Electrocardiography For Healthcare

Professionals Ise (paperback) Kathryn

Booth
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This linternational Student Edition is for use outside of the UJSk
 page i

ELECTROCARDIOGRAPHY
FOR HEALTHCARE PROFESSIONALS

Sixth Edition

Kathryn A. Booth, RN-BSN, RMA (AMT),

RPT (AMT), EFR, CPhT, MS
Total Care Programming, Inc.
Palm Coast, Florida

Thomas E. O’Brien, AAS, CCT, CRAT, RMA, CCMA, CPT

Remington College
Medical Assisting Program, Capstone Instructor
 page ii

ELECTROCARDIOGRAPHY FOR HEALTHCARE PROFESSIONALS

Published by McGraw Hill LLC, 1325 Avenue of the Americas, New York, NY 10019. Copyright ©2024 by McGraw Hill LLC. All rights
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 page iii

Dedication
To the individuals using the information in this book, you have chosen a much needed,
worthwhile, and rewarding profession. Thank you; your skills and services are truly needed.
To my children and grandchildren who keep me young. To my students and patients, may your
futures be even better than expected.
Kathryn Booth

I want to thank my beautiful wife, Michele, and our wonderful children, Thomas, Robert, and
Kathryn. Without their love and support, I would have nothing. They inspire me every day to
make a difference in people’s lives. Today’s students are the difference makers of tomorrow!
Thomas O’Brien
 page iv

About the Authors

Kathryn A. Booth, RN-BSN, RMA (AMT), EFR, RPT, CPhT, MS, is a registered nurse (RN) with
CPR and ACLS training as well as a master’s degree in education. She serves on the Cardiovascular
Credentialing International Certified Rhythm Analysis Technician Item Writer and Reviewer’s committee
and the American Medical Technologists registered Phlebotomy Technician Examinations, Qualifications,
and Standards committee. She has over 40 years in healthcare and education including nursing,
electrocardiography, phlebotomy, and medical assisting. Her experience spans five states. As an educator,
Kathy has been awarded the teacher of the year in three states where she taught various health educational
courses including healthcare science, nursing, and medical assisting. She is a past and current member of
two educational advisory boards. Her larger goal is to develop up-to-date, dynamic healthcare
educational materials to assist other educators as well as to promote the healthcare profession. This is
why she became the owner, author, educator, and consultant for Total Care Programming, Inc. Kathy
enjoys developing and presenting innovative new learning solutions for the changing healthcare and
educational landscape to her fellow professionals nationwide.

Thomas E. Davidson-O’Brien, AAS, CCT, CRAT, RMA, CCMA, CPT, is the capstone instructor for
the Medical Assisting program at Remington College, Fort Worth, Texas. Tom also works as an author
and editor of Practical Clinical Skills (www.practicalclinicalskills.com) and EKG Academy. He is a
former member of the Board of Trustees and Exam Chair for the Certified Cardiographic Technician
(CCT) and Certified Rhythm Analysis Technician (CRAT) Registry Examinations working with
Cardiovascular Credentialing International (CCI). Tom continues to volunteer his efforts as an active
contributor to both credential exams as a member of the Item Writing team. His background includes over
40 years in healthcare including the U.S. Air Force and U.S. Army Medical Corps. Tom’s medical career
as an Air Force Independent Duty Medical Technician (IDMT) has taken him all over the United States
and the world. He has several years of experience working in the Emergency Services and Critical Care
arena (Cardiothoracic Surgery and Cardiac Cath Lab). He was awarded Master Instructor status by the
U.S. Air Force in 1994 upon completion of his teaching practicum. He now has over 20 years of teaching
experience; subjects include Emergency Medicine, Cardiovascular Nursing, Fundamentals of Nursing,
Dysrhythmias, and 12-Lead ECG Interpretation. His current position provides challenges to meet the
ever-changing needs of the medical community and to provide a first-rate education to a diverse adult
education population.
 page v

Brief Contents

Preface xii
Acknowledgments xx

CHAPTER 1 Electrocardiography 1

CHAPTER 2 The Cardiovascular System 36

CHAPTER 3 The Electrocardiograph 57

CHAPTER 4 Performing an ECG 87

CHAPTER 5 Rhythm Strip Interpretation 126

CHAPTER 6 Sinus Rhythms 143

CHAPTER 7 Atrial Dysrhythmias 165

CHAPTER 8 Junctional Dysrhythmias 184

CHAPTER 9 Heart Block Dysrhythmias 204

CHAPTER 10 Ventricular Dysrhythmias 224

CHAPTER 11 Pacemaker Rhythms 253

CHAPTER 12 Cardiac Stress Testing 275

CHAPTER 13 Ambulatory Monitoring 304

 Clinical Presentation and Management of the Cardiac Patient 331
CHAPTER
14
CHAPTER 15 Basic 12-Lead ECG Interpretation 363

page vi

APPENDIX A Cardiovascular Medications A-1

APPENDIX B Standard and Isolation Precautions B-1

APPENDIX C Medical Abbreviations, Acronyms, and Symbols C-1

APPENDIX D Anatomical Terms D-1

APPENDIX E Identifying Components of ECG Strips E-1

APPENDIX F Competency Checklists Available through the Instructor Resources on C

Glossary G-1

Index I-1
 page vii

Contents
Preface xii
Acknowledgments xx

CHAPTER 1 Electrocardiography 1
1.1 The ECG and Its History 2
1.2 Uses of an ECG 3
1.3 Preparing for an ECG 11
1.4 Infection Control 16
1.5 Vital Signs 20
Competency Checklists
1-1 Measuring Pulse and Respirations 32
1-2 Measuring Adult Blood Pressure 34

CHAPTER 2 The Cardiovascular System 36

2.1 Circulation and the ECG 37
2.2 Anatomy of the Heart 37
2.3 Principles of Circulation 42
2.4 The Cardiac Cycle 44
2.5 Conduction System of the Heart 46

CHAPTER 3 The Electrocardiograph 57

3.1 Producing the ECG Waveform 57
 3.2 ECG Machines 63
3.3 ECG Controls 67
3.4 Electrodes 71
3.5 ECG Graph Paper 72
3.6 Calculating Heart Rate 75
page viii

CHAPTER 4 Performing an ECG 87

4.1 Preparation for the ECG Procedure 88
4.2 Communicating with the Patient 89
4.3 Safety 91
4.4 Applying the Electrodes and Leads 93
4.5 Operating the ECG Machine 99
4.6 Checking the ECG Tracing 99
4.7 Reporting ECG Results 104
4.8 Equipment Maintenance 105
4.9 Pediatric ECG 107
4.10 Cardiac Monitoring 108
4.11 Special Patient Considerations 109
4.12 Handling Emergencies 113
Competency Checklists
4-1 Recording an Electrocardiogram 122
4-1 Continuous Cardiac Monitoring 124

CHAPTER 5 Rhythm Strip Interpretation 126

5.1 Electrical Stimulation and the ECG Waveform
126
 5.2 Rhythm Interpretation 130
5.3 Identifying the Components of the Rhythm
132

