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Creating
ASP.NET Core
Web Applications
Proven Approaches to Application
Design and Development
—
Dirk Strauss
 Creating ASP.NET Core
Web Applications
Proven Approaches to Application
Design and Development

Dirk Strauss
Creating ASP.NET Core Web Applications: Proven Approaches to
Application Design and Development
Dirk Strauss
Uitenhage, South Africa

ISBN-13 (pbk): 978-1-4842-6827-8 ISBN-13 (electronic): 978-1-4842-6828-5

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Copyright © 2021 by Dirk Strauss

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For Adele, Irénéé, and Tristan. You are my everything.
Table of Contents
About the Author����������������������������������������������������������������������������������������������������� ix

About the Technical Reviewer��������������������������������������������������������������������������������� xi

Acknowledgments������������������������������������������������������������������������������������������������� xiii
Introduction�������������������������������������������������������������������������������������������������������������xv

Chapter 1: Creating and Setting Up Your Project������������������������������������������������������ 1

Creating Your Web Application Project������������������������������������������������������������������������������������������ 1
Using the .NET CLI������������������������������������������������������������������������������������������������������������������� 5
Adding and Editing Razor Pages��������������������������������������������������������������������������������������������������� 9
Looking at the Configuration������������������������������������������������������������������������������������������������������� 19
Working with Entities������������������������������������������������������������������������������������������������������������������ 23
Creating and Registering a Data Service������������������������������������������������������������������������������������ 29
Displaying Test Data on Your Web Page�������������������������������������������������������������������������������������� 34

Chapter 2: Creating Models������������������������������������������������������������������������������������ 39

Building a Search Form��������������������������������������������������������������������������������������������������������������� 39
Adding Font Awesome����������������������������������������������������������������������������������������������������������� 39
Adding the Search Form Code����������������������������������������������������������������������������������������������� 40
Implementing the Find Logic������������������������������������������������������������������������������������������������������ 43
Using Model Binding and Tag Helpers����������������������������������������������������������������������������������������� 46
Displaying Related Data�������������������������������������������������������������������������������������������������������������� 53
Passing the Video ID Through to the Detail Page������������������������������������������������������������������� 59
Working with Page Routes���������������������������������������������������������������������������������������������������������� 63
Populating Video Details�������������������������������������������������������������������������������������������������������� 68
Handling Bad Requests��������������������������������������������������������������������������������������������������������������� 71

v
Table of Contents

Chapter 3: Modifying Data�������������������������������������������������������������������������������������� 79

Editing Existing Data and Using Tag Helpers������������������������������������������������������������������������������ 79
Building the Edit Form����������������������������������������������������������������������������������������������������������� 87
Changing the Data Service���������������������������������������������������������������������������������������������������� 95
Validate Edited Data and Display Validation Errors��������������������������������������������������������������������� 97
AddSingleton vs. AddScoped vs. AddTransient�������������������������������������������������������������������� 102
Implementing IValidatableObject����������������������������������������������������������������������������������������� 103
Adding a New Video������������������������������������������������������������������������������������������������������������������ 107
Modifying the Data Access Service������������������������������������������������������������������������������������������� 109
Modifying the OnPost Method��������������������������������������������������������������������������������������������� 110
Working with TempData������������������������������������������������������������������������������������������������������������ 111
Changing the TempData Provider���������������������������������������������������������������������������������������� 115

Chapter 4: EF Core and SQL Server����������������������������������������������������������������������� 119

Entity Framework Core������������������������������������������������������������������������������������������������������������� 119
Install Entity Framework����������������������������������������������������������������������������������������������������������� 120
Implement DbContext��������������������������������������������������������������������������������������������������������������� 124
Specify Database Connection Strings��������������������������������������������������������������������������������������� 125
Working with Database Migrations������������������������������������������������������������������������������������������� 132
Implement a New Data Access Service������������������������������������������������������������������������������������ 142
Changing the Data Access Service Registration����������������������������������������������������������������������� 145

Chapter 5: Working with Razor Pages������������������������������������������������������������������ 149

Using Sections in Your Razor Pages������������������������������������������������������������������������������������������ 149
Meta Tags and CSS�������������������������������������������������������������������������������������������������������������� 151
Navigation��������������������������������������������������������������������������������������������������������������������������� 152
@RenderBody���������������������������������������������������������������������������������������������������������������������� 152
Footer���������������������������������������������������������������������������������������������������������������������������������� 152
Scripts Applied Across All Pages����������������������������������������������������������������������������������������� 152
@RenderSection������������������������������������������������������������������������������������������������������������������ 152

vi
 Table of Contents

What Are _ViewImports and _ViewStart Files?������������������������������������������������������������������������� 155

Specifying a Different Layout Page������������������������������������������������������������������������������������� 157
Creating a Custom TagHelper���������������������������������������������������������������������������������������������� 161
Working with Partial Views������������������������������������������������������������������������������������������������������� 165
Adding Video Properties and Updating the Database���������������������������������������������������������� 167
Adding Markup to the Partial View�������������������������������������������������������������������������������������� 170
Working with ViewComponents������������������������������������������������������������������������������������������������ 176

Chapter 6: Adding Client-Side Logic��������������������������������������������������������������������� 183

Separate Production Scripts from Development Scripts����������������������������������������������������������� 183
Setting Up SCSS and Generating CSS��������������������������������������������������������������������������������������� 187
SCSS Partial Files���������������������������������������������������������������������������������������������������������������� 199
Using SCSS @mixin������������������������������������������������������������������������������������������������������������� 201
Using SCSS @extend����������������������������������������������������������������������������������������������������������� 204
Using SCSS Functions��������������������������������������������������������������������������������������������������������� 208
Working with Chrome Developer Tools������������������������������������������������������������������������������������� 212
Dragging Elements�������������������������������������������������������������������������������������������������������������� 213
Adding and Modifying Styles����������������������������������������������������������������������������������������������� 215
Add a New Class������������������������������������������������������������������������������������������������������������������ 218
Testing State Changes��������������������������������������������������������������������������������������������������������� 219
Throttling Network Speed���������������������������������������������������������������������������������������������������� 221
Wrapping Up����������������������������������������������������������������������������������������������������������������������������� 223

Chapter 7: Exploring Middleware������������������������������������������������������������������������� 225

What Is Middleware������������������������������������������������������������������������������������������������������������������ 225
Handling Exceptions������������������������������������������������������������������������������������������������������������ 227
UseHsts������������������������������������������������������������������������������������������������������������������������������� 228
UseHttpsRedirection������������������������������������������������������������������������������������������������������������ 230
UseStaticFiles���������������������������������������������������������������������������������������������������������������������� 230
UseRouting�������������������������������������������������������������������������������������������������������������������������� 232
UseSession�������������������������������������������������������������������������������������������������������������������������� 232
UseEndpoints with MapRazorPages������������������������������������������������������������������������������������ 233

vii
Table of Contents

Creating Custom Middleware���������������������������������������������������������������������������������������������������� 233

Logging Information������������������������������������������������������������������������������������������������������������������ 238
Only Logging What Is Necessary����������������������������������������������������������������������������������������������� 244
Applying a Specific LogLevel to Production������������������������������������������������������������������������������ 247
A Quick Look at the Log Category��������������������������������������������������������������������������������������������� 254
Wrapping Up����������������������������������������������������������������������������������������������������������������������������� 255

Chapter 8: Web Application Deployment�������������������������������������������������������������� 257

Getting Your Site Ready for Deployment����������������������������������������������������������������������������������� 257
Deploying Your Web Application to IIS��������������������������������������������������������������������������������������� 265
Configuring the SQL Server Database��������������������������������������������������������������������������������� 271
A Note About Connection Strings and Secrets�������������������������������������������������������������������� 283

Index��������������������������������������������������������������������������������������������������������������������� 285

viii
About the Author
Dirk Strauss is a software developer from South Africa
who has been writing code since 2003. He has extensive
experience in SYSPRO, with C# and web development being
his main focus. He studied at the Nelson Mandela University,
where he wrote software on a part-time basis to gain a better
understanding of the technology. He remains passionate
about writing code and imparting what he learns to others.

ix
About the Technical Reviewer
Carsten Thomsen is a back-end developer primarily but
working with smaller front-end bits as well. He has authored
and reviewed a number of books and created numerous
Microsoft Learning courses, all to do with software
development. He works as a freelancer/contractor in various
countries in Europe; Azure, Visual Studio, Azure DevOps,
and GitHub are some of the tools he works with. Being an
exceptional troubleshooter, asking the right questions,
including the less logical ones, in a most logical to least
logical fashion, he also enjoys working with architecture,
research, analysis, development, testing, and bug fixing.
Carsten is a very good communicator with great mentoring and team-lead skills, and
great skills in researching and presenting new material.

xi
Visit https://textbookfull.com
now to explore a rich
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Acknowledgments
I would like to thank my wife and kids for their support during the writing of this book.
I love you always!

