Charles Otto Dhonau

Embalming

The central thought of the modern funeral director in the care of the dead and in all the arrangements of the funeral is to remove so far as may be all that is necessarily painful to those who must place out of sight the body through which the soul of the dear one has expressed itself, in all the ways that are prompted by affection. This does not seem to have been the case in the former days when the methods were in striking contrast to those of today and were such as would intensify the suffering of the living. Beginning with the arrangement of the body in the room made cold by nature in winter or by the ice box in the summer and ending by lowering the body into an unlined grave, each detail seems to have been made with little thought of lessening the pain caused by those things which necessarily have to be done. Perhaps the central thought in the old days was the same as that which was the comfort offered upon funeral occasions by a former local pastor which was “death is a horrible thing.” If this was not the controlling thought, it is certain that many details of former funeral customs would be considered horrible today. Today the aim is to lighten the burden and to cheer the hearts of those who mourn.

The introduction of embalming in the seventies has been of untold benefit in improving the environment of the dead prior to interment. Recollections of the use of the old ice box, the crude and cumbersome cooler, the ice water to be cared for and the thought of the chilled body are not pleasant now, and were far from pleasant then to those into whose homes death had entered in hot weather. In winter natural cold was depended upon, the body being placed in the coldest place possible. With the best of care the results were uncertain and far from satisfactory. Modern embalming has changed all this. Its results are with rare exceptions certain and satisfactory and the embalmed body may be dressed and placed in a warm and comfortable room.

CHAPTER X. MODES, SIGNS AND TESTS OF DEATH.

Just as surely as we are born, just so surely must we die, and just as it is the physician's duty to care for the living body, if possible to keep it in a strong and healthful condition, so it is the embalmer's duty to care for the body after death, not so much for the body itself, but from a sanitary standpoint, namely, to see that the body is well disinfected and embalmed so that there will be absolutely no chance for the spread of disease.

Any one who is familiar with hospital work must know that all do not die in the same way. For some it is the long lingering disease, chronic in form, which after a long and tedious course the thread of life is finally broken, and we hardly know the instant at which the change was completed. For others, it is the short, acute attack, which snaps the life away in a very instant, only after a very short duration. For some it is to die from accidental causes, while for others it is only the passing out from the period of old age. For some the mind may be active and the intellectual faculties useful up to the last moment, while for others the contrary is all but too true.

Although there may be many different kinds of disease infecting the human race, yet we find that death ultimately results from the stoppage of any one, or maybe, all three of the vital organs, namely the heart, brain or lungs. Anything whatsoever which plays upon the body, to such an extent, as to affect the functions absolutely, of either the heart, brain or lungs, will result in the death of that body. And since these organs are of such vital importance to us, and since the stoppage of any one of them will result in death, they have been termed the vital organs.

Modes of Death.

—There are, then, only three modes of death: syncope, or the stoppage of the heart; coma, or the failure of the brain to perform its functions; apnea, or the stoppage of the lungs.

Syncope.—For the heart to properly perform its function, namely that of propelling the blood to all parts of the body, it must first be properly nourished itself. If for any reason the heart does not get this proper nourishment, say the coronary arteries should become clogged, or a fatty infiltration, or a lack of red blood corpuscles, we would have a condition in the body known as anemia.

The heart must also have a proper nerve supply from the brain, and if because of any disease, the vaso-motor or the vaso-constrictor fibers should become affected, the heart would cease to contract and expand, and hence the complete stoppage of the heart. A condition of this kind is known as asthenia.

But whether it is death by anemia or asthenia, the state of suspended animation, common to both these forms is expressed by the single term—syncope.

Coma.—In cases of apoplexy, where we have the blood escaping from the ruptured vessels, compressing the brain, we find death ensuing. Also in accidental cases such as fracture of the skull, the injury will often cause death. These are examples of coma, and can be explained in this way, viz.; the power of the brain becomes inactive either through the result of an injury or a disease, and when this inactivity occurs the respiratory apparatus subsides and the heart deprived of its normal stimulus through the vaso-motor and constrictor fibers, soon ceases to beat, and death is the result.

Apnea, Asphyxia.—If for any reason the supply of oxygen is cut off from the lungs, we will have the body dying the result of asphyxia or apnea. The most common forms found of this mode of death are those of hanging, drowning or coal gas poisoning.

Signs of Impending Death.

—The signs of impending death are those conditions which exist on the body or the peculiar features of the body which aid the physician in ascertaining the exact condition of the body. These signs assume many different forms and in no two instances may they be found alike. They of course, are not positive in themselves, but are sufficient to guide us in forming an opinion as to the approach of death.

One of the first signs to be noticed is the coldness of the extremities. In this case the coldness begins at the extreme tips of the fingers and toes and gradually extends toward the trunk. This, of course, is due to the gradual diminishing activity of the heart to propel the blood to the extremities.

The brain also fails to receive its proper blood supply and becomes weakened and we find the mind wandering. This wandering results in the patient going through movements representing the playing with flowers, or picking at the bed clothing. A further result of this weakness is that the patient may have visions of angels and heaven.

Speech begins to grow thick, and a large lump of phlegm gathers in the throat.

The hands now feel cold and clammy, and if they are raised they instantly fall. One cannot detect the act of respiration, as the movements of the thoracic walls are so slight as to be scarcely perceptible.

The heart loses its power to propel the blood and the stoppage of every organ in the body ensues.

The eyes become fixed with a staring look as though they were not focused on anything directly. The eyes lose their lustre on account of the lachrymal glands refusing to secrete.

The vital organs, the heart, brain and lungs come to a halt, and we find the body passing from life to the great beyond.

Tests of Actual Death.

—From the large number of statistics that have been gathered together for our purpose, we find that the time of greatest mortality is in the early morning hours between three and six A. M., for it is between these hours that the body is in a perfect state of relaxation, and at the lowest ebb of vitality.

The time of least mortality is between the hours of eleven and two P. M., as the body is in a relatively high state of vitality during these hours.

The tests of actual death can be placed in two classes, the common tests and the expert tests.

The common tests are those that have long been used by the inexperienced to ascertain the fact of death. They are not necessarily conclusive in themselves, but when all are taken together there can not be much doubt.

(a) The Feather Test.—In this test a feather is held to the nostrils to observe whether it moves. The feather being so light, the slightest respiration of the lung would be apt to move it.

(b) The Mirror Test.—In this test a mirror is held to the mouth and nostrils. If moisture collects on the mirror it is evident that respiratory movements are going on. If there is an absence of moisture we are quite safe in saying that the patient is dead.

(c) The Bandage Test.—In this test a bandage is placed around the arm and then twisted very tightly. If there is the slightest circulation existing in the body the blood will accumulate back of the bandage in the venous system and thus demonstrate the fact. There will also be no swelling or discoloration beyond the ligature.

(d) By placing the ear to the chest over the heart, no sounds will be heard.

(e) If the ear is applied over the lungs, no sounds will be heard.

(f) If a cup of water is placed on the chest there will be no movement of rays or ripples on the surface.

(g) If the skin is cut, no blood will flow, nor will the wound close.

(h) If heat, say for instance a burning match be applied to the skin it will not blister, or if ammonia is hypodermically injected under the skin there will be no redness, but rather the skin will turn to a yellowish color.

(i) The living hand when held to the light shows pink through the inner edges of the fingers, but with the dead hand it shows opaqueness.

(j) When a strong light is brought before the eye the pupil of the eye will not dilate or contract.

(2) The expert tests are those which a doctor or coroner might use to ascertain the fact of death. These tests are made with the stethoscope and the ophthalmoscope.

(a) By the use of the stethoscope the physician can hear the sounds of the heart and if there is the slightest sound he can detect it. In the absence of any sound the body is pronounced dead.

(b) By the use of the ophthalmoscope the physician is enabled to look into the pupil of the eye and if there is life he can see the blood circulating through the tiny capillaries of the retina. If he does not see this capillary circulation he is quite safe in saying the body is dead.

(c) Another method consists in the hypodermic or intravenous injection of certain substances, and ascertaining whether these substances have been dispersed throughout the body. If they have, then a circulation exists and life continues, although the pulsation of the heart may not be detected by auscultation. Among the substances recommended for injection are fluorescin, sodium iodide, lithium iodide and potassium ferro-cyanide. The injection of the small quantities as used will not cause death should the patient still be living.

Fluorescin is usually injected, one gramme dissolved with an equal weight of sodium carbonate in eight cubic centimeters of water, and the whole quantity injected hypodermically. If the circulation is persisting, the skin and the mucous membranes after a very few minutes assume a greenish color; about twenty minutes after the injection, the portion of the eye within the iris assumes a green color from penetration of the fluorescin into the vitreous and aqueous humors, and in the blood the fluorescin may be detected by the following method: One or two threads of cotton are passed under the skin in the form of a seton, and when saturated with blood are transferred to a test tube, and boiled with a little water. As the liquid clears the green color of the fluorescin becomes evident, if that substance has been absorbed into the blood.

(d) Another method for the distinction of real from apparent death consists in picking up a fold of the skin and compressing it with a pair of artery forceps. If the skin does not completely settle down, and if the fine furrows produced by the teeth of the forceps continue indefinitely, then death has occurred. Whereas, if the circulation is continuous, the fold and the marks of the forceps would disappear. Moreover, if death has occurred the portion of the skin compressed by the forceps assumes a parchment-like appearance.