CHAPTER 6 Sinus Rhythms 143

6.1 Rhythms Originating from the Sinus Node
143
6.2 Sinus Bradycardia 146
6.3 Sinus Tachycardia 148
6.4 Sinus Dysrhythmia 150
6.5 Sinus Arrest 152
6.6 Sinus Exit Block 154

CHAPTER 7 Atrial Dysrhythmias 165

7.1 Introduction to Atrial Dysrhythmias 165
7.2 Premature Atrial Complexes 166
7.3 Wandering Atrial Pacemaker 168
7.4 Multifocal Atrial Tachycardia 170
page ix

7.5 Atrial Flutter 171

7.6 Atrial Fibrillation 174

CHAPTER 8 Junctional Dysrhythmias 184

8.1 Introduction to Junctional Dysrhythmias 184
8.2 Premature Junctional Complex (PJC) 186
8.3 Junctional Escape Rhythm 187
8.4 Accelerated Junctional Rhythm 189
 8.5 Junctional Tachycardia 191
8.6 Supraventricular Tachycardia (SVT) 193

CHAPTER 9 Heart Block Dysrhythmias 204

9.1 Introduction to Heart Block Dysrhythmias
204
9.2 First-Degree Atrioventricular (AV) Block 204
9.3 Second-Degree Atrioventricular (AV) Block,
Type I (Mobitz I or Wenckebach) 206
9.4 Second-Degree Atrioventricular (AV) Block,
Type II (Mobitz II) 209
9.5 Third-Degree Atrioventricular (AV) Block
(Complete) 212

CHAPTER 10 Ventricular Dysrhythmias 224

10.1 Introduction to Ventricular Dysrhythmias
224
10.2 Premature Ventricular Complexes (PVCs)
225
10.3 Agonal Rhythm 229
10.4 Idioventricular Rhythm 231
10.5 Accelerated Idioventricular Rhythm 232
10.6 Ventricular Tachycardia 234
10.7 Ventricular Fibrillation 236
10.8 Asystole 239

CHAPTER 11 Pacemaker Rhythms 253

11.1 Introduction to Pacemakers 253
11.2 Evaluating Pacemaker Function 257
 11.3 Pacemaker Complications Relative to the ECG
Tracing 262
Competency Checklists
11-1 Pacemaker Evaluation 273

page x

CHAPTER 12 Cardiac Stress Testing 275

12.1 Cardiac Stress Testing 275
12.2 Why Is Exercise Electrocardiography Used?
277
12.3 Other Types of Cardiac Stress Testing 278
12.4 Preparing the Patient for Exercise
Electrocardiography 281
12.5 Providing Safety 284
12.6 Performing Exercise Electrocardiography
287
12.7 Common Protocols 289
12.8 After Exercise Electrocardiography 292
Competency Checklists
12-1 Assisting with Exercise Electrocardiography (Stress
Testing) 300

CHAPTER 13 Ambulatory Monitoring 304

13.1 Ambulatory Monitoring 304
13.2 How Is Ambulatory Monitoring Used? 306
13.3 Types of Ambulatory Monitoring 307
13.4 Educating the Patient 313
13.5 Preparing the Patient 316
 13.6 Applying an Ambulatory Monitor 316
13.7 Removing an Ambulatory Monitor and
Reporting Results 320
Competency Checklists
13-1 Applying and Removing an Ambulatory (Holter) Monitor
327

CHAPTER 14 Clinical Presentation and Management of the Ca

14.1 Coronary Arteries 332
14.2 Cardiac Symptoms 334
14.3 Atypical Patient Presentation 336
14.4 Acute Coronary Syndrome 338
14.5 Heart Failure 341
14.6 Cardiac Patient Assessment and Immediate
Treatment 344
14.7 Treatment Modalities for the Cardiac Patient
349
Competency Checklists
14-1 Immediate Care for a Cardiac Patient 361

page xi

CHAPTER 15 Basic 12-Lead ECG Interpretation 363

15.1 The Views of a Standard 12-Lead ECG and
Major Vessels 363
15.2 Ischemia, Injury, and Infarction 368
15.3 Introduction to Bundle Branch Block 372
15.4 LBBB vs. RBBB 376
15.5 Electrical Axis 378
15.6 Left Ventricular Hypertrophy 381
Appendix A Cardiovascular Medications A-1

Appendix B Standard and Isolation Precautions B-1

Appendix C Medical Abbreviations, Acronyms, and Symbols C-

1

Appendix D Anatomical Terms D-1

Appendix E Identifying Components of ECG Strips E-1

Appendix F Competency Checklists Available through the

Instructor Resources on Connect and
www.mcgrawhillcreate.com F-1

Glossary G-1

Index I-1
 page xii

Preface

Healthcare is an ever-changing and growing field that needs well-trained individuals who can adapt to
change. Flexibility is key to obtaining, maintaining, and improving a career in electrocardiography.
Obtaining ECG training and certification, whether it be in addition to your current career or as your
career, will make you employable or a more-valued employee. This sixth edition of Electrocardiography
for Healthcare Professionals will prepare users for a national ECG certification examination, but most
importantly, it provides comprehensive training and practice for individuals in the field of
electrocardiography.
The fact that you are currently reading this book means that you are willing to acquire new skills or
improve the skills you already possess. This willingness translates into your enhanced value, job security,
marketability, and mobility. Once you complete this program, taking a certification examination is a great
next step for advancing your career.
This sixth edition of Electrocardiography for Healthcare Professionals can be used in a classroom
as well as for online learning. Checkpoint Questions and Connect exercises correlated to the Learning
Outcomes make the learning process interactive and promote increased comprehension. The variety of
materials included with the program provides for multiple learning styles and ensures individual success.