xiii
Introduction
.NET Core has given .NET developers a lot to think about. Some developers have
embraced the technology, while others have taken a wait-and-see approach. Whatever
approach you are taking, .NET Core is without a doubt here to stay.
Developing web applications is also not one of the easiest things to do. I’ve always
wanted to write a book on developing web applications, but to do it in a way that is very
structured and takes the reader on a journey of discovery.
Creating ASP.NET Core Web Applications is my attempt at that book. I always try to
take the point of view that the book I’m writing is a reference book for my bookshelf.
With this in mind, I, therefore, tried to cover a wide set of topics.
As with all projects, Chapter 1 starts with creating your project and using the .NET
CLI. We have a look at adding Razor pages and also how to configure the application
using the appsettings.json file. I then create a dummy data service, which is used to get
the application up and running with test data. This test data is designed in such a way
that it can easily be swapped out at a later stage (and I show you how to do this).
Chapter 2 takes a look at the process of creating models, model binding, tag helpers,
working with a query string, and page routes. To illustrate these concepts, Chapter 2
shows you how to implement a search form. This allows us to search for data, view the
details, and add in logic to handle bad requests.
Chapter 3 illustrates the concepts of editing the data, displaying validation errors,
and modifying the data access service to suit our needs. I also discuss the differences
between singleton, scoped, and transient lifetime registration for services.
EF Core and SQL Server become the focus in the next chapter. Chapter 4 shows
you how to install Entity Framework Core, define your connection strings, what
database migrations are, and how to use them. We will also be implementing a new
data access service and changing the data access service registration from the test
data to the SQL data.

xv
Introduction

Moving to the front end next, we have a look at working with Razor pages in Chapter 5.
Here, we will look at what sections are and how they benefit you as a developer. We take a
closer look at _ViewImports and _ViewStart files. I also show you how to create your own tag
helper, how to work with partial views, and, finally, how to work with ViewComponents.
Staying front end, we have a look at adding client-side logic in Chapter 6. I show
you how to separate production scripts from development scripts, use SCSS to generate
CSS, how SCSS works, and the different features you can use to create CSS with SCSS, as
well as work with Chrome Developer Tools. This is, in my opinion, crucial for any web
developer to know.
With Chapter 7, we will take a look at what middleware is. This is a very important
chapter and one that will require some explaining. We have a look at some of the built-­
in middleware components, but also how to create a custom middleware component
if the built-in middleware components don’t suit your needs. After creating a custom
middleware component, we will have a look at logging in ASP.NET Core. Logging is a big
subject, but this book tries to cover the basics.
Finally, Chapter 8 will take you through getting your web application ready for
deployment and finally publishing your web application and hooking it up to a SQL
Server database. I hope that you will enjoy this book as much as I enjoyed writing it.

xvi
CHAPTER 1

Creating and Setting

Up Your Project
Welcome to Creating ASP.NET Core Web Applications! This book will guide you through
creating a typical ASP.NET Core Web Application, from start to finish. All the code
illustrated in this book is available on GitHub and will be an invaluable resource to you
as you navigate the code samples in the book.
This chapter will take you through the steps required to start your web application
development. We will also have a look at adding and editing Razor pages, working with
Entities, creating and registering a data service, and using that data service to display test
data on the web page.

Creating Your Web Application Project

In this book, I will be using Visual Studio 2019 to illustrate the concepts surrounding
ASP.NET Core Web Applications. For those folks that do not use Visual Studio, the same
result as detailed in the following can be achieved for creating an application by using
the .NET CLI.

I will assume that you have already installed .NET Core onto your machine. The
web application we will be creating will use .NET Core 3.1. If you have not installed
.NET Core, you can do so by visiting this link: https://dotnet.microsoft.
com/download.

Because we are working with .NET Core which is cross-platform, I will also show you
how to create an application using the Command Prompt later in this section.

1
© Dirk Strauss 2021
D. Strauss, Creating ASP.NET Core Web Applications, https://doi.org/10.1007/978-1-4842-6828-5_1
Chapter 1 Creating and Setting Up Your Project

For now, let us start by creating a new project in Visual Studio. From the file menu,
click New Project. This will display the Create a new project screen as seen in Figure 1-1.

Figure 1-1. The Create New Project Screen

The Create a new project screen that allows you to select the correct project template
lists all the available templates included in Visual Studio. In our case, we will be using
the ASP.NET Core Web Application template.
If you are used to working in previous versions of Visual Studio, you will notice that
this screen has been vastly improved. You can search for templates by typing a template
name into the search text box or by holding down Alt+S.
You can also filter project templates from the drop-downs on the form. You will
notice that you can filter by language, platform, and project type.
Clicking the Next button will take you to the Configure your new project screen as
seen in Figure 1-2.

2
 Chapter 1 Creating and Setting Up Your Project

Figure 1-2. Configure Your New Project

Give the project a suitable name. For this book, we will simply call the project
VideoStore and specify a location to create the project in. When you have done this, click
the Create button.
You will now be taken to a second screen as seen in Figure 1-3 where you can select
the specific type of template that you want to use.

3
Chapter 1 Creating and Setting Up Your Project

Figure 1-3. Selecting a Specific Template Type

It is here that we can specify the version of .NET Core that we want to use. In this
example, we are selecting .NET Core 3.1. We can then tell Visual Studio that we want to
create a basic web application. Just leave the rest of the settings at their default values
and click the Create button.

4
 Chapter 1 Creating and Setting Up Your Project

Figure 1-4. Running the Web Application

After the project has been created in Visual Studio, you can hit Ctrl+F5 to run the
web application. This will run your project without the debugger attached and display
the web application in your browser as seen in Figure 1-4.
You will notice that the web application is running on port 44398 in this example,
but your port will most likely be different. By default, this web application includes some
basic features such as a Home page as well as a Privacy page.
It is from here that we will start to flesh out our web application and add more
features and functionality to it.

Using the .NET CLI

Earlier in this chapter, I mentioned that we can also create the project from the
Command Prompt. Therefore, for those of you that do not use Visual Studio, the .NET
CLI offers a cross-platform way for creating .NET Core projects.

5
Chapter 1 Creating and Setting Up Your Project

Once you have installed .NET Core on your Mac, Linux, or Windows machine, you
should be able to simply open your Terminal, Shell, or Command Prompt and type the
dotnet command as seen in Figure 1-5.

Figure 1-5. Running the dotnet Command

To see more of the commands available with dotnet, you can type dotnet -h in the
Command Prompt. If you typed in dotnet new, you would see all the available project
templates listed in your Command Prompt window.
These templates, along with the short name associated with that specific template,
are listed in the following table.

Templates Short Name Language Tags

Console Application Console C#, F#, VB Common/

Console
Class library classlib C#, F#, VB Common/
Library
WPF Application wpf C# Common/WPF
WPF Class library wpflib C# Common/WPF
(continued)

6
 Chapter 1 Creating and Setting Up Your Project

Templates Short Name Language Tags

WPF Custom Control Library wpfcustomcontrollib C# Common/WPF

WPF User Control Library wpfusercontrollib C# Common/WPF
Windows Forms (WinForms) Application winforms C# Common/
WinForms
Windows Forms (WinForms) Class library winformslib C# Common/
WinForms
Worker Service worker C# Common/
Worker/Web
Unit Test Project mstest C#, F#, VB Test/MSTest
NUnit 3 Test Project nunit C#, F#, VB Test/NUnit
NUnit 3 Test Item nunit-test C#, F#, VB Test/NUnit
xUnit Test Project xunit C#, F#, VB Test/xUnit
Razor Component razorcomponent C# Web/ASP.NET
Razor Page page C# Web/ASP.NET
MVC ViewImports viewimports C# Web/ASP.NET
MVC ViewStart viewstart C# Web/ASP.NET
Blazor Server App blazorserver C# Web/Blazor
Blazor WebAssembly App blazorwasm C# Web/Blazor/
WebAssembly
ASP.NET Core Empty web C#, F# Web/Empty
ASP.NET Core Web App (Model-View-­ mvc C#, F# Web/MVC
Controller)
ASP.NET Core Web App webapp C# Web/MVC/
Razor Pages
ASP.NET Core with Angular angular C# Web/MVC/SPA
ASP.NET Core with React.js React C# Web/MVC/SPA
ASP.NET Core with React.js and Redux Reactredux C# Web/MVC/SPA
(continued)

7
Visit https://textbookfull.com
now to explore a rich
collection of eBooks, textbook
and enjoy exciting offers!
Chapter 1 Creating and Setting Up Your Project

Templates Short Name Language Tags

Razor Class Library Razorclasslib C# Web/Razor/

Library/
Razor Class Library
ASP.NET Core Web API Webapi C#, F# Web/WebAPI
ASP.NET Core gRPC Service Grpc C# Web/gRPC
dotnet gitignore file gitignore Config
global.json file globaljson Config
NuGet Config nugetconfig Config
Dotnet local tool manifest file tool-manifest Config
Web Config webconfig Config
Solution File sln Solution

You will notice that to create an ASP.NET Web Application, we need to specify the
short name webapp with the new command.
As seen in Figure 1-6, typing in the command dotnet new webapp will create the
ASP.NET Web Application inside the current directory.

