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Handbook of Cardiac
Electrophysiology
Handbook of Cardiac
Electrophysiology
Second Edition

Edited by
Andrea Natale
Oussama M. Wazni
Kalyanam Shivkumar
Francis E. Marchlinski
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2020 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

International Standard Book Number-13: 978-1-4822-2439-9 (Hardback)

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 CONTENTS

Preface ix
Acknowledgments x
Editors xi
Contributors xiv

SECTION I
Basic EP Laboratory Setup and Equipment

1 DEVICE LAB SET-UP 2

John Lopez and Mina K. Chung

2 ORGANIZATION OF THE ARRHYTHMIA LAB 6

Roy Chung and Oussama M. Wazni

3 HOLTER AND EVENT MONITOR LABORATORY SETUP 13

Roy Chung, Daniel Cantillon, and Mina K. Chung

SECTION II
Bradyarrhythmia

4 BRADYCARDIA 36
Shiv Bagga and Mandeep Bhargava

5 INDICATIONS FOR PERMANENT PACING AND CARDIAC

RESYNCHRONIZATION THERAPY 48
Shiv Bagga, J. David Burkhardt, and Mandeep Bhargava

SECTION III
Supraventricular Tachyarrhythmia

6 ATRIAL FLUTTER 68
Ayman A. Hussein and Oussama M. Wazni

7 ATRIAL FIBRILLATION 81
Rong Bai, Mohamed Salim, Luigi Di Biase, Robert Schweikert, and Walid Saliba

v
 SECTION IV
Ventricular Tachyarrhythmia

8 GENETICALLY DETERMINED VENTRICULAR

ARRHYTHMIAS94
Houman Khakpour and Jason S. Bradfield

9 IDIOPATHIC VENTRICULAR TACHYCARDIA 116

Jackson J. Liang and David S. Frankel

SECTION V
Syncope

10 SYNCOPE EVENTS, DEFINITIONS, CAUSES,

AND FEATURES126
Subramanya Prasad, Oussama M. Wazni, Mina K. Chung, Kenneth Mayuga,
and Robert Schweikert

11 SYNCOPE MANAGEMENT FACILITIES 143

Subramanya Prasad, Robert Schweikert, Mina K. Chung, Kenneth Mayuga,
and Oussama M. Wazni

12 SYNCOPE MANAGEMENT AND DIAGNOSTIC TESTING 150

Subramanya Prasad, Oussama M. Wazni, Robert Schweikert, Kenneth Mayuga,
and Mina K. Chung

SECTION VI
Device Procedures

13 IMPLANTATION OF PACEMAKERS AND ICDs 164

Kushwin Rajamani, Michael P. Brunner, Oussama M. Wazni,
and Bruce L. Wilkoff

14 LEFT VENTRICULAR LEAD IMPLANTATION FOR

CARDIAC RESYNCHRONIZATION THERAPY 172
Kushwin Rajamani, Michael P. Brunner, Oussama M. Wazni,
and Bruce L. Wilkoff

15 EXTRACTION OF DEVICES 182

Oussama M. Wazni and Bruce L. Wilkoff

vi Contents
 SECTION VII
Performing Basic EP Studies

16 VENOUS AND ARTERIAL ACCESS, EP CATHETERS,

POSITIONING OF CATHETERS 190
Ching Chi Keong, J. David Burkhardt, Thomas Dresing, and Andrea Natale

17 BASIC INTRACARDIAC INTERVALS 198

Duc H. Do and Noel G. Boyle

18 BASICS OF ELECTROPHYSIOLOGY STUDY 203

Jonathan R. Hoffman and Marmar Vaseghi

19 HEAD-UP TILT (HUT) TABLE TESTING 212

Subramanya Prasad, Amer Kadri, J. David Burkhardt, Thomas Dresing,
and Kenneth Mayuga

SECTION VIII
Catheter Ablation Techniques

20 ABLATION OF SVT (AVNRT AND AVRT) 224

Kushwin Rajamani and Patrick Tchou

21 MANAGEMENT AND ABLATION OF ATRIAL FLUTTER 238

Carola Gianni, Amin Al-Ahmad, and Andrea Natale

22 RADIOFREQUENCY ABLATION OF ATRIAL FIBRILLATION 261

Jorge Romero, Carola Gianni, Sanghamitra Mohanty, Chintan Trivedi,
Domenico G. Della Rocca, Andrea Natale, and Luigi Di Biase

23 VENTRICULAR ARRHYTHMIAS IN THE STRUCTURALLY

NORMAL HEART 272
Andres Enriquez and Fermin Garcia

24 CATHETER ABLATION OF VENTRICULAR FIBRILLATION

AND POLYMORPHIC VENTRICULAR TACHYCARDIA 289
Amin Al-Ahmad, Carola Gianni, and Andrea Natale

25 MAPPING AND CATHETER ABLATION OF

POSTMYOCARDIAL INFARCTION VENTRICULAR
TACHYCARDIA (VT): A SUBSTRATE-BASED APPROACH 300
Zaid Aziz and Roderick Tung

Contents vii
26 ARRHYTHMOGENIC RIGHT VENTRICULAR
CARDIOMYOPATHY 316
Daniele Muser and Pasquale Santangeli

27 NON-ISCHEMIC CARDIOMYOPATHY AND

VENTRICULAR ARRHYTHMIAS 335
Matthew C. Hyman and Gregory E. Supple

28 ULTRASOUND IN THE ELECTROPHYSIOLOGY LAB 352

Carola Gianni, Javier E. Sanchez, Domenico G. Della Rocca, Amin Al-Ahmad,
and Andrea Natale

29 LEFT ATRIAL APPENDAGE CLOSURE 364

Rodney P. Horton, Carola Gianni, and Andrea Natale

30 ECG FEATURES OF NORMAL HEART PVCs 385

Robert D. Schaller

31 EPICARDIAL ACCESS AND INDICATIONS 404

Jason S. Bradfield and Kalyanam Shivkumar

32 ECG-BASED ORIGIN OF ATRIAL FLUTTER 415

Decebal Gabriel Laţcu, Nadir Saoudi, and Francis E. Marchlinski

INDEX 431

viii Contents
 PREFACE

This issue of the Handbook of Electrophysiology is a quick reference for EP fellows, allied
health professionals, and electrophysiologists on the state-of-the-art management of rhythm
disorders including discussions on how to set up an arrhythmia lab, different aspects of
the catheter ablation procedure for atrial and ventricular arrhythmia, techniques of device
implantation and lead extraction, and diagnostic testing and management of syncope.
The current edition also addresses the different aspects of ECG-based origin of atrial flutter,
indications for epicardial access, and ECG characteristics of normal heart PVCs. Lastly, the
handbook details on the indications, techniques, and benefits of left atrial appendage closure.
It was our privilege to have a team of world-renowned experts contributing the latest infor-
mation on the entire spectrum of EP knowledge in this handbook. We are confident that this
handbook will not only be relevant to all clinicians and allied health professionals involved
in the management of cardiac arrhythmia, but also will provide the readers an appreciation
of the complexity of procedures that are performed every day in the electrophysiology labs.

ix
 ACKNOWLEDGMENTS

I wish to thank all the authors and staff that worked very hard to make this book possible.
Additionally, I would like to thank my dearest wife Marina and daughters (Veronica and
Eleanora) for supporting me in all my professional endeavors.
Dr. Andrea Natale

x
 EDITORS

Dr. Andrea Nataleis the Executive Medical Director of

Texas Cardiac Arrhythmia Institute at St. David’s Medical
Center, Austin, Texas, and the EP National Medical Director
for HCA Healthcare. A dedicated researcher and pioneer,
Dr. Natale focuses on innovative advances in the treatment of
atrial and ventricular arrhythmia. He perfected a circumfer-
ential ultrasound pulmonary vein-ablation system to correct
atrial fibrillation and performed the procedure on the world’s
first five patients. He also developed some of the current
­catheter-based cures for atrial fibrillation, and was the first
cardiac electrophysiologist in the nation to perform percuta-
neous epicardial radiofrequency ablation, which is a treat-
ment for people who fail conventional ablation.
A very prolific author and speaker, he is the Editor-in-Chief
of JICE and remains a leader of JAFIB, President of Venice Arrhythmia, and Director of
several courses and summits. EP Live is one of the many pioneering accomplishments of
Dr. Natale’s passionate mission to train and educate: every two years, a 2-day intensive edu-
cational meeting is conducted under his direct guidance and supervision, where health care
providers benefit from first-hand information on the recent advancements in arrhythmia
treatment and research as well as get the opportunity to interact with authorities in elec-
trophysiology. His EP Live concept was so well received by the electrophysiologists around
the world that it is now extended to several countries outside USA, i.e., EPLATAM (Latin
America), EP Live Europe, EP Live Dubai, and EP Live India.
Dr. Natale’s greatest reward is restoring his patients to a life free of cardiac arrhythmia.
In his own words, “I give all of myself to make sure my patient’s heart does what it’s sup-
posed to do.”