Text Organization
The text is divided into 15 chapters:
Chapter 1 Electrocardiography includes introductory information about the field as well as legal,
ethical, communication, and patient education information. In addition, basic vital signs and
troubleshooting are addressed. Competency Checklists are included to practice checking vital signs.
Chapter 2 The Cardiovascular System provides a complete introduction and review of the heart and
its electrical system. The information focuses on what you need to know to understand and perform an
ECG. Specific topics include anatomy of the heart, principles of circulation, cardiac cycle, and the
cardiac conduction system.
Chapter 3 The Electrocardiograph creates a basic understanding of the ECG, including producing the
ECG waveform, the ECG machine, electrodes, and ECG graph paper.
Chapter 4 Performing an ECG describes the procedure for performing an ECG in a simple step-by-
step fashion. Each part of the procedure is explained in detail, taking into consideration the latest
guidelines. The chapter is divided into the following topics: preparation, communication, page xiii
safety, anatomical landmarks, applying the electrodes and leads, operating the ECG machine,
checking the tracing, reporting results, and equipment maintenance. Extra sections are included
regarding pediatric ECG, cardiac monitoring, special patient circumstances, and emergencies.
Competency Checklists are included to practice performing both an ECG and continuous monitoring.
Chapter 5 Rhythm Strip Interpretation includes details about the electrical stimulation of the heart
and how the waveform is developed. It then introduces the five-step criteria for the classification
approach to rhythm interpretation that will be utilized throughout Chapters 6 through 11.
Chapter 6 Sinus Rhythms has updated, realistic rhythm strip figures and explanations to learn to
interpret the sinus rhythms, including criteria for classification, how the patient may be affected, basic
patient care, and treatment.
Chapter 7 Atrial Dysrhythmias provides an introduction to and interpretation of the atrial
dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care,
and treatment.
Chapter 8 Junctional Dysrhythmias provides an introduction to and interpretation of the junctional
dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care,
and treatment.
Chapter 9 Heart Block Dysrhythmias provides an introduction to and interpretation of the heart block
dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care,
and treatment.
Chapter 10 Ventricular Dysrhythmias provides an introduction to and interpretation of the
ventricular dysrhythmias, including criteria for classification, how the patient may be affected, basic
patient care, and treatment.
Chapter 11 Pacemaker Rhythms provides an introduction to pacemaker rhythms, evaluation of
pacemaker function, and complications related to the ECG tracing.
Chapter 12 Cardiac Stress Testing provides the information necessary to assist with the exercise
electrocardiography procedure. The Competency Checklist provides the step-by-step procedure for
practice and developing proficiency at the skill.
Chapter 13 Ambulatory Monitoring includes the latest information about various types of ambulatory
monitors and includes what you need to know to apply and remove a monitor. A Procedures Checklist
is provided for this skill.
Chapter 14 Clinical Presentation and Management of the Cardiac Patient expands on the anatomy
of the coronary arteries and relates them to typical and atypical cardiac symptoms. STEMI, non-
STEMI, and heart failure are introduced. The chapter includes a section about sudden cardiac death as
compared to myocardial infarction and finishes with assessment, immediate care, and page xiv
continued treatment of the cardiac patient.
Chapter 15 Basic 12-Lead ECG Interpretation provides an introduction to 12-lead ECG
interpretation. It includes anatomical views of the coronary arteries and correlates the arteries with
the leads and views obtained on a 12-lead ECG. It also identifies the morphologic changes in the
tracing that occur as a result of ischemia, injury, and infarction. An introduction to bundle branch
block dysrhythmias, including criteria for classification, how the patient may be affected, basic patient
care, treatment, and how to differentiate between left and right bundle branch block is included. Axis
deviation and left ventricular hypertrophy round out the chapter concepts. An extra Putting It All
Together section after the chapter review is provided to help users practice the chapter concepts
together for 12-lead interpretation.
These chapters can be utilized in various careers and training programs. Following are some
suggested examples:
Telemetry technicians (Chapters 1–12, depending on requirements)
EKG/ECG technicians (the entire book, depending on requirements)
Medical assistants (the entire book, depending on where they work)
Cardiovascular technicians working in any number of specialty clinics, such as cardiology or internal
medicine (the entire book)
Remote monitoring facilities personnel (Chapters 1–10, 13–15)
Emergency medical technicians (Chapters 2, 5–10, 15, possibly more depending on where they work)
Paramedics (Chapters 2–15)
Nursing, especially for cross-training or specialty training (Chapters 2–15)
Patient care tech or nursing assistant (Chapters 2–4, 13, perhaps more depending on job requirements)
Polysomnography technologist (Chapters 2–10)
Echocardiography technologist (Chapters 2, 5–12)
Cardiac cath lab technologist (Chapters 2–11, 15)

New to the Sixth Edition

We split the 5th edition Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms into two chapters,
which are now Chapter 5 Rhythm Strip Interpretation and Chapter 6 Sinus Rhythms.
Moved the content “Electrical Stimulation and the ECG Waveform” into the new Chapter 5 Rhythm
Strip Interpretation for seamless learning.
Chapter 15 Basic 12-Lead ECG Interpretation now includes the information from the 5th edition
Chapter 10 Bundle Branch Block.
Improved many of the ECG tracings to make them more realistic.
Added and updated content about the following topics: ECG career opportunities, cardiac conduction
system, vital sign ranges by age (new Table 1-5), ECG for adolescents, low cardiac output (new
Table 6-1), various rhythms Interpret-Tips and How the Patient Is Affected sections, ACLS page xv
guidelines, cardiac stress test timing, anticoagulation medications, and axis deviation to name
a few.
Added or updated over 20 images throughout the new content.

Features of the Text

Key Terms and Glossary: Key terms are identified at the beginning of each chapter. These terms are
in bold, color type within the chapter and are defined both in the chapter and in the glossary at the end
of the book.
Checkpoint Questions: At the end of each main heading in the chapter are short-answer Checkpoint
Questions. Answer these questions to make sure you have learned the basic concepts presented.
Think It Through: The Think It Through feature identifies problems and situations that may arise
 when you are caring for patients or performing a procedure. At the end of this feature, you are asked a
question to answer in your own words.
Safety & Infection Control: You are responsible for providing safe care and preventing the spread
of infection. This feature presents tips and techniques to help you practice these important skills
relative to electrocardiography.
Communicate and Connect: Patient interaction and education and intrateam communication are
integral parts of healthcare. As part of your daily duties, you must communicate effectively, both
orally and in writing, and you must provide patient education. Use this feature to learn ways to
perform these tasks.
Law & Ethics: When working in healthcare, you must be conscious of the regulations of HIPAA
(Health Insurance Portability and Accountability Act) and understand your legal responsibilities and
the implications of your actions. You must perform duties within established ethical practices. This
feature helps you gain insight into how HIPAA, law, and ethics relate to the performance of your
duties.
Real ECG Tracings: Actual ECG tracings, or rhythm strips, have been provided for easy viewing
and to make the task of learning the various dysrhythmias easier and more realistic. Use of these ECG
rhythm strips for activities and exercises throughout the program improves comprehension and
accommodates visual learners.
Competency Checklists: Checklists at the end of some chapters (as appropriate) help you practice
your skills in performing key procedures.
Chapter Summary: Once you have completed each chapter, take time to read and review the
summary table. It has been correlated to key concepts and learning outcomes within each chapter and
includes handy page number references.
Chapter Review: Complete the chapter review questions, which are presented in a variety of
formats. These questions help you understand the content presented in each chapter. Chapters page xvi
4, 11, and 12 also include Procedures Checklists for you to use to practice and apply your
knowledge.

