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Veins are very susceptible of inflammation, and the action is very apt to extend along the coats rapidly; in some cases it reaches the right side of the heart, producing most violent symptoms, and speedy dissolution.

Inflammation in the venous, as in the other tissues, may terminate in resolution. Otherwise, lymph is secreted, whereby the coats of the vessel become thickened, and its internal surface agglutinated, causing obliteration of the canal to a greater or less extent. Suppuration also occurs, and the pus may be deposited in a cyst formed amongst the coats of the vessels; or, as is most frequently the case, it is secreted from the internal coat, and occupies the canal of the vein. It then generally accumulates, its passage into the circulation being prevented by a deposition of lymph sufficient to occupy the calibre of the vessel betwixt the heart and the seat of the purulent matter. The termination in purulent secretion is accompanied with a high degree of constitutional irritation, and typhoid symptoms, more especially if any pus finds its way into the circulation.

The integuments in the course of the inflamed vessel or vessels are of a dark red colour, and great pain is caused by pressure. Often there is a considerable œdematous swelling of the limb, occasionally followed by the formation of unhealthy pus, diffused in the cellular membrane, causing sloughing of that tissue, or of the soft parts more deeply seated.

This disease generally follows an accidental wound or operation, as venesection or amputation; it is also of frequent occurrence after the application of a ligature to the extremity of a vein. Many patients have died of this disease, induced by the application of a ligature to the vena saphena major, for the cure of varix. Wounding of large veins ought to be studiously avoided; and if wounded, the bleeding from them should, if possible, be arrested by pressure. When from any cause the extremity of a large vein in a wound is not closed, when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid causes dreadful mischief; great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints.

Inflammation of veins is a very unmanageable disease; the exhibition of purgatives and antimonials will be prudent, in order to evacuate the bowels, produce diaphoresis, and diminish the force of the circulation; the pain will also be much relieved by the application of warm fomentations to the affected part. General depletion is not admissible unless at the very commencement of the disease, and local bleeding must be had recourse to with very great caution; for by copious abstraction of blood, gangrene may be induced, or at least hastened. The limb must be altogether disused and elevated, the patient being kept in a state of complete rest, and not exposed to any excitement or anxiety. Blisters have been employed, but with no good effect. If the vein is much distended, and it is evident that it contains a confined accumulation of pus, it ought to be treated as a common abscess, the matter evacuated by an incision, and various dressings employed, according to circumstances. Such practice I have found successful, and not followed by any untoward symptoms. The abscess is often limited at each extremity by the deposition of lymph in the canal of the vessel; and after the evacuation of its contents, the cavity contracts, and the portion of the vessel which has been the seat of suppuration becomes completely impervious.

Inflammation of a vein is also occasionally followed by the sudden appearance of a purulent depôt in some part of the body, external or internal, at a distance from the inflamed part. Thus, in inflammation of a vein in the forearm, it is not unusual to find an abscess formed suddenly in the axilla on the opposite side; after amputation, or other capital operation, the patient is often suddenly affected with violent symptoms of disease in the chest, and, on examination, abscesses will probably be discovered in the substance of the lungs, the existence of which had only been suspected a short time previous to death. Possibly some pus globules, the seeds of disease, may be arrested in their course through the capillaries of these organs, and thus a foundation be laid for mischief. A very satisfactory explanation of these phenomena cannot readily be given.

It has already been noticed, that the softening of coagulated fibrin must not be confounded with suppuration. The fibrinous pulp has commonly been called pus, though erroneously; and when occurring in the veins, as it frequently does, has been generally described as inflammation and suppuration of the vessel. The distinction is important; first, because many of the so-called cases of phlebitis are shown to be of a different nature, and secondly, as to the theory of suppuration, on which subject many writers in this country have been engaged in making commentaries on, and compilations of, the French doctrines, which are not deserving of much regard.

There exists without doubt a capillary phlebitis, and the vast importance of inflammation, and its consequence in these vessels, will be estimated when their great extent and functions are recollected. It is probably in this class of cases especially that the blood becomes contaminated with pus.