Dr. Oussama M. Wazniis currently the Section Head of

Electrophysiology at the Cleveland Clinic. He specializes
in electrophysiology with special interest in atrial
­fibrillation, ventricular tachycardia, and complex device
management.
Dr. Wazni is principal investigator in several ongoing
research studies related to device management, atrial
fibrillation and ventricular tachycardia ablation, genetics
of ventricular tachycardia, and long-term follow-up after
AF ablation.

xi
 Dr. Kalyanam Shivkumaris a physician scientist who
serves as the director of the UCLA Cardiac Arrhythmia
Center & EP Programs (since its establishment in
2002). He is a graduate of the UCLA STAR Program
(class of 2000) and his field of specialization is inter-
ventional cardiac electrophysiology. He leads a large
group at UCLA (comprising a diverse group of fifteen
faculty members, several trainees, and sixty staff +
allied health professionals) involved in clinical care,
teaching, research, and biomedical innovation.
The team provides state of the art clinical care, has
developed several innovative therapies (e.g., epicardial
ablation, neuromodulation) for the non-­pharmacological
management of cardiac arrhythmias and other cardiac interventions. The team has a major
focus on mechanistic research on the neural control of the mammalian heart. Dr. Shivkumar
also serves as the director and chief of the UCLA Cardiovascular Interventional Programs.
Dr. Shivkumar’s research work relates to mechanisms of cardiac arrhythmias in humans
especially the role of the autonomic nervous system and his research work transcends the
perspective of a single organ and has implications for neurovisceral sciences in general.
The UCLA Neurocardiology Research Program of Excellence was established by him as the
specialized research arm of the Arrhythmia Center in 2014. Dr. Shivkumar and his colleagues
are actively involved in human mechanistic studies and development of new intellectual
property and medical technology for cardiovascular therapeutics. His IP has been incorpo-
rated into medical devices that are now FDA approved and in clinical use. He serves as an
editor for several journals in cardiology and cardiac electrophysiology, and is a peer reviewer
for several basic science and clinical journals. He also serves as a peer reviewer for the NIH
in evaluating cardiac arrhythmia and neuroscience research. His research has been sup-
ported by grants from the American Heart Association, the Doris Duke Foundation, private
donors, and from the NIH (continuously since 2006). Currently Dr. Shivkumar oversees a
15-university NIH consortium on neural control of the heart. Dr. Shivkumar has mentored
several STAR awardees and has received several teaching awards. He has been appointed to
serve on the board of examiners for Clinical Cardiac Electrophysiology Section of the ABIM
(American Board of Internal Medicine). He has been elected to the membership of the
American Society of Clinical Investigation (ASCI) and serves as the institutional representa-
tive of UCLA for the ASCI. He was elected as an honorary Fellow of the Royal College of
Physicians (London) in 2016 and President of the ISAN (International Society of Autonomic
Neuroscience) in 2019.

Dr. Francis E. Marchlinskiis the Richard T and Angela Clark

President’s Distinguished Professor of Medicine at the
Perelman School of Medicine at the University of
Pennsylvania, the Director of Electrophysiology, University
of Pennsylvania Health Care System, and the Director of the
Electrophysiology Laboratory at the Hospital of the
University of Pennsylvania. Dr. Marchlinski is a graduate of
the University of Pennsylvania Medical School. He com-
pleted his postdoctoral internal medicine residency and
cardiology/electrophysiology fellowship training at the
­
Hospital of the University of Pennsylvania. For over thirty
years Dr. Marchlinski has remained at the cutting edge of
cardiac rhythm management. He has authored or co-authored over 450 original scientific
articles and over 200 book chapters/reviews/editorials on a variety of topics in cardiac elec-
trophysiology. His EP team at Penn has worked to successfully improve localizing and

xii Editors
ablation techniques for the treatment of both atrial fibrillation and ventricular tachycardia
and optimize device therapy for treating heart failure and preventing sudden cardiac death.
Dr. Marchlinski has served on the International Heart Rhythm Society Committee to estab-
lish guidelines for the treatment of atrial fibrillation and ventricular tachycardia using cath-
eter ablation techniques. He has been the recipient of the Luigi Mastroianni Clinical
Innovator Award, the Venice Arrhythmia Distinguished Scientist Award and the ACTS
Distinguished Investigator Award—Career Achievement—Translation from Early Clinical
Use to Applicability for Widespread Clinical Practice. Dr. Marchlinski is on the editorial
board of Circulation, Arrhythmias and Electrophysiology, American Journal of Cardiology,
Heart Rhythm Journal, Journal of Cardiovascular Electrophysiology, Journal of Interventional
Cardiac Electrophysiology, and JACC-Electrophysiology and is the Arrhythmia Section Editor
for Journal of the American College of Cardiology. Dr. Marchlinski has organized and directed
multiple fellowship training courses and regional and International EP symposia and has
received numerous teaching awards at the University of Pennsylvania.

Editors xiii
 CONTRIBUTORS

Amin Al-Ahmad Daniel Cantillon

Department of Electrophysiology Cardiac Electrophysiology and Pacemaker
Texas Cardiac Arrhythmia Institute Laboratories
Austin, Texas Heart and Vascular Institute
Cleveland Clinic
Zaid Aziz Cleveland, Ohio
Center for Arrhythmia Care
Pritzker School of Medicine Mina K. Chung
The University of Chicago Medicine Section of Cardiac Pacing and
Chicago, Illinois Electrophysiology
Department of Cardiovascular Medicine
Shiv Bagga Heart and Vascular Institute
Department of Electrophysiology and
St. Vincent’s Medical Center Department of Cardiovascular and
Indianapolis, Indiana Metabolic Sciences
Lerner Research Institute
Rong Bai
and
Beijing Anzhen Hospital Cleveland Clinic Lerner College of
Capital Medical University Medicine
Beijing, China Case Western Reserve University
Cleveland, Ohio
Mandeep Bhargava
Department of Electrophysiology
Roy Chung
Cleveland Clinic
Section of Cardiac Electrophysiology and
Cleveland, Ohio
Pacing
Noel G. Boyle Cleveland Clinic Heart and Vascular
Ronald Reagan UCLA Medical Center Institute
Internal Medicine and Cardiology Cleveland, Ohio
UCLA Cardiac Arrhythmia Center
David Geffen School of Medicine at UCLA Luigi Di Biase
Los Angeles, California Internal Medicine (Cardiology)
Albert Einstein College of Medicine
Jason S. Bradfield Montefiore Hospital
UCLA Cardiac Arrhythmia Center New York City, New York
David Geffen School of Medicine at UCLA
Los Angeles, California Duc H. Do
Department of Cardiology
Michael P. Brunner UCLA Cardiac Arrhythmia Center
Department of Cardiology David Geffen School of Medicine at UCLA
Cardiovascular Medicine Los Angeles, California
Cleveland Clinic
Cleveland, Ohio Thomas Dresing
Cardiac Electrophysiology and Pacemaker
J. David Burkhardt Laboratories
Department of Electrophysiology Heart and Vascular Institute
Texas Cardiac Arrhythmia Institute Cleveland Clinic
Austin, Texas Cleveland, Ohio
xiv
Andres Enriquez Houman Khakpour
Section of Cardiac Electrophysiology UCLA Cardiac Arrhythmia Center
Hospital of the University of Pennsylvania David Geffen School of Medicine at UCLA
Philadelphia, Pennsylvania Los Angeles, California