Figure 1-6. Creating the Web App via the .NET CLI
8
 Chapter 1 Creating and Setting Up Your Project

If you had to compare the project created via the .NET CLI with the one created in
Visual Studio, you will see that these are identical.
The .NET CLI offers a fantastic, quick, and cross-platform way of creating
applications.

Adding and Editing Razor Pages

With your web application running, you will notice that if you click the Privacy link in the
navigation menu, it will go to the following URL: https://localhost:44398/Privacy.
The web application is mapping the request created by clicking the Privacy link with
the Razor pages in your VideoStore project. Looking at Figure 1-7, you will see the Razor
pages in a folder called… you guessed it, Pages.

Figure 1-7. The Razor Pages in the Solution Explorer

This means that when I view the Privacy page in the web application, ASP.NET Core
is busy rendering the Privacy.cshtml page. You will also notice that the cshtml extension
is not required in the URL as seen in Figure 1-8.
9
Chapter 1 Creating and Setting Up Your Project

Figure 1-8. The Privacy Policy Page

You will also notice that when you make your browser window smaller, the menu
collapses into the hamburger icon. This is made possible by Bootstrap, which is included
in the project by default.
If you now click your Privacy.cshtml page in the Solution Explorer, you will see the
code as listed in Code Listing 1-1.

Listing 1-1. The Privacy Razor Page

@page
@model PrivacyModel
@{
    ViewData["Title"] = "Privacy Policy";
}
<h1>@ViewData["Title"]</h1>

<p>Use this page to detail your site's privacy policy.</p>

With your web application running without the debugger attached, if you click the
hamburger menu icon, you will see that we have just two pages listed which are Home
and Privacy.

10
 Chapter 1 Creating and Setting Up Your Project

Looking at Figure 1-9 and comparing that to the code in Code Listing 1-1, you might
be wondering where the code is for the navigation.

Figure 1-9. The Navigation Menu

The answer lies in a special Razor page called a Layout page. Swing back to your
Solution Explorer, and expand the Shared folder under the Pages folder. There you will
see a page called _Layout.cshtml as seen in Figure 1-10.

11
Chapter 1 Creating and Setting Up Your Project

Figure 1-10. The Shared Layout Page

It is this Layout page that renders everything within the web application's <head>
tags, things such as links to all the required stylesheets, as well as <body> tags that
include a <header> section containing the navigation menu. The code for the navigation
menu is listed in Code Listing 1-2.

Listing 1-2. The Navigation Menu Code

<div class="navbar-collapse collapse d-sm-inline-flex flex-sm-row-reverse">
  <ul class="navbar-nav flex-grow-1">
    <li class="nav-item"><a class="nav-link text-dark" asp-area="" asp-­
page="/Index">Home</a></li>
    <li class="nav-item"><a class="nav-link text-dark" asp-area="" asp-­
page="/Privacy">Privacy</a></li>
  </ul>
</div>

