is typically measured from a compo-
site of all leads, with the interval beginning with the earliest onset
of the QRS in any lead and ending with the latest end of the T wave
in any lead.
The Q-T interval changes with heart rates, shorter at faster
heart rates and longer at slower ones. Therefore numerous formulas
have been proposed to correct the measured Q-T interval for this
rate effect to a rate of 60 bpm. The Bazett formula is commonly
used in the clinical practice. The corrected Q-T interval (QTc) is
measured by the ratio of Q-T interval in seconds and the root square
of the R-R interval in seconds (QTc [ms] 5 Q-T/ ORR [sec]).
Because the Bazett correction exaggerates the correction at faster
heart rates and undercorrects at slower heart rates, the Fridericia
correction is often preferred. It uses cube root of R-R interval
instead of square root of R-R interval used in Bazett formula
(QTc 5 Q-T/ 3 ORR).
LEFT AND RIGHT VENTRICULAR HYPERTROPHY
ECG manifestation of left ventricular hypertrophy (LVH) includes
increased amplitude of the QRS complex. R waves in lateral leads (I,
aVL, V5, and V6) and S waves in right precordial leads are increased in
LVH, whereas ST-T segment changes in LVH are varied. The common
findings are downsloping ST segment from a depressed J point and
asymmetrically inverted T waves. Apart from QRS wave changes, ven-
tricular hypertrophy is also associated with atrial abnormalities
(Table 1.5 and Box 1.2).

B
Fig. 1.9 Electrocardiogram depicting short P-R interval with P waves extending into the QRS waves in the first three sinus complexes followed by
short P-R interval (A). It is an isorhythmic atrioventricular dissociation. (B) Electrocardiogram showing normal sinus rhythm of the same patient with
a normal P-R interval of 164 ms.
RIGHT-SIDED PRECORDIAL LEAD PLACEMENT
Right-sided lead placement is needed when dextrocardia or right ven-
tricular infarction is suspected. In acute right ventricular infarction,
V4R shows ST elevation. Dextrocardia and arm reversal is suspected
when the P wave is negative in lead I. However, in dextrocardia, the
QRS morphology of the precordial leads shows poor progression of R
waves, whereas in arm lead reversal precordial progression of R wave is
unchanged. In dextrocardia, ECG placement can be corrected when the
left arm lead is placed on the right arm, the right arm lead is placed on
the left arm, and the V1 through V6 leads are placed in the V1, V2, and
V3R through V6R positions. When Brugada syndrome is suspected
and the typical coving pattern of ST-T segment is present but J point
elevation is less than 2 mm in a routine ECG, precordial leads V1 and
V2 can be placed in third or second intercostal spaces, which may elicit
typical Brugada pattern with more than 2 mm J point elevation and
coved pattern spontaneously or with the use of a class I antiarrhythmic
drug.
GENERALIZED LOW VOLTAGE
Generalized low voltage is defined when the amplitude of the QRS
complexes in precordial leads is less than 1 mV and in the limb leads
are ,0.5 mV. This is commonly present in obesity, pericardial effusion,
CHAPTER 1 Important Concepts 9
chronic obstructive lung disease, and severe myopathy, such as cardiac
amyloidosis. Cardiac amyloidosis is a substrate for conduction block or
ventricular arrhythmias.
CORONARY ARTERY DISEASE
Coronary artery disease is the second most common cause of con-
duction system disease and the most common cause of ventricular
arrhythmias. The ECG plays a major role in the diagnosis of acute
and chronic coronary artery disease. ECG changes result from depo-
larization or repolarization abnormalities (or both). Acute ST eleva-
tion myocardial infarction (STEMI) may be associated with serial
changes: transient hyperacute (tall) T waves, ST elevation in two con-
tiguous leads, and later abnormal Q waves in two contiguous leads.
Non-ST elevation myocardial infarction (NSTEMI) is more difficult
to diagnose, and the diagnosis depends on the elevation of cardiac
biomarkers. ECG signs of NSTEMI include T wave inversion, ST
depression, and fragmentation of the QRS waves in two contiguous
leads. Atrial arrhythmias, such as atrial fibrillation, can occur during
an acute myocardial infarction (MI). Bifascicular block, when it
occurs with anterior MI, carries a poor prognosis. Complete heart
block during anterior MI also carries a poor prognosis because it
represents a large infarction with an extensive involvement of
His-Purkinje system. AV block with an inferior MI usually results
10 CHAPTER 1 Important Concepts

Fig. 1.10 (A) Electrocardiogram (ECG) of a 59-year-old male patient with ischemic cardiomyopathy shows sinus rhythm with a long P-R interval
(270 ms) and intraventricular conduction delay (QRS duration 5 156 ms). (B) ECG of the same patient after 3 months shows long P-R interval, left
bundle branch block, and right axis deviation suggestive of a multifascicular block. (C) ECG showing wide complex tachycardia that is an atrial
tachycardia left bundle branch block with further prolongation of QRS waves.
 CHAPTER 1 Important Concepts 11

III aVF

Fig. 1.11 (A) Fragmented QRS (fQRS) with inferior scar. fQRS is a sign of myocardial infarction. (B) fQRS (arrow) in lead III, and aVF signifies
inferior myocardial scar. (C) Electrocardiogram of the same patient shows a wide complex tachycardia, which is a ventricular tachycardia arising
from the inferoposterior wall of the left ventricle.

from a high vagal tone or ischemia to the AV nodal artery and gener-
ally carries a good prognosis (Fig. 1.29). Polymorphic ventricular
tachycardia and ventricular fibrillation can also be the presenting
manifestation of an acute MI (Fig. 1.30). Repetitive monomorphic
idioventricular rhythm is encountered during the reperfusion phase
of MI (reperfusion arrhythmia) (Fig. 1.31). Sinus node dysfunction
and AV block can occur within the first few months of MI. Patients
with a remote MI are at a risk for scar-related monomorphic, poly-
morphic VT, and ventricular fibrillation (Fig. 1.32A). Fig. 1.32B
shows the baseline ECG showing fragmented QRS inferior leads,
which represents myocardial scar.
QRS ALTERNANS AND T WAVE ALTERNANS
Beat-to-beat variation of QRS or T wave amplitude are called QRS and
T wave alternans, respectively. QRS alternans can occur in pericardial
tamponade, in severe myocardial disease, or during a supraventricular
or ventricular tachycardia (Figs. 1.33 and 1.34). Macroscopic T wave
12 CHAPTER 1 Important Concepts

Fig. 1.12 Electrocardiogram depicting sinus rhythm with right bundle branch block pattern in lead V1-V2, which has three notches, and therefore is
defined as fragmented right bundle branch block. The patient had inferior myocardial scar. The patient developed scar-related ventricular
tachycardia originating near the mitral annulus.

B
Fig. 1.13 Electrocardiogram showing sinus rhythm with Q waves in inferior leads and fragmented QRS in leads V2-V4 in a 64-year-old male patient
with anteroseptal and inferoposterior scar (A). Patient presented with a ventricular tachycardia (B) that terminated spontaneously after a premature
ventricular contraction (arrow).

Fig. 1.14 Electrocardiogram showing typical right bundle branch block with RsR0 (A), rsR0 (B), rSR0 (C), and rsR0 (D) pattern in lead V1, and wide and
slurred S wave in lead V5.
alternans is uncommon and is reported in long QT syndrome preced-
ing an episode of torsades de pointes.
ELECTROLYTE IMBALANCE
Electrolyte imbalance, such as hypokalemia, hyperkalemia, hypocalce-
mia, and hypercalcemia, can cause various ECG changes. Isolated
CHAPTER 1 Important Concepts 13
hypernatremia or hyponatremia does not produce consistent effects on
the ECG. Metabolic acidosis and alkalosis, which are often associated
with hyperkalemia and hypokalemia, respectively, can provoke
arrhythmias. Severe hypermagnesemia can cause AV and intraventri-
cular conduction disturbances, including complete heart block.
Hypomagnesemia is usually associated with hypocalcemia or hypoka-
lemia. Hypomagnesemia and hypokalemia can potentiate certain
14 CHAPTER 1 Important Concepts

Hyperkalemia
TABLE 1.3 Electrocardiogram Criteria for
Mild hyperkalemia is associated with narrowing and peaking (tenting)
Bundle Branch Block and Fascicular Block of the T wave (Fig. 1.36). With the progressive increase in potassium
Block Electrocardiogram Signs level, the P wave decreases in amplitude and the QRS begins to widen.
Complete QRS duration $ 120 ms P-R interval prolongation can occur. It may be followed by AV block.
RBBB Sinus activity is suppressed, P waves may disappear, and junctional
escape rhythm, or so-called sinoventricular rhythm, may appear. The
Broad, notched secondary R waves (rsr, rsR, or rSR patterns) putative sinoventricular rhythm is explained by persisting sinus
in right precordial leads (V1 and V2) rhythm with conduction between the sinus and AV nodes, without
Wide, deep S waves (qRS pattern) in left precordial leads (V5 producing an overt P wave. Experimental evidence of this phenomenon
and V6) is lacking, and it most likely results from very-low-amplitude P waves.
Moderate to severe hyperkalemia occasionally induces ST elevation in
Delayed intrinsicoid deflection ( . 50 ms) in right precordial the right precordial leads (V1 and V2) and simulates an ischemic cur-
leads rent of injury or Brugada-type patterns. Very marked hyperkalemia
Complete QRS duration $ 120 ms leads to eventual asystole, sometimes preceded by a slow undulatory
LBBB (“sine-wave”) ventricular flutter-like pattern.