David S. Frankel Decebal Gabriel Laţcu

Electrophysiology Section Service de Cardiologie
Cardiovascular Division Centre Hospitalier Princesse Grace
Perelman School of Medicine at the La Colle, Monaco
University of Pennsylvania
Philadelphia, Pennsylvania Jackson J. Liang
Department of Internal Medicine
Fermin Garcia (Cardiology)
Section of Cardiac Electrophysiology University of Michigan
Hospital of the University of Pennsylvania Ann Arbor, Michigan
Philadelphia, Pennsylvania
and
Carola Gianni Hospital of the University of Pennsylvania
Department of Electrophysiology Philadelphia, Pennsylvania
Texas Cardiac Arrhythmia Institute
Austin, Texas
John Lopez
Cardiac Electrophysiology and Pacemaker
Jonathan R. Hoffman
Laboratories
Department of Electrophysiology
Heart and Vascular Institute
Central Georgia Heart Center
Cleveland Clinic
Macon, Georgia
Cleveland, Ohio
Rodney P. Horton
Francis E. Marchlinski
Department of Electrophysiology
Cardiology (Electrophysiology)
Texas Cardiac Arrhythmia Institute
Perelman School of Medicine
Austin, Texas
University of Pennsylvania
Philadelphia, Pennsylvania
Ayman A. Hussein
Section of Cardiac Pacing and
Electrophysiology Kenneth Mayuga
Heart and Vascular Institute Cardiac Electrophysiology and Pacemaker
Cleveland Clinic Laboratories
Cleveland, Ohio Heart and Vascular Institute
Cleveland Clinic
Matthew C. Hyman Cleveland, Ohio
Department of Electrophysiology
University of Pennsylvania Sanghamitra Mohanty
Philadelphia, Pennsylvania Department of Electrophysiology
Texas Cardiac Arrhythmia Institute
Amer Kadri Austin, Texas
Department of Electrophysiology
Mercy Medical Center Daniele Muser
Canton, Ohio Electrophysiology Section
Cardiovascular Division
Ching Chi Keong Hospital of the University of Pennsylvania
Department of Cardiology Philadelphia, Pennsylvania
National Heart Centre Singapore
Duke-NUS Graduate Medical School
Singapore
Contributors xv
Andrea Natale
Texas Cardiac Arrhythmia Institute
St. David’s Medical Center
and
Department of Medicine
Dell Medical School
University of Texas at Austin
Austin, Texas
and
HCA National Medical Director
Cardiac Electrophysiology
and
Department of Medicine
Case Western Reserve University
Cleveland, Ohio
and
Interventional Electrophysiology
SCRIPPS Green Hospital
San Diego, California
Subramanya Prasad
Department of Electrophysiology
The Cleveland Clinic Foundation
Cleveland, Ohio
Kushwin Rajamani
Department of Electrophysiology
Cleveland Clinic
Cleveland, Ohio
Domenico G. Della Rocca
Department of Electrophysiology
Texas Cardiac Arrhythmia Institute
Austin, Texas
Jorge Romero
Department of Cardiology Arrhythmia
Services
Montefiore Medical Center
New York City, New York
Walid Saliba
Department of Electrophysiology
Cleveland Clinic
Cleveland, Ohio
Mohamed Salim
Department of Electrophysiology
The Aga Khan Hospital Mombasa (AKHM)
Mombasa, Kenya
xvi Contributors
Javier E. Sanchez
Department of Electrophysiology
Texas Cardiac Arrhythmia Institute
Austin, Texas
Pasquale Santangeli
Electrophysiology Section
Cardiovascular Division
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Nadir Saoudi
Service de Cardiologie
Centre Hospitalier Princesse Grace
La Colle, Monaco
Robert D. Schaller
Department of Cardiac Electrophysiology
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Robert Schweikert
Department of Electrophysiology
Cleveland Clinic Akron General
Cleveland, Ohio
Kalyanam Shivkumar
Medicine (Cardiology), Radiology &
Bioengineering
UCLA Cardiac Arrhythmia Center & EP
Programs
UCLA Interventional CV Programs &
Cardiac Catheterization Laboratories
David Geffen School of Medicine & UCLA
Health System
Los Angeles, California
Gregory E. Supple
Department of Electrophysiology
University of Pennsylvania School of
Medicine
Philadelphia, Pennsylvania
Patrick Tchou
Cardiac Electrophysiology and Pacemaker
Laboratories
Heart and Vascular Institute
Cleveland Clinic
Cleveland, Ohio
Chintan Trivedi Oussama M. Wazni
Department of Electrophysiology Cardiac Electrophysiology and Pacemaker
Texas Cardiac Arrhythmia Institute Laboratories
Austin, Texas Heart and Vascular Institute
Cleveland Clinic
Roderick Tung Cleveland, Ohio
Center for Arrhythmia Care
Pritzker School of Medicine Bruce L. Wilkoff
The University of Chicago Medicine Department of Electrophysiology
Chicago, Illinois Cleveland Clinic Lerner College of
Medicine
Marmar Vaseghi Case Western Reserve University
UCLA Cardiac Arrhythmia Center Cleveland, Ohio
David Geffen School of Medicine at UCLA
Los Angeles, California

Contributors xvii
 Section I

BASIC EP LABORATORY
SETUP AND EQUIPMENT
 1

DEVICE LAB SET-UP

John Lopez and Mina K. Chung

CONTENTS

EP Lab 2
Device Procedures 2
References 5

The modern EP Laboratory caters to two general categories of diagnostic and interven-
tional procedures. They can be classified as either ablation or device related. Ablation pro-
cedures are more involved and may require more equipment and time than device-related
­procedures. It is the purpose of Section II to encompass the whole spectrum when it comes
to preparing the environment so as it is conducive to any of these general categories of
procedures.

EP LAB

The EP Lab should be constructed following the Facility Guidelines Institute (FGI) (http://
www.fgiguidelines.org/). The typical EP laboratory design has used the Cath Lab design
settings for years but there needs to be a separate distinction due to the fact that the EP
Laboratory houses more equipment and is sensitive to a different need that concentrates in the
matter of interpreting clean electrical signals as opposed to pressures and h­ emodynamics.1
The environment has also evolved to be able to accommodate emergent responses that may
require cardiothoracic surgical interventions and general anesthesia services, which make
it necessary for the environment to have adequate heat, ventilation, and air conditioning
(HVAC) standards appropriate for operating room procedures.
It is ideal for the room to be considered as a wet location, which mandates the use of an
isolated power system with line isolation monitoring.2 This panel’s purpose is to ensure that
electrocution hazards are kept at a very minimum. A secondary benefit is that it also serves
as a filter mechanism that can provide clean power to equipment, which helps reduce electri-
cal noise due to the 60 Hz frequency of alternating current (AC). This shields the room from
conducting noise from the main power source but consideration should be taken to trouble-
shoot equipment that may generate noise from within the room that can conduct to other
equipment plugged in the same branch circuit.

DEVICE PROCEDURES

There have been many advances in cardiac implantable electrical devices (CIEDs), includ-
ing pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization devices,
and implantable loop recorders. Newer models are capable of handling more sophisticated

2 Device Lab Set-Up

 Device Procedures

algorithms, they have more data storage capacity, and they are compact and now capable of
interfacing wirelessly. This provides a new challenge and becomes an impetus for change
in the ways that we traditionally pull paraphernalia needed in the procedure. Changes in
interfaces can also create inadvertent issues that create problems between device commu-
nications. As technology advances, procedural considerations and need dynamically evolve
and should be expected.
The equipment needed for CIED Implantation include:
• X-ray system
• EP recording system
• Defibrillator
• Device specific programmer
• Signal analyzer (usually a function provided by the device specific programmer)
• Electrocautery
• Temporary pacemaker
• Ultrasound (for emergent transthoracic scan and vascular access if needed)
• Suction apparatus (typically available as a wall source in procedural areas)
• Operating room instruments
• Open chest and emergency carts

X-RAY SYSTEM
The patient table should be radiolucent and freely movable to allow fluoroscopy from the
patient’s neck to groin. Ample space is necessary on the left and right side as well as the head
of the bed, where personnel can monitor vital signs, oxygen saturation, patient status, and
conscious sedation. Complex cases, such as device extractions or extractions with contra-
lateral re-implants, may require space for bilateral pectoral, groin, or neck vascular access
for a temporary pacer wire or arterial access for invasive blood pressure monitoring. It is
helpful for a table to have options for Trendelenberg and reverse Trendelenberg positioning,
although foam wedges may be placed under the legs to facilitate venous return during venous
access or under the head for patients unable to lay flat.
Fluoroscopy remains essential to optimal lead placement. The fluoroscopy source can
be either portable or fixed and should be maneuverable in oblique and lateral views.
Maneuverability is important for obtaining access, venograms, and lead positioning. An
option for magnification is used to visualize extension and retraction of the lead screw.
The ability to record cine loops is helpful for guidance of vascular insertion and lead place-
ment (e.g., coronary sinus venogram), as well as for teaching purposes. Cinefluoroscopy is
the most commonly used recording mode, with some machines having the option to record
loops from fluoroscopy.
Consideration should also be given to selectable default radiation dose exposure settings for
procedures. While it is more a user preference, EP staff responsible for monitoring radiation
exposure during procedures can opt to configure lower dose settings commensurate to pre-
ferred image quality with the equipment manufacturer engineers. This is preferably done during
equipment installation but can be revisited upon request. Caution should be taken to include
all members of the clinical team for approval to make it standard for their particular practice.

EP RECORDING SYSTEM, DEVICE SPECIFIC PROGRAMMER & SIGNAL ANALYZER

Once the pacing and/or defibrillation leads are positioned, lead impedance, capture thresh-
old, and amplitude are tested. The electrodes are connected using alligator clips to a pac-
ing system analyzer (PSA) and display. The signal can be displayed with standard bipolar
intracardiac electrogram filtering (30 Hertz [Hz] high pass, 500 Hz low pass), as well as with
a wider bandpass filter to facilitate assessment for an injury current on the intracardiac elec-
trograms (0.5 Hz high pass filter and 500 Hz low pass filter). The injury current helps to
confirm appropriate fixation to viable tissue. It is also helpful to have a secondary monitor to

Device Lab Set-Up 3

 Device Procedures

display the PSA or device programmer screens alongside the EP Recording system and X-Ray
displays to the implanting physician.