Features of Connect
Here is what you can expect to find in Connect for Electrocardiography for Healthcare Professionals:
A variety of question types, including Strip Exercises and Practice Exam Questions, that can be
used for homework, quizzes, or tests
Smartbook: An adaptive reading experience that personalizes learning
Health Professions Virtual Labs: Simulated labs that help students learn practical and conceptual
lab skills
Application-Based Activities: Simulated real-life scenarios and animation activities that allow
students to apply knowledge and problem solve

page xvii
Resources

Additional Instructor Resources

Instructor’s Manual with course overview, lesson plans, answers to Checkpoint and End-of-Chapter
Review questions, competency correlations, sample syllabi, and more.
PowerPoint Presentations for each chapter, containing teaching notes correlated to learning
outcomes. Each presentation seeks to reinforce key concepts and provide an additional visual aid for
students.
Transition Guide with a chapter-by-chapter breakdown of how the content has been revised between
editions. The guide is helpful if you are currently using Electrocardiography for Healthcare
Professionals and moving to the new edition.
Instructor Asset Map to help you find the teaching material you need. These online chapter tables are
organized by Learning Outcomes and allow you to find instructor notes, PowerPoint slides, and even
test bank suggestions with ease! The Asset Map is a completely integrated tool designed to help you
plan and instruct your courses efficiently and comprehensively. It labels and organizes course material
for use in a multitude of learning applications.
Competency Correlations provide a correlation structure that enhances the product’s usefulness to
both students and instructors. We have been careful to ensure that the text and digital products provide
coverage of topics crucial to all of the following:
Commission on Accreditation of Allied Health Programs (CAAHEP)
Accrediting Buraus of Health Education Schools (ABHES)
Cardiography Credentialing International (CCI): Certified Cardiographic Technician (CCT) and
Certified Rhythm Analysis Technician (CRAT)
National Center for Competency Testing: ECG Technician (NCET)
National Healthcareer Association: Certified EKG Technician (CET)
Appendix F provides all of the Competency Checklists from the textbook in one handy document.
All of these helpful materials can be found within your Connect course within the Library, under the
Instructor Resources.
 page xviii

Instructors
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Rooted in advanced learning science principles, SmartBook 2.0 delivers each student a
personalized experience, focusing students on their learning gaps, ensuring that the time they
spend studying is time well-spent.mheducation.com/highered/connect/smartbook
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Make technology work for you with LMS integration for single sign-on access, mobile
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more information.

Solutions for your challenges

A product isn’t a solution. Real solutions are affordable, reliable, and come with training
and ongoing support when you need it and how you want it. Visit
supportateverystep.com for videos and resources both you and your students can use
throughout the term.

page xix

Students
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more information.
 page xx

Acknowledgments

Authors
Kathryn Booth: Thanks to all the reviewers who spent time helping to make sure this sixth edition is up-
to-date. In addition, I would like to acknowledge everyone at McGraw-Hill who helped with this edition:
Michelle Vogler, Portfolio Director; Marah Bellegarde, Portfolio Manager; Krystal Faust, Senior Product
Developer; Jeni McAtee and Brent dela Cruz, Content Project Managers; Gina Oberbroeckling, Content
Licensing Specialist; and Tamara Hodge, Marketing Manager. Special thanks to Beth Baugh, Freelance
Product Developer, for getting us through the initial step with patience. Additionally, I would like to
acknowledge Patricia Dei Tos and the members of the Inova Health system, who help to create and
support the original development of this textbook. For the sixth edition, I also want to thank Kathy
Hellums and Lisha Smith for their knowledge and excellent reviews. Last but not least I would also like
to thank my co-author, Thomas O’Brien, for his continued dedication and timely support for the project.
Thomas E. Davidson-O’Brien: I would like to acknowledge Mr. David Rubin, president & CEO of
Aerotel Medical Systems (1998) Ltd., 5 Hazoref St., Holon 58856, Israel. I would like to express my
sincere appreciation to a pair of former students and Central Florida Institute graduates: Rebecca Walton,
CCT, for her contribution of Interpret-Tips and Jamie Merritt, CCT, for “bunny branch block.” I would
also like to extend a special thank you to a Remington College graduate, Tayshaun Gary for offering to be
my model for the 12-Lead ECG image in this edition. I would also like to give a special thank you to the
staff members of the Non-Invasive Cardiology Departments at the Pepin Heart Hospital, Morton Plant
Hospital, All Children’s Hospital, and Palms of Pasadena Hospital for their inputs and generous donation
of their time and expertise.
Additionally, I would like to thank my co-workers and the leadership at Remington College,
especially my Program Directors Dr. Jessalyn Ludley and Dr. Rose Van Alstine for their continued
support in enhancing the training for our students and esteemed colleague Mr. Davy Hobson. A special
thank you to Mr. John Michael Maloney, RCIS (RIP), and Mrs. Kathy Hellums, RCS, for their
contributions of support and expertise without reservation.
Finally, a very special thank you to my son Rob for his hours devoted to scanning many of the cardiac
rhythms and my daughter Kat for proofing my authored works in this text.

page xxi

Sixth Edition Reviewers

Celeste Dator, RMA, ADN
Las Vegas College
Danny Opperman, AAS (AHS), AAS (PS), AAS (EMS), BS
Rowan College at Burlington County
Barbara Pape, CMA, CET, CPT
Tidewater Medical Training
Krista Rodgers, MS, BS, BLS, ECG, RMA (AMT)
ECPI University
Greg Russell, AAS
Front Range Community College
Maria Sgambati, MD
Hillsborough Community College
Carlos Vargas, MS
Monroe College
Suzanne Wambold, RN, PhD
The University of Toledo
Barb Westrick, CMA (AAMA), CPC, CET, CPT, CPCT, CHUC, PTTC, MCBC, AAS
St. Clair County Community College
page xxii
 page 1

1 Electrocardiography

Learning Outcomes
1.1 Describe the history and the importance of the ECG.
1.2 Identify the uses of an ECG and career opportunities for an electrocardiographer.
1.3 Troubleshoot legal, ethical, patient education, and communication issues related to the ECG.
1.4 Perform infection control measures required for the ECG.
1.5 Compare basic vital sign measurements related to the ECG.

Key Terms
auscultated blood pressure
automatic external defibrillator (AED)
cardiac output
cardiopulmonary resuscitation (CPR)
cardiovascular disease (CVD)
cardiovascular technologist
Code Blue
coronary artery disease (CAD)
defibrillator
diastolic blood pressure
dysrhythmia
ECG monitor technician
electrocardiogram (ECG)
electrocardiograph
electrocardiograph (ECG) technician
ethics
event monitor
filtering facepiece respirator
healthcare providers
hypertension
hypotension
isolation precautions
law
libel
medical professional liability
myocardial infarction (MI) (heart attack)
personal protective equipment (PPE)
slander
standard precautions
stat
sphygmomanometer
systolic blood pressure
telemedicine
tilt table test
vital signs

page 2

1.1 The ECG and Its History

According to the Centers for Disease Control and Prevention (CDC), the leading cause of death in the
United States every year since 1921 is cardiovascular disease (CVD), or a disease of the heart and
blood vessels. Approximately 659,000 Americans die every year because of coronary artery disease
(CAD), which is narrowing of the arteries of the heart, causing a reduction of blood flow. Unbelievably,
one out of every three American adults has some form of CAD. You may know someone who has a heart
condition. Maybe someone you know has had a myocardial infarction (MI) or heart attack.

cardiovascular disease (CVD) Disease related to the heart and blood vessels (veins and
arteries).
coronary artery disease (CAD) Narrowing of the arteries of the heart, causing a reduction
of blood flow.
myocardial infarction (MI) (heart attack) Occlusion (blockage) of one or more of the
coronary arteries causing lack of oxygen to the heart and death of the muscle tissue.
An electrocardiograph is an instrument that allows the heart’s electrical activity to be recorded and
studied. It is used to produce an electrical (electro) tracing (graph) of the heart (cardio). This
representative tracing of the electricity as it moves through the heart is known as an electrocardiogram
(ECG).

electrocardiograph An instrument used to record the electrical activity of the heart.

electrocardiogram (ECG) A tracing of the heart’s electrical activity recorded by an
electrocardiograph.
Willem Einthoven (1860–1927) invented the first electrocardiograph, sometimes referred to as EKG
(electro), Kardio (Greek for heart) gram (recording). There is no difference between an ECG and an
EKG. ECG stands for electrocardiogram, and EKG is the German spelling for elektrokardiographie,
which is the word electrocardiogram translated into the German language. An ECG (EKG) is a test that
measures the electrical activity of the heart. An ECG may also be called a 12-lead ECG or a 12-lead
EKG.
Advancements in this technology have brought about today’s modern ECG machines (see Figure 1-1).
Technology continues to improve the availability and speed of computer interpretation and quickly
communicates this information to a healthcare professional. Digital communication allows page 3
healthcare professionals to monitor patients from locations hundreds or even thousands of
miles away.

