The Causes Of Phlebectasis are usually sufficiently obvious; as, for instance, mechanical impediments to the circulation of the blood in consequence of contractions in the openings of the heart; or pressure on a venous trunk; pressure on a large vein by a tumor, which may close or even obliterate it; a flow of arterial blood into a vein; a position of the body interfering with the proper reflux of the blood into certain parts, in which the course of the veins lies in an opposite direction to the force of gravitation; excessive activity of an organ, accompanied with its enlargement and hypertrophy; adventitious products, in which vessels of considerable size have been produced - that is to say, the insertion of a new vascular apparatus into the original venous system of a part; repeated hyperaemia and inflammation of an organ*; or inflammation of the vein itself. The impediments of a mechanical nature have always been regarded as of the greatest importance.

Cases are, however, occasionally met with, in which none of the above-mentioned causes can be detected, and, indeed, where no mechanical hinderance can be perceived. Such cases have recently been often brought forward with the view of opposing the theory of a mechanical impediment, and of establishing other theories of varicosity. It is necessary that we should mention the grounds alleged in relation to this point.

1. The cases in which no mechanical impediment exists are by no means rare.

2. If the veins of dependent parts are more frequently varicose than others, this does not explain why they are oftener varicose in one limb than in another; or why this condition especially occurs in a particular part of a limb, and why neighboring veins, under the same conditions, are not similarly affected.

3. Moreover, varices also occur, without any mechanical impediment, in veins in which the direction of the current coincides with that of the force of gravitation, as, for instance, in the veins of the head and neck.

4. In women, varices often occur in the legs during the early stages of pregnancy, before the uterus can exert any appreciable impediment to the circulation.

5. When constipation induces hemorrhoids, they may be as much ascribed to the irritation and congestion which it excites as to the impediment produced to the course of the blood, for otherwise the hemorrhoids would disappear when the bowels were freely moved, which is not the case.

6. When veins running towards a tumor become varicose, it cannot always be shown that they all undergo compression by the tumor; moreover, the blood might make its way by numerous anastomoses with deeper and non-dilated veins.

7. The blood, far from stagnating, rushes through the varices with great energy, which thus increases the difficulty of checking hemorrhage from them.

8. The blood contained in varices is brighter than venous blood, resembling a mixture of arterial and venous blood.

9. When arterial blood makes its way into a vein, the latter becomes varicose.

10. Varices sometimes present pulsations isochronous with the heart-stroke.

11. When a main artery is tied, in cases of aneurism, we very often see varices disappear in the neighborhood of the aneurism. (Dupuy-tren).

12. Most varices extend from the venous radicles towards the trunks, which can only happen in consequence of the extraordinary impulse that the blood in those vessels receives from the heart, or of the blood flowing from the trunks towards the branches, which is always the case where a morbid formation acts as a centre of attraction for the blood.

Briquet attempted, in an unsatisfactory manner, to explain the formation of varices from an excessive fulness of the subcutaneous veins of the lower extremities, arising from the contraction of the muscles, which drive back the blood from the deep to the superficial veins; and Rima subsequently maintained that varices of the lower extremities were dependent on a retrograde motion of the blood, so that the blood flows back from the femoral into the saphena vein, and is driven from the inguinal region towards the feet by a force which is peculiar to this vein. Pigeaux, from a more general consideration of the same facts, believed that he had solved the difficulty by the assumption that varices anastomose with arteries.

If objections may be raised against some of the above-mentioned facts in opposition to the theory of a mechanical impediment, we are nevertheless convinced of the untenability of the latter view. We have, therefore, after much experience, adduced other causes in explanation of dilatation of the veins. There are, however, always cases occurring in which these cannot be detected; and as varicose veins present many symptoms which are hitherto perfectly unexplained, the theory of phlebectasis is still deficient in an important part. Now, although Pigeaux's view is not yet actually proved to be correct, and is only based on the theoretical application of certain phenomena of varix, it is so far worthy of consideration, as it removes the whole question into the department of anatomy, and thus affords facilities for renewed and more profound investigations. Thus only is it possible to obtain a well-grounded view regarding the correctness of a theory which has become popular in Germany, respecting the production of a congenital (hereditary) or acquired disposition to general or local phlebectasis, respecting the production of a persistent or periodically recurring blood-crasis and its localization, the production of peculiar critical events in the organism, in consequence of many acute processes of plethora and stasis (venous congestion) occurring from time to time in certain portions of the venous system, regarding the high importance of local phlebectases arising from them, etc. - a theory which many, even from the want (as yet) of any material information on the subject, are inclined to regard as a deception and a fiction.

Phlebectasis is most common in the prime of life. Some forms, however, develope themselves earlier, and all may persist to extreme old age. Many forms of phlebectasis may attack both sexes; some, however, chiefly, or even exclusively, affect only one sex.

Of the local phlebectases some require a special notice, in consequence of the frequency of their occurrence, and others from the annoyances and pains to which they give rise. Several very often occur in one and the same individual: whether the frequently isolated occurrence of a definite species of varicosity - as, for instance, of varicocele (Landouzy), and whether the high development of one species, in association with a low degree of another, is indicative of a vicarious action, and must be referred to a deeper cause, are points which must remain for the present undecided. As a general rule, phlebectases are almost entirely confined to the lower half of the body, and their occurrence in the upper half, must be regarded as altogether exceptional. It is almost invariably the superficial or cutaneous veins which become varicose in the lower extremities.

a. Varicosity of the veins of the lower extremities is very frequent, and may be observed in all possible stages. It attacks the system of the saphenous veins, and especially the trunk and branches of the internal saphenous vein. According to our observations, it attacks both sexes with equal frequency. A protracted, uneasy, and upright position of the body is undoubtedly a very frequent cause of this affection, although the cases are not uncommon in which it cannot be traced to this origin. In women, especially amongst the working-classes, it is often ascribed to frequent pregnancies. Hasse remarks that, as a general rule, the dilatation commences in men in the trunk or principal branches of the internal saphena vein, while in women it usually begins in the finest cutaneous branches on the inner side of the limb. The disease is commonly first developed on the lower part of the leg, and from hence it extends to the thigh, where it is for the most part limited to the trunk of the saphena. We believe, however, that, especially in women, the cases are not very rare in which the varicosity first appears and predominates in the femoral region. It often attacks both limbs, but more commonly only one. The dilated venous reticulations either lie loosely in the panniculus, or they are imbedded in a callous, thickened, infiltrated cellular substance, with which they coalesce; while the venous coats themselves are thickened, and have a rigid appearance when cut through. This condition of the saphena vein may give occasion to the entrance of air into it, if it be opened, as is shown by an operation of Dupuytren's. Coagula of blood are very commonly formed in these veins, although it is extremely seldom that we find phlebolites in them.