EMERGENCY EQUIPMENT (DEFIBRILLATOR, TEMPORARY PACEMAKERS, OPEN

CHEST, AND EMERGENCY CARTS)
Every lab should be equipped with emergency equipment. A combination defibrillator/­external
pacemaker is essential. The most frequent use of the defibrillator is for ­cardioversion and as
a back-up to an internal cardiac defibrillator in defibrillation threshold testing. There should
also be a cart stocked with emergency medications used for cardiopulmonary arrests (code
cart), pericardiocentesis kit, and in centers performing high risk procedures, an open chest kit
can be stocked. A pericardiocentesis kit should be available in the event of a lead perforation.

ELECTROCAUTERY
The use of electrocautery is essential for cutting through the dermal layers and also coagulat-
ing the vascularized tissue when creating a pocket for the device. While it has its advantages
to scalpels to prevent nicks on lead insulation, strong electromagnetic interference (EMI)
can be generated that has the potential to temporarily stun or damage device electronics.3
This can be catastrophic in patients who are pacemaker dependent during device replace-
ments. In some instances it may be advisable to insert a temporary pacing lead in patients
who are pacemaker dependent, or to minimize cautery until leads can be secured for pacing.
Temporary pacing should be available and ready for immediate activation, if needed.

OPERATING ROOM INSTRUMENTS & ROOM SUPPLIES

Many labs have instrument sets specially designed for device implantation. Basic ster-
ile surgical instrument sets often include hemostats, forceps, fine forceps, suture scis-
sors, Metzenbaum scissors, a needle holder, Weitlaner retractor, and manual retractors
(Figure 1.1). Vascular ultrasound devices used to obtain vascular access may be helpful to
avoid unnecessary arterial punctures when groin access is needed. Suction should be avail-
able in case of need.

Figure 1.1 Example of a basic kit of instrument sets used and standardized on all implantable
cardiac device procedures in an EP Lab setting.

4 Device Lab Set-Up

 References

In-room stocking or easy availability of single-use items adds to convenience during the
procedure. Items that are used during device implantation include scalpels, absorbable and
non-absorbable suture, splittable vascular sheaths, the implanted leads and device, stylets,
sterile programming wand covers, drape clips, sterile fluoroscopy cover, and often steerable
mapping catheters.

ADDITIONAL REFERENCE
There is also a recent document that was released by the Heart Rhythm Society that was
created by a consensus of experts who aim to provide a standard framework for Cardiac
Electrophysiology Labs in general. This document is entitled “2013 HRS Expert Consensus
Statement on Electrophysiology (EP) Lab Standards: Process, Protocols, Equipment,
Personnel and Safety” and is available for public download at http://www.hrsonline.org/
Practice-Guidance/Clinical-Guidelines-Documents/2013-Electrophysiology-EP-Lab-
Standards-Process-Protocols-Equipment-Personnel-and-Safety#axzz3AklrR1h7.

REFERENCES

1. Haines, D., Beheiry, S., Akar, J., et al. (2014, May 8). Heart Rhythm Society. Retrieved
May 26, 2015, from Heart Rhythm Society: http://www.hrsonline.org/Practice-
Guidance/Clinical-Guidelines-Documents/2013-Electrophysiolog y-EP-Lab-
Standards-Process-Protocols-Equipment-Personnel-and-Safety#axzz3AklrR1h7.
2. Earley, M.W., Sargent, J.S., Sheehan, J.V., & Buss, E.W. (Eds.) (2008). NEC 2008
Handbook. (pp. Article 517, Part VII). Quiny, MA: National Fire Protection Association.
3. Abdelmalak, B., Jagannathan, N., Arain, F., et al. (2011). Electromagnetic interference
in a cardiac pacemaker during cauterization with the coagulating, not cutting mode.
J. Anaesthesiol. Clin. Pharmacol., 27(4), 527–530.

Device Lab Set-Up 5

 2

ORGANIZATION OF THE ARRHYTHMIA LAB

Roy Chung and Oussama M. Wazni

CONTENTS

Setup of the Interventional Electrophysiology Laboratory Mapping Systems 6

Setup of the Interventional Electrophysiology Laboratory 6
Mapping Systems 11
Bibliography 12

SETUP OF THE INTERVENTIONAL ELECTROPHYSIOLOGY LABORATORY

MAPPING SYSTEMS

Setting up an electrophysiology laboratory for cardiac ablations requires specifics in the

layout of laboratory, personnel, and equipment requirements. Conventional electrophysi-
ology (EP) studies and ablation procedures should be performed with adequately trained
personnel. One to two physicians are responsible for catheter manipulation and ablation.
Two nurses are generally required, one to assist with tasks related to ablation and the other
responsible for sedation of the patient. For most procedures, conscious sedation is preferred
to allow for assessment of symptoms and minimization of risks associated with anesthe-
sia, although general anesthesia is routinely employed now for pulmonary vein isolation.1
To that effect, considerations are made to accommodate anesthesia cart and personnel.
Support for complications related to EP studies and ablations should be readily available,
including cardiac and vascular surgery and neurologic imaging modalities.

SETUP OF THE INTERVENTIONAL ELECTROPHYSIOLOGY LABORATORY

An electrophysiology laboratory capable of performing EP studies and ablations must be

equipped with a radiographic system, the ability to separately monitor vital signs, and data
acquisition capabilities.
• The cinefluoroscopic equipment includes the patient table and the C-arm, which allows
for variable angulation of the X-ray beam. Biplane imaging provides simultaneous view-
ing of cardiac structures from different angles and can be useful in transseptal punc-
ture. The video system should consist of 1–2 monitors and have the ability to store cine
images. Above the patient table, one monitor displays fluoroscopic images and another
displays tracings from the physiologic recorder and hangs from a mounted movable
ceiling bracket, allowing the physician manipulating catheters to achieve the optimal
viewing angle (Figure 2.1). Given the amount of fluoroscopy used in prolonged ablations
or device implantation procedures, reduced fluoroscopy intensity is generally used in

6 Organization of the Arrhythmia Lab

 Setup of the Interventional Electrophysiology Laboratory

Figure 2.1 Mounted monitor with various displays, including fluoroscopy, electrophysiologic
mapping system, real-time electrocardiograms.

the EP lab as compared to catheterization laboratories. These settings are typically done
individually for each laboratories to physician’s specification.
• Vital signs monitoring should be performed on independent equipment so that monitor-
ing may continue if the data acquisition system fails. A cardioverter/defibrillator may
be used for monitoring rhythm, and combined modality devices may be used to moni-
tor vital signs. Through the defibrillation pads and ECG leads, several lead configura-
tions can typically be viewed separately from the physiologic recorder. Additionally,
non-invasive measurements of blood pressure and pulse oximetry can be followed.
Capnography is of particular benefit in procedures with moderate sedation for a pro-
longed period of time. This also reduces over-dosing sedative and narcotic usage which
may result in adverse events. Esophageal thermister probe allows monitoring of esopha-
geal temperature for ablation performed along the posterior wall of the left atrium to
avoid risk of atrial-esophageal fistula.
• The data acquisition system includes the physiologic recorder which displays and stores
surface and intracardiac electrograms. The equipment console consists of this system
as well as a slave monitor for radiographic images and an electrophysiologic stimulator.
Input signals are displayed on computer screens and stored on archivable media, such
as optical disks.
Electrical safety must be ensured in the setup of the electrophysiology laboratory to reduce
the risk of current leakage to the patient which can precipitate ventricular arrhythmias.
Leaking of current should remain less than 10 mA.

JUNCTION BOX
The junction boxes receive the intracardiac signals from the catheters and provide an inter-
face into the physiologic recorder (Figure 2.2). Multiple switches within the junction box are

Organization of the Arrhythmia Lab 7

 Setup of the Interventional Electrophysiology Laboratory

Figure 2.2 Junction boxes.

designated to a recording and stimulation channel which can be selected through the record-
ing apparatus. The junction boxes are mounted at the foot of the patient table and connected
to the physiologic recorder, which is kept as close as possible. This helps to minimize noise
on the channels as well as reduce floor clutter.

RECORDING APPARATUS
The physiologic recorder records, displays, and stores intracardiac and surface recordings.
It consists of filters, amplifiers, display screens, and recording software. From the junction
box, the physiologic signals are introduced into the recorder. These signals are typically
low in amplitude and require amplification prior to displaying and recording. The record-
ing system amplifies and filters each input channel separately, with most current systems
supporting up to 64 or more channels. The amplifiers have the ability to automatically or
manually adjust gain control. The amplifiers should be mounted as close to the patient
table as possible. This will reduce the cable length of the intracardiac connections and
surface ECGs, which minimizes the signal noise. The amplifier is then connected to the
main physiologic recorder through a floor channel, which, ideally, should run separately
from electric power cables. Filters are used to eliminate unnecessary signals that distort
electrograms (EGMs). High pass filters eliminate signals below a given frequency and low
pass filters eliminate signals above a given frequency. Most intracardiac electrograms are
clearly identified when the signal is filtered between a high pass of 40 Hz and a low pass of
500 Hz. Several pages can be simultaneously recorded and one of these typically includes
a 12-lead ECG. The page displayed during studies typically shows several intracardiac
electrograms with 3–4 surface ECG leads which allows for axis determination, activation
timing, and P/QRS morphology (Figure 2.3). Pressure channels, if used, allow for simulta-
neous hemodynamic monitoring.