12
Random documents with unrelated
content Scribd suggests to you:
forced itself under the soleus in the course of the muscles,
increasing the size of the leg, and florid blood issued from both
openings on taking the compression off the femoral artery. On
passing the finger into the outer opening, and pressing it against the
fibula, a sort of aneurismal tumor could be felt under it, and the
hemorrhage ceased, indicating that the peroneal artery was in all
probability the vessel wounded.
In this case there was, in addition to the wound of the artery, a
quantity of blood between the muscles, which in gunshot wounds,
accompanied by inflammation, is always a dangerous occurrence, as
it terminates in profuse suppuration of the containing parts, and
frequently in gangrene. Its evacuation therefore became an
important consideration, even if the hemorrhage had ceased
spontaneously.
The leg having been condemned for amputation above the knee, the
officers in charge were pleased to place the man at my disposal: and
being laid on his face, with the calf of the leg uppermost, I made an
incision about seven inches in length in the axis of the limb, taking
the shot-hole nearly as a central point, and carried it by successive
strokes through the gastrocnemius and soleus muscles down to the
deep fascia, when I endeavored to discover the bleeding artery; but
this was more difficult than might be supposed, after such an
opening had been made. The parts were not easily separated, from
the inflammation that had taken place; and those in the immediate
track of the ball were in the different stages from sphacelus to a
state of health, as the ball in its course had produced its effect upon
them, or their powers of life were equal or unequal to the injury
sustained.
The sloughing matter mixed with coagulated blood readily yielded to
the back of the knife, but was not easily dissected out. The spot
which the arterial blood came from was distinguished through it, but
the artery could not be perceived, the swelling and the depth of the
wound rendering any operation on it difficult. To obviate this
inconvenience, I made a transverse incision outward, from the shot-
hole to the edge of the fibula, which enabled me to turn back two
little flaps, and gave greater facility in the use of the instruments
employed. I could now pass a tenaculum under the spot whence the
blood came, which I raised a little with it, but could not distinctly see
the wounded artery in the altered state of parts, so as to secure it
separately. I therefore passed a small needle, bearing two threads, a
sufficient distance above the tenaculum to induce me to believe it
was in sound parts, but including very little in the ligature, when the
hemorrhage ceased; another was passed in the same manner below,
and the tenaculum withdrawn. The coagula under the muscles were
removed, the cavity washed out by a stream of warm water injected
through the external opening, the wound gently drawn together by
two or three straps of adhesive plaster, and the limb enveloped in
cloths constantly wetted with cold water. The patient was placed on
milk diet.
On the 4th, two days after the operation, the wound was dressed,
and looked very well; the weather being very hot, two straps of
plaster only were applied to prevent the parts separating. On the 5th
a poultice was laid over the dressings, in lieu of the cold water, the
stiffness becoming disagreeable. On the 6th, as the wound, although
open in all its extent, did not appear likely to separate more, the
plasters were omitted, and a poultice alone applied. On the 8th and
9th it suppurated kindly; and on the 10th, or eight days from the
operation, the ligatures came away, the limb being free from
tension, and the patient in an amended state of health, his medical
treatment having been steadily attended to.
The man was brought to England, to the York Hospital at Chelsea,
and walked about without appearing lame, although he could not do
so for any great distance. He suffered no pain, except an occasional
cramp in the ball of the foot, and some contraction of the toes,
which took place generally when he rose in a morning, and
continued for a minute or two, until he put them straight with his
hand; this I did not attribute to the operation, but to some additional
injury done to the nerves by the ball in its course through the leg.
This case, which has been followed by many others equally
successful, even after the femoral artery had been ineffectually tied,
established the practice now followed in England by all educated
surgeons; and is another of those great additions to surgery for
which science is indebted to the Peninsular war.
198. It may be permitted to repeat, that if an artery such as the
axillary be laid bare previously to an operation for amputation at the
shoulder, and the surgeon take it between his finger and thumb, he
will find that the slightest possible pressure will be sufficient to stop
the current of blood through it. Retaining the same degree of
pressure on the vessel, he may cut it across below his finger and
thumb, and not one drop of blood will flow. If the artery be fairly
divided by the last incision which separates the arm from the body,
without any pressure being made upon it, it will propel its blood with
a force which is more apparent than real. All that is required to
suppress this usually alarming gush of blood is to place the end of
the forefinger directly against the orifice of the artery, and with the
least possible degree of pressure consistent with keeping it steadily
in one position the hemorrhage will be suppressed. It is more
important to know that if the orifice of the artery, from a natural
curve in the vessel, or from other accidental causes, happen at the
same time to retract and to turn a little to one side, so as to be in
close contact with the side or end of a muscle, the very support of
contact will sometimes be sufficiently auxiliary to prevent its
bleeding.
In amputation at the hip-joint, the femoral and profunda arteries are
frequently divided at or just below the origin of the latter, and bleed
furiously if disregarded; but the slightest compression between the
finger and thumb stops both at once. They never have given me the
smallest concern in these operations, or others of a similar nature;
and surgeons should learn to hold all arteries that can be taken
between the finger and thumb in great contempt. It is quite
impossible for a man to be a good surgeon—to do his patient justice
in great and difficult operations attended by hemorrhage, unless he
has this feeling—unless his mind is fully satisfied of the truth of
these observations. While his attention ought to be directed to other
important circumstances, it is perhaps absorbed by the dread of
bleeding, by the idle fear that he will not be able to compress the
artery and restrain the bleeding from it—that he may have half a
dozen vessels bleeding at once—that his patient will die on the table
before him. Once fairly in dismay, and the patient is really in danger;
but, endowed with that confidence which is only to be acquired
through precept supported by experience, he surveys the scene with
perfect calmness: taking the great artery between the finger and
thumb of one hand, he places the points of all the other fingers, of
both hands if necessary, on the next largest vessels; or he presses
the flaps or sides of the wound together until his other hand can be
set at liberty by an assistant, or in consequence of a ligature having
been passed around the principal artery. This is a scene sufficient to
try the presence of mind of any man; but he is not a good surgeon
who is not equal to it—who does not delight in the recollection of it
when his patient is in safety, and his recovery assured. It was in
consequence of what was then considered the too great boldness of
the practice that my old friend, Sir Charles Bell, whose loss to
science cannot be too much regretted, represented me seated on a
pack saddle on the back of a bourro, (Anglice, a jack-ass,) on the top
of the Pyrenees, expatiating on their merits (which he did not
believe) to the descendants of the Bearnois of Henri Quatre on one
side, and to the children of the lieges of Ferdinand and Isabella on
the other; but no one now disputes their accuracy. The surgery of
the Peninsular war was many years in advance of the surgery of civil
life.
199. The principles laid down for the treatment of wounded arteries
in the lower extremity are equally to be observed with respect to
those of the upper. There is, however, little or no fear of
mortification taking place in the upper extremity, the collateral
circulation being more direct and free; while there is greater danger
from this cause of hemorrhage from the lower end of the artery, if a
ligature should not have been placed upon it, or if it should not be
retained a sufficient length of time.
200. The error of placing a ligature on the subclavian artery above
the clavicle, for a wound of the axillary below it, should never be
committed. One person dies for one who lives after this operation,
when performed under favorable circumstances, independently of
the loss which may be sustained by a recurrence of bleeding from
the original wound, which is always to be expected and ought to
take place; when it does not happen, it is the effect of accident,
which accident in all probability occurs from the state of absolute
rest having been carefully observed.
201. The necessity for an aneurismal sac below the clavicle, and for
its remaining and continuing to remain intact, until the cure is
completed, when the subclavian artery has been tied above, is
rendered unmistakable by the following case:—
Ambrose C. was admitted into the Charing Cross Hospital, in August,
1848, in consequence of a bruise from a sack of beans; there was
axillary aneurism, extending under the pectoral muscle up to the
clavicle. A ligature was applied in the usual situation on the outside
of the scalenus muscle, and came away on the twenty-second day.
The aneurismal sac suppurated, and burst three days afterward,
when a quantity of pus and blood, partly fluid, partly coagulated, but
very offensive, was discharged. The opening was enlarged, and
everything appeared to be going on well, at which time I saw him.
On the nineteenth day after the ligature came away, I visited him
again with Mr. Hancock, and merely observed that he must keep
himself very quiet, and I thought he would do well. In the evening
he died from hemorrhage, while eating some gruel. On examination
after death, the artery was found to be sound, except where it
communicated with the sac by an opening three-quarters of an inch
in length. The ligature had been applied midway between the thyroid
axis and the first of the thoracic branches. There was a small
coagulum, of half an inch in length, both internal and external to the
ligature, but not extending to the branch above or below it. The
artery was of its natural size as far as the remains of the sac, but
beyond it the axillary artery was diminished; the remains of the sac
were void of coagulum, except where it communicated with the
artery, to which opening a small coagulum had adhered, but had
given way at its lower part, and thus caused his death. Between the
opening and the ligature, five large branches entered into or were
given off by the artery, and through some of these blood was
brought round by the collateral branches in an almost direct manner,
so that the man’s life depended on the resistance offered by the
small coagulum after the sac had given way; proving in an
exemplary manner the value of the sac remaining entire.
If this case will not convince the incredulous, it would be useless to
bring even the sufferers in such cases from their graves, to affirm
the fact of the inapplicability of the theory of aneurism to the
treatment of a wounded artery—of the impropriety of placing a
ligature on the subclavian artery above the clavicle, for a wound of
the artery below it.
Corporal W. Robinson, 48th Regiment, was wounded at the battle of
Toulouse, by a piece of shell, which rendered amputation of the right
leg immediately necessary, and so injured the right arm as to cause
its loss close to the shoulder-joint eighteen days afterward. At the
end of a month the ligatures had separated, and the wound was
nearly healed, although a small abscess had formed on the inside,
near where the upper part of the tendon of the pectoralis major had
been separated from the bone. Sent to Plymouth, this little abscess
formed again, and was opened on the 2d of August, three months
after the amputation. The next day blood flowed so impetuously
from it as to induce the surgeon to make an incision, and seek for
the bleeding vessel, which could not be found. The late Staff-
