SOME NOTES 
ON THE 
TREATMENT OF MORBUS CORDIS 
BY 
IODIDES AND OTHER DRUGS WHICH LOWER 
THE BLOOD-PRESSURE. 
BY 
A. HAIG, M.D. (Oxon.), F.R.C.P. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, SEPTEMBER ib, 18Q5 
DETROIT, MICH. : 
GEORGE S. DAVIS, PUBLISHER.' 
1895. Some Notes on the Treatment of Mor- 
bus Cordis by Iodides and other 
Drugs which lower the 
Blood-Pressure. 
SO far as I can recollect the teaching of my 
student days, the treatment of morbus 
cordis seemed to consist of little else than the 
prescription of digitalis, strychnine, or iron, 
either singly or in combination, with perhaps 
an occasional dose of nitrite of amyl. Since 
that time, however, we have not only had to 
add a considerable number of more or less 
useful drugs to our list, but we have also, a 
more complete and workmanlike grasp of the 
physics and physiology of the circulation. 
To-day there are quite a large number of 
heart or circulatory troubles in which the use 
of digitalis is not even thought of, or is con- 
sidered only as a possible adjunct to other 
drugs; and, further, there are cases in which 
we know that, though the heart is apparently 
failing, digitalis may do absolute harm and 
make matters worse. 
From this point of view it has seemed to me 
that one of the most useful remarks in Sir Wil- 2 
liam Broadbent’s well-known work on “The 
Pulse,” published in 1890, is that on page 262, 
where, speaking of the pulse in kidney-disease, 
he says, “ Greater service is often rendered to 
an overweighted heart by relieving it of work 
than by endeavoring to improve its strength 
and a few lines farther on he adds, “ unless it 
[the heart] is completely worn out, there is a 
possibility that a diminution in the resistance 
may enable it to resume its command over the 
circulation.” 
Did time permit, I think I could show that 
there are a number of conditions in which kid- 
ney-disease takes no part, in which, neverthe- 
less, far more good may be done by diminish- 
ing the work the heart has to do than by 
endeavoring to improve its strength with 
digitalis. 
But be this as it may, it is to this side of the 
treatment of morbus cordis, by diminishing the 
resistance it has to overcome, that I wish to di- 
rect your attention to-night. 
To a certain extent this is a very old obser- 
vation, for it has long been recognized that 
rest in bed did as much for morbus cordis as 
any drugs; but here, again, the more recent 
treatment by exercise must have been a surprise 
to many, and seems at first sight almost a con- 
tradiction of previous experiences. 
But when we come to look into the matter 
more closely, I think we shall see that the one 
effect common to the use of baths, exercises, 
iodides, opium, mercury, nitrites, ammonia, 
alcohol, ether, and other drugs is that they re- 
lax the arterioles and capillaries all over the 
body and thus lessen the resistance the heart 
has to overcome. 3 
With regard to many of these drugs, I have 
already pointed out elsewhere* the way in 
which they produce this relaxation of the 
arterioles and capillaries; but that does not 
concern us just now. 
In this connection I was much interested to 
see in the current number of the Practitioner a 
paper by Dr. John Broadbent and Sir William 
Broadbent on the treatment of morbus cordis 
by baths and exercises of the Schott system, in 
which, after considering the explanation of 
their action given by the authors of the system, 
they conclude that the baths act by dilating the 
vessels in the skin, and the exercises by di- 
lating the vessels in the muscles; so that both, 
either separately or together, diminish the work 
of the heart. 
It appears to me to be practically certain 
that this is the real explanation of their good 
effects, and that the writings of Dr. Bezley 
Thorne f and others have demonstrated in a 
very interesting manner the great and rapid 
effects on the position of the apex and the area 
of cardiac dulness which these changes of re- 
sistance produce. And where such effects are 
produced, we can no longer have any doubt of 
the enormous power which the resistances at 
the periphery have over the central organ of 
the circulation. 
It is all very well to read Sir William Broad- 
bent’s statement (previous reference, page 153) 
that under certain conditions the peripheral 
arterioles may contract so completely as to 
bring the heart to a dead stand; but if you 
* Medico-Chi. Trans., vol. lxxvi. p. 113, and “Uric 
Acid,” second edition, 1894. 
f Lancet, 1894, vol. i. p. 1117. 4 
watch for yourself the alteration of the apex 
and the area of dulness of the heart, as you keep 
the peripheral vessels dilated in renal disease or 
in other conditions of high tension, or listen to 
the different sounds made by the aortic valves 
under the two conditions, you will realize what 
these things are and what they mean for the 
heart far more completely than it is possible to 
do from any printed description. 