Broad, notched, monophasic R waves in V5 and V6, and

usually in leads I and aVL HYPOCALCEMIA AND HYPERCALCEMIA
Small or absent initial r waves in V1 and V2, followed by Changes in serum calcium levels predominantly alter the myocardial
deep S waves (rS or QS patterns) action potential duration. Hypercalcemia shortens the ventricular
action potential duration by shortening phase 2 of the action potential,
Absent septal q waves in left-sided leads (leads I, V5, and thereby shortening the ST segment, which results in shortening of the
V6) Q-T interval. In contrast, hypocalcemia prolongs phase 2 of the action
Delayed intrinsicoid deflection ( . 60 ms) in V5 and V6 potential and prolongs the ST segment, and therefore the Q-T interval
(Figs. 1.37
1.39).
ST segment and T wave directed opposite to the predominant
deflection of the QRS complex
GAP PHENOMENON
LAFB Frontal plane mean QRS axis of 245 to 290
The gap phenomenon is an unexpected sequence of AV nodal or bun-
rS patterns in leads II, III, and aVF (the S wave in lead III is dle branch conduction in which a late premature atrial beat fails to con-
deeper than lead II) duct the ventricles or one of the bundle branches, but the conduction
qR pattern in aVL resumes when a premature atrial beat occurs earlier (shorter R-P0 inter-
val) (Fig. 1.39). The physiologic basis of the gap phenomenon depends
Delayed intrinsicoid deflection in aVL on a distal area with a long refractory period and a proximal site with a
QRS duration ,120 ms shorter refractory period. During the gap phenomenon, initial block
occurs distally. With earlier impulses, proximal conduction delay is
LPFB Frontal plane of mean QRS axis $ 100 encountered, which allows the distal site of early block to recover excit-
rS pattern in leads I and aVL, and qR patterns in leads II, III, ability and resume conduction. Therefore, proximal delay in conduc-
and aVF (S1-Q3 pattern) tion allows distal recovery of refractoriness.

QRS duration ,110 ms

Exclusion of other factors causing right axis deviation (right
ventricular overload patterns, lateral MI)
Delayed intrinsicoid deflection in aVF
LAFB, Left anterior fascicular block; LBBB, left bundle branch block;
LPFB, left posterior fascicular block; MI, myocardial infarction; RBBB,
right bundle branch block.
digitalis toxic arrhythmias. ECG signs of electrolyte imbalance may be
lacking even in severe imbalance and may not correlate with the levels
of the electrolyte.
Hypokalemia
ECG manifestations of hypokalemia include ST depression with
flattened T waves and increased U wave prominence (Fig. 1.35).
The U waves can exceed the amplitude of T waves. Clinically, dis-
tinguishing T waves from U waves can be difficult or impossible
from the 12-lead ECG. The prolongation of repolarization with
hypokalemia, as part of an acquired long QT(U) syndrome, predis-
poses to torsades de pointes.
PARASYSTOLE
Parasystole is due to the function of a secondary pacemaker in the heart
(Figs. 1.40
1.42) and requires not only “focal” impulse formation but
also an area that protects (shields) the “focus” from discharge of the
rest of the myocardium. Generally, the protected “focus” of automati-
city of this type can fire at its own intrinsic frequency. The three classi-
cal criteria are (1) varying coupling intervals, (2) mathematically
related interectopic intervals, and (3) presence of fusion beats. Pure
ventricular parasystole is usually classified as continuous, but without
exit block; continuous with exit block; or intermittent. Frequently,
however, modulated parasystole occurs in which the normal QRS com-
plex modulates the timing of the parasystolic focus.
CONCEALED CONDUCTION
Concealed conduction is defined as the propagation of an impulse with-
in the specialized conduction system (AV node and His-Purkinje sys-
tem), which cannot be recognized on surface ECG because of its low
amplitude. This impulse travels only a limited distance within the con-
duction tissue with incomplete anterograde or retrograde penetration.
 CHAPTER 1 Important Concepts 15

Fig. 1.15 Electrocardiograms depicting different types of left bundle branch block patterns: RsR in (A), rsR in (B), and RsR in lead V6 in (C).
16 CHAPTER 1 Important Concepts

Fig. 1.16 Electrocardiogram showing sinus rhythm with left bundle branch block in alternate QRS complexes.

Fig. 1.17 Electrocardiogram showing sinus rhythm with frequent premature atrial contractions initiating short, long-short cycles conducting to the
ventricles with right bundle branch block aberrancy (Ashman phenomenon).

TABLE 1.4 Electrocardiographic Manifestations of Multifasciular Block

Type of Block Cause Electrocardiogram Manifestations
Bifascicular block RBBB 1 LAFB RBBB with left axis deviation beyond 245
RBBB 1 LPFB RBBB with a mean QRS axis deviation to the right of 1120
LAFB 1 LPFB LBBB alone that may be caused by delay in both the anterior and posterior fascicles.a
Trifascicular block RBBB 1 LAFB 1 LPFB PR .200 ms 1 RBBB 1 LAD
RBBB 1 LBBB Alternate RBBB and LBBB
LAD, Left axis deviation; LAFB, left anterior fascicular block; LBBB, left bundle branch block; LPFB, left posterior fascicular block; RBBB, right
bundle branch block.
a
This form of LBBB represents one of the inadequacies of current electrocardiographic terminology and the simplification inherent in the
trifascicular schema of the conduction system.

Fig. 1.18 Electrocardiogram showing atrial fibrillation with intermittent left bundle branch block aberrancy.
Therefore it can interfere with the formation or propagation of subse-
quent supraventricular or ventricular impulse. It can be recognized on
the ECG by a change in subsequent interval or cycle length.
Concealment at the Atrioventricular Nodal Level
The commonest example of concealment is seen at the AV nodal level.
During atrial fibrillation a slow ventricular rate is due to repeated con-
cealed conduction with varying degrees of penetration and block into
the AV node. This is an example of anterograde concealment of AV
node. Prolongation of the P-R interval or AV nodal block after a non-
conducted premature depolarization of any origin (ventricle or His
bundle) can also occur. When premature ventricular complexes or a
junctional complex incompletely penetrates the AV node, it resets its
refractoriness and can make it fully or partially refractory in the face of
the next sinus impulse. Therefore the next sinus impulse can be blocked
or can conduct with a longer P-R interval. Typically, it occurs with
interpolated premature ventricular complex with retrograde conceal-
ment in the AV node resulting in a longer P-R interval in the subse-
quent cycle (Figs. 1.43 and 1.44; see also Chapter 4).
CONCEALED CONDUCTION AT THE HIS-PURKINJE
LEVEL
Concealment of conduction at the His-Purkinje level occurs as a
result of perpetuation of aberrant conduction during supraventricular
tachycardia with a BBB aberrancy. The perpetuation of aberrant con-
duction results from retrograde penetration of the BBB subsequent to
transseptal conduction. Perpetuation of aberrant ventricular conduc-
tion (functional BBB) is induced by a sudden increase in the
CHAPTER 1 Important Concepts 17
ventricular rate. Often, the aberrancy shows hysteresis and persists
even after the ventricular rate slows to rates less than the rate that
initiated the functional BBB. This phenomenon can be explained by
transseptal activation of the aberrant bundle from the contralateral
bundle branch. Alternatively, a premature ventricular complex from
the left ventricle during a supraventricular tachycardia can activate
the left bundle branch early and then conduct transseptally and later
penetrate the right bundle branch retrogradely. Subsequently, the left
bundle branch recovers in time for the next supraventricular impulse,
whereas the right remains refractory. Therefore the next supraventri-
cular tachycardia impulse travels to the left ventricle over the left bun-
dle branch (with an RBBB pattern). Conduction subsequently
propagates from the left ventricle across the septum to the right ven-
tricle. By this time the distal right bundle branch has recovered, allow-
ing for retrograde penetration of the right bundle branch by the
transseptal wavefront, thereby rendering the right bundle branch
refractory to each subsequent supraventricular tachycardia impulse.
This scenario is repeated, and RBBB continues until another, well-
timed premature ventricular complex preexcites the right bundle
branch (and either peels back or shortens its refractoriness), so that
the next impulse from above finds the right bundle branch fully
recovered and conducts without aberration (Figs. 1.45 and 1.46).
UNEXPECTED FACILITATION OF CONDUCTION
Mechanistically, when a premature impulse penetrates the conduction
system, it can result in facilitation of AV conduction and normalization
of a previously present AV block or BBB. For example, sometimes a
premature ventricular complex abruptly normalizes the aberrancy by
retrograde concealment into the AV node or the bundle branch tissue.
18 CHAPTER 1 Important Concepts

Fig. 1.19 Rate-related right bundle branch block (RBBB). (A) Electrocardiogram (ECG) of a 34-year-old male patient with congenital heart disease
shows sinus rhythm, right axis deviation, and poor progression of R waves in the precordial leads. (B) ECG depicting RBBB aberrancy with right
axis deviation during atrial tachycardia. (C) ECG showing RBBB aberrancy with a progressive widening of the QRS complexes for few complexes
(arrow) followed by a wide QRS tachycardia during the same atrial tachycardia. The QRS morphology is wider in ECG because of amiodarone
therapy, which was initiated for ventricular tachycardia.
 CHAPTER 1 Important Concepts 19

B
Fig. 1.20 Atrial tachycardia (A) with left bundle branch block aberrancy. The atrial tachycardia is slightly irregular and terminates spontaneously
followed by three sinus beats and a three-beat run of atrial tachycardia without aberrancy. (B) Similar aberrancy pattern during the atrial tachycardia,
which terminates spontaneously. The atrial tachycardia reinitiates (arrow), but this time there is no aberrancy, although the cycle length of the atrial
tachycardia is similar to that associated with the aberrancy.

Fig. 1.21 Electrocardiogram depicting atrial fibrillation with narrow QRS complexes. There are two successive left bundle branch block morphology
QRS complexes after a short-long-short sequence. This is most likely a left bundle branch block aberrancy, although a ventricular couplet cannot be
ruled out.
20 CHAPTER 1 Important Concepts

Fig. 1.22 Electrocardiogram showing sinus rhythm with frequent premature atrial complexes. QRS morphology varies between narrow QRS complex
similar to that during the sinus rhythm, and right bundle branch block aberrancy and a QSR complex with left bundle branch block aberrancy.