Surgeon Dease, warned by the case of Sergeant Lillie, (page 198,)
strongly objected to the subclavian artery being tied above the
clavicle, and, true to the principle inculcated at Toulouse, advised the
application of a ligature below the clavicle on a sound part of the
artery, but as near as possible to that which was diseased. The
operation was done by the senior officer, Mr. Dowling, who carried
an incision from the clavicle downward through the integuments and
great pectoral muscle, until the pectoralis minor was exposed. This
was then divided, and a ligature placed beneath it on the artery
where it was sound, at a short distance from the face of the stump,
where it was diseased. The man recovered without further
inconvenience.
202. In all those cases in which it has been supposed necessary to
place a ligature on the artery above the clavicle, after a failure in the
attempt to find the artery below it, the failure has occurred from the
error committed in not dividing the integuments and great pectoral
muscle directly across from the lower edge of the clavicle downward.
It is quite useless dividing these parts in the course of the fibers of
the muscle, and the case of Robinson is the model on which all such
operations should be done. If this operation had not succeeded, the
ligature of the artery above the clavicle was a further resource; but
as the artery was sound below, with the exception of the end
engaged in the face of the stump, the operation was successful; no
doubt should be entertained in such cases of the propriety of an
operation which is attended with little risk, compared with that which
destroys one man for every one it saves.
203. Punctured wounds of the arteries of the arm and forearm ought
to be treated by pressure applied especially to the part injured, and
to the limb generally; but when the bleeding cannot be restrained in
this manner, in consequence of the extent of the external wound,
the bleeding artery is to be exposed, and a ligature applied above,
and another below the part injured, whether the artery be radial,
ulnar, or interosseal.
204. When the external wound closes under pressure, and blood is
extravasated in such quantity under the fascia and between the
muscular structures as is not likely to be removed by absorption
under general pressure, the wounded artery should be laid bare by
incision and secured in a similar manner, even at the expense of any
muscular fiber which may intervene.
205. When an aneurismal tumor forms some time after such an
accident, in the upper part of the forearm in particular, the
application of a ligature on the brachial artery is admissible, on the
Hunterian principle.
206. When the ulnar artery is wounded in the hand, which is
comparatively a superficial vessel, two ligatures should be placed
upon it in the manner hereafter to be directed. When the opening is
small, pressure may be tried.
207. When the radial artery is wounded in the hand, in which
situation it is deep seated, the case requires greater consideration.
When there is a large open wound, and the bleeding end or ends of
the artery can be seen, a ligature should be placed on each; but this
cannot always be done without more extensive incisions than the
tendinous and nervous parts will justify.
208. When search has been made by incisions through the fascia,
(as extensively as the situation of the tendons and nerves in the
hand will permit,) which are best effected by introducing a bent
director under it, the current of blood, through either the ulnar or
the radial artery at the wrist, or even through both, should be
arrested in turn by pressure, which in most cases of this kind will
succeed, if properly applied, and thus show the vessel injured. The
bleeding point should be fully exposed, and all coagula removed,
when a piece of lint, rolled tight and hard, but of a size only
sufficient to cover the bleeding point, should be laid upon it. A
second and larger hard piece should then be placed over it, and so
on, until the compresses rise so much above the level of the wound
as to allow the pressure to be continued and retained on the proper
spot, without including the neighboring parts. A piece of linen, kept
constantly wet and cold, should be applied over the sides of the
wound, which should not be closed so as to allow of any blood being
freely evacuated; and if the back of the hand be then laid on a
padded splint, broader than the hand, a narrow roller may be so
applied as to retain the compresses in their proper situation, without
making compression on or impeding the swelling of the adjacent
parts, the fingers being bent, in order to relax the palmar
aponeurosis—a proceeding which should never be neglected in any
operation in the palm of the hand. It has been lately proposed by M.
Thierry, a French surgeon, to raise and bend the arm, as a means of
impeding the circulation where the artery passes over the elbow-
joint, and the proposal deserves adoption, but not to the extent he
recommends, which cannot be long submitted to. Pressure made at
the same time on the radial or ulnar artery, or on both, by a piece of
hard wood two inches long, shaped like a flattened pencil, is much
more effectual, and more to be depended upon. When from the
bones being broken, or the hand so swollen, or from other
circumstances, pressure, however lightly and carefully applied,
cannot be borne in the manner directed, and the attempts to secure
the artery at the bleeding spot have failed, and pressure on the
radial or ulnar artery has been equally unsuccessful, in consequence
of the swelling or other circumstances, both may be tied at the wrist
in preference to placing a ligature on the brachial artery, although
that even must be done as a last resource, if the bleeding should still
continue. If it be asked why not do this in the first, rather than in
the last instance, the answer is, that it has so often failed to prevent
a renewal of the bleeding from both ends of a wounded artery in the
hand, that complete dependence cannot be placed upon it,
particularly if there should be a division high in the arm of the
brachial into the radial and ulnar arteries. When, however, the
arteries leading to the wound have been secured, either by pressure
or ligature, near to the part, and the bleeding returns by the
collateral circulation, which in the hand is so free, the arresting the
supply of blood through the main trunk may and often has
suppressed the hemorrhage, at all events for a sufficient time to
enable the injured parts to recover themselves, provided the forearm
is bent and raised, and the person kept at rest in the most restricted
manner, without which this operation will in all probability fail. It is in
these cases that the instrument alluded to, page 226, will be useful,
rendering the ligature on the trunk of the vessel unnecessary, more
particularly if the bleeding should appear to depend on some
peculiarity in the structure of the coats of the artery.
209. When the obstacle to the application of pressure arises from
the injured state of the metacarpal bone or bones, one or more
should be removed, with the fingers if necessary, so as to expose a
clear and new surface, on which the bleeding vessels may be seen
and secured. In some cases, particularly if there should be a
hemorrhagic tendency in the arterial system generally, as known
from previous accidents, the first compress may be wetted with the
perchloride of iron, the ol. terebinth., the dilute sulphuric acid, or the
tincture of matico; these remedies may be also administered
internally. Some new styptics have lately been much lauded in Malta
and other places, but sufficient proofs have not been given of their
efficiency.
210. When the radial artery is wounded as it turns from the back to
the inside of the hand, to form the deep-seated palmar arch, it
meets a branch of the ulnar nerve about to terminate in the muscles
of the thumb. If the treatment by pressure above recommended
should not succeed, the muscles forming what is called the web,
between the thumb and metacarpal bone of the forefinger, should be
cut through, and the bleeding vessel exposed. They are the adductor
pollicis on the inside, and the abductor indicis on back of the hand.
 LECTURE XIII.
WOUNDS OF THE ARTERIES, ETC.
211. The precept so strongly insisted upon, that no operation should
be done on a wounded artery unless it bleed, and at the place from
which it bleeds, has been particularly opposed with reference to the
neck, the opponents believing that placing a ligature on the primitive
carotid is an operation not attended with much risk, and that it may
therefore be done as a precautionary measure when the wounded
part does not bleed; this statement is an error. Of thirty-eight cases
collected by Dr. Norris in 1847, in which this vessel was tied for
aneurism, twenty-six died, and twelve suffered from affection of the
brain, the frequency of which occurrence has been singularly
overlooked by practical surgeons; although proving, in a very
marked manner, that the operation of tying the primitive carotid is
not a trifling affair, and that the success, when compared with the
failures, is only as one and one. A much more important objection is
the difficulty of deciding, in many cases of wounds of the neck, what
artery is wounded, and what trunk should be tied; whether it be the
external carotid or its branches, or the internal, or the vertebral
artery. Errors have been committed on all these points by men of the
greatest anatomical and surgical knowledge; the trunk of a sound
artery having been tied instead of that of a wounded one, inflicting
thereby on the patient a second and useless wound, more
dangerous, perhaps, than the original one it was intended to relieve.
When Professor of Anatomy and Surgery to the College of Surgeons
in 1830, I stated that in wounds of the neck which rendered it
advisable to place a ligature on some part of the carotid, on account
of the supposed impracticability of laying bare the bleeding orifice, it
was generally the external carotid which should be secured, rather
than the primitive trunk; there not being sufficient reason for cutting
off the supply of blood to the head by the internal carotid, unless the
operation on the external carotid should fail. This direction should be
implicitly followed.
212. A man was wounded by a ball in the side of the neck, and
suffered severely from secondary hemorrhage. Some days after
being brought into the hospital, M. Breschet, unable to arrest the
bleeding, was about to apply a ligature to the common carotid, when
the man died in time to prevent it. On examination after death, the
vertebral was found to be the artery wounded, between the second
and third vertebræ. The ligature of the carotid, had he lived a little
longer, would have been a useless addition to his misery.
Professor Chiari, of Naples, tied the trunk of the left common carotid
on the 18th of July, 1829, on account of a false aneurism below the
mastoid process, consecutive to a wound made by a sharp-pointed
instrument under the angle of the jaw. The man died on the ninth
day, and the wounded artery was found to be the vertebral, between
the transverse processes of the first and second vertebræ. M.
Ramaglia says, a man, thirty-nine years of age, was wounded by a
sharp-cutting, penetrating instrument, below the left ear, from which
an aneurismal swelling resulted. The common carotid was tied, but
as this did not arrest the pulsations of the aneurism, the ligature was
removed, and the patient, after suffering from various accidents,
died, when the vertebral was found to be the artery wounded.
M. Maisonneuve, of Paris, lately laid the following most instructive
case before the Academy of Medicine: A lady was shot by her
husband, who stood close to her, with a pistol loaded with ball. The
wound was inflicted on the anterior part of the neck, on a level with
the left side of the cricoid cartilage. The hemorrhage had been
considerable when the surgeons, Messrs. Maisonneuve and Favrot,
arrived, though the wound looked at first as if the ball had not
penetrated deeply. There were pain and numbness of the left arm;
respiration, voice, and deglutition were, however, normal. On
examining with the probe, it was found that the cricoid cartilage had
been bared, and that the ball had then run from above downward,
leaving the trachea and œsophagus internally, and the common
carotid artery, the internal jugular vein, and the pneumogastric
nerve externally, and was impacted in the body of the sixth cervical
vertebra, where it could easily be felt. Some attempts at extraction
were made, but they caused so much pain that they were given up.
The patient was bled six times in four days, and had large doses of