STIMULATOR
A programmable stimulator is necessary to obtain electrophysiologic data beyond measure-
ments of conduction intervals. Stimulators are capable of various modes of pacing, including

8 Organization of the Arrhythmia Lab

 Setup of the Interventional Electrophysiology Laboratory

Figure 2.3 Intracardiac electrograms display with coronary sinus electrograms.

rapid pacing, delivery of single or multiple extra stimuli following a paced drive train, and
delivery of timed extra stimuli following sensed beats. Stimulators should be capable of
delivering variable currents, ranging from 0.1 to 20 mA. With satisfactory positioning of
catheters, current thresholds under 2 mA (with 2 ms pulse width) can usually be achieved in
both the atrium and ventricle. Higher outputs are seen with diseased myocardium, within
the coronary sinus, and with the use of anti-arrhythmic medications. Output is usually set
at twice the diastolic threshold. Most stimulators have the ability to pace through more than
one channel; however, one channel generally suffices for all studies unless dual chamber pac-
ing is required.

CARDIOVERTER/DEFIBRILLATOR
A primary and back-up cardioverter/defibrillator should be available throughout all EP
studies (Figure 2.4). Current defibrillators deliver energy in a biphasic waveform which
offers enhanced defibrillation success. Defibrillation pads are attached to the patient
and electrically grounded. In our laboratory, the defibrillator and energy delivered by
RFA share a common ground patch on the patient which connects through the Booker
box. ECGs can be recorded through the defibrillation pads separate from the data acquisi-
tion system. 2,3

RADIOFREQUENCY ABLATION
Radiofrequency ablation uses alternating current delivered between the catheter tip and
grounding source to deliver energy to tissue, resulting in necrosis. Radiofrequency genera-
tors deliver current with a frequency between 300 and 750 kHz, with generation of heat
occurring as a result of resistive and conductive heating. Monitoring of time, power, and

Organization of the Arrhythmia Lab 9

 Setup of the Interventional Electrophysiology Laboratory

Figure 2.4 Cardioverter defibrillator.

impedance is necessary to ensure safe and effective ablation lesions. The new SmartAblate
system comes with a generator, system pump, and remote control, is an integrated platform
which streamlines the ablation procedure in an electrophysiology laboratory. Through the
generator, limits on impedance and temperature are programmed and the desired power
level is set (Figure 2.5).

Figure 2.5 Biosense webster smart ablate generator.

10 Organization of the Arrhythmia Lab

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The Project Gutenberg eBook of The Survey,
Volume 30, Number 3, Apr 19, 1913
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Title: The Survey, Volume 30, Number 3, Apr 19, 1913

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*** START OF THE PROJECT GUTENBERG EBOOK THE

SURVEY, VOLUME 30, NUMBER 3, APR 19, 1913 ***
Transcriber’s Note:
New original cover art included with this eBook is
granted to the public domain.
The Survey, Volume XXX, No. 3,
Apr 19, 1913
 THE COMMON WELFARE