Fig. 1.23 Bradycardia-dependent left bundle branch block (LBBB) aberrancy and fragmentation of QRS with LBBB pattern and fragmentation of the
premature ventricular complex. Electrocardiogram shows sinus rhythm with LBBB in alternate QRS complexes. R-R interval preceding the aberrant
complexes is longer than R-R interval preceding the narrow QRS complexes. A premature ventricular complex is followed by a compensatory
pause that is significantly longer than sinus R-R interval; still, the QRS complex followed by the long pause has LBBB aberrancy. This is an example
of bradycardia-dependent (phase IV) BBB. There is fragmentation of the QRS with LBBB pattern in lead I and aVL ( . 2 notches) and fragmentation
of the premature ventricular complex (notches are .40 ms apart).

Fig. 1.24 Early repolarization abnormality. Electrocardiogram shows sinus rhythm with JT segment elevation in inferior leads and leads V5 and V6
in a patient without structural heart disease.
 A

B
Fig. 1.25 Electrocardiogram showing sinus rhythm and J point elevation (J wave) in a 32-year-old male patient with methadone overdose (A) and
severe acidosis (arterial pH 5 7.1) (B). The electrocardiogram normalized after the correction of acidosis.

B
Fig. 1.26 (A) Electrocardiogram with prominent J waves (Osborn wave) in inferolateral leads and leads V2 to V4 in a patient who suffered from
hypothermia. (B) Electrocardiogram depicts resolution of Osborn wave after correction of hypothermia.
 A

B
Fig. 1.27 (A) Incomplete right bundle branch block pattern caused by J point elevation and downsloping (coved) ST segment in lead V1-V2. It is
called Brugada pattern electrocardiogram. ST-T waves can vary day by day, probably as a result of autonomic tone (vagal stimulation increases the
J wave elevation) and can even normalize at times. (B) Electrocardiogram of the same patient shows no right bundle branch pattern but J point
elevation and mild concavity upward (saddleback) in ST segment in lead V2.

B
Fig. 1.28 (A) Electrocardiogram of a 55-year-old male patient with long QT syndrome type 1. The sinus rate is 80 bpm, the Q-T interval is 525, and corrected
Q-T interval by Bazett formula is 581 ms. (B) Electrocardiogram of the same patient depicts frequent premature ventricular complexes in a bigeminal pattern.
Premature ventricular complexes with a shorter coupling interval in this patient would be on the T wave and could trigger torsades de pointes.
 CHAPTER 1 Important Concepts 23

BOX 1.1 Occurrence of ST horizontal or covering segment elevation

Myocardial ischemia or infarction Myocarditis (may resemble myocardial infarction or
Noninfarction, transmural ischemia (e.g., Prinzmetal angina pattern, pericarditis)
takotsubo syndrome) Tumor invading the left ventricle
Postmyocardial infarction (ventricular aneurysm pattern) Hypothermia (J wave, Osborn wave)
Acute pericarditis DC cardioversion (just following)
Normal variants (including the classic early repolarization pattern) Intracranial hemorrhage
LVH, LBBB (V1-V2 or V3 only) Hyperkalemiaa
Other (rarer) Brugada pattern (RBBB-like pattern and ST-segment elevations in
Acute pulmonary embolism (right midchest leads) right precordial leads)a
Hypothermia (J wave, Osborn wave) Type 1C antiarrhythmic drugsa
Myocardial injury Hypercalcemiaa
a
Usually most apparent in V1 to V2.
DC, Direct current; LBBB, left bundle branch block; LVH, left ventricular hypertrophy; RBBB, right bundle branch block.
Modified from Goldberger AL. Clinical Electrocardiography: A Simplified Approach. 7th ed. St. Louis, MO: Mosby; 2017.

TABLE 1.5 Left Ventricular Hypertrophy

Measurements Criteria
Sokolow-Lyon voltages SV1 1 RV5 .3.5 mV (35 mm) or
RaVL .1.1 mV (11 mm)
a
Romhilt-Estes point score system Any limb lead R wave or S wave .2.0 mV (3 points)
or SV1 or SV2 $ 3.0 mV (3 points)
or RV5 to RV6 $ 3.0 mV (3 points)
ST-T wave abnormality, no digitalis therapy (3 points)
ST-T wave abnormality, digitalis therapy (1 point)
Left atrial abnormality (3 points)
Left axis deviation 230 or more (2 points)
QRS duration $ 90 ms (1 point)
Intrinsicoid deflection in V5 or V6 $ 50 ms (1 point)
Cornell voltage criteria SV3 1 RaVL $ 2.8 mV (for men)
SV3 1 RaVL .2.0 mV (for women)
a
Probable left ventricular hypertrophy (LVH) is diagnosed if four points are present, and definite LVH is diagnosed if five or more points are present.

BOX 1.2 Right ventricular hypertrophy

R in V1 $ 0.7 mV R in V5 or V6 $ 0.4 mV with S in V1 # 0.2 mV
QR in V1 Right axis deviation ( . 90 )
R/S in V1 .1 with R .0.5 mV S1Q3 pattern
R/S in V5 or V6 ,1 S1S2S3 pattern
S in V5 or V6 .0.7 mV P pulmonale
24 CHAPTER 1 Important Concepts

Fig. 1.29 Complete heart block in a patient with acute inferior wall myocardial infarction (ST elevation in leads II and III and aVF).

Fig. 1.30 Ventricular fibrillation during an anterior wall myocardial infarction (ST elevation from V1-V5).

Fig. 1.31 Electrocardiogram of a patient who suffered from an acute non-ST elevation myocardial infarction shows sinus rhythm with salvos of
idioventricular rhythm after percutaneous intervention. This is a reperfusion arrhythmia.
 CHAPTER 1 Important Concepts 25

Fig. 1.32 Ventricular fibrillation in a patient with remote myocardial infarction. (A) Electrocardiogram showing polymorphic ventricular tachycardia
initiated by an R on T phenomenon that degenerates into ventricular fibrillation. (B) Electrocardiogram depicting fragmented QRS in inferior leads
(arrow) and no Q waves are present. The position emission tomography-computed tomography scan confirmed inferior myocardial scar.
26 CHAPTER 1 Important Concepts

Fig. 1.33 (A) Electrocardiogram (ECG) showing a long RP0 tachycardia with narrow QRS complexes with QRS alternans. ECG of the same patient
depicting same tachycardia with the same rate as ECG (B). This is an example of atrial tachycardia with left bundle branch aberrancy.

Fig. 1.34 Electrocardiogram showing QRS alternans during atrial flutter.

Fig. 1.35 Electrocardiogram depicting sinus rhythm at 57 bpm with prolonged QT-U interval (638 ms) in a 56-year-old female patient in the setting
of hypokalemia. There are prominent U waves in inferior leads and leads V2 to V5 (arrow).

Fig. 1.36 (A) Electrocardiogram of a 58-year-old male patient with renal failure and K 1 level of 8.1 mEq/L shows no P waves and a wide QRS (A
and B). The baseline electrocardiogram (C) of the same patient shows sinus rhythm with a normal P-R interval and narrow QRS and T waves after
correction of hyperkalemia.
28 CHAPTER 1 Important Concepts

B
Fig. 1.37 Electrocardiogram of a 58-year-old female patient with chronic renal failure shows sinus rhythm with a prominent T wave (hyperkalemia)
in leads V3 to V5 and a prolonged QTc interval of 516 ms. (A) The prolongation of Q-T interval is mainly due to prolongation of JT segment caused
by associated hypocalcemia. (B) A peaked T wave (from hyperkalemia), Q-T prolongation (from hypocalcemia), and left ventricular hypertrophy
(from hypertension) on an electrocardiogram is strongly suggestive of chronic renal failure in another patient.
 CHAPTER 1 Important Concepts 29

B
Fig. 1.38 (A) Electrocardiogram of a 58-year-old female patient with hyperparathyroidism and a serum calcium level of 13.2 mEq/L shows sinus
rhythm at 54 bpm with a short corrected Q-T interval of 358 ms. (B) The QTc interval normalized to 400 ms with a calcium level of 9.4 mEq/L after
parathyroidectomy in the same patient.
30 CHAPTER 1 Important Concepts

APC APC

P – P = 420
P – P = 400
A

HRA

A1 A2

H1 H2
His

HRA

A1 A2

H1 H2
His

B
Fig. 1.39 Gap phenomenon of atrioventricular (AV) nodal conduction. Rhythm strip (A) shows sinus rhythm followed by blocked premature atrial
complexes (premature atrial complexes do not conduct to the ventricles). The second premature atrial complex has a shorter coupling interval (in
ms) but conducts to the ventricle with right bundle branch block aberrancy. (B) Anterograde AV gap phenomenon demonstrated during the
electrophysiology study. Atrial extrastimulus (A2) (upper panel) conducting with modest delay through the AV node finds the His bundle still
refractory, causing AV block. Earlier atrial extrastimulus (lower panel) results in further prolongation of the A2-H2 interval and the subsequent H1-
H2 interval (shaded area). The longer H1-H2 interval now exceeds the refractory period of the His bundle, and by the time the impulse traverses
the atrioventricular node the His bundle has completed its effective refractory period and conduction resumes; however, the conducted QRS has a
left bundle branch block, morphology, and a longer HV interval because the left bundle is still refractory. (From Issa ZF, Miller JM, Zipes DP, eds.
Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald’s Heart Disease. 1st ed. Philadelphia, PA: WB Saunders; 2019.)
 CHAPTER 1 Important Concepts 31

Continuous tracings

A
CSP 2060

6090 = 2030 × 3 2080 2000 1980 2000 2000

C
2060 2080 2100 2240

E
Fig. 1.40 Intermittent ventricular parasystole. (A) Continuous rhythm shows sinus rhythm. Note that the ventricular parasystole appears
unexpectedly (B) at a cycle length (2060 ms) that is shorter than the immediately preceding ventricular pause elicited by carotid sinus pressure
(CSP). After “warming up” to 1980 ms (C), the parasystole gradually “cools off” to 2240 ms (D) before it disappears (E). Although several other
mechanisms have been shown in other figures, variants of this type of parasystole constitutes the one most frequently found when the diagnosis
is made from Holter recordings. (Arrows indicate manifest parasystolic beats.) (From Zipes DP, Jalife J, eds. Cardiac Electrophysiology: From Cell
to Bedside. 5th ed. St. Louis, MO: WB Saunders; 2018.)
32 CHAPTER 1 Important Concepts

Fig. 1.41 Ventricular parasystole. Electrocardiogram shows sinus rhythm with premature ventricular contractions occurring at a regular interval
(blue arrow). First and third wide complexes are fusion beats between the sinus complex and premature ventricular contraction (red arrow).