(e) The electrical current affords a means of determining death. It is now known that the muscles, after cadaveric rigidity has set in, do not respond to electric stimuli. The faradic current will cause, when death has occurred, muscular contractions until a short time before post-mortem rigidity occurs. The faradic stimulus is lost first and the galvanic stimulus soon after. We may be enabled to approximate the time at which death occurred, for, if we find any response to either the faradic or the galvanic current, we know at once that post-mortem rigidity has not yet occurred.

No person should be buried as long as the muscles contract when stimulated by either the faradic or the galvanic current. If the electrical test were always applied before a death certificate was signed, there would be absolutely no possibility of a person being buried alive and the public would soon lose the morbid fear of such an occurrence.

Later and More Positive Signs.

—(a) After a few hours the blood gradually sinks to the dependent parts of the body giving a reddish-blue discoloration, known as post-mortem discoloration, or cadaveric lividity.

(b) The eyes become sunken in the sockets, the eye balls become flattened, the cornea opaque and the pupil irregular in shape.

(c) The eyelid loses its elasticity, and the white transparent color of the conjunctiva is lost, often becoming black or gray.

(d) Rigor mortis may or may not be present.

(e) The body gradually cools to the temperature of the surrounding atmosphere.

(f) On opening an artery it is generally found to be empty after death.

(g) The latest and most positive sign of all is putrefaction, and when this is found to be present all other signs may be ignored.

(h) Skin slip present on the body is only another manifestation of putrefaction, and also signifies that the body is dead.

CHAPTER XI. PREMATURE BURIAL.

Premature Burial.

—In this enlightened age, with our knowledge of respiration and the circulation of the blood, with our complete mastery of the phenomena of death with scientific tests, it is absolutely impossible to have such a thing as a premature burial.

Nevertheless from the earliest times the fear of premature burial has been felt by many, and curious and strange methods have been adopted to prevent the possibility of individuals being consigned to their graves before life was extinct.

Tradition records many cases where, in spite of their precautions, such unfortunate actions have happened. It may be that tradition is an uncertain and erring guide. And yet underlying all tradition, as Dieulafoy said, is a solid substratum of truth which the thoughtful investigator must take into consideration. The tale of the Cologne goldsmith's wife, that survives in the legend of the neighing horses, may be weird, bizarre, and from a scientific point of view, demonstratively ludicrous, but its germ is to be found in the recorded fact that in times of epidemics, when the dying were huddled away with the dead, mistakes did occur, and one or two were rectified by the resurrection of the “dead.” In cases where burial took place in commodious family vaults, the changes in the position of the coffin, produced by atmospheric and other physical factors and were startlingly disclosed when the vaults were opened to receive new bodies, doubtless gave an impetus to the belief in the comparative frequency of such mistakes. The medical man remembers that on occasions he has found it difficult, without applying some of the common and finer tests, to certify death in a patient dying of a lingering disease, but his knowledge forbids him believing that such difficulties as he may have experienced in his own practice can ever have caused his fellow practitioner to make so grievous a mistake in a similar case. The public has no such knowledge; it relies on the exceptional cases and glibly credits the statement—true enough in a limited sense that there is no certain proof of death. While it is certainly true that no single sign can be absolutely relied upon to prove that life is extinct, all practitioners will agree that several signs taken in combination and methodically applied are sufficiently accurate to obviate the possibility of mistake. Much has been made of the cataleptic condition and the probability of mistaking it for death, which has formed the basis of one of Poe's narratives. As a matter of fact, catalepsy, of such a nature as to be confounded with tota exitus, is extremely rare—so rare that we doubt if any practitioner with a large experience of nervous conditions has met with more than one or two instances. Further, even in such extremely rare conditions, the usual tests are applicable and to the trained medical man at least clearly prove the nature of the case. The stethoscope and the mirror held in front of the patient's mouth are usually sufficient to demonstrate that the patient is alive and we should want more conclusive evidence than such as has been brought forward up to the present, to feel that cataleptic patients have been consigned to their coffins before life was totally extinct.

Newspaper writers delight in the fictitious and marvelous, and without any regard whatever to the scientific phase of the subject, frequent mention of cases of premature burial is to be found almost daily in the press of the country. But upon investigating these newspaper stories, it will be found that they have been either originated in the fertile brain of some reporter or were merely published to consume space.

CHAPTER XII. THE CHANGES IN THE BODY AFTER DEATH.

The time occupied by the cooling of the body may be prolonged after sudden death from accidents, acute diseases, apoplexy, and asphyxia. A number of cases is reported in which the body retained its heat for several days without known cause.

After death from wasting chronic diseases, and in some cases after severe hemorrhage, the cooling of the body is very rapid, the internal temperature being reduced to that of the surrounding air within four or five hours.

Fat bodies cool less quickly than lean ones, the bodies of well nourished adults less quickly than those of children or old persons. The temperature of the surrounding atmosphere, the degree of protection of the body from currents of air, of course, modify the progress of cooling; and the internal organs naturally retain their heat longer than the surface of the body. The rate at which cooling occurs is most rapid as a rule, during the hours immediately following death, notwithstanding the postmortem rise which may ensue.

After life becomes extinct, and before the blood coagulates, it changes its position chiefly in two ways: First, it is driven by their contraction out of the arteries and into the veins; second, it settles in the veins and the capillaries of the more dependent parts of the body, inducing, usually within a few hours after death, a mottling of the surface with irregular livid patches. These patches may coalesce, forming a uniform dusky red color over the back of the trunk, head and extremities, and sometimes over the ears, face and neck. The same effect is noticed on the anterior aspect of the body if it has lain on the face. At points of pressure, from the folds in the clothing, and from the weight of the body on the bed or the cooling board, the red color is absent or less marked. This to the undertaker and the embalmer is known as postmortem discoloration. These changes occur before putrefaction sets in. This cadaveric lividity should not be mistaken for the antemortem ecchymoses from which it may usually be distinguished by its position and extent by the fact that the surface of the skin is not elevated, and by the fact that on incision no blood is found free in the interstices of the tissues. Not infrequently the subcutaneous tissue in the neighborhood of these postmortem discolorations become infiltrated with a reddish serum. Very soon after death, particularly in warm weather, the tissues immediately around the subcutaneous veins of the neck and the thorax and in other situations, may become stained a bluish red color from the decomposition and escape from the vessels of the coloring matter of the blood. This to the undertaker and the embalmer is known as postmortem discoloration.

The tissues of the body undergo various changes as to consistency of the solids, semi-solids, fluids, and as to color.

Putrefactive changes are caused by the presence of putrefactive germs normally present in the tissues or gaining access to them, which in their effort to satisfy their own nutrition, break down those complex molecules of which the tissues are composed into simpler compounds.

Putrefaction then is organic decomposition or decay the result of putrefactive bacteria. Putrefaction may also be defined as the separating of the constituent elements of the body due to the presence and growth of bacteria.

Although septic changes may take place before the death of a body, yet the term putrefaction is not applied until after the death of a body, and denotes those changes in color, consistence, and smell so clearly perceptible.

Usually in from one to three days, depending upon circumstances, a greenish discoloration of the skin occurs at first upon the middle of the abdomen, over which it gradually spreads, assuming a deeper hue, and often changing to greenish purple or brown. Greenish patches may now appear on the different parts of the body, earliest upon those overlying the internal cavities; this discoloration is probably produced by the action on the haemoglobin of gases developed by decomposition.

The eyeballs now become placid and if the eyelids are not closed the conjunctiva and cornea become brown and dry. The pressure of gases developed by decomposition in the internal cavities not infrequently forces a greater or less quantity of frothy, reddish fluid or mucous from the mouth and nostrils, distends the abdomen, and, if excessive, may lead to changes in the position of the blood in the vessels and even a moderate amount of displacement of the internal organs.

After five or six days, under ordinary circumstances, the entire surface is discolored to a green or a brown. After this the epidermis becomes loosened through the formation of gases and separating of fluids beneath, and the tissues become flaccid.

The abdomen and the thorax may be greatly distended, and the features distorted and scarcely recognizable from swelling, and the hair and nails loosened.

On the interior of the body, those soft and less compact tissues, or those tissues in which there is a great amount of fluid, are the first to decompose. This may be noticed by examining the walls of the trachea, esophagus and the intestines and noting the change in color.

Decomposition of the soft and liquid portions of the body take place almost immediately after the death of the body, and then follow in rapid succession the decomposition of the semi-solids and finally the solids. Beyond this stage of putrefaction, the consecutive changes can scarcely be followed with accuracy.

The putrefactive changes can not be said to begin at the same place in all bodies, as the conditions under which death occurred will regulate that. The rapidity with which these changes follow one another depends upon a variety of conditions such as temperature, moisture, access of air and the diseases which have preceded or caused death.

Various temperature relations will effect greatly the more or less rapid decomposition of the body. Bodies dying in mid-summer are decomposed much more quickly than those dying in mid-winter.

Moisture added to the temperature relation will hasten the rapidity of the decomposition as can be noticed in those localities with a high temperature but moist climate that the decomposition takes place very quickly. In those climates with high temperature, but dry or absence of moisture, the tendency is to dry up the tissues, and instead of putrefaction we have mummification as the result. This last statement then serves to explain the reason for the high state of preservation in the forms of mummification as exists in those countries like Egypt with their extremely hot and dry climates.