Figure 1-1 Today’s 12-lead ECG machine is attached to the patient’s chest, arms, and legs using electrodes and lead wires. It
records a tracing of the electrical activity of the heart.

Jim Varney/Science Source

 Performing the actual ECG procedure is not difficult; however, it must be performed competently. The
tracing of the electrical current of the heart must be accurate because it is used to make decisions about a
patient’s care. An inaccurate tracing could result in a wrong decision about the patient’s medication or
treatment. These decisions could result in a negative outcome for the patient.

Checkpoint Questions (LO 1.1)

1. What is the leading cause of death in the United States?

2. Who invented the first electrocardiograph?

1.2 Uses of an ECG

Healthcare providers study the ECG tracing to determine many things about the patient’s heart. They look
for abnormalities in the recording and changes from earlier recordings when available. The American
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imperfect contrivance. The ancient monarchy never seems to have
made use of flat signets. The impression of one has been sought for
in vain on those contracts of the time of Hammourabi, where so
many cylinders have left their mark. The oldest document on which
the trace of a circular seal has been recognized belongs to the
northern kingdom, and dates from the reign of Bin-Nirari, who
occupied the throne of Assyria towards the end of the ninth century
B.C. From this moment the use of the cone becomes rapidly
common. Under the Sargonids, and still more during the second
Chaldee monarchy and under the Achæmenids, it superseded the
cylinder. The dates inscribed on the tablets prove their age; the
space on the cones themselves was too narrow, as a rule, for a
legend. On a few specimens we find one or two characters
engraved, generally a divine monogram or the traditional emblems of
the sidereal powers. A few cones have inscriptions in Aramaic
characters (see Fig. 157); on the example figured we again
encounter the strange composite beast we have already seen upon
a stone tablet and a cylinder (Figs. 87 and 141). In spite of the
alphabet employed, this cone must have been engraved either in
Nineveh or its neighbourhood.
The narrowness of the field explains the want of variety in the
subjects. In a small circle like this there was no room for more than a
single figure with a few accessories, or, at most, for two figures. We
cannot expect to find scenes as varied and complicated as those
upon the cylinders. A very small number of the simplest themes
formed the stock-in-trade of the engraver.
There are about four hundred specimens in the British Museum,
and as many more in Paris, in the Louvre and the Cabinet des
Antiques. In the presence of them all we can only confess to a
feeling of embarrassment. They are never arranged in chronological
order; Assyrian intaglios are mixed up with those from Chaldæa,
from Phœnicia and Persia. Certain types were reproduced and
copied in this region even as late as the Arsacids and Sassanids.
We shall choose a few, however, which we may with some certainty
attribute to Assyria. There is in the first place one on which two
winged figures seem to be adorning the sacred tree (Fig. 158). We
find the impression of an almost exactly similar cone on a contract
dated 650 B.C. The only differences lie in the more careful execution
of the latter seal and in the substitution of the radiant disk of the sun
for the crescent moon.[331] In another impression we find the radiant
disk changed into the winged globe.[332] The shape and fringe of the
Assyrian robe may be recognized in the intaglio in which a man with
long hair and beard does homage to a winged genius (Fig. 159). The
worshipper is standing, but behind him appears a kneeling figure.
This posture is rare, but it is met with in a few instances on
monuments from this period, and is always used to suggest the
profound respect with which a man does obeisance either to his god
or his king.[333]
We need not hesitate to ascribe to the second Chaldæan
monarchy a cone with a bearded individual standing before an altar
on which lies a fantastic animal (Fig. 160); above his head appear
the sun, the moon, and a star. We have already mentioned two
examples of this theme, which begins to appear in the time of
Nebuchadnezzar and remains in fashion until the Macedonian
conquest.[334]

Fig. 159.—Amethyst cone.

National Library, Paris.[335]
 Fig. 160.—Agate cone. National
Library, Paris.[336]
Among the themes in most frequent use under the Sargonids we
might have quoted the single combat of the king with a lion, the god
standing upon a lion’s back, the king over whose head a servant
holds an umbrella, the heads and bodies of different animals, and
others.[337] We cannot pretend, however, to enumerate them all. It is
sufficient to show, as we have done, that after the ninth century at
latest both cylinders and cones were produced in the same
workshops, and that the differences in their figuration are to be
explained by the dimensions and form of the new surface. Those
who have supposed that the use of flat seals only commenced under
the Achæmenids are mistaken. All that we can say with truth is that
intaglios cut upon sections of cones, spheres and pyramids are less
ancient than the cylinders of Ur, Erech, Accad and Sippara.
This is proved by the dated contracts to which we have already
so often had to refer; but supposing no such contracts to have been
in existence we could have arrived at the same conclusion by
another path. Cones in calcareous stone, in marble, or even in pietra
dura are either wanting altogether, or very few and far between; they
are almost all in precious stones, most of them in carnelian and
chalcedony. Sapphirine chalcedony, with its fine bluish tint, seems to
have been most in favour.
In Egypt we found intaglios upon metal as well as upon lapidary
substances.[338] This use of metal was a result of mounting seals in
circles of gold or silver. Precious stones were rare and difficult to cut;
what could be more natural than to substitute metal for them and to
make the bezel of a ring of the same material as its hoop. For its
engraving neither lathe nor diamond dust was wanted; the burin
alone was necessary, and the figures cut by it gave a result no less
satisfactory than those obtained by the slower process and in the
more stubborn material. The temptation was great for the Egyptian
artist, and we are not surprised that he succumbed to it, but it did not
exist for the Chaldæan engraver. The latter had only to deliver a
stone which his client could wear fastened to his wrist, or hung round
his neck by a cord. He had no direct and intimate relations with the
worker in metal; he was not compelled to call in the latter to mount
his creation. Sometimes, under the influence perhaps of foreign
models, he may have attempted to substitute metal for stone, but
isolated attempts did not make a school. We can point to only one
example of such work. The British Museum possesses a silver
cylinder, but the only interesting thing about it is its material.[339] The
composition of the type is naive and its execution rough. All this
allows us to believe that metal seals were very rare and never came
into general use.
Oriental artists, at least during the period of which we are now
speaking, hardly ever practised any kind of gem-cutting but intaglio,
but there are two stones in existence in which first attempts at a
process that must have led in time to the production of cameos, may
be traced. “In one of these gems, an onyx, the upper layer is cut
away from the one below it and an inscription left. In the other the
eyes and neck of a serpent are rendered with the aid of three
different tints in the stone.”[340]

§ 9. The General Characteristics of Chaldæo-Assyrian Sculpture.