A
Fusion beat
X 2X X 2X X X

1 2 3 4 5 6

Atrium
AV node
Ventricle
B

Fig. 1.42 (A) Intermittent ventricular parasystole with exit block. The rhythm strip (B) of the same electrocardiogram shows that the interval
between the PVC2 and PVC3 is double the interval between PVC1 and PVC2 and between PVC3 and PVC4. Between PVC5 and PVC6 is the fusion
beat following a premature atrial complex that conducts with a narrow QRS. Because the baseline QRS has incomplete right bundle branch block
but the PVC originates from the right ventricle (left bundle branch block morphology), the fusion beat normalizes the QRS. Blue arrows depict
impulses originating from the sinus node and the red arrows depict impulses originating from the ventricle. AV, atrioventricular.
Fig. 1.43 Electrocardiogram shows sinus rhythm with a premature ventricular complex that does not change the next sinus cycle length; however,
the P-R interval prolongs after the next P wave (arrow) because of a retrograde concealment of the ventricular impulse generated by the premature
ventricular contraction in the atrioventricular node.

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

V1

II

V5
A

V1

Sinus APC Sinus Sinus Sinus APC

AV node

Ventricle

B RBBB
Fig. 1.44 Interpolated premature ventricular complex versus aberrancy. (A) Electrocardiogram showing sinus rhythm with a right bundle branch
block (RBBB) morphology QRS between the alternate narrow QRS complexes. On close observation (B) the RBBB pattern QRS complexes are
aberrantly conducted (arrow), and the QRS following that has a normal duration, which may be a result of a supernormal conduction via the RBBB.
The P wave next to it is an atrial premature contraction and does not penetrate the atrioventricular node (blocked atrial premature contraction). Red
double lines show the sites of block of supraventricular impulses. APC, atrial premature complexes; AV, atrioventricular.
34 CHAPTER 1 Important Concepts

Fig. 1.45 Electrocardiogram depicting sinus rhythm with frequent interpolated premature ventricular contractions. The P-R interval (arrow) after
these premature ventricular contractions is longer compared with the baseline P-R interval. This is because of retrograde concealment into the
atrioventricular node of ventricular impulse generated by the premature ventricular contraction.
 CHAPTER 1 Important Concepts 35

1000 ms
A

Atrium

AV node

Ventricle

RBBB PVC Narrow QRS

B
Fig. 1.46 Supraventricular tachycardia with tachycardia-dependent (phase 3) right bundle branch block. Electrocardiogram (A) depicts a short RP0
tachycardia with narrow QRS tachycardia. The tachycardia spontaneously changes to a wide complex tachycardia with the same tachycardia cycle
length. This is an example of right bundle branch block aberrancy. An extrastimulus (premature ventricular contraction) delivered during the wide
complex tachycardia changes the QRS duration to a narrow complex tachycardia. Delivery of a late ventricular extrastimulus (arrow) during the
supraventricular tachycardia (B) preexcites the right bundle branch (and either peels back or shortens its refractoriness) and restores normal
conduction. PVC, premature ventricular impulse. (From Issa ZF, Miller JM, Zipes DP, eds. Clinical Arrhythmology and Electrophysiology: A
Companion to Braunwald’s Heart Disease. 1st ed. Philadelphia, PA: Saunders; 2019.)
36 CHAPTER 1 Important Concepts

Fig. 1.47 Electrocardiogram showing atrial fibrillation with right bundle branch block. One of the QRS complexes is narrow without any signs of
bundle branch block. This can be explained as supernormal conduction via the RBBB, which resulted in a narrow QRS. Narrow QRS complex is
marked by an arrow.

SUPERNORMAL CONDUCTION
BIBLIOGRAPHY
Supernormal conduction implies conduction that is better than antici-
pated or conduction that occurs when block is expected. At the AV nodal Goldberger AL. Clinical Electrocardiography: A Simplified Approach. 7th ed.
level, intermittent AV conduction can occur during periods of high- St. Louis, MO: Mosby; 2006.
degree AV block. At the His-Purkinje level, supernormal conduction can Issa ZF, Miller JM, Zipes DP, eds. Clinical Arrhythmology and
Electrophysiology: A Companion to Braunwald’s Heart Disease. 1st ed.
occur with a paradoxical normalization of bundle branch conduction at
Philadelphia, PA: WB Saunders; 2019.
an R-R interval shorter than that with BBB. This can also occur with an
Zipes DP, Jalife J, eds. Cardiac Electrophysiology: From Cell to Bedside. 5th ed.
atrial premature complex conducting with a narrow QRS during baseline St. Louis, MO: WB Saunders; 2018.
sinus rhythm with BBB, or with acceleration-dependent BBB that nor-
malizes at even faster rates (Fig. 1.47).

The normal sinoatrial node (SAN) is capable of generating impulses at
a rate that meets metabolic demands at rest and during increased
requirements, such as during exercise. The symptoms reported by
patients with sinus node disease include palpitations, dizzy spells, pre-
syncope, and syncope. These symptoms can be persistent or intermit-
tent. More than half of the patients affected are aged older than 50
years. The normal heart rate for an adult is 60 to 100 bpm. Sinus node
dysfunction (SND) includes symptomatic sinus bradycardia, sinus
pauses, sinus arrest, tachycardia-bradycardia syndrome, and sympto-
matic chronotropic incompetence (Table 2.1). Patients with sinus bra-
dycardia or chronotropic incompetence can present with decreased
exercise capacity or fatigue. Sinus bradycardia may be physiologic in
well-trained athletes because of high vagal tone (Fig. 2.1). Marked sinus
bradycardia (40 bpm) can result in emergence of a junctional rhythm
at 30 to 40 beats (Figs. 2.2 and 2.3). SND can occur in the setting of
intrinsic sinus node disease (e.g., primary conduction system disease,
coronary artery disease, cardiomyopathy, heart failure) or as a result of
extrinsic factors. such as autonomic imbalance (neurocardiogenic syn-
cope, carotid sinus hypersensitivity, autonomic neuropathy), cardiac
surgery (maze surgery, mitral valve surgery) electrolyte imbalance
(hyperkalemia), or drug therapy (e.g., antiarrhythmic drugs, clonidine,
lithium) (Figs. 2.4 through 2.8). Usually an electrocardiogram confirms
persistent sinus node abnormalities in symptomatic patients. However,
intermittent arrhythmia with frequent symptoms requires 24- or 48-
hour ambulatory Holter monitoring. Less frequent arrhythmias require
cardiac event monitoring or implantable loop recorders for diagnosis.
Wearable technology, such as smart watches and phones, can be
useful to document SND in some patients. Invasive electrophysiology
testing can be performed in symptomatic patients in whom SND is sus-
pected but cannot be documented in association with symptoms.
Electrophysiology study can be of value in evaluation of other potential
causes for symptoms of syncope and palpitations, such as atrioventri-
cular (AV) node disease or ventricular tachycardia. Head-up tilt test is
also helpful in patients with neurocardiogenic syncope (bradycardia,
hypotension, or both during upright posture) and postural orthostatic
tachycardia syndrome (POTS).
SINUS ARRHYTHMIA
Sinus arrhythmia is usually a normal physiologic response to respira-
tion or vagal stimulation. In sinus arrhythmia, P wave morphology is
consistent with sinus rhythm, and the P-P intervals vary by more than
160 ms (Figs. 2.9 through 2.12). In respiratory sinus arrhythmia, the
sinus rate increases with inspiration and decreases with expiration. A
2
Sinus Node Dysfunction
respiratory variation in the sinus P wave contour can be seen in the
inferior leads. It is most commonly seen in young healthy subjects.
Nonrespiratory sinus arrhythmia of unknown mechanisms can occur
during digitalis and morphine administration.
VENTRICULOPHASIC SINUS ARRHYTHMIA
Ventriculophasic sinus arrhythmia is a nonpathological arrhythmia
that occurs during sinus rhythm with high-grade or complete AV
block. Electrographic recording shows shorter P-P intervals when they
enclose QRS complexes and longer P-P intervals when no QRS com-
plexes are enclosed (Fig. 2.13). The mechanism of this arrhythmia is
not known but may be related to the effects of the mechanical ventricu-
lar systole, which increases the blood supply to the sinus node, thereby
transiently increasing its firing rate. Alternatively, it could be carotid
sinus stimulation with a larger stroke volume leading to reflex slowing
of the sinus node in the next P-P cycle.
SINOATRIAL EXIT BLOCK
Sinoatrial exit block results when the sinus impulse fails to conduct to
the atria because of delay in conduction or block within the sinus node
area or perinodal tissue. Sinoatrial exit block produces a pause that is a
multiple of the P-P interval unless there is type 1 second-degree sinoa-
trial block or sinus arrhythmia because the normal impulse is formed
on time and just cannot exit. These pauses are eventually terminated by
a delayed sinus beat or subsidiary escape beats from the atrium, His
bundle, or ventricle. Like AV node block, sinoatrial block is classified
into three types (Table 2.2).
CHRONOTROPIC INCOMPETENCE
Chronotropic incompetence is defined as the inability to accelerate the
sinus rate appropriately to the level needed by the body’s metabolism,
usually during exercise. This definition includes the inability to reach
the 80th percentile of maximum predicted heart rate, delayed peak of
heart rate (heart rate peaks during recovery period after the exercise),
early peaking of heart rate (before the peak exercise), fluctuations of
heart rate during exercise, or the inability to reach a heart rate of 100 to
120 bpm. However, this definition of chronotropic incompetence is not
universally agreed upon. The heart rate response to exercise also
depends on several factors, such as deconditioning, drug therapy, and
comorbidities.
37
Another random document with
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even to forgotten and moth-eaten twopenny pamphlets, which may
be used to the disadvantage of his own country. But, as to the
Hartford Convention, sir, allow me to say that the proceedings of
that body seem now to be less read and studied in New England than
farther south. They appear to be looked to, not in New England, but
elsewhere, for the purpose of seeing how far they may serve as a
precedent. But they will not answer the purpose—they are quite too
tame. The latitude in which they originated was too cold. Other
conventions, of more recent existence, have gone a whole bar’s
length beyond it. The learned doctors of Colleton and Abbeville have
pushed their commentaries on the Hartford collect so far that the
original text writers are thrown entirely into the shade. I have
nothing to do, sir, with the Hartford Convention. Its journal, which
the gentleman has quoted, I never read. So far as the honorable
member may discover in its proceedings a spirit in any degree
resembling that which was avowed and justified in those other
conventions to which I have alluded, or so far as those proceedings
can be shown to be disloyal to the constitution, or tending to
disunion, so far I shall be as ready as any one to bestow on them
reprehension and censure.
Having dwelt long on this convention, and other occurrences of
that day, in the hope, probably, (which will not be gratified,) that I
should leave the course of this debate to follow him at length in those
excursions, the honorable member returned, and attempted another
object. He referred to a speech of mine in the other house, the same
which I had occasion to allude to myself the other day; and has
quoted a passage or two from it, with a bold though uneasy and
laboring air of confidence, as if he had detected in me an
inconsistency. Judging from the gentleman’s manner, a stranger to
the course of the debate, and to the point in discussion, would have
imagined, from so triumphant a tone, that the honorable member
was about to overwhelm me with a manifest contradiction. Any one
who heard him, and who had not heard what I had, in fact,
previously said, must have thought me routed and discomfited, as
the gentleman had promised. Sir, a breath blows all this triumph
away. There is not the slightest difference in the sentiments of my
remarks on the two occasions. What I said here on Wednesday is in
exact accordance with the opinions expressed by me in the other
house in 1825. Though the gentleman had the metaphysics of
Hudibras—though he were able
“to sever and divide
A hair ’twixt north and north west side,”