Exposure added to the temperature and the moisture relations adds greatly to the rapidity of the decomposition. A moist climate with a hot temperature and free exposure favors rapid decomposition. We notice that putrefaction progresses much more rapidly in the air than in the water and in the earth its progress is slower than in the water. The more exposed a body is then, to the elements, especially the air, the more rapid will be the decomposition.

An elevated temperature and the presence of air and moisture hasten the advent and progress of putrefactive changes.

Bodies dying in high fever and edematous subjects are much more quickly decomposed than those dying with the ordinary wasting away disease.

The bodies of infants usually decompose more rapidly than those of adults, fat bodies more rapidly than lean ones.

The infectious diseases, intemperance, and the puerperal condition promote rapid decomposition as also does death from suffocation.

Poisoning from arsenic, alcohol, antimony, sulphuric acid, strychnine and chloroform may retard the progress of decay.

It is impossible, then, to say how long a body will keep without the use of preservatives, as it depends partly upon temperature, partly upon moisture, partly upon the amount of exposure and partly upon the conditions existing in the body before death.

We can easily understand the reason for all this if we understand the bacteriology relating to the subject.

In the first place, bacteria require for their best and most rapid growth the proper temperature, moisture and media relations. By this we mean that the temperature should be moderately warm, ranging from about forty to one hundred degrees Fahrenheit, the optimum being about the body temperature 98.6 degrees Fahrenheit or 37 degrees on the centigrade scale. With this optimum temperature, the element of moisture should always be present, as we find that nothing in nature will germinate without the necessary moisture. Then the bacteria must have the proper media, meaning that they must have the right substance on which to grow. Inasmuch as the cause of putrefaction is the host of putrefactive bacteria which abound trying to satisfy their own nutrition, and since these bacteria require a moderately warm and moist media on which to grow, it is only natural that putrefaction and decomposition should occur much more rapidly in warm moist climates than in dry cold climates.

In regard to exposure we learn that certain putrefactive bacteria are aerobic in character, i. e., that they need a great quantity of oxygen for their growth, and for this reason a body in water or buried in the earth does not decompose as rapidly as one exposed to the air. But although they do not decompose as rapidly yet we find that they do decompose in time. This is due to the fact that there is another class of bacteria, called anaerobic, i. e., which do not need oxygen for their growth. In the case of the body in water these anaerobic bacteria exist and develope slowly in the alimentary tract, and eliminate gases sufficient to bring the body to the surface, where the aerobic bacteria enter, and putrefaction progresses much more rapidly.

The starting point of decomposition is usually at the seat of the disease the subject had before death, but it soon spreads to all the various tissues of the body.

Putrefaction is always accompanied by a great amount of odor, which is caused by the generation of gases the result of bacterial action. The obnoxious gases, offensive to the smell are sulphureted hydrogen, nitrogen, carbonic acid and ammonia.

The material actually present when the body is actually decomposed has been determined as being water, nitrogen, methane, carbon dioxide, etc.

Treatment by the Embalmer.—Putrefaction always means that there is present a great amount of putrefactive bacteria and if you are to arrest this condition you must resort to the most thorough embalming. By placing some preservative fluid in the arteries and having a thorough circulation all the tissues of the body can be reached and hence the complete destruction of those bacteria causing the putrefaction.

If all the tissues are properly bathed with embalming fluid there need be no further danger of putrefaction; but what seems sometimes at first a thorough circulation, proves afterward to be only a partial one. If after several days the body still shows signs of decomposition it is best to reinject or if the decomposition only occurs in spots a simple hypodermic injection will prove adequate.

Skin slip is caused by a putrefactive softening of the epidermis. There is a watery infiltration from the minute capillaries and the surrounding tissues between the dermis and the epidermis, causing the latter to loosen and if touched to slip and tear away from the dermis or true skin.

Many embalmers have been led to believe that the slipping of the skin is due to the use of certain fluids used in injecting the arterial system. This error should be corrected, as it is most generally the absence of the fluid from the part which results in the slipping of the skin.

Diseases of the heart, liver, kidney and dropsical conditions predispose to the early skin slip. The immense amount of water occurring in the minute capillaries of the skin prohibits the embalming fluid from reaching the tissues.

Skin slip then is due to putrefactive changes occurring in the skin, and if it should occur after embalming, it is positive proof that the part or parts have not received a sufficient quantity of a preservative fluid.

Treatment by the Embalmer.—In the average case you will never see skin slip, because you will be called comparatively soon after death has occurred and the body will be embalmed and buried before this later form of putrefaction will manifest itself. But in some few cases you will have to keep the body for a greater length of time, say to await the arrival of some friend living abroad, or it may be a coroner's case. In cases like this the body being kept for a period of weeks, will if it is not perfectly embalmed show signs of skin slip. As has been stated above, cases that die from diseases causing dropsical infiltration in the subcutaneous tissues should also be handled carefully. If you are aware before hand that you are to keep the body for a great length of time or that you have a dropsical subject, a little formaldehyde should be added to the fluid that is injected, about two or three ounces to each quart of fluid. Zinc compounds might be added, but formaldehyde is better because of its great affinity for water.

If skin slip occurs after the body is embalmed it is best to place a layer of cotton over the part where the skin slip occurs and saturate the cotton with equal parts of alcohol, formaldehyde and glycerine.

In drowned cases where all the skin is slipping it is best to envelope the whole body with a layer of cotton saturated with formaldehyde.

When the muscle substance dies it becomes rigid, or goes into a condition of rigor; it passes from a fluid to a solid state. The rigor that appears in the muscles after somatic death is designated usually as rigor mortis, since its occurrence explains the death stiffening in the cadaver. It is characterized by several features: the muscles become rigid, they shorten, they develope an acid reaction, and they lose their irritability to stimuli.

After the death of an individual the muscles enter into rigor mortis at different times. Usually there is a certain sequence, the order given being the jaws, neck, trunk, upper limbs, lower limbs, the rigor, therefore, taking a downward course. The actual time of the appearance of the rigidity varies greatly, however; it may come on within a few minutes or a number of hours may elapse before it can be detected.

Death after great muscular exertion, as in the case of hunted animals, or soldiers killed in battle, is usually followed quickly by muscle rigor. Death after wasting diseases is also followed by an early rigor, which in this case is of a more feeble character and shorter duration.

Certain drugs such as veratrum, hydrocyanic acid, caffeine and chloroform, will hasten the development of rigor.

People who die in full habit, meaning that there has been no muscular exertion or wasting processes before death, usually have the rigor developing more slowly and of a longer duration.

After a certain interval, which also varies greatly, from one to six days, the rigidity passes off, the muscles become soft and flexible; this phenomenon is known as the release of the rigor.

The usual explanation that is given of rigor is that it is due to a coagulation of the fluid substance, the muscle plasma, of which the fibers are constituted. During life the fluids exist in a liquid or viscous condition; after death they coagulate into a solid form.

Rigor mortis is not a sign of death, as there is rigidity of the muscles following apparent death, as in cases of asphyxia and trance. If the body is rigid, in a case in which there is a doubt that death is present the rigidity may be broken up. If it is a case of trance or that of the contraction of the muscles following drowning, it is likely to return, especially in case of trance; but if death is actually present it will not return.

The chemical changes occurring, the result of rigor mortis can be briefly stated:

(a) There is a coagulation of the proteid material of the muscle plasma.

(b) There is an increased acidity, which is doubtless due to the production of lactic acid.

(c) There is a production of carbon dioxide.

(d) There is a consumption of glycogen.

Treatment by the Embalmer.—Many times when called to embalm a subject you will find the body in a state of rigor. In cases of this kind the rigor mortis should be broken up. This can be done by taking each of the joints and gradually bend them a little at a time until they become perfectly lax. Once a joint is bent the stiffening disappears and the embalmer can proceed.

An atom is one of the ultimate particles composing a molecule. A complex molecule is one in which two or more elements have been combined. Example: water molecules are formed by two atoms of hydrogen and one atom of oxygen.

A ferment is a substance causing fermentation in other matter with which it comes in contact. There are two kinds of ferment expressed by the names organized and unorganized.

Unorganized ferments are chemical substances having the power to produce or assist in the production of fermentation.

Organized ferments are bacteria having the power to produce fermentation.

Fermentation means the process through which complex molecules are decomposed and their ingredients disassociated by the action of ferments. As an example of fermentation, we can take proteid food substances, the molecules of which are always of complex form, and by subjecting them to the action of organized ferments (bacteria), decompose them, and separate each gas ingredient, obtaining therefrom a variety of gases from what was formerly a substance of perfect chemical union. Fermentation is present in most of the natural processes whereby chemical changes are produced in animal and vegetable matter. Fermentation is taking place all the time in all the climes excepting possibly the frigid zones. The organized ferments (bacteria) are subject to the same temperature limits that govern the reproduction and the growth of all bacteria.

Fermentation is divided into spirituous fermentation, digestive fermentation, metabolic fermentation, and putrefactive fermentation.

Enzymes are unorganized ferments and are cast off the living body within the living body.