We have now reached the end of our inquiry into the history of
Mesopotamian sculpture—an inquiry that we have endeavoured to
make as complete as the existing remains would allow. So far as
Chaldæa is concerned, these are very few in number. On the other
hand, the three centuries over which the Assyrian power extended
are pictured in such a vast number of reliefs that we are
embarrassed by their number as much as by their want of variety.
Our difficulty in the case of Assyria has been to make a selection
from a vast quantity of objects that tell us the same thing again and
again, while, in the case of Chaldæa, it has been to insure that none
of the scanty salvage from so great a wreck should be lost. We have
more than once had to make induction and conjecture take the place
of examination and assertion before we could complete even a
rough sketch of the development of Chaldæan art.
There is one question that must have been asked by many of our
readers before these pages came in their way, but is now, we
venture to hope, fully answered, and that is, whether the Semites of
Chaldæa drew their first inspiration from a foreign source, or whether
it was an original result from the natural aptitudes of the race.
Ancient as civilization may have been in the Euphrates valley, it was
still more ancient, to all appearance, in the valley of the Nile. And yet
all who have examined the figures we have placed before them must
acknowledge the originality and independence of Chaldæan art. No;
the sculptors of Memphis and Thebes were not the masters of those
of Babylon and Nineveh; they preceded them indeed, but they left
them no teaching and no models to copy.
This is proved in the first place by the difference, we might say
the opposition, between the two styles. The Egyptian sculptor
simplifies, abridges, and summarizes form; the Assyrian amplifies it
and accents its details. The former seems to see the human body
through a veil of gauze, which hides the accidents of the surface and
the secondary forms, allowing nothing to be clearly grasped but the
contour and the great leading lines. One would say that the second
studied nature through a magnifying-glass; he insists upon what the
first slurs over.
This is not the only difference between the two methods and the
two interpretations. The Egyptian artist can seize the character of a
movement with much justice and vivacity, but he endeavours to
ennoble it by giving it a general and typical value. This he does, for
example, in the gesture of the king who brandishes his mace or
sword over the head of his conquered enemy while he holds him by
the hair with his other hand.[341]
 He thinks more about elegance in arranging the posture of his
figures; look, for instance, at the men and women carrying offerings,
at the dancers and musicians who abound in the reliefs and pictures.
His favourite attitude, however, is one expressive of force in repose.
We cannot deny that in his figures in the round the Mesopotamian
sculptor showed the same predilection, but his choice was
suggested, or rather imposed, by the resistance of the materials he
employed and the necessity of avoiding certain executive difficulties
over which he could not triumph. We can hardly see how he could
have given his figures more animation or have better expressed the
freedom of their limbs and the swing of their bodies; the stones he
used were either too hard or too soft, and he was without the needful
skill in the management of his tools.
It is in the reliefs, where he is more at his ease, that he allows us
to see whither his natural inclinations would lead him. They contain
hardly any seated figures. Man is there always on his feet and in
action. Movement, to interest the Mesopotamian artist, need not be
the expression of an idea, or the cause of graceful lines. It pleases
him for its own sake by its freedom and unexpectedness, I am
almost tempted to say, by its violence.
This feeling is visible chiefly in the battle pictures and hunting
scenes. In these, no doubt, the drawing of limbs, &c., often leaves
much to be desired. The hand has been unable to render all that the
eye has seen. The unveiled human body has not been displayed
often enough to the sculptor for him to know thoroughly the
construction of its framework and the mode of attachment of its
limbs. On the other hand, when animals have to be treated, with
what singular power and complete success the same artist has often
represented the tension of the contracting muscles, the speed of the
horse as he stretches himself in the gallop, the spring of the lion as
he throws himself upon the spear (see Fig. 161), and, finally, the
trembling of the flesh in the last struggle against suffering and death!
It is in the Assyrian monuments that these things are treated with the
greatest success. A people of soldiers and hunters, whose truculent
energy gave them the empire of all western Asia, they had neither
the mild humour nor the fine taste of the Egyptians, they were less
easily moved, and we find ourselves wondering that they never hit
upon the fights of gladiators as a national pastime. They were
touched and interested by force passing from repose into action, by
force putting forth all its energies in contempt of danger and in spite
of the most determined resistance.

Fig. 161.—Assurbanipal attacked by lions. British Museum.