THE STRIKE OF THE

JERSEY SILK WORKERS
For seven weeks the 27,000 workers in the silk mills and dye
houses of Paterson, N. J., have been on strike for improved
conditions and against a proposed change in method that will, they
declare, alter the character of the industry.
The strike began with the broad silk weavers as a protest against
the introduction of the three and four loom system. They were soon
joined by the ribbon weavers and the dye house men, whose
demands are for an eight-hour day and a minimum wage of $12 a
week. The dye house men have been laboring in two shifts of twelve
hours each. Their work is often carried on under unhealthful
conditions of dampness, high temperature and poor ventilation.
All the strikers joined the branch of the Industrial Workers of the
World which conducted the Lawrence strike. This is one factor which
has caused tension in a situation, in which statutes dating back to
colonial days have been brought to bear on a modern industrial
struggle till a Supreme Court judge denounced the lengths to which
the police have gone.
Back of the police incidents and the spreading of the revolutionary
doctrines of the Industrial Socialists is a profound economic change
involved in the introduction of the four loom system. This is not
merely the substitution of machines for skilled men due to invention,
but the supplanting of high-grade textile manufacture by low-grade
output because of the greater profits in the cheap goods. It is as if a
vineyard were giving way to a hay farm—a change which seriously
affects the working population of Paterson.
In order to make the situation clear it is necessary to take a brief
look at the history of the silk industry in this country. Twenty years
or so ago the competition between Pennsylvania and New Jersey for
the manufacture of cheap silks was keen, but within a few years the
battle was over. Induced, it is said, by real estate companies, the
manufacture of cheap silk on a large scale migrated to Pennsylvania.
Great factories were built and leased on easy terms, and these were
equipped with automatic looms, four of which could be operated by
one girl or boy. There the wives and children of the coal miners
furnished a cheap labor supply.
Since this migration the best grade of silk has been made in
Paterson, and there has been no competition to speak of that the
Paterson manufacturers needed to fear. Yet they have been making
only moderate profits while the Pennsylvania manufacturers of
cheap silk have been making fortunes. Under the system of multiple
looms, the business of Pennsylvania, has expanded 97 per cent in the
last six years; under the one and two loom systems of Paterson its
business has expanded only 22 per cent in the same time. Therefore
the Paterson manufacturers propose to compete in the manufacture
of cheaper silks and consequently decided to introduce the multiple
loom system. To them this is only a natural economic development,
and the opposition of the workers they feel is irrational, as opposed
to progress. This view is made apparent in a statement issued by the
silk manufacturers’ association:
“As regards the three and four loom system, it is applicable only in the case of
the very simplest grade of broad silks and as a matter of fact has for a long time
been worked successfully and on a very large scale in other localities. Paterson
cannot be excluded from this same privilege. No fight against improved machinery
has ever been successful.”
The beginning of the change came in one of the big Paterson mills
about a year ago and the strike of last spring[1] was at first against the
four loom system. The strike became general, however, and this
demand was completely lost sight of before the strike came to an
end. Since then nine or ten other mills have installed the four loom
system and a score have begun to require the weavers to tend three
looms instead of two.
 1. See The Survey of March 16, 1912.
The strikers claim that the new system will cause unemployment,
as did the installation of the two loom system together with other
improvements in the mechanical equipment of the loom some years
ago, and that the logical consequence will be the employment of
unskilled women and children in place of the skilled weaver, and a
forcing down of the level of wages until the Paterson average of
$11.69, as given in the federal report for the year 1908, becomes as
low as the Pennsylvania average of $6.56. As the percentage of
women employed in Paterson mills has increased in the last few
years and as the average of wages given out by the manufacturers
this year is under $10, there is basis for these fears. Nor do the
manufacturers deny these possibilities; they claim that the loss of
skill is an inevitable accompaniment of improved processes, and the
replacing of men by women and children is only in line with the
development in all the textile trades.
Some of the claims of the strikers are thus summarized by the
Paterson Evening News:
“The best information obtainable appears to show that the alleged mechanical
advantages of the new system have not proved themselves sufficient to offset the
additional strain to which the care of three or four looms subjects the weavers; that
the premium wages first paid as an inducement to users of the system have been
pared down; that at present a day’s work under the system is proportionately less
well paid than a day’s work at two looms; and, finally, that the wages of two loom
workers have been depressed with the scaling down of the piece-rate paid to the
three and four loom workers.”
In spite of the fact that it is only the large manufacturers who
propose to install the new system, the strike is general. The multiple
looms, which are large and equipped with automatic devices, can
only be installed in large mills. By this system cheap silks alone can
be made; the smaller mills must use the Jacquard or other small
looms fitted to the making of the fancy grades of silk for which
Paterson is famous. The small manufacturer, therefore, does not fear
the installation of the new system in the large mills; but he does feel
strongly that he has a grievance toward the workers in his mills who
struck sympathetically for a wrong not their own.
But it is a very real fear that the entire industry will be undermined
that has made the workers stand together, regardless of individual
grievances.
 While the desire to keep up with industrial progress and to realize
large profits is the reason for the importing of the four loom system
into Paterson; the desire to save their present standard of living and
prevent their industry from coming into the hands of women and
children like the other textile trades is the reason for the workers’
opposition. Today Pennsylvania and New Jersey present different
phases of the industry, and New Jersey has had a higher wage
standard; tomorrow with the triumph of the four loom system they
may tend to an equalization of conditions.
The outstanding features in the strike now in its seventh week are
lack of violence and disorder, the refusal of the employers to meet or
confer with the strikers, aggressive repression by the police and the
city government and the efforts of citizens to bring about a
settlement. Although practically all the workers in the major industry
of the city are on strike, there has been little disorderly conduct
attributable to the strikers. There have been reports of the breaking
of a window by a stone in a house occupied by a boss dyer and at
least one attempt was made to damage a house by means of a bomb,
but responsibility for these acts has not been fixed.
CITY OFFICIALS ADOPT
REPRESSIVE MEASURES
In striking contrast to the order maintained by the rank and file of
the strikers, there have been actions on the part of the city officials
that leading newspapers outside of the strike district have not
hesitated to characterize as anarchical. Soon after the strike began
and it became known that it was to be conducted under the auspices
of the I. W. W., the police began to arrest strike leaders and others
who addressed meetings of strikers, regardless of whether they had
yet been guilty of any illegal act. Several of them were held in jail for
a time and then so great was the outcry raised that for a period of two
or three weeks these tactics were abandoned.
On Sunday, March 30, however, the police resumed their former
tactics. William D. Haywood, the leader of the strike, had announced
that he would speak at an open air meeting, and a large crowd
gathered to hear him. As Haywood was going to the meeting place to
speak he was approached by members of the police force. They told
him that the chief of police had issued an order forbidding any out-
door meeting. According to all reports, including testimony given by
the police authorities themselves, Haywood acquiesced at once and
passed the word to the assemblage that the meeting would take place
in Haledon, an independent borough just outside the city limits of
Paterson. Accordingly, Haywood started to walk down the street in
the direction of Haledon and he was followed by the crowd. Just
before he reached the city limits, a patrol wagon bore down upon
him. Together with Lessig, another strike leader, he was arrested,
taken before the Recorder’s Court, charged with disorderly conduct
and unlawful assemblage under the English act of 1635. After being
held in jail in lieu of $5,000 bail, both were found guilty of unlawful
assemblage and were sentenced by the recorder to six months’
imprisonment.
A writ of certiorari was immediately sought by Haywood’s
attorneys and a hearing on this appeal was held by Supreme Court
Justice Minturn. When the evidence, most of it furnished by the
police department, was in, Justice Minturn ordered the release of
Haywood and Lessig. He was unable to find that there had been any
unlawful assemblage. The evidence tended rather to show that
Haywood was co-operating with the authorities in an endeavor to
carry out their orders. At the time of this resumption of their activity
the police began also to arrest pickets. From twenty to one hundred a
day were taken to headquarters. After Judge Minturn’s decision, all
those held in jail were discharged. Since then, while the arrest of
pickets has gone steadily on, Recorder Carroll has refused to hold
them.
Throughout the strike to date the manufacturers have consistently
refused to meet with a committee of strikers or to discuss terms with
them in any way. At one time a delegation of clergymen endeavored
to get them to meet a committee of strikers in order to discuss
grievances. This suggestion was instantly voted down. Last week,
when a public meeting of citizens was held to consider whether or
not the strike could be brought to an end, the manufacturers,
through their representative, stated their position in just two
propositions: First, the employers will refuse to meet any committee
of strikers “dominated as they are by the I. W. W.”; second, they will
meet any of their individual employes “who are not dominated by the
I. W. W.”
All along there has been a lively public interest in the strike.
Ministers and public-spirited citizens have at different times
endeavored to ascertain the underlying causes and to co-operate in
restoring harmonious relations. These efforts reached their most
formal stage when last week at the call of the president of the Board
of Aldermen a public meeting was held in the high school auditorium
on Wednesday evening to which employers, strikers, church
organizations, the board of trade, organizations of bankers and
professional men, and the general public were invited.
Representatives of the strikers explained their grievances, a single
representative of the employers stated their position as just quoted,
and the ministerial association came forward with a proposal for a
legislative investigation. Finally, a committee of the Board of
Aldermen proposed in a series of resolutions that a committee of
fifteen be appointed to discuss a basis upon which the strike could be
settled, the committee to consist of five representatives of the
strikers, five representatives of employers and five men to be
appointed from the membership of the Board of Aldermen. The
resolution was passed by the unanimous vote of an audience two-
thirds of which were strikers. The strikers appointed their
committee. But the employers, in line with their official policy which
has been against any meeting with any body of men even to discuss a
settlement, refused to do so.
“A MAN’S
FRIENDS”
“I don’t believe there is a man in the country who will not put
himself or some one he loves above the whole nation if he is put to a
hard enough test.”
These words, spoken by one of the principal characters, contain
the essence of a new play, A Man’s Friends, written by Ernest Poole
and recently presented in New York. Without moralizing on the need
for a wider social consciousness, Mr. Poole seeks to show the limits
of the average man’s circle of human loyalty and how far his loyalty
to the whole people’s welfare is inhibited by his devotion to his own
“crowd.” The play aims to point out that, however much our
attention has been focused on graft in its great anti-social
consequences, a larger factor in thwarting social progress is our
restricted loyalty to groups which are less than the whole people.
A district attorney fights a political machine which, through
bribery, has defeated a new building code. He convicts the bribed
alderman but cannot obtain from him any information as to the
“men higher up.” At last he discovers that his own son-in-law was the
go-between in the matter of the bribe. The intense loyalty of wife to
husband is shown by his daughter who says to her father: “Your life
and principles are nothing now—promise me you’ll keep Hal out of
jail,” and by the wife of the guilty alderman who declares “it is not a
question of right and wrong—it’s what I think of Nick.”
The play brings out the loyalty to one’s circle of intimates, shown
in the refusal of the convicted alderman to divulge incriminating
information; and the loyalty to a political coterie whose watchword is
“You might as well be dead as a squealer,” and concerning whom the
district attorney says: “It is the unwritten law of your system to
perjure yourself to save a friend.” He further remarks to the boss,
“You won’t help those not in your crowd—and your crowd is too
small, even though you can call a hundred thousand people in New
York by their first names.”
 One element in the play is the definite human appraisal of just
what graft and disloyalty to public welfare involve. It flashes out
when the boss after telling how he had given a few dollars to a “down
and outer” is silenced by the district attorney’s daughter who points
out that he owns the gambling place in which the derelict lost his
money. It is again emphasized when the district attorney says to
those who appeal for leniency toward the men responsible for the
defeat of the building code, “All right let’s be human,” and then refers
to the 149 factory girls who lost their lives in a factory fire which the
building code would have prevented. “People vote,” he says at
another time, “with the man who laughs, but the laugh is too
expensive.”
How the district attorney shows his own human qualities in the
end by saving his son-in-law from prison, but in a way to render
important service to the 9,000,000 people of the state, is the climax
of the piece.
The play is intended to show how the absorption of the average
man in his own affairs and in the interests of his small group of
friends is responsible for popular indifference which often makes the
conscientious public servant lonely and disheartened. The district
attorney, as candidate for governor, has returned from a campaign
trip. “There are one million men out for the graft and nine million
who don’t care,” he says. His daughter replies: “That does not seem
like you, father.” “Well,” he adds, “you ought to have seen them all
along the line of my trip; big meetings, cheering, too, plenty of
enthusiasm. But the minute I left each town I felt it all suddenly die
right out. Every man jack of them back to his business, his job and
his friends—the things he really cares about—and I felt as though I
had carried on the cheers of each town. Each town throwing it all at
my head and shouting ‘Go on, be a hero, save the country—only for
God’s sake leave us alone, we have not time, we are busy.’”
BRIEUX’S “DAMAGED
GOODS” PRESENTED
“I didn’t know” bids fair to become an obsolete phrase in
connection with the nature of the social evil, if the ripples started by
the production of Brieux’s Damaged Goods in New York this spring
extend as far as its sponsors intend. The Committee of the
Sociological Fund of the Medical Review of Reviews believe that
syphilis should no longer be regarded as a mysterious disease, whose
ravages are to be shunned but its causes ignored.
Bernard Shaw’s preface to the Brieux play, with its warning against
the usual treatment of the subject as taboo and its appeal for
publicity and legal assistance in coping with the evil, was read by a
clergyman well known for his human contact with every-day social
conditions. The drama itself was simply staged and given a
sympathetic reading by a strong cast. Almost every bearing of the
menace on family and social life is brought out in a way well
calculated to meet prejudice due to indifference, ignorance or
tradition, and to create a conviction that here is a scourge to be
conquered by publicity.
Those who saw the play had come with various mental attitudes.
Some were even vaguely questioning whether they had come to see a
play or hear a sermon. Not a few of the theatrical critics have dubbed
it the latter, but to many parents this very quality made it seem
peculiarly profitable for young men who are breaking loose from
home life. By some it was even felt that the educational value of the
piece would justify its being given a special performance at some
holiday season, and that prevention through knowledge would thus
be promoted.
NEW YORK CHARITIES
AND THE LAW MAKERS
Convinced that the state charitable and correctional institutions
are facing a serious crisis, New York social workers are protesting
against certain of the recommendations of Governor Sulzer’s
Committee of Inquiry which they fear the Legislature may act upon.
This committee, which was appointed by the governor to examine
into the administration of the state’s departments in the furtherance
of economy, has made recommendations, relative to state charities
and corrections, ranging from the repeal of the act establishing the
state industrial farm colony for tramps to the refusal of large part of
the sums asked for repairs on state institutions. The Prison Farm for
Women, Letchworth Village and the State Training School for Boys
are among the institutions that would be most seriously affected. The
Committee of inquiry also recommended that the State Probation
Commission, a non-salaried body, be merged with the Prison
Commission.
All told, there are fourteen state hospitals for the insane and
sixteen state charitable institutions with a total of 42,000 patients
and inmates. The Committee of Inquiry, partly on the alleged ground
that the state has little control over the expenditures of these
institutions, has made sweeping recommendations for retrenchment
on projects to which the state has already committed itself by
legislation. Social workers who dispute the findings of the
commission point out that it had but a few weeks in which to gain an
understanding of the workings and relations of the state institutions
to various supervisory and administrative state bodies and that its
statements as to excessive cost of housing the inmates are apparently
made without a comparison of the situation in other states.
The Committee of Inquiry recommends that the state charitable
institutions in some way ought to be consolidated, This, social
workers urge, could not be done except by putting together state
wards of entirely different types since the only institutions having a
capacity of less than 300 are the State Women’s Relief Home, an
institution for aged veterans and their wives; the Thomas Indian
School; the State School for Blind: the State Hospital for Crippled
Children, and Letchworth Village for the Feeble-minded.
For many years the state has been gradually building up a group of
institutions for the care of the insane and feeble-minded, the
epileptic, and delinquent cases requiring reformatory treatment. The
insane are increasing at the rate of about one thousand a year. There
is an accumulation at the present time of 5,000 patients in excess of
the certified capacity of the fourteen state hospitals. To delay
appropriations for new state hospitals already started, it is claimed,
is only to put off what must be eventually done.
For the feeble-minded and epileptic New York has provided four
institutions in the central and western part of the state which care
altogether for about 4,000 inmates and one, Letchworth Village in
the southeastern part of the state, which as yet has less than 100
inmates. This, when completed, will serve New York city and vicinity
where more than half the population of the state centers.
The next largest group of institutions is the reformatories of which
there are two for women, one at Bedford and one at Albion; one for
girls at Hudson; and two for boys, of which the State Agricultural and
Industrial School at Industry is known the country over as a model of
its kind. This institution for caring for boys outside the metropolitan
district, social Workers urge, should be paralleled without further
delay as suggested by the Committee of Inquiry by one in
Westchester County for the boys of New York City and its vicinity.
The state has also undertaken to round out its reformatory and
penal system by providing a state farm for women over thirty years
of age, the age up to which they may be received in reformatories,
and the state industrial farm colony for tramps. These institutions
are planned to care for offenders who now cause much expense to
localities. Both of these institutions were established after long study
of the subject by organizations and individuals expert in dealing with
dependents and delinquents but the committee recommends the
abandonment of the second and further investigation as to the
desirability of the first.
After discussing the situation at a meeting held in New York on
April 3, a committee consisting of Henry Morgenthau; Homer Folks,
secretary of the State Charities Aid Association; John A. Kingsbury,
general agent of the New York Association for Improving the
Condition of the Poor; the Right Rev. N. G. R. McMahon, supervisor
of Catholic Charities, and Mrs. John M. Glenn, was appointed to
confer with the governor who has given the committee assurance
that he is considering the situation as a whole and will not make
separate judgments on each institution by itself.
A similar meeting was held in Buffalo. At this delegates were also
selected who have interviewed the governor in behalf of the
important humanitarian projects undertaken by the state in the last
ten years which are now threatened.