Intestinal fermentation is hastened in the dead body by the presence of much undigested food and the absence of any restraining organisms. The gases produced in the intestines of either the living or dead body by the action of putrefactive ferment bacteria are: carbon-dioxide (CO₂), hydrogen (H), nitrogen (N) hydrogen sulphide (H₂S), methane (CH₄). The continued fermentation in the stomach and the intestines causes a coffee colored material of a frothy character to purge from the mouth.

When the hollow needle or trocar is used to reach the scene of ferment activity, the gases mentioned are released from the effected organs. As these gases are extremely odorous, they should be passed through a pledget of cotton saturated with formaldehyde, before being allowed to pass into the open air. Germicidal fluids when directed against the bacteria in an intelligent manner should destroy them and prevent their becoming active again.

Putrefactive fermentation is divided as follows: abdominal fermentation, gastric fermentation, and intestinal fermentation.

Certain diseases predispose to abdominal fermentation as inflammatory diseases which effect the peritoneal covering of the organs, and cause a swollen abdominal wall after death.

Treatment.—In the treatment of these cases it is always advisable that the operator be familiar with the location of the disease, so that direct trocar application can be made to the affected part. The location of the affected part is not always the same, as it varies with the location of the particular tissue or organ affected. In appendicitis, where death has occurred without surgical attempts to remove the appendix, the operator should spray the right inguinal space with enough fluid to neutralize the cause of the gas. Where the cause of death has been typhoid, the umbilical, hypogastric and epigastric spaces should be sprayed. Where the cause of death is puerperal fever, the right and left inguinal and hypogastric spaces should be sprayed. The gas itself, will be eliminated from the cavity of the body by simply inserting the trocar and allowing the gas to escape until the internal pressure approximates that of the atmospheric pressure. This though does not prevent the reformation of gas, as the origin of the gas is the living and growing fermentative and putrefactive bacteria. To prevent a recurrence the bacteria must be killed, and this is done by spraying a germicidal fluid around the affected part. Abdominal fermentation and gas is much easier to treat than gastric or intestinal fermentation.

Treatment.—When the body is placed in your care, the embalmer should make a careful and thoughtful survey of the condition of the body and the cause of death. Any inflammatory disease of the abdominal tissues or a full meal eaten shortly before death will almost always predispose to the formation of gas. The treatment would be to take proper care of the stomach contents.

(a) Insert the trocar at a point two inches to the left of the median line, half the distance from the ensiform cartilage and the umbilicus. Direct the trocar downward and diagonally to the left to a depth of three to four inches. Remove the trocar rod and allow the gas to escape into a fluid bottle, containing a small amount of fluid, so that the gas may be deodorized. Before removing the trocar, inject not less than one pint of normal fluid into the stomach, so that the fermentable materials and the bacteria may be destroyed.

(b) Make an incision in the median line of the body, three inches long, from the tip of the ensiform cartilage downward toward the umbilicus, and proceed as directed for the direct incision described on page 257.

The treatment for gastric fermentation demands the specific treatment as directed above. No short treatments can be depended upon for certain results. Cotton placed in the mouth only delays the time for the purging to begin from the mouth. Gastric fermentation can be prevented in all cases by the use of the specific treatments as described in (a) and (b).

If in your practice, you receive a body from a shipping undertaker, which unfortunately was not treated in the correct manner, and which is purging from the mouth, arrange to puncture the stomach in the manner described in treatment (a). This can be done without disturbing the position of the body in the casket, by opening the clothes above the stomach. After puncturing the stomach and allowing the gas to escape, inject not less than one pint of fluid therein, cleanse the mouth with absorbent cotton by the use of the lock forceps and a recurrence of the purge will not be possible.

If in your practice you have overlooked the possibility of gastric fermentation, and find, either by advice from the family or from your own observation, that purging is going on, use either the treatment (a) or (b), neutralize the fermentable material, cleanse the mouth and no recurrence will be possible.

Treatment.—(a) Insert the trocar through the umbilicus, and direct the point downward into the right inguinal region so as to relieve the gases from the caecum, then inject a small quantity of fluid; then direct the point of the trocar upward into the left inguinal region so as to relieve gases from the sigmoid flexure, and inject a small quantity of fluid; then direct the point of the trocar upward into the right hypogastric region so as to relieve gases from the hepatic flexure, and inject a small quantity of fluid; then direct the point of the trocar upward into the left hypogastric region so as to remove gases from the splenic flexure, and inject a small quantity of fluid; and if at this time it is thought that the stomach contains gas, relieve it, and inject therein a small quantity of fluid; now place some fluid directly into the abdomen around the small intestine and with this treatment you are assured that your intestinal fermentation is taken care of.

(b) Intestinal fermentation may also be treated by the direct incision, as described on page 257.

CHAPTER XIII. DISCOLORATIONS.

Discolorations may not occur in conjunction with tissue changes, so when they do occur we should look for the cause of the same before deciding just what the name of the discoloration is, or what treatment should be given to eradicate it.

For convenience in study, and for the proper classification of the various conditions, the subject has been divided into those discolorations occurring before death, and those discolorations which may occur in the body after death.

• (a) Yellow jaundice,
• (b) Pigmentary atrophy,
• (c) Cancerous spots,
• (d) Gangrene,
• (e) Ecchymosis or ante-mortem staining,
• (f) Wounds, fractures, scars and tattoo marks.

Bile acts as the natural antiseptic of the intestines in life, and aids with the digestion of fatty food substances along with other actions. The principal coloring matter of the bile is a yellow substance called bili-rubin. Biliverdin, green, is precipitated by alkalies.

The course of this bile in life is from the liver to the gall bladder, which acts as the reservoir, into the cystic duct and then into the common bile duct and into the cavity of the duodenum (first section of the small intestines). It sometimes happens that there may be an obstruction of the bile ducts with the result that the bile is backed up into the gall bladder, and from there into the liver again, throwing it into the blood vessels of the liver and out into the tissues of the body along with the blood. As the blood traverses the entire area of the body, and as the yellow coloring matter of the bile acts as a stain, it is only a matter of course that the tissues will be stained the characteristic color of the bile.

This stain will be found all over the body from the outer layer of the skin to the membrane covering the bone (the periosteum) and will adhere very closely to the tissues, rendering the removal practically impossible.

Ordinary arterial injection of a body of this character will have absolutely no effect, no matter what preservative fluid may be used and regardless of whatever any one may say, as it stands to reason that when the discoloration is not located in the blood vessels, that the removal of same can not be accomplished by flushing the blood vessels alone.

Of course, the washing of the blood vessels with a solution will aid the removal of the discoloration, but it is necessary to employ a strong bleaching solution on the outer surface of the exposed parts in order to better the conditions so that the body may be made presentable.

In addition to this treatment, it would be advisable to color the lights in the room in which the body is to be shown, so as to make every thing in the room about the same color of the body, including the persons viewing the remains. This will have the effect of lessening the apparent bad color of the body, and will add to your reputation as an embalmer.

You will see very readily that the main point of difference between yellow jaundice and pigmentary atrophy is in the color, and also in the fact that the cells in yellow jaundice are in their normal state and in pigmentary atrophy are in a contracted condition. The treatment given for yellow jaundice as follows: injecting and washing the blood vessels with a mild solution and the application to the affected parts of a strong bleaching solution, should be given for pigmentary atrophy.

The suggestions as regarding the lights to show the body under, should also be noted and used in these cases.

As cancer is in fact a rottening or mortification of the tissues, the injection with a hypodermic outfit of a strong hardening and bleaching solution will harden and bleach out the color of the cancer to a great extent, and thus improve the appearance greatly, the ordinary cosmetic powders will finish the preparation.

For the hypodermic injection we would suggest the following:

The cancerous spot should not be confounded with the color of dessication which will resemble it somewhat. The main point of difference would be that the cancer would be present before death, and the dessication could not possibly occur until after the body is embalmed. This caution is advised on account of the tendency the solution to be injected hypodermically would have to make a dried spot worse in color than better.

Gangrene with its peculiar color, a dark green, is not often found on the exposed surfaces of the body, but will more often be found on the lower extremities and then only on the bodies of aged persons. For this reason it will be unnecessary to treat it for the removal of color.

This form of discoloration is mostly seen in accident cases, where death was due to mechanical causes.

In ecchymosis the blood capillaries being ruptured, the blood permeates the bruised tissues surrounding the ruptured vessels and thus gives the characteristic color of venous blood. There seems to be no positive treatment, but in some cases it can be remedied to some degree by a hypodermic injection of a good bleacher, and then massaging the part with a strong bleaching solution. Spots of this kind can sometimes be covered with flesh tints.

It is often important to determine whether violence has been inflicted on a body before death. In regard to this point, we must remember, first, that blows and falls of sufficient violence to fracture bones and rupture the viscera may leave no marks on the skin, even though the person has survived for several days; and, second, that there are postmortem appearances which simulate antemortem bruises. A severe contusion during life may present, at first, no mark or only a general redness. After a short time the injured part becomes swollen and of a red color, this color may be succeeded by a dark blue, and this in turn fade into a greenish yellow or yellow; these later appearances are due to an escape of blood from the vessels and to a subsequent decomposition of the hemoglobin. If, therefore, we cut into such an ecchymosis after death, we find extravasated blood or the coloring matter of the blood, in the form of pigment granules, free in the tissues. Postmortem discolorations, on the other hand, although their external appearance may resemble that of antemortem ecchymosis, are not formed by an extravasation of blood, but by a circumscribed congestion of the vessels or by an escape of blood stained serum. If you cut into such discolorations, therefore, we find no blood outside the vessels. Care should be taken not to mistake the lesions of hemorrhagic infection for traumatic ecchymosis.

