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Stages in operation.A, prostatic urethra and lateral lobes exposed.B, bladder flap sutured between lateral lobes.

raw cavity or cutting the lateral prostatic arteries therisks of haemorrhage and infection are reduced. Ina series of fourteen patients, the results have shownthat this concept is valid-they all passed urine withease immediately after operation and none had a

severe hxmorrhage. The series comprised four

patients with valve replacements, four with pace-makers, four Jehovah’s witnesses, and two with theso-called small fibrous prostate.The operation is relatively simple for anyone con-

versant with retropubic surgery.After emptying the bladder, a sound is passed and an

incision made on to the sound from the bladder neckdownwards from the transverse vein, the dimple of Millin,to expose the veru montanum (see accompanying figure A).This incision may be facilitated by using a sound witha groove cut on the concave surface to direct the knife.It is not necessary to continue the incision below theveru, so the external sphincter is not at risk. With amini-boomerang a full-length suture is inserted into theprostatic capsule in the midline at the level of the apexof the lateral prostatic lobes. This suture is tied so thatequal lengths are left for the capsular closure. Theexposure of the posterior urethra can be made easier bythe use of a Morson anterior retractor. The midlineincision is then extended from the bladder neck upwardsand outwards on either side for about four centimetres.A Harris catheter is passed and a nylon stitch placedthrough the catheter some eight or ten centimetres fromthe tip. This stitch allows the catheter to be used as aT tractor when finally closing the bladder incision. One

length of the anterior capsular suture is then passedthrough the apex of the bladder flap and tied to its fellow.The bladder flap is pulled down to below the veru mon-tanum (figure, B). The two lengths of suture are thenused as a continuous suture to join the urethral mucosaoverlying the lateral prostatic lobes to the bladder mucosaof the anterior flap. The mini-boomerang allows themuscle of the prostatic capsule, the urethral mucosa, thebladder mucosa, and the bladder wall to be taken in acontinuous stitch. The anterior aspect of the prostaticcapsule has pre-capsular veins which can be tied and

capsular veins which need to be sutured, but there is no

major arterial supply provided the incision is kept to themidline.

This somewhat novel approach to the problem ofprostatic obstruction is not put forward as a stand-ard method; but in certain patients it is a possiblealternative to catheter life, or an operation while thepatient is on anticoagulants. It results in an epithe-lialised prostatic urethra without sloughs and a

bladder neck that is sufficiently open to allow the

patient to pass his water with pleasure.There have been few inquiries or investigations

carried out to determine why men develop adeno-matous enlargement of their prostates. Whether itis due to hormones or to the effects of social or sexualenvironment as suggested by Schlotthauer, of the

Mayo Clinic, has never been decided.The obstruction at the bladder neck, the inter-

ference with function, is a separate problem sincethis may occur with large or small prostates. Obstruc-tion may be produced by a variety of circumstances-overstretching the detrusor muscle, tightening of thebladder neck possibly by exposure to cold or sym-pathetic stimulation, sudden increase in the size ofan adenoma by, for example, infarction; but the

degree of obstruction is not directly related to thesize of the prostate. Alteration in function may bea more important factor than anatomical size. Con-sequently, the surgical removal of an anatomical massmay be only one method of dealing with this problem;and under certain specific conditions one may bejustified in enlarging the bladder neck opening, with-out excising the prostatic adenoma. The object ofthe exercise-to restore normal micturition withminimal surgical risk-can be achieved by a relativelysimple operation which avoids the possibility of

haemorrhage or infection.

REFERENCES1. Murphy, L. J. T. The History of Urology; p. 399. Springfield,

Illinois, 1972.2. Turner-Warwick, R., Whiteside, C. G., Arnold, E. P., Bates, C. P.,

Worth, P. H. L., Milroy, E. G. J., Webster, J. R., Weir, J. Br. J.Urol. 1973, 45, 631.

3. Wallace, D. M. Proc. R. Soc. Med. 1951, 44, 434.4. de Bono, E. The Use of Lateral Thinking; p. 1. London, 1967.

A Fresh Look at Cardiac Arrhythmias

ELECTROCARDIOGRAPHIC DIAGNOSIS*

DENNIS M. KRIKLER

Cardiovascular Division, Royal Postgraduate MedicalSchool, London W12 0HS

THE key to arrhythmia analysis lies in a search forp waves and appraisal of QRS morphology. A logicalapproach to the E.C.G. tracing can be helped by theuse of a flow-diagram (fig. 28), in which tachy-arrhythmias are subdivided according to the regu-larity or otherwise of the ventricular response,followed by consideration of these factors. This doesnot cover some of the more complex but less commonarrhythmias, which require scrutiny for otherfeatures.4o,41 Nevertheless, with a plan like this the

diagnosis can be reached in the majority of cases.