opium; she improved considerably under this treatment, and the
inflammation was very moderate.
On the eighth day hemorrhage occurred at the wound, and again on
the ninth, but it ceased of itself on each occasion. When, however, it
broke out a third time, the surgeons proceeded at once to search for
the bleeding vessel. An incision about three inches long was made
on the anterior edge of the sterno-mastoid muscle, a little external
to the wound inflicted by the ball; the carotid sheath was then
brought into view, and the vessels were found intact. The cricoid
cartilage and the first rings of the trachea were afterward seen to
have been grazed by the ball, which was found implanted in the
body of the sixth cervical vertebra, whence it was easily extracted.
Severe hemorrhage ensued immediately upon the removal of the
ball, the blood seeming to proceed from the vertebral artery, which
appeared to have been wounded within the canal formed by the
foramina of the transverse processes. By placing the finger on the
hole left by the ball, the orifice whence the blood issued was
distinctly seen; forceps were applied to it, and held firmly for a little
while to arrest the hemorrhage. An aneurismal needle, with a very
small curve, was then made to carry a double thread behind the
vessel. One of these was used to tie the artery above, and the other
below the aperture whence the blood issued.
The operators at first thought they were mistaken in supposing that
they had tied the vertebral artery, as the vessel seemed quite free,
while it is known to be protected by the transverse processes in that
locality, and believed they had secured the inferior thyroid. The
hemorrhage ceased at once, and some smaller vessels were then
tied, among which was the inferior thyroid artery. Everything went
on favorably at first; the threads fell on the ninth day after the
deligation of the vessel, and the patient remained in a satisfactory
state for the next five days, when severe febrile symptoms,
unpreceded by shivering, set in; and on the eighteenth day after the
operation, the twenty-seventh after the infliction of the wound, the
patient was suddenly seized with a violent pain in the cervical
region, cried out loudly, and fell into deep coma, which lasted for
about seven hours, when she expired, notwithstanding the most
strenuous means were used to rouse her.
On the post-mortem examination, the course of the ball was found
as stated above, viz., it had run from the integuments to the body of
the sixth cervical vertebra, leaving the trachea and œsophagus
internally, and the carotid sheath and its contents externally,
untouched. The inferior thyroid artery was wounded just before it
reaches the thyroid gland, and had a firm clot, about half an inch in
length, filling its cylinder. The transverse process of the sixth cervical
vertebra was fractured, and had left the wounded vertebral artery
unprotected. The vessel above and below the wound in its coats was
filled with a firm clot for about an inch in each direction. The body of
the sixth cervical vertebra had been perforated by the ball, which
had dug for itself a canal communicating with the cavity of the spine
by a small aperture, evidently of very recent formation. This
aperture resulted clearly from the necrosis of the thin shell of bone
which formed the bottom of the canal. The cancelous texture of the
body of the vertebra was infiltrated with pus, and a sero-purulent
fluid was found in the spinal canal, both in the cellular tissue
external to the dura mater and in the sub-serous texture of the
meninges. No other lesion existed in any other part of the frame.
213. M. S., a female, aged fifty-three, was admitted into the
Westminster Hospital, with a large, movable tumor in the neck,
under the sterno-mastoid muscle of the right side. An operation
having been commenced for its removal, the tumor was found to be
of a more than doubtful character, and to dip down between and
behind the great vessels of the neck. In the course of the operation,
the external carotid was opened a little above its bifurcation, and a
ligature was applied on the common carotid. The bleeding was not
in the least arrested; a ligature was then placed on the external
carotid above the hole in the artery, which still continued to pour out
blood; a third ligature was now put upon the internal carotid, with
no better success. A fourth ligature was then applied on the external
carotid, below the hole in it, including the superior thyroid, which
was given off at that part; after which the bleeding ceased, and
never returned. Three ligatures came away in three weeks; the
fourth remained during five weeks. The patient recovered from the
operation, but the tumor grew again, and the woman died
exhausted at the end of six months. On examination after death, the
arteries referred to were found to be obliterated for some distance
above and below the parts injured.
The utter inefficiency of everything but the two ligatures, the one
immediately above, the other immediately below the part opened,
could not be more distinctly proved, if a case were even invented for
the purpose; and the fact could not be more satisfactorily shown
that in every case of wounded—not aneurismal—artery in the neck,
one ligature should be applied above, and another below the
opening in the injured vessel, and not one alone on the common
trunk, even if that should be the part injured.
It is argued that when a man has his internal carotid cut on the
inside of his throat, by a foreign body of any kind thrust through his
mouth, the artery cannot be tied by two ligatures at the wounded
part through the mouth, not even if it were enlarged from ear to ear.
What, then, is to be done? The artery should be secured by ligature
by an incision made on the outside of the neck. This being admitted,
the question then is, shall the wounded artery be laid bare at the
part injured, or two inches or so lower down, where the main trunk
can be most easily got at by men of even very moderate anatomical
knowledge?—an operation which has frequently failed, although it
has frequently succeeded, and is therefore most approved. I am
willing, for the present, to consider it nearly impracticable to tie the
internal carotid safely from the outside of the neck, at the part
wounded, without great anatomical knowledge, and to accept, for
the moment, as the proper operation, the ligature of the common
trunk of the carotid, at the distance of two or more inches, being the
operation of Anel; but I venture to ask, with what fairness can this
operation, thus done on one side of the neck, at the distance of two
inches, the other side remaining sound, be considered similar to that
of Mr. Hunter, done on the thigh for a wound in the calf of the leg, at
the distance of perhaps twenty inches, with all the intervening
collateral branches perfectly sound? It cannot be considered an
analogous operation, with propriety or fairness, nor ought the one to
be compared with the other, although it is done; and thus the
subject is mystified to all those who do not understand it thoroughly.
It is because English surgeons miscall this the operation of Hunter,
that French surgeons claim the operation of Hunter as that of Anel,
and deny the priority of Hunter, although the two operations are
essentially distinct. The operation of Anel for aneurism of the
popliteal artery would be destructive; the operation of Hunter for a
wound of the popliteal artery would be equally so.
This point must, however, be pressed further. Let us suppose that
the internal carotid has been opened by a wound inflicted through
the mouth, and death is about to follow, unless the hole in the artery
can be tied up. How is it to be done? The Hunterian theorists say it
is impracticable to tie the artery at the wounded part, and the
primitive trunk must therefore be secured.
Let us now suppose that a ligature has been placed on the common
carotid, and the bleeding continues; what is to be done? By the
Hunterian and Anellian theorists there is nothing more to be done—
the patient must die. By my theory there is another operation to be
done, and the patient need not necessarily die. As there is already a
wound in the neck made by the surgeon, there would be little
difficulty, by extending it, in ascertaining that the blood came from
the brain, and that nothing but a ligature on the internal carotid
artery above the part wounded through the mouth could save the
patient; and why not do this operation at first, and place a ligature
above and another below the wound in the artery?
214. It is with great satisfaction I quote the opinion of M. Velpean on
this subject, as showing the greater advance Parisian surgeons have
made than even many of high attainments in London: “In
hemorrhage from the neck, the mouth, the throat, the ear, or the
skull, everything should be done to reach the branch of the carotid
which has been wounded, rather than tie the carotid itself.” Alluding
to a wound of the inferior pharyngeal artery, he says: “The search
for this artery will cause but little or no inconvenience, for the same
incision will suffice for the ligature of the external or internal carotid,
the lingual, the facial, or the superior thyroid artery, if it become
necessary, each artery being capable of being taken hold of and
compressed, until the one which is really wounded is ascertained.”
He further adds: “Surgeons found it formerly more convenient and
sure to tie the primitive trunk of the carotid, for all arterial diseases
of the head, than to tie the external or internal carotid or their
branches; but this is not admissible in the present day.” Operating
for a tumor on the left temple, which he considered aneurismal, he
first tied the common trunk of the carotid, and then the internal. The
tumor diminished in size, but hemorrhage took place from the
wound, and was frequently repeated until the sixteenth day, when
the patient died hemiplegic. The hemorrhage came from the
external carotid, and the blood escaped through the upper opening
of the common carotid. He says himself he ought to have tied the
external carotid also; or, after the first bleeding, have applied a
ligature on the upper end of the common trunk.
215. Dr. Twitchell, of Keene, N. H., United States, says a soldier, in a
sham fight, in 1807, received a wound, from the wadding of a pistol,
on the right side of the head, face, and neck, which was much
burned. A large wound was made in the mouth and pharynx; nearly
the whole of the parotid gland, with the temporal, masseter, and
pharyngeal muscles, was destroyed. The neighboring bones were
shattered, and the tongue injured. The hemorrhage was not
copious, although the external carotid and its branches were divided.
Ten days after the accident, the sloughs had all separated, and left a
large circular aperture, of from two to three inches in diameter, at
the bottom of which might be seen distinctly the internal carotid
artery, denuded from near the bifurcation of the common trunk to
where it forms a turn to enter the canal in the temporal bone.
Directly on this part there was a dark speck, of a line or two in
diameter, which suddenly gave way while Dr. Twitchell was in the
house. With the thumb of his left hand he compressed the artery
against the base of the skull, and effectually controlled the
hemorrhage. The patient fainted. As soon as he recovered, the
doctor says: “I proceeded to clear the wound from blood, and
having done this I made an incision with a scalpel downward, along
the course of the artery, to more than an inch below the point where
the external branch was given off, which, as stated above, had been
destroyed at the time of the injury. Having but one hand at liberty, I
depended upon the mother of the patient to separate the sides of
the wound, which she did, partly with a hook, and occasionally with
her fingers. At length, partly by careful dissection, and partly by
using my fingers and the handle of the scalpel, I succeeded in
separating the artery from its attachments; and, passing my finger
under it, I raised it up sufficiently for my assistant to pass a ligature
round it. She tied it with a surgeon’s knot, as I directed, about half
an inch below the bifurcation.” Dr. Twitchell removed his thumb, and
sponged away the blood, not doubting that the hemorrhage was
effectually controlled; but, to his surprise and disappointment, the
blood immediately began to ooze from the rupture in the artery, and
in less than ten minutes it flowed with a pulsating jet. He
compressed it again with his thumb, and began to despair of saving
his patient, but resolved to make another attempt. Raising his
thumb, he placed a small piece of dry sponge directly over the
orifice in the artery, and renewed the compression till a rather larger