he could not yet insert his metaphysical scissors between the fair
reading of my remarks in 1825 and what I said here last week. There
is not only no contradiction, no difference, but, in truth, too exact a
similarity, both in thought and language, to be entirely in just taste. I
had myself quoted the same speech; had recurred to it, and spoke
with it open before me; and much of what I said was little more than
a repetition from it. In order to make finishing work with this alleged
contradiction, permit me to recur to the origin of this debate, and
review its course. This seems expedient, and may be done as well
now as at any time.
Well, then, its history is this: the honorable member from
Connecticut moved a resolution, which constituted the first branch of
that which is now before us; that is to say, a resolution instructing
the committee on public lands to inquire into the expediency of
limiting, for a certain period, the sales of public lands to such as have
heretofore been offered for sale; and whether sundry offices,
connected with the sales of the lands, might not be abolished without
detriment to the public service.
In the progress of the discussion which arose on this resolution, an
honorable member from New Hampshire moved to amend the
resolution, so as entirely to reverse its object; that is to strike it all
out, and insert a direction to the committee to inquire into the
expediency of adopting measures to hasten the sales, and extend
more rapidly the surveys of the lands.
The honorable member from Maine (Mr. Sprague) suggested that
both these propositions might well enough go, for consideration, to
the committee; and in this state of the question, the member from
South Carolina addressed the Senate in his first speech. He rose, he
said, to give his own free thoughts on the public lands. I saw him
rise, with pleasure, and listened with expectation, though before he
concluded I was filled with surprise. Certainly, I was never more
surprised than to find him following up, to the extent he did, the
sentiments and opinions which the gentleman from Missouri had put
forth, and which it is known he has long entertained.
I need not repeat, at large, the general topics of the honorable
gentleman’s speech. When he said, yesterday, that he did not attack
the Eastern States, he certainly must have forgotten not only
particular remarks, but the whole drift and tenor of his speech;
unless he means by not attacking, that he did not commence
hostilities, but that another had preceded him in the attack. He, in
the first place, disapproved of the whole course of the government
for forty years, in regard to its dispositions of the public land; and
then, turning northward and eastward, and fancying he had found a
cause for alleged narrowness and niggardliness in the “accursed
policy” of the tariff, to which he represented the people of New
England as wedded, he went on, for a full hour, with remarks, the
whole scope of which was to exhibit the results of this policy, in
feelings and in measures unfavorable to the west. I thought his
opinions unfounded and erroneous, as to the general course of the
government, and ventured to reply to them.
The gentleman had remarked on the analogy of other cases, and
quoted the conduct of European governments towards their own
subjects, settling on this continent, as in point, to show that we had
been harsh and rigid in selling when we should have given the public
lands to settlers. I thought the honorable member had suffered his
judgment to be betrayed by a false analogy; that he was struck with
an appearance of resemblance where there was no real similitude. I
think so still. The first settlers of North America were enterprising
spirits, engaging in private adventure, or fleeing from tyranny at
home. When arrived here, they were forgotten by the mother
country, or remembered only to be oppressed. Carried away again by
the appearance of analogy, or struck with the eloquence of the
passage, the honorable member yesterday observed that the conduct
of government towards the western emigrants, or my representation
of it, brought to his mind a celebrated speech in the British
Parliament. It was, sir, the speech of Colonel Barre. On the question
of the stamp act, or tea tax, I forget which, Colonel Barre had heard a
member on the treasury bench argue, that the people of the United
States, being British colonists, planted by the maternal care,
nourished by the indulgence, and protected by the arms of England,
would not grudge their mite to relieve the mother country from the
heavy burden under which she groaned. The language of Colonel
Barre, in reply to this, was, “They planted by your care? Your
oppression planted them in America. They fled from your tyranny,
and grew by your neglect of them. So soon as you began to care for
them, you showed your care by sending persons to spy out their
liberties, misrepresent their character, prey upon them, and eat out
their substance.”
And does this honorable gentleman mean to maintain that
language like this is applicable to the conduct of the government of
the United States towards the western emigrants, or to any
representation given by me of that conduct? Were the settlers in the
west driven thither by our oppression? Have they flourished only by
our neglect of them? Has the government done nothing but prey
upon them, and eat out their substance? Sir, this fervid eloquence of
the British speaker, just when and where it was uttered, and fit to
remain an exercise for the schools, is not a little out of place, when it
was brought thence to be applied here, to the conduct of our own
country towards her own citizens. From America to England it may
be true; from Americans to their own government it would be
strange language. Let us leave it to be recited and declaimed by our
boys against a foreign nation; not introduce it here, to recite and
declaim ourselves against our own.
But I come to the point of the alleged contradiction. In my remarks
on Wednesday, I contended that we could not give away gratuitously
all the public lands; that we held them in trust; that the government
had solemnly pledged itself to dispose of them as a common fund for
the common benefit, and to sell and settle them as its discretion
should dictate. Now, sir, what contradiction does the gentleman find
to this sentiment in the speech of 1825? He quotes me as having then
said, that we ought not to hug these lands as a very great treasure.
Very well, sir; supposing me to be accurately reported in that
expression, what is the contradiction? I have not now said, that we
should hug these lands as a favorite source of pecuniary income. No
such thing. It is not my view. What I have said, and what I do say, is,
that they are a common fund—to be disposed of for the common
benefit—to be sold at low prices, for the accommodation of settlers,
keeping the object of settling the lands as much in view as that of
raising money from them. This I say now, and this I have always
said. Is this hugging them as a favorite treasure? Is there no
difference between hugging and hoarding this fund, on the one hand,
as a great treasure, and on the other of disposing of it at low prices,
placing the proceeds in the general treasury of the Union? My
opinion is, that as much is to be made of the land, as fair and
reasonably may be, selling it all the while at such rates as to give the
fullest effect to settlement. This is not giving it all away to the states,
as the gentleman would propose, nor is it hugging the fund closely
and tenaciously, as a favorite treasure; but it is, in my judgment, a
just and wise policy, perfectly according with all the various duties
which rest on government. So much for my contradiction. And what
is it? Where is the ground of the gentleman’s triumph? What
inconsistency, in word or doctrine, has he been able to detect? Sir, if
this be a sample of that discomfiture with which the honorable
gentleman threatened me, commend me to the word discomfiture for
the rest of my life.
But, after all, this is not the point of the debate; and I must bring
the gentleman back to that which is the point.
The real question between me and him is, Where has the doctrine
been advanced, at the south or the east, that the population of the
west should be retarded, or, at least, need not be hastened, on
account of its effect to drain off the people from the Atlantic States?
Is this doctrine, as has been alleged, of eastern origin? That is the
question. Has the gentleman found anything by which he can make
good his accusation? I submit to the Senate, that he has entirely
failed; and as far as this debate has shown, the only person who has
advanced such sentiments is a gentleman from South Carolina, and a
friend to the honorable member himself. This honorable gentleman
has given no answer to this; there is none which can be given. This
simple fact, while it requires no comment to enforce it, defies all
argument to refute it. I could refer to the speeches of another
southern gentleman, in years before, of the same general character,
and to the same effect, as that which has been quoted; but I will not
consume the time of the Senate by the reading of them.
So then, sir, New England is guiltless of the policy of retarding
western population, and of all envy and jealousy of the growth of the
new states. Whatever there be of that policy in the country, no part of
it is hers. If it has a local habitation, the honorable member has
probably seen, by this time, where he is to look for it; and if it now
has received a name, he himself has christened it.
We approach, at length, sir, to a more important part of the
honorable gentleman’s observations. Since it does not accord with
my views of justice and policy, to vote away the public lands
altogether, as mere matter of gratuity, I am asked, by the honorable
gentleman, on what ground it is that I consent to give them away in
particular instances. How, he inquires, do I reconcile with these
professed sentiments my support of measures appropriating portions
of the lands to particular roads, particular canals, particular rivers,
and particular institutions of education in the west? This leads, sir, to
the real and wide difference in political opinions between the
honorable gentleman and myself. On my part, I look upon all these
objects as connected with the common good, fairly embraced in its
objects and its terms; he, on the contrary, deems them all, if good at
all, only local good. This is our difference. The interrogatory which
he proceeded to put, at once explains this difference. “What interest,”
asks he, “has South Carolina in a canal in Ohio?” Sir, this very
question is full of significance. It develops the gentleman’s whole
political system; and its answer expounds mine. Here we differ toto
cœlo. I look upon a road over the Alleghany, a canal round the falls of
the Ohio, or a canal or railway from the Atlantic to the western
waters, as being objects large and extensive enough to be fairly said
to be for the common benefit. The gentleman thinks otherwise, and
this is the key to open his construction of the powers of the
government. He may well ask, upon his system, What interest has
South Carolina in a canal in Ohio? On that system, it is true, she has
no interest. On that system, Ohio and Carolina are different
governments and different countries, connected here, it is true, by
some slight and ill-defined bond of union, but in all main respects
separate and diverse. On that system, Carolina has no more interest
in a canal in Ohio than in Mexico. The gentleman, therefore, only
follows out his own principles; he does no more than arrive at the
