1915 The Lancet  
May 29th opens up a question that I have often asked myself : When is a pulsus alternans not a pulsus alternans, so far as its now usually accepted gravity of prognosis goes ? Dr. Hawthorne, alluding to this, gives at the end of his paper the case of a young woman who has not died as she should have done, and his earlier remarks and the tracings given from sphygmograph and manometer seem to me to suggest the answer. In thus showing that a pulsus alternans is of quite a common occurrence, he
more » ... ribes what surely must be the common experience of us all. Everyone must be familiar with the fact that at the radial pulse at the wrist every heart beat need not have an equivalent value, and this variation may range from complete intermission down to a lessening of force that cannot be recognised by the finger. One had almost said when we are dealing with a muscular organ such as the heart with the variety of minor details that energise it and detract from its nervous supplies, it could hardly be otherwise. This in nowise detracts from the value of the observation that there is a pulsus alternans that has a grave significance ; it does go to show that one may expect at times a pulsus alternans that has not such an ominous outlook. And surely there must be many who have lived-well ! to pre-senility-who have met with this condition many a time, with a form but not the grave form of pulsus alternans. I have also met occasionally with a sort of double pulsus alternans, two full beats followed by two small beats, that had no serious meaning. Then how are we to distinguish between the two ? I may leave others to answer this question. For myself I shall only venture to suggest that the serious form generally goes with signs of cardiac failure, whilst the alternation to which I am directing attention comes and goes-sometimes the rhythm may change two or three times in one examination-and maybe in quite young people who have no signs whatever of any cardiac distress. It is clearly a neuromuscular eccentricity of action that has no serious meaning. There are other points in Dr. Hawthorne's paper quite well worth taking up, and chief of them, to my mind, is the comparative value of the sphygmograph and the manometer. It has always seemed to me that the latter is a much less precise and reliable instrument than the sphygmograph which has so much yielded place to it. There can be no doubt that the facts of the pressure gauge, if so I may call the manometer, require the most careful valuation before drawing inferences therefrom. I am, Sir, yours faithfully, May 31st, 1915.
doi:10.1016/s0140-6736(01)66747-3 fatcat:ei3sx3p6d5a4pgzbfhwgwrrlte