Blows on the skin of a body which has been dead for not more than two hours may produce true ecchymosis with extravasation of blood, such as can be distinguished with great difficulty or not at all from those formed during life. If putrefactive changes be present, the difficulty of distinguishing between antemortem and postmortem bruises is greatly enhanced.

Hanging and strangulation are attended with the formation of marks on the neck which are described in works on forensic medicine. These marks must not be confounded with the natural creases of the skin of the neck. Many adults during life have creases of the skin of the neck, one or more in number, running downward from the ear under the chin or encircling the neck. After death these creases may be much more evident than during life, and may be rendered more decided by the position of the head, or if the body be frozen. They usually persist until the skin putrefies.

If the edges of a wound be inflamed and suppurating, or beginning to heal, it must have been inflicted some time before death. In a wound inflicted a short time before death the edges are usually everted; there may be more or less extravasation of blood into the surrounding tissues, and the vessels contain coagulated blood; but sometimes none of these changes occur. The chief characteristics of a wound inflicted after death are absence of a considerable amount of bleeding, non-retraction of edges, and the absence of extravasation of blood into the tissues. But a wound inflicted within two hours after death may resemble very closely one received during life. In general, unless a wound is old enough for the edges to present inflammatory changes, the embalmer must be very careful in asserting its antemortem or postmortem character.

The discoloration produced by tattooing may, although it rarely does, disappear during life. The embalmer should not try to remove it.

CHAPTER XIV. DISCOLORATIONS.—Continued.

• (a) Desiccation.
• (b) Greenish tinge of putrefaction.
• (c) Chemical action.
• (d) Postmortem discoloration.
• (e) Postmortem staining.
• (f) Capillary or venous congestion.

Natural evaporation, the drying action of formaldehyde, freezing the skin, feverish conditions of the body before death, absence of a normal amount of moisture in the skin of the dead body.

Natural Evaporation.—The passage of moisture from the skin into a dry atmosphere reduces the normal amount of moisture in the skin, thereby producing an altered color. The extent of the moisture reduction governs the color produced. When evaporation begins, the skin loses its softness and becomes slightly yellow in color. As evaporation continues the skin becomes more hard and the color changes from yellow to brown. At this time nothing can be done to restore the original color as in the absence of the blood circulation, the pigment of the skin will not take up moisture, nor will moisture penetrate the skin itself.

Treatment.—The only treatment for a condition of this kind is necessarily a preventive one. While embalming a body, the operator should apply either water or one of the commercial face solutions to the skin of all the exposed portions of the body. If the condition within the skin is one in which there is a predisposition toward dryness, the face solution or the water by being present on the skin will reduce evaporation from the skin itself; in this way maintaining the natural degree of moisture. Should a hard, dry spot appear in the absence of any preventive treatment, the operator can only coat the spot with grease paint and thereby hide it.

The Drying Action of Formaldehyde.—Formaldehyde is derived from methyl spirits, which in itself has an active affinity for water. The amount of water ordinarily mixed in formalin in the compounding of a formaldehyde fluid is not sufficient to satisfy the appetite of the formaldehyde for more water. When a formaldehyde fluid comes in contact with moisture laden skin, there will be a movement of moisture from the skin toward the formaldehyde fluid, thereby reducing the degree of moisture in the skin and in that way causing it to become dry. When the skin becomes dry, it changes in color the same as in natural evaporation.

Treatment.—There are three conditions in the skin met by the operator. The first is where there is a predisposition toward dryness and this is where the skin does not contain a normal amount of moisture to begin with. In old age cases, tubercular, and anemic bodies, the ordinary embalming fluid should be diluted at least one half for the first part of the injection, thus reducing the appetite for moisture on the part of the fluid. In addition to this, water or a face solution should be used externally to prevent outward evaporation from further reducing the moisture in the skin. The fluid exhibits a tendency to draw water into the pores, thus maintaining to a large degree, the normal moisture percentage.

The second condition met with is one in which the skin contains a normal amount of moisture. In this case it would not be necessary to reduce the strength of the standard fluid at any time during the injection, but it is necessary to apply water or a face solution externally to limit outward evaporation and to provide a source whereby moisture could be drawn into the pores by the appetite of the formaldehyde, thus again maintaining the normal percentage of moisture in the skin.

The third condition is one in which the skin along with the balance of the body, will contain more than a normal percentage of moisture. This condition may be looked for in edematous or dropsical cases. The injection in these cases should be normal in strength unless the dropsy is very pronounced, when an overnormal injection can be given without reducing the moisture percentage in the skin below the normal point.

Should the above precautions not be used and the skin be dried through the appetite of formaldehyde for water, no treatment can be given which will restore the moisture to the skin. When moisture is drawn from the skin and the percentage is below normal, the skin will shrink and will draw tight against the bones and subcutaneous tissue. This frequently gives rise to the sharp nose and to the drawn appearance so common in those cases. Prevention is the only remedy.

Freezing the Skin.—When the body is subjected to a temperature of 32 degrees Fahrenheit, the moisture in the skin freezes, thereby removing it from its usual consideration, as the element that is responsible for the usual softness and flexibility of the skin.

In the cold months, bodies are sometimes left in cold rooms with the windows open. The embalmer did this in the past, thinking that subjecting the body to the influence of a cold atmosphere would simplify preservation.

From the standpoint of preservation alone, this theory is correct, but in accomplishing the above result the moisture of the skin may be frozen. The resulting color is light yellow. The texture of the skin is changed from soft to a slightly hardened condition.

Treatment.—Never allow the room temperature to approach the freezing point. Should the above treatment be disregarded, and the yellow color become present, have the room warmed, and the color will slowly disappear.

Feverish Conditions in the Body Before Death.—Fever is the name usually given to the rise of temperature that goes with inflammation. In severe inflammatory diseases, the tissues lose much of their moisture through the arrest of the saturating power of the blood stream and the disturbance of circulation. The skin contains a sub-normal amount of moisture when the embalmer reaches these cases, which may be further reduced by outward evaporation and the dehydrating power of the embalming fluid. Small brown spots resembling the fever blister in the living body may be present around the mouth.

Treatment.—Use half strength fluid for the first part of the injection, followed by normal fluid for the second, third and fourth parts. Apply water or a commercial skin or face solution while the injection is going on.

Absence of a Normal Amount of Moisture in the Skin of the Body.—The normal amount of moisture in the skin has been determined to be an amount equal to seventy-five per cent. of the weight of the skin. Any percentage less than seventy-five per cent. is considered subnormal. This condition can be expected in all fever cases, in anemics, and in old age.

Treatment.—When the skin appears rather dry, the injection of fluid should be half strength for the first and second parts, normal for the third and fourth. The skin of the exposed parts of the body should be dampened with an application of water or a commercial face or skin solution, while the injection is being made.

This discoloration appears generally about the second day, unless preservative fluids have been applied to prevent it. It first begins in the ileocaecal region or lower part of the abdomen. The skin covering these parts assumes a brownish color which shades to yellow, yellowish green, and finally a green color. This green discoloration will in a few days spread all over the surface of the body.

Among the putrefactive bacteria is the bacillus fluorescens, a chromogenic germ, which produces a greenish color when it becomes active in the tissues. One of the first external evidences of putrefaction is the production of a greenish color in the abdominal wall. This, of course, could not occur when embalming had been done with any degree of completeness. Should an insufficient circulation be encountered when embalming a body, the part which does not receive the fluid, being unprotected, may be affected by the color producing germ mentioned above. The most likely to be affected by an insufficient circulation will be located somewhere in the extremities of the circulation, that is to say, in the skin. We can place the affected part more definitely in the skin of the face, particularly the nose, which has a rather poor circulation. This condition will not make its presence known until three or four days after embalming has been done, making it almost entirely absent in bodies embalmed in ordinary practice. Should several days elapse between the time the body died and embalming, allowing the discoloration to appear, the following treatment would be advisable:

Treatment.—Inject a very small portion of the following solution just under the skin, using a hypodermic needle.

Just a small portion of the above solution is all that will be necessary, working it under the skin with the finger tip, so as to avoid destroying the features by swelling the tissues.

This treatment being a chemical one, it is necessarily slow in its action of bleaching the green color. Should haste be necessary, inject a very small quantity of embalming fluid to arrest the putrefactive process and then cover the spot with theatrical grease of the proper color to match the surrounding skin.

Often, in cases of chronic malaria, or diseases of the liver, or again as a general antiseptic, methylene blue will be administered by the attending physician, and you should learn this fact beforehand, for if methylene blue has been administered it is advisable not to use a formaldehyde fluid. There is a chemical action set up between the formaldehyde and the methylene blue, which gives the tissues a greenish color, which is quite objectionable.

In this case you would use some fluid which does not contain formaldehyde, benzoate of soda, or borax, or peroxide solution should be used.