Where the E.c.G. provides insufficient information,intracardiac electrography may be needed.

INTRACARDIAC ELECTROGRAPHY

Under local anaesthesia one or more electrodecatheters are inserted percutaneously into a peripheralvein and, under fluoroscopic observation, passed intothe heart. One is positioned next to the septal leafletof the tricuspid valve, when deflections due to

* The third of 4 articles.

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depolarisation of the low right atrium, bundle ofHis, and right ventricle can be recorded (His-bundleelectrogram) and analysed in conjunction with simul-taneously recorded surface E.C.G. leads.42.43 Withadditional electrodes, recordings can also be obtainedfrom the high right atrium (fig. 29), right ventricle,coronary sinus, and (using trans-septal puncture) leftatrium. Rapid pacing at one of these sites may help

Fig. 29-Normat His-bundle electrogram (H.B.E.), with simul-taneous high right atrial electrogram (H.A.E.) and surfaceE.C.G.

Fig. 30-Intracardiac electrogram, abbreviations as in fig. 29.L.A.B.= low right atrial electrogram. The first four com-

plexes represent paroxysmal reciprocating A.v.-nodal tachycardia;note that retrograde atrial activation (A’) occurs earlier in L.A.E.than H.A.E. The tachycardia is terminated by an electric stimulus(st) in the atrium, and the last three complexes are sinus beats inwhich atrial activation occurs earlier in H.A.E. than in L.A.E.

elucidate conduction disturbances. The intervalbetween the low-right-atrial complex (A) and the Hisdeflection (H) represents the intranodal conduction-time which, at heart-rates of 80 a minute, is usually50-120 msec.; H-v or H (from H to the onset ofthe ventricular complex on the His-bundle electro-

gram or surface E.c.G., respectively) indicates the

passage of the impulse through the His-Purkinjesystem and is normally 35-55 msec., irrespective ofthe heart-rate 44 With rapid atrial pacing the A-Hinterval lengthens until, physiologically, at rates ofabout 160-180 beats a minute, partial A.v. nodalblock develops; with ventricular pacing retrograde(v.-a.) conduction also lengthens, but the H-v timedoes not vary in this way. The normal supero-inferior direction of atrial activation is indicated byearlier high than low right atrial deflections; thereverse applies in A.v.-nodal reciprocating tachycardia(fig. 30).

Prolongation of the A-H interval is a good indica-tion of partial A.V. nodal block, though when the P-Ainterval (normally 25 msec.) is lengthened and A-H isnormal, sinoatrial block should be inferred. Shorten-

ing of A-H is usually due to a bypass short-circuiting

Fig. 31-Intracardiac electrogram. W.P.W. syndrome, showingH deflection after onset of QRS complex in surface leads.R.A.E. =right atrial electrogram.. -

* bundle branch block or aberrant or anomalous conduction.

Fig. 28-Flow diagram showing electrocardiographic diagnostic approach to tachyarrhythmias.After each situation is recognised (block capitals), statement in parentheses provides the next question.

976

the A.v. node only, especially if pacing fails to prolongit (L.G.L. syndrome). Lengthening of H-V indicatesdisturbance of conduction in all fascicles of thebundle branches and is usually accompanied by E.c.G.evidence of complex bundle-branch-block pattems.45H-v shortening is characteristic of the W.P.W. syn-drome (fig. 31) and may be exaggerated (often so thatH follows v) by rapid atrial pacing ; with ventricularpacing, retrograde (V-A) conduction is also rapid.