SLEEPING IN THE LAVATORY

AT BEDFORD
BEDFORD REFORMATORY
NOW FACING A CRISIS
It was not much more than a year ago that, in connection with the
founding of the Bureau of Social Hygiene, the New York magistrates
began to make extensive use of Bedford Reformatory for women as a
means of saving the young prostitute. And yet the reformatory is
already facing a crisis through overcrowding.
The Committee on Criminal Courts of the New York Charity
Organization Society has appealed to the public to write, urging an
appropriation of $700,000 for this institution, to the leaders of the
Legislature: James J. Frawley, chairman Finance Committee of the
Senate; Alfred E. Smith, speaker of the Assembly; Robert F. Wagner,
majority leader of the Senate; Aaron J. Levy, majority leader of the
Assembly. This the committee believes to be a conservative and
economical estimate of what will be needed to put up new cottages
and other buildings to accommodate present inmates, and to provide
for reasonable growth in the next few years.
The letter sent out by the committee reads in part as follows:
“Twelve years ago the state authorities established Bedford
Reformatory to care for women between the ages of sixteen and
thirty, to try and save some, at least, of the young girls who were
otherwise destined to a life of shame and degradation. What Bedford
means to the community, the extraordinary work it is doing and has
done is set forth in the enclosed article by Ida M. Tarbell.[2] That
article is a challenge and a call to every man and woman in the state.
2. Miss Tarbell’s article which appeared in the American Magazine was
reprinted as a pamphlet by the committee.
“Bedford Reformatory now faces a crisis.”
“Today there are 178 more girls there than the place will hold.
They are sleeping on cots in the hallways, in parlors, in the
gymnasium, in the lavatories, in the linen room, everywhere they can
put a bed. Two girls in a room is the rule instead of the exception,
notwithstanding the moral dangers of this.”
 “Chief Magistrate McAdoo and Chief Magistrate Kempner and
their associates in New York and Brooklyn have been asked not to
commit any more girls to the institution and the stream has stopped
for a moment. But the magistrates are now at their wits’ ends. What
are they to do with first offenders? The young girl who is just
embarking on this kind of career—shall they fine her and force her to
work all the harder at her unlawful calling to earn the money with
which to pay the fine? All are agreed that this is objectionable. Fines
neither deter nor reform. Shall they send her then to the work-house
to mingle in close confinement with the hardened offender, there to
become embittered and to have a prostitute’s life fastened more
firmly than ever upon her? They must do this or discharge her to
walk the streets again.”
 EDITORIAL GRIST