Another good formula to use is the following:

or

What is usually meant, though, when this term is used is the settling of the blood to the dependent parts of the body after death. If the body is lying on the back, the blood will naturally gravitate toward the back, into the azygos system and cause a bluish discoloration, or the same condition will result, if the body is found lying on the face and stomach, in which case the discoloration will be in the face and the anterior chest and abdominal walls.

CHAPTER XV. ARTERIAL EMBALMING.

The habit of inquiring about the sex, and age of the person, as well as the cause of death, should be cultivated. The importance of knowing the sex of the person lies in the fact that in some communities different styles of door badges or decorations are more appropriate for one sex than for the other. When the ruling decoration is some form of fresh flowers, this should be ordered before the embalmer leaves for the house of mourning if possible, unless the call should be received at night or in the early hours of the morning, when this item is usually left until the earliest business hour. The age of the person also determines to a great extent the style of decoration which is to be used.

The cause of death is vitally necessary. In some cases, the ordinary contents of the embalmer's grip or hand bag are sufficient for the usual needs. In other cases, extra material of various kinds are necessary, for instance, the rubber floor covering for the carpet in dropsical cases; the sanitary clothes in eruptive contagious diseases; the fumigating outfit in the same diseases, (providing this duty is not performed by the health authorities); and other articles needed only in the treatment of special cases.

After obtaining the above information, examine your grip or hand bag to see that you have all the equipment needed to care for the case in the proper manner. This saves many cases for those who follow these rules, as they are enabled to have just what is needed, and prevents the slighting of a case for which there may be some excuse if the proper materials are not in the outfit. From a professional standpoint, it should be necessary for the embalmer to carry anything he may need, otherwise carelessness may dictate his procedure and disaster may result.

An ordinary case can be attended with the following material[1]:—

• The couch embalming board.
• The slumber robe, and face cover.
• A rubber or oil cloth cover for the board.
• A suit case grip, or hand bag.
• Concentrated fluid (at least 4 bottles).
• One or two empty 64-oz. bottles (for mixing fluid).
• One bottle for blood drainage.
• One injecting outfit (pump, tubes, etc.)
• One blood drainage outfit.
• One instrument wallet, containing:—
• 2 scalpels, 1 bone separator, 2 aneurism needles, 1 spool linen thread, 1 grooved director, 3 arterial tubes (assorted diameters), 1 bistoury, 1 lock forceps, 1 spring forceps, 1 artery forceps, 1 case needles, 1 6-inch child's trocar, 1 12 or 14-inch trocar, 1 chin rest, 1 hypodermic outfit, 1 roll absorbent cotton, 1 sponge, 1 box face powder, 1 nail file, 1 hair brush, 1 bottle bichloride of mercury tablets, 1 shaving outfit.

For special cases it would be well to have on hand the following articles:—

• 1 small can plaster of paris.
• 1 tube lip cement.
• 2 rubber bandages.
• 1 can hardening compound.
• 1 bottle Platt's chlorides or any other good deodorant.
• 1 outfit of formalin and permanganate of potash, or any other standard gaseous germicide preparation for fumigating.
• 1 small bottle of tincture of iodine as a preventive to infection should you cut yourself.

After the outfit has been found correct for the case at hand, place everything in the conveyance, and leave for the house. Upon arriving at the house, enter alone and meet the member or members of the family who have been delegated to talk to you. At this time it will be well to ascertain the position of the body, the wishes of the family in reference to where the body is to be placed after embalming and to where the body is to rest in the casket until the time of the funeral.

If you meet with any objection as to embalming, it will be well for you to consider the sanitary aspect of the case in speaking to those interested. In this case the sanitary aspect should always take precedence over the preservative aspect, since you can count on the assistance of the physicians in supporting embalming on that account. Should your wishes be overruled after you have presented the facts in the matter, it would be well for you to place the entire responsibility for the condition of the body upon the family, since without embalming you are unable to know the final condition of the body, and should not be held responsible for it regardless of what the condition may be in that case.

After this short talk with the family, return to your conveyance and carry your outfit to the room of death. Everything that you carry should be properly covered, as there is nothing quite as indecorous as the display of an embalming board without a cover. When you have placed the outfit in the room, call for everything that you will need from the family, which will include such things as a pail, warm water, soap, towels, etc. Do all of this before touching the body; and after securing all the necessary items, close the door, and do not open it again until the work has been completed.

Should unforeseen circumstances cause you to re-open the door, present yourself with a coat on, and never, under any circumstances, appear before any one in your shirt sleeves, as that is another indecorous procedure. After the preservation has been completed, dust a little face powder on the face and hands, to remove the moist, clammy appearance which may have been left on those parts. Place the undergarments on the body and then any other garments which may have been given to you by the family. Cover the body with the slumber robe, and then call in as many members of the family as may wish to view the body, asking them to criticize your work. Before calling in the family it would be well to put everything out of sight and not have any grips open.

If favorable comment is heard from the family, your work is done for the time being. If unfavorable comment is heard, ascertain the cause of the comment and do not leave the house until the proper appearance has been secured. If your work has been pleasing to the family, you can rest assured that the case is a success and that you have done your work well. When you are satisfied in your own mind that all is well with the body, make arrangements for the selection of the casket, and then retire from the house. If the door decoration has not been placed in position before you leave, you will place it in position yourself.

Some funeral directors set the time for the funeral during the first call, and some wait until later. The same for the other arrangements, such as newspaper notices, minister, singers, church or chapel services, number of conveyances, etc. Whatever method you choose to use in your community should be carried out systematically so that at no time, will anything be left undone to cause confusion at some inopportune time.

After much experience with various classes of bodies, we find that the adjustment mentioned is a very valuable aid in securing the best results both as to completeness of the circulation and amount of blood drained.

In anemic, tubercular, cancer of the stomach and exhaustion cases, together with other conditions resulting in emaciation, the head end of the board should be raised to the height that seems suitable for the position of the upper part of the body when placed in the casket during the injection of the first bottle of fluid. When the first bottle of fluid has been injected, lower the head end of the board until the entire board is level, and leave it in that position until you have completed the injection, when you will again raise the end of the board until the position of the body is just as it will be in the casket.

When pneumonia and other non-emaciated bodies are to be injected, with drainage, use the same procedure as is stated above for the emaciated bodies.

In dropsical cases, raise the head end of the board only for the first bottle of the injection; then for the second bottle, lower the head end to about half of its first height, and set the foot end of the board on some object that will raise it five and six inches. In this way you will have a slight elevation at both ends of the body, and drainage can better be obtained from the center of the circulation. When the operation is complete, lower the foot end again and raise the head end so that the body occupies the proper position for the casket.

These adjustments are practical methods of overcoming gravity handicaps in the distribution of the fluid, and of accelerating the amount of drainage obtainable by keeping the level of the drainage tube below the blood level in the body, thus accomplishing a universal distribution of fluid, and securing a greater quantity of undiluted blood from the vein.

It is very important to remember when you are through injecting the body that you are to place the body in the exact position on the cooling board which you want it to have in the casket. After a little time the body will become more or less rigid due to the action of the preservative fluid used, and will set in the position you have placed it which condition will be hard to change later.

Convenience usually governs the operator as to the artery he is to use. If blood is to be removed it is best to raise one of the larger blood vessels, such as the carotid artery and the internal jugular vein, or the femoral artery and femoral vein, or the axillary artery and axillary vein. If it is desired to draw the maximum amount of blood, the femoral artery and vein should be selected, as they are more dependent, and control more of the blood, when the body is placed on an incline. A drainage tube sufficiently long to reach above Poupart's ligament as far as the common iliac is all that is necessary as there are no valves intervening between the bifurcation of the common iliac and the right auricle. However if you can, extend the tube up through the ascending vena cava and eustachian valve into the right auricle. This will give you a chance to draw blood from the right auricle and is a much better procedure than tapping the right auricle with the trocar.

If the body is already dressed and the hands or feet need to be re-injected, the radial or posterior tibial likely will be most convenient as their use will not necessitate the removal or cutting of the clothing.

Oftimes there is but a single window to admit light and the operator should be so skilled as to be able to raise the arteries either on the right or left side without having to turn the cooling board.

In emaciated subjects the linear and anatomical guides are always plain but in fleshy subjects this is not always the case. Look over the subject and see which artery will be the most convenient to raise. Usually in fleshy subjects the femoral is hard to raise as there is a great amount of fat in Scarpa's triangle making the artery lie very deep, but in these subjects the guide for the brachial is quite plain, a distinct groove being seen between the biceps and triceps muscles.

In a short necked subject it is never advisable or convenient to raise the carotid as there is not much room to work and the incision is very liable to show. Another artery will be found much more advantageous in these subjects.

In accident cases the seat of injury will determine the artery to be raised, using the one through which you can give the body the greatest supply of fluid to all parts. Often it will be necessary to raise several arteries to complete the injection.

There is no necessity for undue exposure in either sex, however it is hardly ever advisable to inject the femoral in the female, as some mischief-maker might without any real cause influence others in the community against your methods.

When selecting the brachial and femoral arteries always raise them at a place below the point where collateral circulation is given off or in other words raise them in the middle third. By so doing the fluid will reach, by means of collateral circulation, the tissues of the arm and leg below the point of injection.

As far as the injection of fluid is concerned, one artery is just as good as another. All arteries are parts of the same channel branches of the aorta. No valves exist in any part of their course.