In complete heart-block the A-H-v relationshipindicates the level of the lesion; if nodal, the sub-sidiary QRS complexes are usually narrow, and each His followed by a v at a normal interval. With distalblock, there is a normal A-H relationship, but the vwaves are independent and the QRS complexes usuallywide. It may even be possible to locate the blockwithin the bundle of His if the H wave is split, withseparate P-H and H-v relationships.4’ When ventri-cular extrasystoles penetrate upwards, the H deflec-tion may differ in configuration, indicating retrogradeactivation.47

This basic technique has been amplified (pro-grammed electric stimulation) 48; the heart is pacedat a constant rate, and an extra stimulus is intro-duced after every 8-10 driven beats. The intervalbetween the last regular and the extra beats can beadjusted, the refractory period of the tissue studiedbeing shown when the stimulus is too premature tobe conducted. This technique will bring to lightmasked pre-excitation and enable the refractoryperiods of the A-v node and bypass to be calculated;retrograde conduction studies, stimulating the rightventricle, are often very useful. An atrial extra-

systole may thus find the bypass blocked, traverse

the A.V. node anterogradely, and return up the thennon-refractory bypass-the mechanism of recipro-cating tachycardia in the W.P.W. syndrome (fig. 32).Ventricular extrasystoles may have the same effect,returning up the bypass and down the A.v. node; theanalogous situation is seen with A.v.-nodal recipro-

Fig. 32-W.P.W. syndrome with reciprocating tachycardia (samecase as fig. 31).K=anomalous bypass, H=normal pathway. Second and

fourth complexes show right-bundle-branch-block pattern. Notenormal H-v-time.

cating tachycardia. Conversely, a suitably timed

premature beat interrupts the circuit and stops the

tachycardia (fig. 30); in such studies the effects of

drugs can be observed 49 .

In sinus rhythm the right atrium is activated beforethe left, but the sequence is disturbed in reciprocat-ing A.v. tachycardias, as seen on simultaneous leftand right atrial recordings. When the mechanisminvolves the A.v. node, retrograde right and left atrialactivation is virtually simultaneous, but in the W.P.W.syndrome the atrium harbouring the bypass willreceive the returning impulse before the other; withmultiple bypasses this will indicate which is active.50When surgery is contemplated for intractable

arrhythmia, it is preceded by epicardial mapping, inwhich the earliest area of activation of the affected partis identified at open heart surgery, by means ofneedle electrodes. In this way a bypass can belocalised in the W.P.W. syndrome 51 and the affectedarea identified in ectopic atrial tachycardia 52 andventricular tachycardia.53

REFERENCES40. Schamroth, L. Circulation, 1973, 47, 420.41. Phillips, R. E., Feeney, M. K. Cardiac Rhythms. London and

Philadelphia. 1973.42. Latour, H., Puech, P. L’Eectrocardiographie Endocavitaire. Paris,

1957.43. Scherlag, B. J., Lau, S. H., Helfant, R. H., Berkowitz, W. D.,

Stein, E., Damato A. N. Circulation, 1969, 39, 13.44. Damato, A. N., Lau, S. H., Helfant, R. H., Stein, E., Berkowitz,

W. D., Cohen, S. I. ibid. p. 287.45. Spurrell, R. A. J., Krikler, D. M., Sowton, E. Br. Heart J. 1972,

34, 1244.46. Smithen, C. S., Krikler, D. M. ibid. p. 735.47. Puech, P., Grolleau, R. L’Activité du Faisceau de His, Normale et

Pathologique. Paris, 1972.48. Wellens, H. J. J. Electrical Stimulation of the Heart in the Study

and Treatment of Tachycardias. Leiden, 1971.49. Krikler, D. M., Spurrell, R. A. J. Postgrad. med. J. (in the press).50. Spurrell, R. A. J., Krikler, D. M., Sowton, E. Am. J. Cardiol. 1974,

33, 171.51. Burchell, H. B., Frye, R. L., Anderson, M. W., McGoon, D. C.

Circulation, 1967, 36, 663.52. Coumel, Ph., Aigueperse, J., Perrault, M.-A., Fantoni, A., Slama,

R., Bouvrain, Y. Ann. Cardiol., Angéiol. 1973, 22, 189.53. Spurrell, R. A. J., Sowton, E., Deuchar, D. C. Br. Heart J. 1973,

35, 1014.

Medical Alliance

BAREFOOT DOCTORS IN CHINA

CHI WENPeking

BEFORE liberation in 1949, the working people ofsemi-colonial, semi-feudal China-a country longsubjected to imperialist aggression-weie ruthlesslyexploited and oppressed and lived in dire poverty.They had virtually no medical service. This wasespecially’ true for rural China where 80% of thenation’s population lived. Some counties had

poorly equipped medical institutions and privatedoctors, but the general picture was one of acute

shortage of medicine and doctors. A popular sayingin those days went: " Just put up with it when you’renot well, stay in bed if you get worse, and die if

you’re seriously sick."Since the founding of New China, the People’s

Government has taken a number of effective measuresto carry out the principles of serving the workers,peasants, and soldiers, putting prevention first,