[Reprinted from the Transactions of the Philadelphia County Medical Society, March 11,1891.] 
ARTERIO-CAPILLARY FIBROSIS; 
By AUGUSTUS A. ESHNER, M.D., 
Every cell inherits from its parent cell a certain lease of life, at the 
end of which physiological death occurs. This period, however, may 
be influenced by external conditions. Premature death is patho- 
logical. We cannot recognize a pathological longevity. Similar 
laws apply to the human individual, the composite of a vast aggrega- 
tion of cells of widely differentiated function. 
The life of man may be divided into three periods : that of evolu- 
tion, of growth, of development; that of maturity, of perfection ; and 
that of involution, of decline. The first begins with birth, the last 
ends with death. 
During the period of growth and development, tissue-change and 
destruction—catabolism—are more than offset by tissue-construction 
and repair—anabolism. Nutrition exceeds waste. Building-up <is 
more active than tearing-down. With the activity of life comes the 
demand for the highest differentiation of function of which the organ- 
ism is capable. This represents the perfect individual. For a time, 
a condition of equilibrium is maintained. Sooner or later, however, 
the tide begins to turn. The equilibrium is disturbed. Waste exceeds 
repair. The cellular assimilative function becomes impaired, the con- 
stitution of the nutritive fluids defective. Tissues and organs are 
imperfectly furnished with the materials for their maintenance. Vas- 
cular changes occur. In a vicious circle, one baneful influence reacts 
upon another. The entire organism is reduced to a condition of 
deterioration. Finally, the state of nutrition falls to so low a level as 
to be insufficient for the purposes of life, and functional activity comes 
to a standstill. This is the physiological process,' as it occurs at 
advanced age, and constitutes the condition of senility. Occurring at 
an earlier period, however, the process becomes pathological, recog- 
nized clinically by signs and symptoms which may be conveniently 
included in the designation premature senility. 
As the component parts of the organism depend for their sustenance 
upon the nutritive elements of the blood, so will their functional 
stability be governed by the quality and quantity of the circulating 
medium. Thus, we would be led to look to the blood as containing 
the excitant which induces the earliest changes. The function of the 
cell once impaired, the deleterious action of the blood would be aug- 
mented by the retention of matters which it was the part of the cell to 
remove, and the addition of products from the degeneration of the cell. 2 
Pathologically, the condition under discussion may be considered a 
general fibrous substitution and hyperplasia, displacing parenchyma- 
tous structures and narrowing the lumen of arteries and capillaries; 
hence the names arterio-capillary fibrosis, arterio-sclerosis. 
The histological changes may arise in one of two ways, or in a com- 
bination of both. When tissue degenerates or is destroyed, nature 
endeavors to make restoration. The attempt is often only partially 
successful. The newly-formed tissue is apt to be of a lower grade than 
that which it replaces. The more highly organized the latter, the 
wider, of course, is the variance. In this way, fibrous tissue takes 
the place of vital structure. This is illustrated in the cicatrix, be 
it cerebral or cutaneous or parenchymatous. Under other circum- 
stances, there occurs a primary hyperplasia of preexisting connective- 
tissue, perhaps of a subacute or slowly chronic character, displacing 
the tissue proper to the organ, and finally leading to its disorganiza- 
tion. These two processes may be illustrated by the modern patho- 
logical conceptions of the changes that occur in certain diseases of the 
central nervous system. In the acute inflammatory disease known as 
anterior poliomyelitis, the destruction of the ganglion cells in the 
anterior horns of the gray matter of the spinal cord is followed by a 
reparative process, in which fibrous tissue replaces that which has 
been destroyed. In the systemic scleroses, posterior and lateral; in 
the degenerations, ascending and descending, primary destruction of 
axis-cylinders takes place, with secondary substitution of fibrous 
tissue. In insular sclerosis, on the other hand, there is at first an 
increase in the connective-tissue, followed by gradual destruction of 
nerve-elements and interruption of function. The difference is that 
between inflammation and cirrhosis. Solid viscera may be unchanged 
in size. They are rarely enlarged, but often shrunken, from contrac- 
tion of the fibrous elements. The coats of the vessels are thickened, 
and their lumen narrowed. In whatever structure the process begins, 
it is slowly progressive, especially if the exciting influence be main- 
tained. The change, as it affects the arteries, is to be distinguished 
from atheroma, with which it may be associated. Both are evidences 
of senile disorganization. In atheroma, however, the process is one 
of fatty degeneration of the intima, giving rise to ulceration, which is 
in turn followed by cicatrization and calcification. In the one condi- 
tion, clinically, the vessel, to the eye and to the examining finger, is 
tortuous and resistant; in the other, it is rigid and unyielding, like a 
pipe-stem. It is the difference between fibrous and calcareous infil- 
tration. 
The etiological elements concerned in the production of arterio- 
capillary fibrosis are comprised in the group of noxae which we now 
knowr as toxic and infectious, and include syphilis, alcoholism, lead- 
poisoning, gout, rheumatism, and infectious diseases in general. 3 
Heredity, too, probably plays some part in transmitting a predisposi- 
tion to the occurrence of fibrous degeneration. 