natural conclusions of his own doctrines; he only announces the true
results of that creed which he has adopted himself, and would
persuade others to adopt, when he thus declares that South Carolina
has no interest in a public work in Ohio. Sir, we narrow-minded
people of New England do not reason thus. Our notion of things is
entirely different. We look upon the states not as separated, but as
united. We love to dwell on that Union, and on the mutual happiness
which it has so much promoted, and the common renown which it
has so greatly contributed to acquire. In our contemplation, Carolina
and Ohio are parts of the same country—states united under the
same general government, having interests common, associated,
intermingled. In whatever is within the proper sphere of the
constitutional power of this government, we look upon the states as
one. We do not impose geographical limits to our patriotic feeling or
regard; we do not follow rivers, and mountains, and lines of latitude,
to find boundaries beyond which public improvements do not benefit
us. We, who come here as agents and representatives of those
narrow-minded and selfish men of New England, consider ourselves
as bound to regard, with equal eye, the good of the whole, in
whatever is within our power of legislation. Sir, if a railroad or canal,
beginning in South Carolina, appeared to me to be of national
importance and national magnitude, believing as I do that the power
of government extends to the encouragement of works of that
description, if I were to stand up here and ask, “What interest has
Massachusetts in a railroad in South Carolina?” I should not be
willing to face my constituents. These same narrow-minded men
would tell me that they had sent me to act for the whole country, and
that one who possessed too little comprehension, either of intellect
or feeling—one who was not large enough, in mind and heart, to
embrace the whole—was not fit to be intrusted with the interest of
any part. Sir, I do not desire to enlarge the powers of government by
unjustifiable construction, nor to exercise any not within a fair
interpretation. But when it is believed that a power does exist, then it
is, in my judgment, to be exercised for the general benefit of the
whole: so far as respects the exercise of such a power, the states are
one. It was the very great object of the constitution to create unity of
interests to the extent of the powers of the general government. In
war and peace we are one; in commerce one; because the authority of
the general government reaches to war and peace, and to the
regulation of commerce. I have never seen any more difficulty in
erecting lighthouses on the lakes than on the ocean; in improving the
harbors of inland seas, than if they were within the ebb and flow of
the tide; or of removing obstructions in the vast streams of the west,
more than in any work to facilitate commerce on the Atlantic coast. If
there be power for one, there is power also for the other; and they are
all and equally for the country.
There are other objects, apparently more local, or the benefit of
which is less general, towards which, nevertheless, I have concurred
with others to give aid by donations of land. It is proposed to
construct a road in or through one of the new states in which the
government possesses large quantities of land. Have the United
States no right, as a great and untaxed proprietor—are they under no
obligation—to contribute to an object thus calculated to promote the
common good of all the proprietors, themselves included? And even
with respect to education, which is the extreme case, let the question
be considered. In the first place, as we have seen, it was made matter
of compact with these states that they should do their part to
promote education. In the next place, our whole system of land laws
proceeds on the idea that education is for the common good;
because, in every division, a certain portion is uniformly reserved
and appropriated for the use of schools. And, finally have not these
new states singularly strong claims, founded on the ground already
stated, that the government is a great untaxed proprietor in the
ownership of the soil? It is a consideration of great importance that
probably there is in no part of the country, or of the world, so great a
call for the means of education as in those new states, owing to the
vast number of persons within those ages in which education and
instruction are usually received, if received at all. This is the natural
consequence of recency of settlement and rapid increase. The census
of these states shows how great a proportion of the whole population
occupies the classes between infancy and childhood. These are the
wide fields, and here is the deep and quick soil for the seeds of
knowledge and virtue; and this is the favored season, the spring time
for sowing them. Let them be disseminated without stint. Let them
be scattered with a bountiful broadcast. Whatever the government
can fairly do towards these objects, in my opinion, ought to be done.
These, sir, are the grounds, succinctly stated, on which my vote for
grants of lands for particular objects rest, while I maintain, at the
same time, that it is all a common fund, for the common benefit. And
reasons like these, I presume, have influenced the votes of other
gentlemen from New England. Those who have a different view of
the powers of the government, of course, come to different
conclusions on these as on other questions. I observed, when
speaking on this subject before, that if we looked to any measure,
whether for a road, a canal, or any thing else intended for the
improvement of the west, it would be found, that if the New England
ayes were struck out of the list of votes, the southern noes would
always have rejected the measure. The truth of this has not been
denied, and cannot be denied. In stating this, I thought it just to
ascribe it to the constitutional scruples of the south, rather than to
any other less favorable or less charitable cause. But no sooner had I
done this, than the honorable gentleman asks if I reproach him and
his friends with their constitutional scruples. Sir, I reproach nobody.
I stated a fact, and gave the most respectful reason for it that
occurred to me. The gentleman cannot deny the fact—he may, if he
choose, disclaim the reason. It is not long since I had occasion, in
presenting a petition from his own state, to account for its being
intrusted to my hands by saying, that the constitutional opinions of
the gentleman and his worthy colleague prevented them from
supporting it. Sir, did I state this as a matter of reproach? Far from it.
Did I attempt to find any other cause than an honest one for these
scruples? Sir, I did not. It did not become me to doubt, nor to
insinuate that the gentleman had either changed his sentiments, or
that he had made up a set of constitutional opinions, accommodated
to any particular combination of political occurrences. Had I done so,
I should have felt, that while I was entitled to little respect in thus
questioning other people’s motives, I justified the whole world in
suspecting my own.
But how has the gentleman returned this respect for others’
opinions? His own candor and justice, how have they been exhibited
towards the motives of others, while he has been at so much pains to
maintain—what nobody has disputed—the purity of his own? Why,
sir, he has asked when, and how, and why New England votes were
found going for measures favorable to the west; he has demanded to
be informed whether all this did not begin in 1825, and while the
election of President was still pending. Sir, to these questions retort
would be justified; and it is both cogent and at hand. Nevertheless, I
will answer the inquiry not by retort, but by facts. I will tell the
gentleman when, and how, and why New England has supported
measures favorable to the west. I have already referred to the early
history of the government—to the first acquisition of the lands—to
the original laws for disposing of them and for governing the
territories where they lie; and have shown the influence of New
England men and New England principles in all these leading
measures. I should not be pardoned were I to go over that ground
again. Coming to more recent times, and to measures of a less
general character, I have endeavored to prove that every thing of this
kind designed for western improvement has depended on the votes
of New England. All this is true beyond the power of contradiction.
And now, sir, there are two measures to which I will refer, not so
ancient as to belong to the early history of the public lands, and not
so recent as to be on this side of the period when the gentleman
charitably imagines a new direction may have been given to New
England feeling and New England votes. These measures, and the
New England votes in support of them, may be taken as samples and
specimens of all the rest. In 1820, (observe, Mr. President, in 1820,)
the people of the west besought Congress for a reduction in the price
of lands. In favor of that reduction, New England, with a delegation
of forty members in the other house, gave thirty-three votes, and one
only against it. The four Southern States, with fifty members, gave
thirty-two votes for it, and seven against it. Again, in 1821, (observe
again, sir, the time,) the law passed for the relief of the purchasers of
the public lands. This was a measure of vital importance to the west,
and more especially to the southwest. It authorized the
relinquishment of contracts for lands, which had been entered into at
high prices, and a reduction, in other cases, of not less than 37½ per
cent. on the purchase money. Many millions of dollars, six or seven I
believe at least,—probably much more,—were relinquished by this
law. On this bill New England, with her forty members, gave more
affirmative votes than the four Southern States with their fifty-two or
three members. These two are far the most important measures
respecting the public lands which have been adopted within the last
twenty years. They took place in 1820 and 1821. That is the time
when. And as to the manner how, the gentleman already sees that it
was by voting, in solid column, for the required relief; and lastly, as
to the cause why, I tell the gentleman, it was because the members
from New England thought the measures just and salutary; because
they entertained towards the west neither envy, hatred, nor malice;
because they deemed it becoming them, as just and enlightened
public men, to meet the exigency which had arisen in the west with
the appropriate measure of relief; because they felt it due to their
own characters of their New England predecessors in this
government, to act towards the new states in the spirit of a liberal,
patronizing, magnanimous policy. So much, sir, for the cause why;
and I hope that by this time, sir, the honorable gentleman is
satisfied; if not, I do not know when, or how, or why, he ever will be.
Having recurred to these two important measures, in answer to
the gentleman’s inquiries, I must now beg permission to go back to a
period still something earlier, for the purpose still further of showing
how much, or rather how little reason there is for the gentleman’s
insinuation that political hopes, or fears, or party associations, were
the grounds of these New England votes. And after what has been
said, I hope it may be forgiven me if I allude to some political
opinions and votes of my own, of very little public importance,
certainly, but which, from the time at which they were given and
expressed, may pass for good witnesses on this occasion.
This government, Mr. President, from its origin to the peace of