THE BATTLE LINES OF CHILD LABOR

LEGISLATION
ANNA ROCHESTER
National Child Labor Committee

A majority of the twenty-nine state Legislatures which have been

considering child labor laws this winter are still in session, so that
many of the most important bills are still pending.
The campaign that is being waged against the most outspoken
opposition is on in Pennsylvania, one of the two strongholds of glass
manufacturers who employ boys under sixteen at night. With the
single exception of West Virginia, where a bill based on the uniform
child labor law was defeated this winter, night work for youths under
sixteen is no longer allowed in the important glass-producing states.
The uniform law was introduced in the present Pennsylvania
Legislature by Representative Walnut and referred to the Committee
on Labor and Industry. The committee reported it to the House with
several amendments. The House rejected all but two of these. Now
the uniform law, with the street-trading age limit reduced from
twelve years to ten, and the age limit for breaker boys reduced from
sixteen to fourteen, has reached its third reading in the House. If its
friends can still protect it from the mutilations desired by the glass
interests, the telegraph companies, the textile manufacturers and
other opponents, Pennsylvania will be in a fair way to protect the
29,170 children employed in manufactories in that state.
The uniform law is also pending in Massachusetts, where it met no
opposition in the hearing before the Committee on Social Welfare.
Massachusetts has now a ten-hour day and the uniform law would
bring her into line with Ohio, New York, Illinois, Mississippi and
twelve other states that have the eight-hour day for all under sixteen.
But Massachusetts would lead the country in one respect if
another bill that is likewise before the Committee on Social Welfare
should pass. This provides for a five-hour day and compulsory school
attendance for all workers under sixteen. If this is put into effect it
will set a new standard for the Uniform Child Labor Law, which has
been drafted by the National Child Labor Committee and endorsed
by the American Bar Association. It is based on the best provisions of
the best statutes now in force in the several states. Yet the National
Child Labor Committee, fearing that two five-hour shifts for certain
minors might tend to fasten on industry the ten-hour day for adults,
would suggest that Massachusetts go one step further and fix a four-
hour day for all under sixteen.
Connecticut, Ohio and Michigan will also advance beyond the
standard of the uniform law if bills now pending are enacted.
Michigan, it is true, is not trying to reduce the working day below
nine hours, but merely to extend it to include canneries and four
other occupations hitherto exempt. But Michigan and Ohio propose
to raise the general age limit for employment from fourteen to
fifteen, while Connecticut is considering sixteen years. Ohio intends
also to increase the compulsory school attendance age from fourteen
to fifteen for boys and sixteen for girls, and to require that boys of
fifteen may not go to work unless they have completed the sixth
instead of the fifth grade, the requirement of the present Ohio law
and of the uniform law.[3]
3. The Ohio law has passed both Houses.
The Ohio bill includes, also, the street trading provisions of the
uniform law. Special street trading bills are pending in Iowa,
Nebraska, New York and also, we understand, in Michigan and
Minnesota. Their outcome is doubtful because the average legislator
seems to be blind to the bad results of street trading and cheerfully
reflects the popular view that these “sturdy, little merchants” are all
supporting widowed mothers and headed straight for the White
House.
Many states are coming to recognize the needs of children over
fourteen. This is evidenced not only by the wide discussion of
vocational schools and the bills before the Legislatures of Illinois,
Indiana, Ohio, Massachusetts, New York and other states, but also by
the extension of child labor laws. Thus California, having proved the
advantage of the eight-hour day for women and boys under sixteen,
is considering the eight-hour limit for all under eighteen. Wisconsin
is proposing to enlarge the list of hazardous occupations forbidden
under eighteen and to provide for continued revision in the future by
the Industrial Commission. The prohibition of night messenger
service for those under twenty-one is included in the uniform law, as
pending in Pennsylvania and passed in Delaware, but not in
Massachusetts and Utah, where it has already been enacted. In
Connecticut, a dangerous trades bill is pending and the bill for a
general sixteen year limit includes an age restriction of twenty-one
years for night messenger service. The same night messenger
prohibition was included also in the bills based on the uniform law
that went down to defeat this year in Utah, Idaho, Arkansas, Texas
and West Virginia. Iowa, the only other state in which a night
messenger law has been introduced this year, proposes an eighteen
year limit.
Regulation of hours for all under sixteen was proposed in Nevada.
In Tennessee, there is a bill now before the House Committee on
Labor, providing for an eight-hour day under sixteen instead of the
present sixty-hour week. A second measure adds mercantile
establishments and the stage to the occupations prohibited to
children under fourteen. Still another bill has passed in Tennessee,
enlarging the Factory Inspection Department by adding a clerk and
two deputy inspectors. The matter of enforcement has not received
as wide consideration as it deserved. Industrial commissions are
under discussion in many states, notably California and Ohio. In
Iowa it is proposed to create within the Labor Department a bureau
of women and children. Montana’s educational bill would provide for
truant officers to enforce the child labor law. In Wisconsin a bill is
pending covering some details of the issuing of employment
certificates and in Utah it was proposed to increase the number of
inspectors. Most important in this connection is the bill in Missouri
to extend the jurisdiction of the Factory Inspection Department over
the entire state (it is now confined to cities of 10,000 or more
inhabitants) and to abolish the present fee system.
 Two of the bills recommended by the New York Factory
Investigating Commission and directly affecting child labor are still
pending: one to prohibit work in cannery sheds by children under
fourteen, and the other to prohibit the manufacture in tenement
houses of dolls or dolls’ clothing and articles of food or of children’s
or infants’ wearing apparel. Other bills recommended by the
commission and already passed and signed standardize the issuing of
employment certificates throughout the state; give the commissioner
of labor power to inquire into the thoroughness of this work as
carried on by local health officers; provide for physical examination
in factories of children fourteen to sixteen. This last provision
promises to be better than the present Massachusetts law because it
permits the cancelling of employment certificates of children whom
the examination reveals to be physically unfit for factory
employment. Following the recommendation of the commission the
present Legislature has also reorganized the Labor Department,
established an industrial board, increased the number of inspectors
and extended the jurisdiction of the Labor Department to cover the
enforcement of the labor law concerning women and children in
mercantile establishments in second class cities.
In a few states there is a fair record of progress in the legislation
already enacted this year. New Jersey and Indiana have brought their
educational requirements and provisions for working certificates up
to the standard of the uniform law. Vermont has established a nine-
hour day and Rhode Island a ten-hour day. The Vermont law also
does away with the twelve year limit in certain occupations and
substitutes the provision that
“A child under sixteen years of age, who has not completed the course of study
prepared for the elementary schools shall not be employed in work connected with
railroading, mining, manufacturing or quarrying, or be employed in a hotel or
bowling alley, or in delivering messages, except during vacation and before and
after school.”
Along with this the law has an absolute fourteen-year limit in
“mill, factory, quarry or workshop, wherein are employed more than
ten persons.” In North Carolina a bill was introduced with a
fourteen-year age limit and a prohibition of night work, but the age
limit was immediately amended back to the old thirteen (twelve for
apprentices), the increased appropriation for inspectors was cut out,
and only the night work prohibition was passed. The Child Labor
Commission in Delaware drafted a bill based on the uniform law,
which, in a much mutilated form, was finally passed and signed.
Only a few backward states show no progress whatever. Georgia
defeated a child labor bill last summer. Alabama has no legislative
session until January, 1915. The Florida Legislature has just
convened and a bill based on the uniform law will be introduced. No
child labor bill was introduced in South Carolina but a compulsory
school attendance law was passed by the Legislature, only to be
vetoed by the governor. The House passed it again over the
governor’s veto, but it failed in the Senate by two votes. In New
Hampshire, the only northern state with a general twelve-year age
limit, a bill providing for a fourteen-year limit has been unanimously
reported to the House and there seems to be a good chance of
passing it.
The National Child Labor Committee is watching the situation and
helping where it can in these campaigns. It hopes to report many
more victories when the legislative season closes. Meanwhile it
appeals to the citizens in every state to aid in the enactment and the
enforcement of these laws.
 [4]
ETERNITY AND A PENNY PILL
RICHARD C. CABOT, M. D.
4. See Courses on Sex Hygiene. By Jane R. McCrady on page 124 of this Issue.
There are some things (chocolate, for instance, or tracts, or paper
drinking-cups) that can be shot out of a slot at you and hit their
mark. You can apply them to their uses at once. It is the same with
the facts fired at you through the window of his booth by the railroad
information man. Such facts set you on your track or your train at
once.
But when people ask for clear directions about the train to
proficiency in violin playing, belief in immortality, or understanding
of sex, they always miss their train. Sometimes they complain of the
officials.
After a course of lectures on sex last year some workers of my
acquaintance handed in written questions beginning “What should I
say to a young girl who,” etc., and were disappointed when no
definite answer was forthcoming. To illustrate the difficulties of an
answer let us ask a few parallel questions:
What paint shall I use for a Madonna?
What are the best words to use in a love sonnet?
What is the best book on being a millionaire?
What kind of bread makes you popular and handsome?
What liniment makes one’s sympathies most supple?
People rush to lectures on “sex hygiene,” sometimes for good
reasons, sometimes to satisfy morbid curiosity, but often with a
pathetic hunger for the bread of life. In the hope of forestalling such
disappointments the lecturer should hang up before them a sign
reading:
“This lecture will not solve fundamental problems. Seek ye the Lord.”
 THE DAWN OF A BETTER DAY
A MANUFACTURER SPEAKS
Dudley D. Sicher
[This poem was read at a banquet of the Cotton Garment Manufacturers
of New York during the last week of March. The author, a representative
manufacturer, dedicated these verses, reflecting a new attitude toward
employes, to his business associates.—Ed.]

Do we purchase Toil at the lowest rate

As we buy our cloth and thread?
Do our workers labor long and late
For the price of their daily bread
In gloomy lofts where shadows frown,
In foul, unwholesome air,
Till Want and Weariness drag them down
Where—we neither know nor care?
If such things be, they must pass away
Ere we hail the Dawn of a Better Day.

Have they wrought us harm in the darker days,

Have they kept the whole truth hid?
Have they told false tales of our works and ways
And of wrongs that we never did?
Be not too wroth at the hiss of shame,
But pass old slanders by.
And cleanse your shirts of the taint of blame
Where e’er the blame may lie.
Old feuds, old sores be forgot for aye
In the hopeful Dawn of a Better Day.

Let us wipe the slate of the bitter score,

Let us turn the blotted page,
And grant that we owe our workers more
Than the dole of a “living wage.”
They give us more than their time and skill
In the health and strength they spend;
And earn the right to the kindly will
And helpful hand of a friend.
We must give them more than the coin we pay
Ere we hail the Dawn of a Better Day.

So, here’s a task that we may not shirk,

For the toiling thousands plead;
We must give them comfort while they work
And help in every need;
We must lend them strength if their souls are weak
And teach them how to live;
Nor let us, all to meanly seek
Return for all we give,
As we lift our eyes for the gladdening ray
Of the golden Dawn of a Better Day.

If this light that leads us shall not dim

They will see, ere the course is run,
That the worker’s weal and the weal of him
Who owns the shops are one.
Then each shall have his rightful gain
Ungrudged—and great and small
Shall give their best of hand and brain
For the good of each and all,—
And we’ll stand together, come what may
In the brighter Dawn of a Better Day!