Perhaps the most conspicuous symptom, and that for which the 
patient first seeks relief, is shortness of breath on the slightest exer- 
tion. The onset of this condition is so insidious that the patient is 
unaware of its existence, until suddenly revealed by a demand for 
some special activity. With it is often associated palpitation, which 
the patient is apt to describe as a fluttering of the heart. Hie cardiac 
action is found to be irregular, perhaps intermittent, with occasional 
duplication of the second sound or an abortive first. The second 
sound is distinctly accentuated at the base. The pulse is tense and 
resistant. The temporal arteries are prominent and tortuous. In addi- 
tion, the patient complains of coldness of the extremities or of numb- 
ness or of formication, with, perhaps, some muscular weakness. There 
may be vertigo, especially on sudden changes of posture, lightness in 
the head, as the patient says. The memory is impaired, and there 
may be headache. The knee-jerk is frequently exaggerated, but not 
always. Often there is tremor, and sometimes nystagmus. In some 
cases, the complexus of symptoms approaches that seen in insular 
sclerosis, in others that seen in paralysis agitans, though typical of 
neither. It may be that such cases represent incipient stages of the 
one or the other of these affections, which, in their turn, perhaps, may 
be more intimately related than we as yet know. Occasionally, we 
meet with transient pareses and local paralyses, sometimes ascribed to 
uraemia. It seems easier to explain the occurrence of these on the 
assumption of partial vascular occlusion. The feet are sometimes 
swollen. There is apt to be increased fieqency of micturition of a 
urine of low specific gravity, but rarely containing albumin or casts. 
The train of symptoms here outlined may be readily explained by 
the pathological lesion. How common it is at autopsies to find organs 
the vessels of which gape with open mouths, while, during life, the 
only condition determinable was such an association of symptoms. It 
is neither nephritis nor arteritis, neither myocarditis nor cerebritis, 
but a diffuse fibroid change, the manifestations of which are perhaps 
most patent in the small arteries. Thus, we see associated with this 
condition miliary aneurisms in the brain, which we now know to be so 
generally antecedent to cerebral hemorrhage. In the absence of 
aneurism, the vascular fibrosis may alone act as a predisposing cause 
of rupture. The narrowing of the cerebral capillaries may become so 
marked as to permit of the formation of thrombi in situ, thus 
explaining certain cases of hemiplegia in which cardiac lesion or other 
source of embolism cannot be detected. It is also probably in the 
thickening of the wall of the capillary and the narrowing of its lumen 
that certain cases of transient or permanent loss of power, in which 
the severity of the symptoms soon abates, may find explanation. The 4 
derangement of cardiac function is a result of defective nutrition and 
innervation. The shortness of breath is brought about bv the cardiac 
incompetency, by the vascular changes in the pulmonary structures, 
and, finally, by lowered innervation, in some cases aided by concur- 
rent emphysema. Other visceral symptoms are due to changes of a 
similar nature in the respective organs. The extremities are cold 
because the blood-supply through the narrowed vessels is imperfect. 
In the consideration of the treatment of this condition, not much 
need be said in the way of prophylaxis. “All the medicines in the 
world will not replace right living.” It is the secret of longevity. 
In the general management of the case, the individual is to be 
directed to lead a tranquil life, to avoid excitement and undue physical 
exertion, to partake of a light, nutritious diet, which, with benefit, 
may include a liberal supply of milk, and to take an occasional saline 
laxative. 
Of medicaments, I have personally had the most gratifying results 
from the administration of nitroglycerin, in combination with digitalis 
when the cardiac action is feeble or its rhythm disturbed. Nitrogly- 
cerin is a diffusible stimulant, causing dilatation of the peripheral 
capillaries, thus permitting a flushing of the tissues with arterial blood, 
and promoting nutrition. By diminishing the resistance in the vessels, 
the demands upon the heart are lessened, while this organ, being 
better nourished, is more competent to carry on its functions. Begin- 
ning with one minim of a one-per-cent, solution three times a day, the 
dose is progressively' increased one minim every second day, until 
physiological effects—flushing of the face, sensation of a band around 
the forehead, headache, and dizziness—are observed. Probably the 
most appropriate menstruum is spirits of nitrous ether, the action ot 
which, as a nitrite, is synergistic. In administering digitalis, I like 
to prescribe two to five minims of the tincture in two drachms of the 
infusion, in this way obtaining the benefit of all the principles of the 
crude drug soluble in alcohol and in water. 
Strychnine and atropine may prove useful adjuvants in the treat- 
ment. Under certain circumstances, it may be desirable to substitute 
strophanthus for digitalis. Caffeine or cocaine may fulfil certain indi- 
cations, Cod-liver oil might be used as a nutrient, alcohol as a 
stimulant. Iodide of potassium is of doubtful utility, except during 
the active stage of syphilis. 
The conclusions I wish to record are: That there is a pathological 
condition in which the manifestations of senility occur prematurely, 
and that the best means of combating it is by improving the general 
nutrition and giving tone and stability to the cardio-vascular apparatus 
—a healthy nutritive fluid, with a competent distributing apparatus. 
Philadelphia,853 Forth Fifth Street