With the handle of the aneurism needle separate the tissues between the muscles, artery, vein and nerve, then use the hook end of the aneurism needle, pass it under the artery and raise it to the surface, passing the bone separator or the forceps with the closed end underneath. Remove the individual sheath surrounding the artery. Likewise raise the vein to the surface.

If the artery and vein lie side by side and it is desired only to raise the artery, hook down between the two, away from the vein, sliding the hook forward and backward underneath the artery, then raise to the surface.

If the artery and vein lie side by side and it is desired to raise both, pass the hook around the vein first, as by hooking around the artery toward the vein the point of the hook will often rupture the vein.

The nerve will appear as a glistening white cord, very solid to the touch and showing bands of nerve fibres which can be separated by the aneurism hook. It will not have any central opening.

The vein will appear as a dark blue color and collapsible because of the fact that they have thinner walls than the arteries, lacking the middle circular layer of fibres. Veins have a central opening. As a rule the vein contains blood after death, which gives it the dark blue color but should it not contain blood, it resembles the artery very closely as to color.

The vein contains valves which can be seen distinctly, if the blood be pushed the opposite way from which it runs in life.

The artery is of a creamish white color and non-collapsible because of the fact that it has heavy walls and a middle circular layer of fibres. The arteries feel firm to the touch while the veins are soft and velvety. Arteries have a central opening and as a rule do not contain blood after death. They likewise do not have valves. The artery is usually more constant than the vein.

Should all these not convince you, raise the one you think is the artery with the hook, pass the forceps underneath, spread these and pass the bone separator under for a bridge and with the scalpel incise the artery about one-fourth the way. Attach the arterial tube and if there is blood present, allow it to drain by lowering the arm. When it has ceased to flow, inject very gently and slowly. If you get a half-pint of fluid in the body, you may be assured of its being the artery.

Another way to tell the artery from the vein is to roll them lightly between the fingers. If it feels like a thin rubber tube, and does not roll together in a little bundle, the supposition is that the vessel is an artery. This however is not certain, as phlebitis, or some other diseased condition of the veins may result in the thickening of the walls of those vessels, to such an extent as to make it impossible to distinguish in this way between the artery and the vein.

The anatomical and the linear guides for the arteries and veins, and their relation to the accompanying nerve, will help also to tell them, one from the other.

The artery may be cut in several ways as follows—a T shaped incision may be made. This is a very old method, one of the first to be used for this purpose. To make this kind of an incision in the artery, the scalpel is placed point down about one-fourth the distance from the edge of the artery, and then by forcibly bearing down on the scalpel cut the artery crosswise. Rotating the artery the cut will now be on the upper surface. Now from the middle of the crosswise cut, extend a longitudinal cut lengthwise of the artery, for almost one half inch. We have no comment to make on this kind of an incision, excepting to say that the method is old and obsolete, and no longer used, and that a much better method is now used.

Another method suggested by some authors is the longitudinal incision. With the belly of the scalpel cut the artery lengthwise for a distance of a little less than one half inch. The disadvantage of this kind of a cut is that the operator does not know when he has cut to the center of the artery and no more than the center. If the cut has been made to a distance beyond the center, then the inside wall on the opposite side will be cut and if the wall is in the least diseased, the arterial tube when it is inserted may get between the walls which will mean that no fluid can be injected.

Another method is to cut the artery crosswise, placing the point of the knife on the artery about one fourth the distance from the edge of the artery, bearing down so that the point will come through to the bone separator which is beneath, then forcibly bearing down cut outward with the belly of the knife. Now rotate the artery and the cut will be on the front of the artery.

Another better method is the same as the above, but instead of cutting outward perpendicular to the artery, cut outward diagonally, then when the artery is rotated there will be a V—shaped cut. The point of the V should be made opposite the way the operator is to inject the fluid. With the aneurism hook, pick up the point of the V, which will mean that the hook will have to be inside of the artery, and using the hook as a guide insert the arterial tube. The only disadvantage of this method is that the tensil strength of the artery is to a certain extent weakened, but if the artery is not cut too deep, this is not a serious disadvantage. The advantage is that the operator is always certain that he is in the center of the artery, that if his knife is sharp, that he will always cut all three walls of the artery at once, and thus prevent a ruffling up of the inner wall of the artery should it be diseased.

Upon this one thing will depend very largely the success you will have with the perfect circulation of the fluid and cosmetic effects.

Some authorities on the art and science of embalming have made the claim that it makes no difference how rapidly a body is injected as the fluid is so widely distributed through so many branches of the artery that no harm can come from this source. This is very erroneous for when the fluid is forced rapidly through the arteries, it also flows rapidly through the capillaries into the veins, thereby enlarging the quantity of fluid in those vessels and often forcing the blood into the exposed parts of the body, causing serious discolorations.

The capillaries are sometimes ruptured by the rapid injection of fluid, causing spots to appear on the face that would never have been there had the body been injected more slowly.

A further reason for slow injection is that the disinfecting fluid is given an opportunity to be absorbed by the tissues as it passes into the capillaries and not be forced through those little vessels into the veins, as it is by the absorption of the fluid that the body is disinfected. This is especially true when the drainage tube is being used as the fluid, seeking the course of least resistance, passes through the artery, into the capillaries, through those vessels to the veins and out through the drainage tube.

As it takes but little blood to color a large quantity of embalming fluid, many embalmers are led to believe that they are removing large quantities of blood, while in reality perhaps one-half of the colored liquid which flows from their drainage tube is the fluid which is being injected. Many failures have resulted from this error.

Fluid should always be injected into the body very slowly, and the more slowly it is injected the more perfect will be the cosmetic effect.

If necessary make a second injection. An embalmer who makes the proper charge for his services as a professional can afford to make two injections if necessary. He can let it be known that he will not be content with anything but perfect work, and patrons will not only cheerfully pay for it, but will have a better opinion of his professional standing. Thorough drainage and slow injection are the best safeguards against discoloration.

Dr. Erdman before the Minnesota association suggests that the amount of fluid that fills the arteries is not enough to percolate through the capillaries and into the tissues, and saturate all the parts of the body. He favors the gravity injection by merely allowing the fluid to flow naturally into the arteries from an elevated vessel, and would use no force or pressure in injection. Ideal embalming would be a series of gravity injections at intervals of several hours. While the gravity injection such as the doctor describes will undoubtedly be a sure method of getting a perfect circulation, and while it is the process generally pursued in morgue work where the apparatus is convenient, it is in the majority of cases in the home impractical.

All bodies to be shipped must be thoroughly arterially embalmed, that is, to have introduced into the arterial system sufficient amount of disinfecting fluid to thoroughly sterilize every particle of matter in the dead body. This can only be done by introducing into the arteries an approved disinfecting fluid.[2]

In order to succeed in a chosen calling one must first have a liking and a natural adaptation for the work; second, he must prepare himself by obtaining a thorough working knowledge of the profession or business he expects to follow. He must educate himself for the work. This is fundamental and has been proven many times with the successes in every profession. It is fair to presume then that the great majority of men entering this profession have considered the probabilities of success and have met the requirements needed to qualify them to follow this calling and to receive the support of any who through necessity need their services.

Without going into the non-essentials showing the rights of individuals holding a license as an embalmer to practice, we may naturally come to the next question in this connection, the value of his services and how they should be charged for. Charge what your work is worth, and do not conceal the amount in the price made on the casket or any other part of the funeral expenses. Make it a specific charge in every instance for there is a good and sufficient reason why you should.

An explanation of these reasons may be summed up as follows: the conscientious effort in qualifying yourself to meet the needs of your calling and the requirements of the state, the cost of your training and education in time and money, the years spent in the hard school of practical experience and self development.

Next your business equipment and investment, the care of the case on which you are called, its peculiar requirements and how it taxes your skill in doing the work, the risk from infection, the distance you must travel and the expense of the trip. All of these considerations enter into the cost and should be the basis on which to formulate a charge for the work.

Just as the well equipped surgeon of wide experience and training skillfully performs operations relieving suffering, saving and prolonging life, naturally allows the difficulties of the case and the distinctive personal service rendered to govern him in the amount of the fee, so in a very similar sense the services of the embalmer should hold a certain ratio of value to the conditions under which he works and the ability he employs in its performance. Therefore let me again urge that you make it a specific charge showing it a distinctive personal service.

In the matter of the value of personal services the question is often raised: “Which is the more important part of the work in our profession, directing and managing the funeral or the embalming and care of the body.” In answer to this let me say that the care and the embalming of the body is first importance because the law says so, because the education of the embalmer is paramount to other considerations and so regarded by the national association, because sanitary science demands it, because without a body properly embalmed and prepared for burial the funeral is a failure from whatever standpoint you wish to judge it.

A director may bungle the arrangements and at the most it is but a matter of annoyance to the family. However, let him fail to properly fit and prepare the body so that the relatives can see restored to them the face of their beloved one, beautified in the last long sleep of death, and they will never forgive him. They secured his services first as an embalmer and incidentally as a director of the funeral, naturally, therefore, the greater importance of his work centers around his services to the family in that capacity. Now in all candor, why should he not make a specific charge for his work? He is rendering the greater service in caring for the body, it should be the first item charged for on the funeral bill.

CHAPTER XVI. THE ANATOMICAL AND LINEAR GUIDES FOR SPECIAL ARTERIES.