Veins frequently become dilated or varicose; they assume a tortuous course, appear much enlarged, and present an elastic, soft feel, except in the situation of the valves, where they are more hard and incompressible: occasionally the tortuous windings form a bluish tumour of considerable size. The dilatation of the superficial branches is increased by heat, the skin being thus relaxed, so as to give less support. The limb is swollen and œdematous. The dilatation is generally supposed to be confined to the vessels near the surface, but it appears that the deep-seated ramifications are not exempt from the affection. When a dilated vein becomes inflamed, great pain is felt in the part; the vessel feels like a firm chord, its coats are much thickened, and its cavity proportionally contracted; lymph is effused, and by it the canal may be obliterated to a greater or less extent; a spontaneous cure is thus accomplished. In the lower limbs, the disease is often complicated with ulcers; and as long as the veins remain varicose, the ulcers are almost incurable, or if they are brought to cicatrise, the skin soon ulcerates again, and the disease is reëstablished. The coats of the vessel not unfrequently ulcerate, and blood is discharged in appalling profusion: such an occurrence may even prove rapidly fatal. Sometimes, though rarely, skin thinned by pressure from within gives way without previous ulceration, and profuse bleeding ensues.

The cause of this affection is obstruction to a free return of the blood; as by tumours, either natural or adventitious, from pregnancy, constipation, &c.; or by the tight application of a ligature round the limb, as of a garter. It often occurs in those who have been in the habit of great muscular exertion, the blood being thereby forced from the deep-seated veins into the superficial. This even occurs, though very rarely, in the upper extremity, and I have witnessed more than one instance of it. Here it is more readily got rid of. Dilatation of venous branches is met with in the scrotum, labium pudendi, lower part of the abdomen, in the neighbourhood of the anus, and at the lower part of the neck. The lower limb is, however, the most common seat of the disease: when the veins in this situation are dilated, the valves are insufficient to obstruct the calibre of the vessels, and consequently the lower and smaller ramifications have to sustain the column of blood in the superficial veins of the whole limb, its weight not being diminished by the support which, in the natural state of parts, is afforded by the valves; the disease is thus more and more aggravated. The left limb is generally the one affected; and this circumstance may probably be explained by the pressure of the sigmoid flexure of the colon on the left iliac vein.

In the majority of cases, the palliative treatment can only be adopted. The limb must be used as little as possible, and, if practicable, be kept in a state of complete rest; the veins must also be supported by the application of a bandage, or the wearing of a laced stocking. The Indian rubber bandage worn over the stocking or drawers answers fully as well as any other method. In some instances, the application of cold has been of advantage, by promoting the contraction of the dilated vessels. When pregnancy is the cause, it is needless to commence any method of cure, until the cause be removed; and the same remark is applicable when the affection arises from habitual constipation. The varices occasionally become inflamed, painful, and much swollen, with considerable œdema of the whole limb. Their contents become coagulated, and their coats thickened; in the end, the swelling abates and the vessels are closed. In certain cases, this spontaneous cure, a radical one, may be imitated by the surgeon; an escharotic being applied over the trunk of the vein at a healthy point, whereby inflammation is produced in the coats of the vessel, and obliteration of its cavity accomplished: the caustic which will be found most convenient and effectual, is the potassa fusa. The caustic may be made into a paste with soap; or a solid piece, of the size of a split pea, is placed over the vein, and there retained for a few hours by plaster or bandage. The vessel being obliterated, the lower venous branches necessarily pour their contents into those deeply seated; as they freely communicate with these, they readily empty themselves of their accumulated contents, and soon regain their calibre under the employment of bandaging. When the varicose veins are numerous, as is generally the case, the potass is to be applied to the healthy point of the larger trunk in which they terminate. But the practice is not unattended with danger, for the coats of the vessel may ulcerate in consequence of the application, and violent hemorrhage ensue; the degree of inflammation excited may be greater than that intended, and extend so as to give rise to suppuration in the vessel and the most alarming constitutional disturbance. These unfavourable results, however, must be of rare occurrence. Success has, however, followed the practice in innumerable instances.

A much preferable method, as being less painful and unattended with risk, is that of passing needles under the vessel, and twisting a piece of thick and strong silk round them. Two needles should be applied together, at an interval of about half an inch, at whatever points it is thought right to close the vein. Coagulation takes place in the included part, and also frequently for some distance below it; the coats of the vessel are thickened, and its canal closed. The needles are withdrawn before they begin to cut their way out by ulceration,—say at the end of from three to five days,—according as the parts become condensed. The needles suited to the purpose are soft, but tempered at the point, which is spear-shaped; the ends are cut off with pliers after the thread is fixed. Other operations have been performed on the veins, to procure a radical cure of varix; one or more ligatures have been passed round the vessel, as in the operation for aneurism; and the vessel has been divided, or a portion of it dissected out, and its cut extremities afterwards either compressed or secured. Such proceedings are now almost entirely abandoned.