Drawn by Saint-Elme Gautier.
 The temperaments of the two nations were, then, vastly different,
and by the time their mutual relations became close and continuous,
each had thought too much, had worked too much, and created too
much for itself to be in any great danger of losing its originality under
the influence of the other. Moreover, the two civilizations never
penetrated within one another. Their moments of contact were short
and superficial. Under the great Theban conquerors of the
eighteenth dynasty, the Egyptian armies advanced to the Euphrates,
and the princes of Mesopotamia may, for a time, have recognized
the suzerainty of the Pharaohs; this is proved to some extent by the
numerous scarabs engraved with the name of Thothmes III., which
have been found in the valley of the Khabour,[342] but after the
nineteenth dynasty their hold upon these distant conquests must
have been lost. Their access to them was barred by the Khetas, in
Syria, and, a few centuries later, it was the Sargonids who invaded
Egypt and admired its monuments so much that they carried some of
them away, such as the lion found at Bagdad. It bears the oval of a
Pharaoh who is believed to be one of the shepherd kings.[343] In the
interval the importation of objects of luxury, which was carried on
through the Phœnicians, had introduced a few foreign motives into
the repertory of the Assyrian artists, such as the crouching sphinx
and the lotus flower; the winged globe may also be Egyptian; but
these borrowings never go beyond details; even if they were far
more numerous than they are, they would not deprive the sculpture
of the Mesopotamian Semites of its right to be considered an
independent and autonomous form of art, whose merits and defects
are to be explained by the inborn genius of the race, by its manner
and beliefs, by the natural conditions of its home, and the qualities of
the different materials employed.[344]
It is in the same order of ideas that we must seek a reason for the
differences we have remarked between the art of the early
Chaldæan monarchy as it has been revealed to us in the
monuments recently discovered, and Assyrian art as we have known
it ever since the explorations at Khorsabad, Nimroud, and
Kouyundjik. In all this there is a most interesting question for the
study of the historian. Of what nature was the bond by which the
sculptors of Calah and Nineveh were allied to those who had
chiselled the Sirtella statues, perhaps a thousand years before?
What place does the brilliant and prolific art of Assyria occupy in the
series of phases whose succession was governed by the laws that
have presided over the development of human societies in every age
and place? Until within the last few months we should have found it
difficult to give a satisfactory answer to this question. Assyrian art
offered contradictory features to the observer, and it was not easy to
understand how, with so lively a feeling for form, and especially for
movement, it could have admitted so much conventionality and
repeated itself with so much insistence and prolixity. The
combination of skill and awkwardness, of energy and platitude, was
more than surprising. But the problem resolves itself as soon as we
go back to the art of Chaldæa, the first-born of the two sister nations,
and the pioneer of Mesopotamian civilization.
Assyrian art, even in its most ancient productions, was not, as we
once believed, a primitive or even an archaic art; neither was it what
we call a classic art, an art employing the skill it has acquired for the
renewed study of nature and the sincere imitation of its beauties. We
shall not call it a debased art or an art in its decadence; to do so
would be to exaggerate our meaning; but it was an art no longer in
its progress, an art that, for the sake of rapid and ample production,
made use of conventional formulæ invented by deceased masters
and handed down by tradition.
Perhaps we may give a clearer notion of what we mean by a
comparison.
Under all the reserves implied by such collations, we should say
that Chaldæan art was to that of Assyria what the Greek art of
Phidias, Praxiteles, and Lysippus was to the Alexandrian and
Græco-Roman art which we now call Hellenistic. In the studios of
Nineveh, as in those of Pergamus, of Rhodes, of Antioch, of Rome,
great activity, great skill, and no little science were to be found; even
originality was sought for, but it was sought rather than won. Thus
we find in Macedonian and Roman Greece, here a school drawing
attention by audacious and perhaps theatrical execution, there
another devoting its skill to pathetic subjects, and attempting to
render physical agony by contracted muscles. So it is in Assyria. The
ease with which alabaster and soft limestone could be cut allowed
the artists who worked for Assurnazirpal to give to the ornamentation
of the rich stuffs they figured a delicacy and refinement that were
impossible in the stubborn stones of Chaldæa. Two centuries later
the sculptors of Assurbanipal sought a new element of success in
the complication of their scenes, in the grace of their execution, in
the picturesque details of their landscape backgrounds, in the
increased slenderness of their figures, and in a certain elegance
spread over their compositions as a whole.
It is certain that neither the Greek of the later centuries nor the
Assyrian invented and created in the proper sense of the word. The
Greek sculptor, thanks to a deeper comprehension of the true
conditions of art and to the necessity under which he laboured of
reproducing the nude, certainly did not remit his care for modelling,
but he looked at the contours and the significance of the human
body rather with the eyes of his masters and predecessors than with
his own. It was to those masters that he was indebted for his
propensity to see one set of features rather than another, and to give
that interpretation to form that, taken altogether, constitutes the
Greek style.
The Assyrian sculptor was in much the same case, but as his
figures were draped, almost without exception, it was much easier
for him to put nature aside altogether and to fall into manner and
routine. It is only when he has to represent animals that he seems to
work from the living model. The human body, hidden under its long
and heavy robes, did not discover enough to awake his interest; all
that he sees—the features and the profile of the face, the throat, the
lower parts of the arms and legs—he treats after the examples left to
him by his Chaldæan leader. In the whole of Assyrian sculpture there
is no passage studied from nature with faith and sincerity, like the
hand, the shoulder, and the back in the statues of Gudea. The
Chaldæan sculptor had a taste for strong modelling, and in this his
Assyrian pupil copied him with such an excess of zeal that he arrived
at exaggeration and pure convention. He knotted the knees of his
figures, he gave them knee-caps standing out like huge bosses, and
muscles so stretched and salient that they look like cables rather
than flesh and blood. It is an early edition of what is now an old story.
The master is betrayed by the pupil, who copies his mannerisms
rather than his beauties and turns many of his fine qualities into
defects.
We may now see how much the Chaldæan excavations and the
collection which the Louvre owes to M. de Sarzec are calculated to
teach the historian of art. These discoveries, by their intrinsic
importance and by the light they have thrown on the origin of a great
civilization, may almost be compared to those of Lepsius and
Mariette, to the systematic researches and happy finds that have
revealed the Egypt of the ancient empire to us. Assyrian art is no
longer a puzzling phenomenon. Like the Egyptian art of the Theban
epoch, it was preceded by a realistic and naturalistic, an inquisitive,
simple-minded, and single-hearted art, which had faithfully studied
the human form and had thus created one of the original styles of
antiquity, a style, perhaps, in which Greece at its first beginning
found the most useful lessons and the most fertile suggestions.
As we have already confessed, we can form but a very imperfect
notion of what the art of Chaldæa was in its best days, in its period of
youth and freshness. The remains are few and small; they are heads
separated from the bodies to which they once belonged, chips from
broken reliefs and a few small bronze and terra-cotta statuettes.
Even supposing that new discoveries come to fill up the gaps, so
that the development of Chaldæo-Assyrian art may be embraced as
a whole, even then it would, we believe, be interior to that of Egypt.
No doubt it possesses certain qualities not to be found in the latter.
The statues from Tello have a freedom and vigour of modelling in
certain parts that can hardly be prized too highly, and the Memphite
artist never chiselled anything so full of intense life and movement as
the animals at Kouyundjik; but without again referring to faults
already treated at length we may say that the supreme defect of
Mesopotamian sculpture is its want of variety.
It is a powerful but monotonous art. For each class of figures it
had but one mould. It seems never to have suspected how unlike
men are to each other when they are looked at closely; we are
tempted to believe that it never made a portrait in the true sense of
the word. It held through many centuries to the general and abstract
types created at first, and repeated them with a constancy that
inevitably causes some weariness in the spectator. It also committed
the mistake of spreading a single colour, speaking metaphorically,
over all its pictures; as a musician would say, all its compositions
were in the same key; it was always serious; it did not understand
how to laugh or unbend. In the elaboration of its demons it certainly
cast about for as much ugliness as it could find, but that was to
frighten and not to amuse. In all the remains of Assyrian art there is
no trace of playful humour, of the light-hearted gaiety that is so
conspicuous in more than one Egyptian monument. In the
subordinate parts of some of the reliefs from the Sargonid period we
find certain groups and scenes belonging to what we should call
genre, but neither here, nor in the bronzes, nor in engraved gems,
nor even in the terra-cottas, do we find anything that approaches
caricature. The comic element, without which no representation of
life can be faithful and complete, is entirely wanting.
A final defect of Assyrian art is the almost total absence of
woman from its creations. In Chaldæa we found her in the small
bronzes and in a few clay figures; the canephorus with bare arms
and bust, the nursing goddesses who bear a child in their arms or
who press their breasts with their open hands, will be remembered,
but it would seem that such subjects were treated only in figures of
very small dimensions. In the fragmentary reliefs and statues from
Chaldæa there is nothing to suggest that female forms, either wholly
or partially nude, were either cast or chiselled in anything
approaching life size. Still less were such things made in Assyria,
where no terra-cotta figure even of the deity to whom the names of
Istar, Beltis, Mylitta, and Zarpanitu have all been given, has yet been
found. It was, however, at Kouyundjik that the only nude female torso
yet discovered in Mesopotamia was dug up. It bears the name
Assurbilkala, and is now, as we have said above, in the British
Museum.[345] Among the ivories, indeed, we find female statuettes in
which we are tempted to recognize the same goddess; but where
were those ivories carved? We have good reason to believe that not
a few are of Phœnician workmanship.
The real national art of Assyria must be sought in the palace
reliefs, and in that long illustrated chronicle of the court, the chase,
and the royal campaigns, woman plays a very subordinate part. It
has been thought that a tall, beardless individual who occurs near
one of the doorways of Assurnazirpal’s palace, in the place generally
reserved for divinities, should be accepted as a goddess (Fig. 162).
[346] She is winged, and her hair is gathered together at the back of
the neck, one long knotted and tasselled tress falling nearly to her
loins. Her right arm is raised, her left lowered; in her left hand she
holds a small wreath or garland. A wide girdle at the waist confines a
long robe falling to the feet, and a fringed and flounced mantle.
Nothing is seen through this drapery, such as amplitude of bosom or
hips, to suggest the female sex, while the jewels that may be noticed
on the neck and wrists and in the ears are also to be found on
figures that are certainly male. In fact there is nothing to suggest a
woman but the arrangement of the hair and a certain unwonted
refinement in the execution of the features. And it is only by external
signs like these, by the pose and the costume, that the few women in
the bas-reliefs are to be recognized. This observation holds good for
the queen of Assurbanipal as well as for the musicians who
celebrate his victories and the captives led into slavery by the
Assyrian armies.
 Fig. 162.—Figure of a goddess. British
Museum. Drawn by Wallet.
We can hardly say then that woman had any place in Assyrian
art; she was represented, if at all, only by her robes. In the long
series of reliefs you find none of the charming variety given to
Egyptian art by the slender forms of goddesses, queens, dancers,
and players on the mandolin, who crowd the pictures and allow the
graceful contours of their youthful bodies to be seen through their
transparent robes. In spite, then, of all its merits, the art of the
Assyrian sculptor is far from complete. His neglect of the soft
nobleness inherent in the beauty of woman deprived him of a
precious resource; his works are without the telling contrasts that
nature has set up between the forms of man and those of his mate.
We have endeavoured to do him justice; we have sought to put in full
light the merits by which he attracts our admiration, but we cannot
help seeing that he lacks something that we have found in Egypt and
shall find again in Greece; he is without the charm of grace and light.
 CHAPTER III.
PAINTING.