piece of sponge could be prepared. He placed that upon the first,
and so went on, pressing the gradually enlarged pieces obliquely
upward and backward against the base of the skull, till he had filled
the wound with a firm cone of sponge, the base of which projected
two or three inches externally. He then applied a linen roller in such
a manner as to press firmly upon the sponge, passing it in repeated
turns over the head, face, and neck. On the 30th of December the
patient was discharged cured, several fragments of bone and two
teeth from the upper jaw having been cast off. Some deformity
remained, in consequence of the depression on the side of the face.
The inutility of tying the primitive trunk for a wound of the internal
carotid is distinctly shown in this case, which is no less valuable from
the fact demonstrated, that if the internal carotid can be exposed
and injured within the angle of the jaw by an accident, it can be
exposed and secured by ligature at the same part by an operation.
216. When, then, the internal carotid is wounded through the
mouth, what operation is to be performed? That of placing a ligature
above, and another below the opening made into it; and after much
consideration, and many trials, the following operative process is
recommended to the attention of those who are best acquainted
with the subject:—
An incision is to be begun opposite to and on the outside of the
extremity of the lobe of the ear, and carried downward in a straight
line, until it reaches a little below the angle of the jaw, at the
distance of nearly half an inch, more or less, as may be found most
convenient from the form of the neck. This incision exposes the
parotid gland without injuring it. A second is then to be made from
the extremity of the first, extending at a right angle forward, under
or along the base of the lower jaw, until the end of it is opposite the
first molar tooth. This incision should divide the skin, superficial
fascia, platysma myoides muscle, and the facial artery and vein. The
second molar tooth should then be removed, and the jaw sawn
through at that part. Then cut through the deep fascia, the mylo-
hyoideus muscle, and the mucous membrane of the floor of the
mouth, exposing the insertion of the internal pterygoid muscle,
which is to be divided. The surgeon will next be able to raise and
partially evert the angle of the jaw, and thus obtain room for the
performance of the remaining part of the operation, which should be
effected by the pointed but blunt end of a scalpel, or other
instrument chosen for the purpose of separating, but not of cutting.
The styloid process of the temporal bone may then be readily felt,
and exposed by the separation of a little cellular membrane, and
with it the stylo-hyoid muscle, which is to be carefully raised and
divided. The external carotid artery will thus be brought into view,
together with the stylo-pharyngeus muscle and the glosso-
pharyngeal nerve attached to it. These are to be drawn inward by a
blunt hook, when, if care be taken to avoid the pneumogastric
nerve, the internal carotid may be felt, seen, and secured by ligature
with comparative facility outside the tonsil, there being between
them the superior constrictor of the pharynx, which, in a case of
wound through the mouth, must have been divided. The
pneumogastric nerve should be drawn outward, and the external
carotid artery also, if in the way. The division of the jaw will not lead
to further inconvenience, as the bone always reunites, when divided,
with little difficulty. That this operation requires a thorough
knowledge of the anatomy of the parts, is true; and this can only be
acquired by repeated dissections.
217. The nearest successful case to the operation thus
recommended was performed by Dr. Keith, of Aberdeen.
E. Kennedy, aged twenty-five, accidentally swallowed a pin, the head
of which could be felt below and behind the left tonsil, covered by
the lining membrane of the pharynx; it could not be extracted by
any attempt made for its removal. The membrane was snipped by a
pair of probe-pointed scissors, to expose the head of the pin. This
was followed by the discharge of mouthfuls of arterial blood, and it
was evident that the internal carotid artery had been injured.
Pressure on the common carotid stopped the bleeding, and the
operation of placing a ligature on the internal carotid was effected in
the following manner: The patient’s head being supported by a
pillow, her face was turned toward the right shoulder, when an
incision was made from below the ear along the ramus of the lower
jaw to below its angle. No hemorrhage occurred, and the vessel was
speedily exposed and secured by a double ligature passed under it,
with less difficulty than the depth of the vessel would lead one to
expect. One ligature arrested the flow of blood, and the other was
therefore withdrawn. The woman recovered, without any return of
the bleeding. Dr. Keith, aware of the necessity for tying the other
end of the artery, if it should bleed, watched the case day and night
until the period of danger had passed away. The pin gave no
trouble, until felt by the patient as about to go down the
œsophagus, which it did to her great satisfaction and relief from
further anxiety.
 LECTURE XIV.
LIGATURE OF THE COMMON ILIAC ARTERY, ETC.
218. The operation for placing a ligature on the aorta should not be
done by making an opening through the front of the abdomen, as
has hitherto been proposed. It should in future be attempted and
executed nearly in the same manner as the operation for placing a
ligature on the common iliac, which has succeeded. The aorta
bifurcates usually on the body of the fourth, or on the inter-vertebral
substance between it and the fifth vertebra, although it may be
higher or lower—a fact which cannot be ascertained previously to
the operation; the most usual place is nearly opposite to the margin
of the umbilicus on the left side. It is about half an inch above this
that the ligature should be placed on the aorta, if this operation is
ever done again, rather lower than higher, on account of the origin
of the inferior mesenteric artery. As the aorta is to be reached by
carrying the finger along the common iliac, the comparative situation
of that vessel is next to be estimated.
The length of the two common iliac arteries varies according to the
stature of the patient, and the place at which the aorta bifurcates.
The common iliacs again divide into the external and internal iliacs,
which division is usually opposite to the sacro-iliac symphysis. The
length of the common iliac artery is therefore tolerably well defined,
as scarcely ever exceeding two inches and three-quarters, and
seldom being less than two inches. The external iliac is a little longer
than the common iliac, and the place of subdivision of the common
iliac into external and internal can always be ascertained, during an
operation, by tracing the external iliac upward to its junction with
the internal to form the common trunk, which proceeds upward and
inward to the aorta. The left margin of the umbilicus being taken as
a point opposite to that which may be presumed to be the part at
which the aorta divides, and the situation of the external iliac
becoming femoral being clearly ascertained, a line drawn between
the two will nearly indicate the course of these two vessels;
sufficiently so, at all events, to enable the operator to mark with his
eye, or with ink, the place where he expects to tie the artery; and to
regulate the length of the incision, so that this ideal spot may
correspond to its center. It is necessary to recollect, also, that the
whole of one hand and part of the other must be introduced into the
wound, to enable the operator to pass a ligature round the artery,
and to tie the knots: so that an external excision of less extent than
five inches will not suffice, and six will afford a facility in operating,
which will save pain to the patient and inconvenience to the
operator. In calculating the length of the incision, allowance must be
made for the size, obesity, and muscularity of the patient. If a rule
be placed on the crest of each ilium, about one inch and a half
behind the anterior superior spinous process, it will pass in a well-
formed man across the junction of the fifth lumbar vertebra with the
upper part of the sacrum, and a little way behind where the common
iliac divides into external and internal. The center of an incision, six
inches in length, beginning about half an inch above Poupart’s
ligament, and about the same distance to the outside of the inner
ring, and carried upward, will fall nearly on a line with this point. The
incision should be nearly parallel to the course of the epigastric
artery, but a little more to the outside, in order to avoid it and the
spermatic cord, and having a gradual inclination inward toward the
external edge of the rectus muscle; the patient being on his back,
with the head and shoulders raised, and the legs bent on the trunk.
The aponeurosis of the external oblique muscle having been opened
inferiorly, is to be slit up for the whole length of the external incision;
and the director having been first passed under the internal oblique
muscle, through a small opening carefully made into it, it is to be
divided in a similar manner. The transversalis is then to be cut
through at the under part, and its tendinous expansion divided at
the upper part, the greatest precaution being taken by the finger to
prevent the peritoneum being injured. The fascia transversalis is
then to be torn through at the lower and outer part, so that the
fingers may be passed inward from the ilium, and the peritoneum
detached from the iliac fossa, and turned with its contents inward,
by a gradual and sidelong movement of the fore and second fingers
inward and upward, until, passing over the psoas muscle, the
external iliac artery is discovered by its pulsation. It is then to be
traced upward and inward toward the spine, when its origin and that
of the internal iliac from the common trunk will be felt. The point of
the forefinger will then be nearly in the center of a line drawn from
the umbilicus to the anterior superior spine of the ilium; hence the
necessity for an incision six inches in length, if the artery is to be
tied high up, which is to be accomplished by tracing it in a similar
manner to its origin from the aorta.
The common trunk of the iliac arteries and the aorta itself may be
tied by the same method of proceeding; the only difference which
can be practiced with advantage will be to make the incision a little
longer at its upper part, no inconvenience arising from the addition
to the length of the external wound, while the subsequent steps of
the operation will be much facilitated by it. The following method of
proceeding, adopted in two cases in which I placed a ligature on the
common iliac artery with a successful result, will bring the operation
so graphically before the reader that it cannot be misunderstood,
and may be readily followed in operating: I began the operation, the
patient lying on the back, by an incision on the fore part of the
abdomen, commencing an inch and a half below the inside of the
anterior spine of the ilium, and the same distance within it, carrying
it upward, and diagonally inward toward the edge of the rectus
muscle above the umbilicus, so that the incision was between six
and seven inches long. If the incision be made more outwardly,
toward the side in a straight or vertical line from the ilium toward the
ribs, great difficulty will be experienced in turning over the
peritoneum with its contents, so as to place the finger on the last
lumbar vertebra—an inconvenience which will be avoided by making
the incision diagonally, and of the length directed.
After dividing the common integuments, the three layers of muscles
were cut through in the most careful manner; the division of the
transversalis muscle was attended with some difficulty, inasmuch as
there was but little fascia transversalis, and the peritoneum was
remarkably thin—as thin as white silver paper. On attempting to
reach the under part on the inside of the ilium, so as to turn the
peritoneum over, which in sound parts is always done without the
least difficulty, I found that it could not be done on account of the
tumor which projected inward adhering to it; some bleeding took
place from the large veins which surrounded it, giving rise to the
caution not to proceed further in that direction. At this moment, in
spite of the greatest possible care that could be taken by Mr. Keate,
who raised and protected the peritoneum, a very small nick was
made in it, sufficient to show the intestine through it. Perceiving that
I could not tie the internal iliac as I had at first intended, and that I