Let any one who suffers from migraine listen 
over his aortic valves when the pain is severe 
and again when it has passed away, and he will 
never again doubt the effects of contracted ar- 
terioles on the work of the heart and the pressure 
in the aorta. 
It is interesting to note in passing that baths 
and exercises which dilate the arterioles will 
promptly cure this headache, and that it passes 
away as soon as the dilatation of vessels is com- 
plete, just as it does under the influence of mer- 
cury, opium, or any other of the drugs mentioned 
above. 
Similar observations may be made in mental 
depression associated with high blood-pressure, 
and in similar functional conditions up to 
Bright’s disease itself; and in mental depres- 
sion the good effects of exercise have been 
pointed out by Professor Lange, of Copen- 
hagen, and others. 
In thus speaking of the good effects of baths, 
exercises, and drugs, that dilate the arterioles 
and capillaries and lessen the work the heart 
has to do, we must not, I think, lose sight of 
the further fact that in dilating or allowing the 
dilatation of the capillaries all over the body 
they of necessity dilate those of the heart itself; 
so that they not only reduce the work it has to do, but at the same time improve its interstitial 
circulation and its nutrition. 
Before going on to the application of our 
knowledge to every-day work, I will show three 
sets of pulse tracings,—A showing the effects of 
exercise, B the effects of opium, and C the 
effects of iodides. 
A, I think, speaks for itself, the difference 
between the fairly normal pulse at the top and 
the tracings below being very marked. 
B has at the top the pulse of opium, being 
fairly quick and moderately soft; and below, 
in contrast with this, the pulse of what I have 
called the opium rebound; and it is well 
known that if a single dose of opium is taken, 
there will come in the following twelve hours a 
feeling of headache, depression, malaise, and if 
the pulse is then examined, it will be found to 
be slow and will yield tracings such as those in 
the lower part of B. 
I have elsewhere* pointed out the way in 
which opium acts in causing, first, relaxed ar- 
terioles and low tension, and then a rebound, 
with contracted arterioles and high tension, 
and also the way in which this latter condition 
may be avoided. 
In the two middle tracings at the lower part 
of B there is a further point of interest, as the 
pulse is irregular, with imperfect systoles in 
the upper and drops a beat in the lower, thus 
demonstrating, as I believe, how great a trial 
this high blood-pressure is to the power and 
regularity of the heart’s action. 
And this constitutes, to my mind, the great 
5 
* “ Influence of Opium and Morphine on Uric Acid” 
[Brit. Med. Journ., 18S9, vol. ii.), and “Uric Acid,” 
second edition, p. 33. 6 
B. Well being produced by opium; pulse, 76; low blood-pressure. 
Rebound after opium; pulse, 58, 65, and 68; high blood pressure. 7 
A. A fairly normal pulse tracing rendered quick. 
Effects of exercise. 8 
A. II., November 15, 1892, 11.20 A.M.; rate, 86; tension slight; second day after iodides. Threats of rebound each 
morning early, going off later on. 
A. II., 14, 1892, 11.20 A.M.; rate, 90, soft; well-being of iodides taken yesterday continues. 
C. Soft pulse under iodides; blood-pressure low. 
A. H., November 13, 1892, 11.20 A.M.; rate, 92. 
First after capsule, second; pulse-rate, 85. 
Same under iodide of ethyl. drawback to the use of opium in morbus cordis, 
that when you reduce the dose or leave it off, 
you will get a rebound with very high blood- 
pressure, which is a dangerous condition, 
rendering the patient liable to heart-failure, 
on the one hand, or rupture of a vessel in the 
brain, on the other. 
C shows the effects of the iodides; the three 
upper tracings of iodide of potassium and so- 
dium, and the bottom one of the inhalation of 
iodide of ethyl. 
The second and third tracings are given to 
show that the effect of an iodide given on 
the thirteenth day continues on the fourteenth 
and fifteenth, and this is, I think, the most 
important point about the reduction of blood- 
pressure by iodides, that it is fairly steady and 
continues for some considerable time. 
The iodides, however, like opium, are fol- 
lowed by a rebound, but this rarely gives much 
trouble till they have been taken for weeks or 
perhaps months, and meanwhile the heart’s 
nutrition ought to have very greatly im- 
proved. 