In the inventory we are compiling of the various methods used by

the Semites of Mesopotamia to address the intellect through the
eyes, we shall consecrate a chapter to painting for form’s sake. The
kind of representation we call by that name was no more known to
the Assyrians and Chaldæans than it was to the Egyptians.[347] They
loved brilliant colours, but they only made use of them for what was,
in fact, illumination; they coloured figures and ornaments, but they
never painted, as the word is understood in all modern languages.
In our endeavours to explain how the Mesopotamian architect
disguised, under a robe of gay tints, the poverty of the materials with
which he was forced to work, we showed that he employed colour in
two different ways, according to the place occupied in the building by
the wall he had to cover.[348] In the interiors of rooms he was, in
most cases, satisfied with spreading upon the plaster a coat of some
pigment that could be easily renewed when it began to fade; but in
those parts of the building that were exposed to the weather, and
even in some rooms that were the objects of particular care, he had
recourse to the solidity of enamel. We have pointed out the favourite
motives both in the distemper paintings and in the kind of mosaic
given by the glazed or enamelled bricks; we have yet to say what
tints the enameller used and how he used them. Our coloured plates
will give a better idea of this decoration than we can give in words
(Plates XIII., XIV., and XV.).[349]
In the carpets still woven in Asia Minor, Kurdistan, Khorassan and
Persia there are colours at once brilliant and soft that are a constant
delight to the eye of the connoisseur. We may point, for instance, to
certain reds and greens at which the manufacturers of Europe gaze
in despair, in spite of the resources of modern chemistry. This
freshness and solidity of tint is explained by the almost exclusive use
of vegetable dyes. These the Kurd or Turkoman extracts from
mountain plants, sometimes from the stem or the root, sometimes
from the blossom or the seed.[350] These inventions and recipes
have been handed down from generation to generation through
many ages; the secret of many dyes must have been discovered
long before the fall of Nineveh or the beginning of the Babylonian
decadence. Down to the very last days of antiquity the dyers of
Mesopotamia were famous for their processes and the harmonious
splendour of their colours. Since the days of Nebuchadnezzar the
people of that region have forgotten much, while they have learnt
nothing, perhaps, but how to hasten the depopulation of their country
by the use of gunpowder. All the professional skill and creative
activity of which they still can boast they owe to the survival of this
ancient industry, whose traditions and practical methods are
preserved in the hut of the mountaineer, under the tent of the nomad,
and in those bazaars where so many agile weavers repeat, with
marvellous rapidity of hand and sureness of eye, the designs and
motives of thirty or forty centuries ago.
Among the colouring materials still in use in the woollen fabrics of
the Levant there can be very few with which the ancients were not
acquainted, and perhaps they used some of them in their distemper
paintings; but the latter were no more than feeble shadows when
discovered, and they soon vanished when exposed to the air. It was
different with those that had been subjected to the action of fire.
They could be removed and analyzed. But the enameller confined
himself almost exclusively to mineral colours, of which alone we can
now describe the composition.
The two colours most frequently used were blue and yellow.
Backgrounds were nearly always blue (Plates XIII. and XV.), and
most of the figures yellow. Certain details were reinforced by touches
of black and white. In the brick representing the king followed by his
servants (Plate XIV., Fig. 1), the royal tiara is white, the hair, beards,
bows, and sandals are black. Red only appears in a few ornamental
details (Ibid., Fig. 2). Green is still more rare. It has been found at
Khorsabad. In a fragment of painting upon stucco it affords the
ground against which the figures are relieved;[351] and in the
enamelled brick decoration on the harem wall (Vol. I., Fig. 101), it is
used for the foliage of a tree that looks at first sight like an orange
tree; its leaves however are rather those of an apple (see Plate XV.,
Fig. 3).
According to Sir H. Layard, the blue which was spread in such
great quantities on the enamelled bricks was given by an oxide of
copper mixed with a little lead, the latter metal being introduced in
order to render the mixture more fusible.[352] This analysis applies
only to the bricks of Nimroud. In the Sargonid period another
process, borrowed, perhaps, from Egypt, seems to have been
employed. Place tells us that in the course of his excavations he
found two blocks of colour in one of the offices at Khorsabad. One of
these blocks, weighing some two pounds and a little over, was blue.
An artist was at the time engaged in copying in water-colours the
decoration of one of the walls covered with enamelled bricks. In
order to get as near as possible to the tint of the original the notion
occurred to him to make use of the Assyrian blue. But the latter was
stubborn and would not mix; it left a vitreous deposit at the bottom of
the cup. At first it was supposed that its long sojourn in the earth had
deprived it of some of its qualities, but later analysis explained the
difficulty in a more satisfactory manner. Its unfitness for use as
water-colour was not the result of any alteration. Being intended for
use as a glaze or enamel upon pottery, it was composed of lapis-
lazuli reduced to powder.[353]
PLATE XIII

From Layard Sulpis sc.

ENAMELLED BRICK FROM NIMROUD
British Museum