1815, had been too much engrossed with various other important
concerns to be able to turn its thoughts inward, and look to the
development of its vast internal resources. In the early part of
President Washington’s administration, it was fully occupied with
organizing the government, providing for the public debt, defending
the frontiers, and maintaining domestic peace. Before the
termination of that administration, the fires of the French revolution
blazed forth, as from a new opened volcano, and the whole breadth
of the ocean did not entirely secure us from its effects. The smoke
and the cinders reached us, though not the burning lava. Difficult
and agitating questions, embarrassing to government, and dividing
public opinion, sprung out of the new state of our foreign relations,
and were succeeded by others, and yet again by others, equally
embarrassing, and equally exciting division and discord, through the
long series of twenty years, till they finally issued in the war with
England. Down to the close of that war, no distinct, marked and
deliberate attention had been given, or could have been given, to the
internal condition of the country, its capacities of improvement, or
the constitutional power of the government, in regard to objects
connected with such improvement.
 The peace, Mr. President, brought about an entirely new and a
most interesting state of things; it opened to us other prospects, and
suggested other duties; we ourselves were changed, and the whole
world was changed. The pacification of Europe, after June, 1815,
assumed a firm and permanent aspect. The nations evidently
manifested that they were disposed for peace: some agitation of the
waves might be expected, even after the storm had subsided; but the
tendency was, strongly and rapidly, towards settled repose.
It so happened, sir, that I was at that time a member of Congress,
and, like others, naturally turned my attention to the contemplation
of the newly-altered condition of the country, and of the world. It
appeared plainly enough to me, as well as to wiser and more
experienced men, that the policy of the government would
necessarily take a start in a new direction, because new directions
would necessarily be given to the pursuits and occupations of the
people. We had pushed our commerce far and fast, under the
advantage of a neutral flag. But there were now no longer flags,
either neutral or belligerent. The harvest of neutrality had been
great, but we had gathered it all. With the peace of Europe, it was
obvious there would spring up, in her circle of nations, a revived and
invigorated spirit of trade, and a new activity in all the business and
objects of civilized life. Hereafter, our commercial gains were to be
earned only by success in a close and intense competition. Other
nations would produce for themselves, and carry for themselves, and
manufacture for themselves, to the full extent of their abilities. The
crops of our plains would no longer sustain European armies, nor
our ships longer supply those whom war had rendered unable to
supply themselves. It was obvious that under these circumstances,
the country would begin to survey itself, and to estimate its own
capacity of improvement. And this improvement, how was it to be
accomplished, and who was to accomplish it?
We were ten or twelve millions of people, spread over almost half a
world. We were twenty-four states, some stretching along the same
seaboard, some along the same line of inland frontier, and others on
opposite banks of the same vast rivers. Two considerations at once
presented themselves, in looking at this state of things, with great
force. One was that that great branch of improvement, which
consisted in furnishing new facilities of intercourse, necessarily ran
into different states, in every leading instance, and would benefit the
citizens of all such states. No one state therefore, in such cases,
would assume the whole expense, nor was the co-operation of several
states to be expected. Take the instance of the Delaware Breakwater.
It will cost several millions of money. Would Pennsylvania, New
Jersey, and Delaware have united to accomplish it at their joint
expense? Certainly not, for the same reason. It could not be done,
therefore, but by the general government. The same may be said of
the large inland undertakings, except that, in them, government,
instead of bearing the whole expense, co-operates with others to bear
a part. The other consideration is, that the United States have the
means. They enjoy the revenues derived from commerce, and the
states have no abundant and easy sources of public income. The
custom houses fill the general treasury, while the states have scanty
resources, except by resort to heavy direct taxes.
Under this view of things, I thought it necessary to settle, at least
for myself, some definite notions, with respect to the powers of
government, in regard to internal affairs. It may not savor too much
of self-commendation to remark, that, with this object, I considered
the constitution, its judicial construction, its contemporaneous
exposition, and the whole history of the legislation of Congress under
it; and I arrived at the conclusion that government had power to
accomplish sundry objects, or aid in their accomplishment, which
are now commonly spoken of as Internal Improvements. That
conclusion, sir, may have been right or it may have been wrong. I am
not about to argue the grounds of it at large. I say only that it was
adopted, and acted on, even so early as in 1816. Yes, Mr. President, I
made up my opinion, and determined on my intended course of
political conduct on these subjects, in the 14th Congress in 1816. And
now, Mr. President, I have further to say, that I made up these
opinions, and entered on this course of political conduct, Teucro
duce. Yes, sir, I pursued, in all this, a South Carolina track. On the
doctrines of internal improvement, South Carolina, as she was then
represented in the other house, set forth, in 1816, under a fresh and
leading breeze; and I was among the followers. But if my leader sees
new lights, and turns a sharp corner, unless I see new lights also, I
keep straight on in the same path. I repeat, that leading gentlemen
from South Carolina were first and foremost in behalf of the
doctrines of internal improvements, when those doctrines first came
to be considered and acted upon in Congress. The debate on the bank
question, on the tariff of 1816, and on the direct tax, will show who
was who, and what was what, at that time. The tariff of 1816, one of
the plain cases of oppression and usurpation, from which, if the
government does not recede, individual states may justly secede
from the government, is, sir, in truth, a South Carolina tariff,
supported by South Carolina votes. But for those votes, it could not
have passed in the form in which it did pass; whereas, if it had
depended on Massachusetts votes, it would have been lost. Does not
the honorable gentleman well know all this? There are certainly
those who do full well know it all. I do not say this to reproach South
Carolina; I only state the fact, and I think it will appear to be true,
that among the earliest and boldest advocates of the tariff, as a
measure of protection, and on the express ground of protection, were
leading gentlemen of South Carolina in Congress. I did not then, and
cannot now, understand their language in any other sense. While this
tariff of 1816 was under discussion in the House of Representatives,
an honorable gentleman from Georgia, now of this house, (Mr.
Forsyth,) moved to reduce the proposed duty on cotton. He failed by
four votes, South Carolina giving three votes (enough to have turned
the scale) against his motion. The act, sir, then passed, and received
on its passage the support of a majority of the representatives of
South Carolina present and voting. This act is the first, in the order
of those now denounced as plain usurpations. We see it daily in the
list by the side of those of 1824 and 1828, as a case of manifest
oppression, justifying disunion. I put it home to the honorable
member from South Carolina, that his own state was not only “art
and part” in this measure, but the causa causans. Without her aid,
this seminal principle of mischief, this root of upas, could not have
been planted. I have already said—and, it is true—that this act
preceded on the ground of protection. It interfered directly with
existing interests of great value and amount. It cut up the Calcutta
cotton trade by the roots. But it passed, nevertheless, and it passed
on the principle of protecting manufactures, on the principle against
free trade, on the principle opposed to that which lets us alone.
Such, Mr. President, were the opinions of important and leading
gentlemen of South Carolina, on the subject of internal
improvement, in 1816. I went out of Congress the next year, and
returning again in 1823, thought I found South Carolina where I had
left her. I really supposed that all things remained as they were, and
that the South Carolina doctrine of internal improvements would be
defended by the same eloquent voices, and the same strong arms as
formerly. In the lapse of these six years, it is true, political
associations had assumed a new aspect and new divisions. A party
had arisen in the south, hostile to the doctrine of internal
improvements, and had vigorously attacked that doctrine. Anti-
consolidation was the flag under which this party fought, and its
supporters inveighed against internal improvements, much after the
same manner in which the honorable gentleman has now inveighed
against them, as part and parcel of the system of consolidation.
Whether this party arose in South Carolina herself, or in her
neighborhood, is more than I know. I think the latter. However that
may have been, there were those found in South Carolina ready to
make war upon it, and who did make intrepid war upon it. Names
being regarded as things, in such controversies, they bestowed on the
anti-improvement gentlemen the appellation of radicals. Yes, sir, the
name of radicals, as a term of distinction, applicable and applied to
those who defended the liberal doctrines of internal improvements,
originated, according to the best of my recollection, somewhere
between North Carolina and Georgia. Well, sir, those mischievous
radicals were to be put down, and the strong arm of South Carolina
was stretched out to put them down. About this time, sir, I returned
to Congress. The battle with the radicals had been fought, and our
South Carolina champions of the doctrine of internal improvements
had nobly maintained their ground, and were understood to have
achieved a victory. They had driven back the enemy with
discomfiture; a thing, by the way, sir, which is not always performed
when it is promised. A gentleman, to whom I have already referred in
this debate, had come into Congress, during my absence from it,
from South Carolina, and had brought with him a high reputation for
ability. He came from a school with which we had been acquainted,
et noscitur a sociis. I hold in my hand, sir, a printed speech of this
distinguished gentleman, (Mr. McDuffie,) “ON INTERNAL
IMPROVEMENTS,” delivered about the period to which I now refer, and
printed with a few introductory remarks upon consolidation; in
which, sir, I think he quite consolidated the arguments of his
opponents, the radicals, if to crush be to consolidate. I give you a
short but substantive quotation from these remarks. He is speaking
of a pamphlet, then recently published, entitled, “Consolidation;”
and having alluded to the question of re-chartering the former Bank