The rebound after iodides can be prevented 
just like that after opium, and by the same 
means ; and in cases such as those of chronic 
Bright’s disease, which often have to take these 
drugs for years, it is necessary to do this now 
and again from time to time by giving a short 
course of salicylate of sodium to carry off the 
accumulated uric acid (see previous references 
in the case of opium). 
With regard to the cases in which drugs that 
lower the blood-pressure are of use, we may 
divide morbus cordis into two large groups : 
A, those in which the heart fails on account 
9 of valvular, pericardial, or other mechanical 
lesion of its structure. 
B, those in which it fails mainly on account 
of excess of work from contracted arterioles 
and high blood-pressure. 
A includes most cases of rheumatic morbus 
cordis as met with in early life, and here digi- 
talis finds its most useful field; but even here 
there are not a few cases in which it is an ad- 
vantage to combine with the digitalis some 
drug, as an iodide, which will insure that the 
arterioles are not adding to the heart’s troubles 
by undue contraction. 
B includes the morbus cordis of advanced 
life, which originates more often in high blood- 
pressure than in rheumatism, and here digitalis, 
with its power of adding to the contraction of 
arterioles, may be decidedly harmful, while the 
iodides, which relax the arterioles and lower 
blood-pressure, find their greatest utility. 
I could easily give more cases of these con- 
ditions than you would have time to listen to; 
but as my special object is to point out the 
utility of drugs that lower the blood-pressure, I 
shall content myself with pointing out the chief 
clinical features of cases in Class B, in which 
they are specially useful. 
A patient in middle life, or past it, complains 
of irregularity or intermission of the heart’s ac- 
tion, perhaps of pain in the chest or shoulders ; 
the pain may be worse on exertion and the 
breath rather short. 
There may be slight oedema of the ankles, 
slight enlargement of the liver. 
On examining the chest, the second sound 
of the heart is decidedly loud both over the 
aortic area and at the apex, and in later stages 
10 11 
the loud second sound may be followed by the 
whiff of aortic regurgitation. The apex is some- 
what displaced to the left and is ill defined ; the 
first sound is long, or it may be reduplicated, 
or followed by a murmur of mitral regurgitation, 
due to dilatation and slight incompetence of 
the mitral valves. 
The pulse-rate may have been slow, but with 
the general signs of cardiac dilatation and fail- 
ure it has probably quickened up to 80 or 90, 
and yet the second sound is decidedly loud 
and the first sound long or reduplicated at the 
apex. 
There is no history of acute rheumatism, 
and the whole of the circulatory troubles may 
be the result of more or less chronic contrac- 
tion of arterioles and high blood-pressure so 
common at this time of life, and occurring 
either as the initial stage of Bright’s disease 
(pre-albuminuric stage of Mahomed) or in its 
course. 
The obvious indication is at once to relax 
the arterioles and lower the blood-pressure, and 
if you are able to do this and keep the arteri- 
oles relaxed for a considerable time, you may 
find that the heart not only completely recovers 
itself, but that you have at the same time pre- 
vented or greatly delayed the appearance of the 
more definite symptoms of Bright’s disease. 
The action of iodides, opium, etc., on the 
blood-pressure and the heart’s action has, I am 
aware, been pointed out by many people, both 
in this country and abroad; but I alone have 
been able to give an explanation of their action 
which applies not only to the iodides, but also to 
a large number of drugs which may be relied on 
to produce almost equally good results in mor- 12 
bus cordis, and my knowledge of their action 
also enables me to prevent them doing harm 
when the rebound occurs. 
I have also been able to explain completely 
why a diet in which milk is the only animal 
food is (as has long been known) so great a 
help to the drugs in keeping the blood-pressure 
low. 
I conclude, then, that in the morbus cordis 
of middle or later life there are no more im- 
portant drugs than those which, like the iodides, 
relax the arterioles and lower the blood-press- 
ure ; while those, like digitalis, which contract 
the arterioles and raise the blood-pressure may 
do great harm. 
The one danger in the use of the drugs 
which relax the arterioles is that their sudden 
intermission may cause extreme contraction of 
arterioles and very high pressure, as exemplified 
in the case of opium; but when their mode of 
action is kept in mind, such cause of danger 
can generally be prevented, and if the diet is 
also altered, very high blood-pressure can be 
rendered practically impossible for the future. MAY 15. 1895. 
WHOLE SERIES. VOL. XIX. 
THE 
Therapeutic Gazette 
A MONTHLY JOURNAL 
— op— 
General, Special, and Physiological Therapeutics. 
No. 8. 
THIRD 9BRIES. VOL. XIV 
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