must place the ligature on the common iliac, I tried to gain a greater
extent of space upward; but where the tendon of the transversalis
muscle passes directly across from the lower ribs to aid in forming
the sheath of the rectus, the peritoneum is usually so thin and so
closely attached to it that it can only be separated with great
difficulty. I knew this from the operation I had before performed,
when, in spite of all the precaution I could then take, the
peritoneum was at this spot slightly opened. It occurred in the
present instance, and the right lobe of the liver was thus exposed.
The opening thus made on the fore part of the abdomen was not
large enough to admit two hands. The peritoneum being, however,
separated a little from the posterior wall of the abdomen from the
outside, by the fingers, for a cutting instrument was inadmissible,
four of the fingers of one hand were introduced beneath it, and it
was turned a little over toward the opposite side. In doing this it
must be remembered that the peritoneum must be raised, the hand
being pushed toward the back as little as possible, in order to avoid
getting behind the fat commonly found in that part of the body,
which would lead to the under edge of the psoas muscle instead of
the upper surface, and thus render the operation embarrassing.
The peritoneum being carefully drawn over with its contents, I found
I could only get one hand, or a little more, underneath it in search of
the artery, the tumor below preventing any further detachment of
the peritoneum in that direction. I therefore passed my finger across
the psoas muscle, and it rested on the fifth lumbar vertebra. The
common iliac artery was not to be felt, however, even as high up as
the fourth lumbar vertebra, nor was the aorta; they had both risen
with the peritoneum, and my finger resting on the spine was
beneath them. Mr. Keate endeavored to raise or draw over the
peritoneum, to give me an opportunity of seeing the vessels, but it
could not be done. However, he felt the pulsation of the iliac artery,
which had been raised with the peritoneum, to which I found it
adhering. Carefully separating it with the end of the forefinger of the
right hand, I passed a single thread of strong dentists’ silk, as it is
termed, in a common solid aneurismal needle, by the aid of the
thumb and forefinger of the left hand, round the artery without
seeing it. I could then bring the artery a little forward by means of
the aneurismal needle, when it appeared to be perfectly clear, and
from the distance of the bifurcation of the aorta above, which could
be distinctly felt, I calculated that the common iliac was tied exactly
at its middle part. All pulsation below immediately ceased.
The two ends of the ligature were twisted, and the peritoneum
replaced in its proper situation, care being taken that the two small
openings into it should be well covered under the skin, so that they
might not be in the line of the incision, and that they should be
covered by newly divided healthy parts, so that they might thus
adhere to each other. Three strong sutures and three or four smaller
ones were put in through the skin, in order to prevent the parts
bursting asunder from the movements of the patient. This operation
was only formidable, as a whole, from the circumstance that space
could not be obtained for the introduction of both hands; for, strange
as it may appear, the safety of and ease in doing the operation
depend on the first incision in the fore part of the abdomen being so
large that the peritoneum containing the bowels may be freely
drawn over by the expanded hands of the assistant, so that the
operator can see what he is doing beneath. In my first case the
whole of the parts under the peritoneum could be distinctly seen,
and several gentlemen (not in the profession) who were present saw
the common iliac artery in its natural situation.
The patient suffered little or nothing from the operation, which was
performed on the Saturday; there was no augmentation of the pulse
until Sunday evening, when it rose to 120; she then experienced
some pain, which was materially diminished, although not altogether
removed, by the abstraction of fourteen ounces of blood. At four in
the morning, Mr. Hancock, now senior surgeon to the Charing Cross
Hospital, took away fourteen ounces more, after which she had not
a bad symptom. The bowels were not moved for the first four days.
The temperature of the limb diminished, but not much, which may
be attributed to its having been constantly rubbed night and day by
two persons; and a hot brick, or bottles of hot water, covered with
flannel, having been applied to the feet, of the temperature of from
120° to 140°. One nurse rubbed the lower part of the limb, and
another the upper, for three days and three nights; if an interval of a
few minutes occurred, a hot flannel was put on the limb. The friction
was very slight, so as not to injure the cuticle. The patient
occasionally dozed a little; still the same gentle friction was kept up.
The ligature came away on the twenty-sixth day after the operation.
The external incision healed very readily, but was followed, as is
usual in all extensive wounds of the muscular wall of the abdomen,
by a slight herniary projection, requiring the support of an abdominal
bandage.
The situation of the ureter and rectum on the left side in this
operation, and of the ureter and cæcum with its appendix on the
right side, should be well understood, and it should be known that
the ureter rises with the peritoneum. The relative situation of the
common iliac artery and vein should be particularly attended to,
when passing the ligature around the vessel. On the left side, the
artery lies external and anterior to its commencement; on the right,
the artery passes over the commencement of the vena cava and the
left iliac vein, which do not follow the peritoneum when drawn
toward the opposite side. The bowels should be thoroughly well
evacuated before the operation is performed, but purgatives should
not be given for some days after it has been done. The food should
be liquid, and inflammation should be subdued by leeches, general
bleeding, fomentations, and opium.
219. The aorta may be as readily tied by this mode of proceeding as
the common iliac; and I am satisfied it is in this way such an
operation ought to be performed, provided it become necessary to
attempt it, which I suspect it will not be; for when an aneurism has
formed so high up that it prevents the application of a ligature on
the side on which the disease is situated, the common iliac will be
more readily tied above it, instead of the aorta, by performing the
operation on the opposite or sound side of the body; for as a
ligature can be applied with great ease on the sound side on the
middle of the common iliac artery, it requires very little more
knowledge and dexterity to pass over to the opposite or diseased
side, and tie the artery above the aneurismal tumor, the size of
which would have prevented the operation being done on its own or
the affected side. The placing a ligature on the aorta for an aneurism
in the pelvis will thus be rendered unnecessary—a most important
result, deduced from the operation described.
220. If the internal iliac is to be tied, the operator traces it
downward from its origin, in preference to passing his finger from
the external iliac artery inward in search of it. Having placed the
point of his forefinger on the vessel at the part where he intends to
pass his ligature, he scratches with the nail upon and on each side of
it, so as to separate it from its cellular attachments, and from the
vein which accompanies, but lies behind it. Thus far the operator
proceeds by feeling; but it is now necessary that the sides of the
wound should be separated, and kept apart by blunt spatulæ curved
at the ends, so as to take up as little space as possible, and not to
injure the peritoneum. The surgeon should, if possible, see the
artery, and the ligature carried on the eye of a bent probe, or a
convenient aneurismal needle, should be passed under it from within
outward, when it should be taken hold of with the forceps; the probe
or needle should then be withdrawn, and the ligature firmly tied
twice, or with a double knot. Great care must be taken to avoid
everything but the artery. The peritoneum which covers it and the
ureter which crosses it must be particularly kept in mind. The
situation of the external iliac artery and vein, which have been
crossed to reach it, must always be recollected, and, if there be
sufficient space, they should be kept out of the way, and guarded by
the finger of an assistant.
221. The external iliac artery has been so often and so successfully
tied that a description of the two methods of proceeding commonly
adopted will suffice, with a few additional remarks. The first,
recommended by Mr. Abernethy, is in accordance with the operations
on the common, and on the internal iliac. The patient being laid on
his back, with the shoulders slightly raised, and the legs bent on the
trunk, an incision is to be made about three inches and a half in
length in the direction of the artery, terminating over or a little above
Poupart’s ligament. The aponeurosis of the external oblique muscle
will be exposed, and an opening being made into it, a director is to
be introduced, and it is to be slit up to the extent of the external
incision. The internal oblique and transversalis muscles are then to
be “nicked,” so as to allow a director or the point of the finger to be
introduced below them, when they also are to be divided, the finger
separating them from the fascia transversalis and the peritoneum.
The fascia transversalis running from Poupart’s ligament to the
peritoneum is now to be torn through with the nail, immediately
over the pulsating artery, and the peritoneum is to be separated by
the finger, and pushed upward until sufficient room has been
obtained; which in this, as well as in all other operations on the iliac
arteries, is sometimes difficult on account of the protrusion of the
intestines covered by the peritoneum, when the patient is not
sufficiently tranquil. The artery is yet at some depth; it is covered by
a dense cellular membrane, connecting it to the vein on its inside,
which must be torn through with the nail. The anterior crural nerve
is separated from the artery by the psoas muscle, at the outer edge
of which it lies. The aneurismal needle should be passed between
the vein and the artery, and the point made to appear on the outside
of the latter.
In this operation the ligature is placed on the external iliac, above
where it gives off the epigastric and the circumflexa ilii arteries; as
the operation is very much the same as that already described, with
the exception of the incision being shorter and nearer to Poupart’s
ligament, it is obvious, if it were found necessary from disease to tie
the artery higher up, or even to tie the common iliac, that it might
be done by merely enlarging the wound. It is therefore the best
mode of proceeding when the aneurismal swelling in the groin has
encroached on Poupart’s ligament.
Another method has been recommended by Sir Astley Cooper, which
is perhaps more followed where there is little doubt of the artery
being sound.
“The patient being placed in the recumbent posture, on a table of
convenient height, the incision is to be begun within an inch of the
anterior superior spinous process of the ilium, and is to be extended
downward in a semicircular direction to the upper edge of Poupart’s
ligament. This incision exposes the tendon of the external oblique
muscle; in the same direction the above tendon is to be cut through,
and the lower edges of the internal oblique and transversalis
abdominis muscles exposed; the center of these muscles is then to
be raised from Poupart’s ligament; the opening by which the
spermatic cord quits the abdomen is thus exposed, and the finger
passed through this space is directly applied upon the iliac artery,
above the origin of the epigastric and circumflexa ilii arteries. The
iliac artery is placed upon the outer side of the vein; the next step in
the operation consists in gently separating the vein from the artery
by the extremity of a director, or by the end of the finger. The solid
curved aneurismal needle is then passed under the artery, and
between it and the vein from without inward, carrying a ligature,
which, being brought out at the wound, the needle is withdrawn,
and the ligature is then tied around the artery, as in the operation
for popliteal aneurism. One end of the ligature being cut away, the
other is suspended from the wound, the edges of which are brought
together by adhesive plaster, and the wound is treated as any other
containing a ligature.”