of the United States, he says: “Moreover, in the early history of
parties, and when Mr. Crawford advocated the renewal of the old
charter, it was considered a federal measure; which internal
improvement never was, as this author erroneously states. This latter
measure originated in the administration of Mr. Jefferson, with the
appropriation for the Cumberland road; and was first proposed, as a
system, by Mr. Calhoun, and carried through the House of
Representatives by a large majority of the republicans, including
almost every one of the leading men who carried us through the late
war.”
So, then, internal improvement is not one of the federal heresies.
One paragraph more, sir.
“The author in question, not content with denouncing as
federalists Gen. Jackson, Mr. Adams, Mr. Calhoun, and the majority
of the South Carolina delegation in Congress, modestly extends the
denunciation to Mr. Monroe and the whole republican party. Here
are his words. ‘During the administration of Mr. Monroe, much has
passed which the republican party would be glad to approve, if they
could!! But the principal feature, and that which has chiefly elicited
these observations, is the renewal of the SYSTEM OF INTERNAL
IMPROVEMENTS.’ Now, this measure was adopted by a vote of 115 to
86, of a republican Congress, and sanctioned by a republican
president. Who, then, is this author, who assumes the high
prerogative of denouncing, in the name of the republican party, the
republican administration of the country—a denunciation including
within its sweep Calhoun, Lowndes, and Cheves; men who will be
regarded as the brightest ornaments of South Carolina, and the
strongest pillars of the republican party, as long as the late war shall
be remembered, and talents and patriotism shall be regarded as the
proper objects of the admiration and gratitude of a free people!!”
Such are the opinions, sir, which were maintained by South
Carolina gentlemen in the House of Representatives on the subject of
internal improvements, when I took my seat there as a member from
Massachusetts, in 1823. But this is not all; we had a bill before us,
and passed it in that house, entitled, “An act to procure the necessary
surveys, plans, and estimates upon the subject of roads and canals.”
It authorized the president to cause surveys and estimates to be
made of the routes of such roads and canals as he might deem of
national importance in a commercial or military point of view, or
for the transportation of the mail; and appropriated thirty thousand
dollars out of the treasury to defray the expense. This act, though
preliminary in its nature, covered the whole ground. It took for
granted the complete power of internal improvement, as far as any of
its advocates had ever contended for it. Having passed the other
house, the bill came up to the Senate, and was here considered and
debated in April, 1824. The honorable member from South Carolina
was a member of the Senate at that time. While the bill was under
consideration here, a motion was made to add the following proviso:
—
“Provided, That nothing herein contained shall be construed to
affirm or admit a power in Congress, on their own authority, to make
roads or canals within any of the states of the Union.”
The yeas and nays were taken on this proviso, and the honorable
member voted in the negative. The proviso failed.
A motion was then made to add this proviso, viz:—
“Provided, That the faith of the United States is hereby pledged,
that no money shall ever be expended for roads or canals except it
shall be among the several states, and in the same proportion as
direct taxes are laid and assessed by the provisions of the
constitution.”
The honorable member voted against this proviso also, and it
failed.
The bill was then put on its passage, and the honorable member
voted for it, and it passed, and became a law.
Now, it strikes me, sir, that there is no maintaining these votes but
upon the power of internal improvement, in its broadest sense. In
truth, these bills for surveys and estimates have always been
considered as test questions. They show who is for and who against
internal improvement. This law itself went the whole length, and
assumed the full and complete power. The gentleman’s vote
sustained that power, in every form in which the various
propositions to amend presented it. He went for the entire and
unrestrained authority, without consulting the states, and without
agreeing to any proportionate distribution. And now, suffer me to
remind you, Mr. President, that it is this very same power, thus
sanctioned, in every form, by the gentleman’s own opinion, that is so
plain and manifest a usurpation, that the state of South Carolina is
supposed to be justified in refusing submission to any laws carrying
the power into effect. Truly, sir, is not this a little too hard? May we
not crave some mercy, under favor and protection of the gentleman’s
own authority? Admitting that a road or a canal must be written
down flat usurpation as ever was committed, may we find no
mitigation in our respect for his place, and his vote, as one that
knows the law?
The tariff which South Carolina had an efficient hand in
establishing in 1816, and this asserted power of internal
improvement—advanced by her in the same year, and, as we have
seen, approved and sanctioned by her representatives in 1824,—
these two measures are the great grounds on which she is now
thought to be justified in breaking up the Union, if she sees fit to
break it up.
I may now safely say, I think, that we have had the authority of
leading and distinguished gentlemen from South Carolina in support
of the doctrine of internal improvement. I repeat that, up to 1824, I,
for one, followed South Carolina; but when that star in its ascension
veered off in an unexpected direction, I relied on its light no longer.
[Here the Vice-President said, Does the Chair understand the
gentleman from Massachusetts to say that the person now occupying
the chair of the Senate has changed his opinion on the subject of
internal improvement?] From nothing ever said to me, sir, have I
had reason to know of any change in the opinions of the person
filling the chair of the Senate. If such change has taken place, I regret
it; I speak generally of the state of South Carolina. Individuals we
know there are who hold opinions favorable to the power. An
application for its exercise in behalf of a public work in South
Carolina itself is now pending, I believe, in the other house,
presented by members from that state.
I have thus, sir, perhaps not without some tediousness of detail,
shown that, if I am in error on the subject of internal improvements,
how and in what company I fell into that error. If I am wrong, it is
apparent who misled me.
 I go to other remarks of the honorable member—and I have to
complain of an entire misapprehension of what I said on the subject
of the national debt—though I can hardly perceive how any one could
misunderstand me. What I said was, not that I wished to put off the
payment of the debt, but, on the contrary, that I had always voted for
every measure for its reduction, as uniformly as the gentleman
himself. He seems to claim the exclusive merit of a disposition to
reduce the public charge; I do not allow it to him. As a debt, I was, I
am, for paying it; because it is a charge on our finances, and on the
industry of the country. But I observed that I thought I perceived a
morbid fervor on that subject; an excessive anxiety to pay off the
debt; not so much because it is a debt simply, as because, while it
lasts, it furnishes one objection to disunion. It is a tie of common
interest while it lasts. I did not impute such motive to the honorable
member himself; but that there is such a feeling in existence I have
not a particle of doubt. The most I said was, that if one effect of the
debt was to strengthen our Union, that effect itself was not regretted
by me, however much others might regret it. The gentleman has not
seen how to reply to this otherwise than by supposing me to have
advanced the doctrine that a national debt is a national blessing.
Others, I must hope, will find less difficulty in understanding me. I
distinctly and pointedly cautioned the honorable member not to
understand me as expressing an opinion favorable to the
continuance of the debt. I repeated this caution, and repeated it more
than once—but it was thrown away.
On yet another point I was still more unaccountably
misunderstood. The gentleman had harangued against
“consolidation.” I told him, in reply, that there was one kind of
consolidation to which I was attached, and that was, the
consolidation of our Union; and that this was precisely that
consolidation to which I feared others were not attached; that such
consolidation was the very end of the constitution—the leading
object, as they had informed us themselves, which its framers had
kept in view. I turned to their communication, and read their very
words,—“the consolidation of the Union,”—and expressed my
devotion to this sort of consolidation. I said in terms that I wished
not, in the slightest degree, to augment the powers of this
government; that my object was to preserve, not to enlarge; and that,
by consolidating the Union, I understood no more than the
strengthening of the Union and perpetuating it. Having been thus
explicit; having thus read, from the printed book, the precise words
which I adopted, as expressing my own sentiments, it passes
comprehension, how any man could understand me as contending
for an extension of the powers of the government, or for
consolidation in the odious sense in which it means an accumulation,
in the federal government, of the powers properly belonging to the
states.
I repeat, sir, that, in adopting the sentiments of the framers of the
constitution, I read their language audibly, and word for word; and I
pointed out the distinction, just as fully as I have now done, between
the consolidation of the Union and that other obnoxious
consolidation which I disclaimed; and yet the honorable gentleman
misunderstood me. The gentleman had said that he wished for no
fixed revenue—not a shilling. If, by a word, he could convert the
Capitol into gold, he would not do it. Why all this fear of revenue?
Why, sir, because, as the gentleman told us, it tends to consolidation.
Now, this can mean neither more or less than that a common
revenue is a common interest, and that all common interests tend to
hold the union of the states together. I confess I like that tendency; if
the gentleman dislikes it, he is right in deprecating a shilling’s fixed
revenue. So much, sir, for consolidation.
As well as I recollect the course of his remarks, the honorable
gentleman next recurred to the subject of the tariff. He did not doubt
the word must be of unpleasant sound to me, and proceeded, with an
effort neither new nor attended with new success, to involve me and
my votes in inconsistency and contradiction. I am happy the
honorable gentleman has furnished me an opportunity of a timely
remark or two on that subject. I was glad he approached it, for it is a
question I enter upon without fear from any body. The strenuous toil
of the gentleman has been to raise an inconsistency between my
dissent to the tariff, in 1824 and my vote in 1828. It is labor lost. He
pays undeserved compliment to my speech in 1824; but this is to
raise me high, that my fall, as he would have it, in 1828 may be the
more signal. Sir, there was no fall at all. Between the ground I stood
on in 1824 and that I took in 1828, there was not only no precipice,
but no declivity. It was a change of position, to meet new
circumstances, but on the same level. A plain tale explains the whole