Linear Guide.—By a linear guide is meant that an imaginary line is drawn from a point to a point the same direction the artery runs so that by mentally imagining this line one can be safe to cut on the line and be sure that the desired artery will be reached.

The linear guide for the carotid is represented by a line drawn from the sterno-clavicular junction to a point between the angle of the jaw and the lobe of the ear. (Mastoid process).

As the body lies on the cooling-board place one finger on the sterno-clavicular junction and the other at a point between the angle of the jaw and the lobe of the ear, and by cutting on this imaginary line, the artery will be reached, providing the artery is normal and if the embalmer is thoroughly acquainted with the anatomy about the artery, as is summed up in the anatomical guide.

Anatomical Guide.—By the anatomical guide is meant the relation which the artery bears to the surrounding tissues.

The anatomical guide for the carotid artery is that the artery lies between the sterno-mastoid muscle to the outside, and the muscles surrounding the trachea (wind pipe) and the esophagus, to the inside. In the middle third or sometimes between the middle and upper third the omohyoid muscle crosses over the artery.

Perpendicular Incision.—The artery is divided for the sake of description into thirds. By making an incision on the linear guide in any one of the thirds the tissues that must be passed through are the following:—skin, platysma muscle, superficial fascia, deep fascia, common sheath, and the individual sheath.

The platysma muscle is a broad tissue paper like muscle, placed immediately beneath the skin and a part of the superficial fascia, in the cervicle or neck region. It arises by thin fibrous bands from the fascia covering the pectoral and deltoid muscles on the thoracic wall, and passes upward over the clavicle and inserts the lower jaw. This muscle is so delicate and the fibers so finely divided that it is hardly perceptible. When the skin is cut, the platysma muscle will as a rule be cut too, and because of its thinness it will rarely be seen or does it form any hindrance to the raising of the artery. It is only mentioned here because it forms part of one of the questions so often asked by the State Board in their examination: “What tissues would you pass through in raising the carotid artery?”

Having cut through the skin and platysma muscle, the superficial fascia is next seen. In this part of the body it consists of but a single layer and very thin.

The deep fascia lies next and constitutes a complete investment of the neck. When this is torn or cut through the sternomastoid muscle comes into view.

The sternomastoid, is a large, thick muscle, which passes obliquely across the side of the neck, being inclosed between two layers of deep fascia. It has its origin at the sternum and clavicle and attaches to the mastoid process of the temporal bone. By making the perpendicular incision in the lower third, in as much as the muscle slightly covers the artery, it can either be cut or pushed to the outside of the incision. It is best to push the muscle to the outside with the thumb, and with the handle of the scalpel, work down deep through the areolar tissue. The operator will now arrive at the common sheath, or that part of the deep fascia surrounding the artery, vein and nerve. The common sheath will be very tough and a slit must first be cut, then it can be torn the length of the incision.

The artery will now be seen lying next to the wind pipe and the internal jugular vein to the outside. In the lower third the artery will be about one-half inch deep, while in the upper third it will be about one to two inches deep, owing to the amount of fat in this region. In the upper third, the omohyoid muscle crosses over the artery, which must be either pushed aside or cut in two.

It is always advisable, to raise this artery in the lower third, as it is less apt to show in that third.

Loosen the artery well from the surrounding tissues with the aneurism hook, raise to the surface and place a bone separator beneath the artery.

Now remove the individual sheath, incise the artery and insert the arterial tube.

If it is desired to raise the internal jugular vein for the withdrawal of blood, it is best not to open up the common sheath, but to raise the artery and the vein both at the same time. Having raised them to the surface they can then be separated by the removal of the common sheath and dropping it back into the incision.

If it is desired only to raise the carotid, the hook should always be inserted between the artery and the vein, and directed toward the trachea. If it is directed around the artery in the other direction there is danger of rupturing the vein, and thus getting a bloody incision.

The Circular Incision.—In the circular incision as much of the skin as can be, is pushed above the clavical bone from off the chest wall. The cut is then made from one sterno-clavicular junction to the other following the supra-sternal notch. This method was devised for the use of the “Y” shaped tube, where both sides of the face could be injected at the same time. One precaution however should be noted, which is, that care should be taken that not more than the skin, be incised with the first cut. Just below the incision will be noticed a little branch vein which runs into the arch connecting the two external jugular veins. If the first cut is too deep this branch will be cut, and a flow of blood will result. However by cutting carefully this little branch can be noticed, tied off in two places and cut in between, and thus cause no further trouble. Remembering the linear guide, the artery can be reached by going down at either end of the incision. The tissues to go through will be the same as for the perpendicular incision, and the method of raising the artery will be the same, only, in the circular incision usually both carotids are raised, so as to inject both sides of the face at the same time.

The only advantages derived from the circular incision is that one can by the use of the “Y” shaped tube inject both sides of the face at the same time and get an equal distribution of fluid, and that after the injection is over, and the incision sewed up, the skin can be pulled back in place, making the incision appear much below the clavical, and where it is less liable to show than in the perpendicular incision.

For embalming female subjects, if the carotid is chosen as the artery to use, it will be best to use the circular incision. However for ordinary embalming it will perhaps be best to choose some other artery, which will be less apt to show, and not so deep.

We should be so skilled as to never make a mistake, but the best sometimes do make mistakes. If in raising another artery, a mistake should occur, the operator can raise either above or below the original cut, but with the carotid, the only advisable incision to make is in the lower third, and if a mistake is made the last chance is lost. For this reason then a great amount of care should be taken.

In injecting the body from the carotid, the arterial tube should be inserted first toward the heart, and after the body has received a sufficient amount of fluid, if it is noticed that the side of the face from which you are injecting has not received a supply of fluid, then reverse the tube and inject a few bulbs of fluid upward.

Relation of Artery, Vein and Nerve.—The common carotid artery lies in relation to the internal jugular vein and the pneumogastric nerve. The artery lies to the inside next to the muscles surrounding the trachea (windpipe). The internal jugular artery lies to the outside of the artery. Just back of the common carotid artery and the internal jugular vein and between the two lies the pneumogastric (vagus) nerve. These all as a rule lie in the same common sheath of deep fascia.

Then after the operation is completed and the arm placed back in normal position, the casual observer is not liable to see the incision, even though the body be only partially dressed.

Linear Guide.—A line drawn through the center of the axillary space (arm pit), at the anterior border of the hair line.

The Axillary Space.—When the arm is maintained in a horizontal plane, the axilla has the shape of a three-sided pyramid, the apex of which lies above, below the clavicle, and the base of which corresponds to the lower wall, covered only by skin and fascia.

The axilla is filled with blood vessels, lymph vessels, lymph glands, nerves, and masses of fat.

To Raise the Artery.—Make an incision on the linear guide. After the skin is passed through there is a large quantity of fascia, lymph glands, and lymph vessels, which must be carefully dissected through, and at the same time the axillary vein will be discovered. This vein, for the present, should not be loosened from the surrounding tissues. Dissect down to the upper side of the vein, and the common sheath of fascia surrounding the artery and nerves will be seen. By carefully tearing this the length of the incision, the brachial plexus of nerves now is exposed. Now by gently pushing the nerves apart with the handle of the scalpel, the artery will be seen. With a hook loosen the artery from the surrounding tissues and raise to the surface.

If it is desired to draw blood, now proceed to raise the vein to the surface. Open the vein and insert a drainage tube, which should be long enough to reach through the entire length of the axillary and subclavian veins, because they have valves along their entire course nearly to the bifurcation of the innominate.

Inject a few ounces of fluid toward the hand as the axillary is above the point of collateral circulation. Then reverse the tube and inject toward the heart, until a sufficient amount of fluid has been injected.

Relation of Artery, Vein and Nerve.—The vein is quite superficial, just below it and to the upper part of the incision is the brachial plexus of nerves, which surrounds the artery.

The anatomy of this vessel is simple, yet, when we take into consideration all the numerous anomalies or irregularities that surround its use to us as embalmers, we feel the necessity of making the description very thorough and complete, in order to raise it under all the various difficulties that attend its use.

The brachial artery has its several branches, the most prominent of which are the artery profunda brachii (superior profunda artery) and the artery collateralis ulnaris superior (inferior profunda artery) and the artery collateralis inferior (anastomotica magna artery).

For the sake of a more correct description we divide the artery into thirds, viz: the upper, middle and lower thirds. The upper third begins at the extreme upper part of the arm and extends one third of the way to the elbow, the middle and lower thirds occupy the remainder of the artery. In the upper third we have the superior and inferior profunda arteries coming off; their position is not always the same, and in the extreme lower third the anastomotica magna artery. These arteries continue down the outer and inner arm and anastomose with the recurrent radial and ulnar arteries, thus furnishing collateral circulation. Thus if the fluid is injected in the middle third, toward the heart, these branches that come off the brachial in the upper third will convey the fluid down the arm, filling the branches below the point of injection, which supply the forearm and the hand.

The brachial artery is one continuous vessel, the entire length of the upper arm, and varies in size according to the size of the person and the development of the arm. It is accompanied by the venae comites or deep brachial veins, the one to the inner side of the artery about one-third to one-half the size of the artery, the other about one-half its size lies directly underneath. All are encased in the same common sheath of deep fascia that surrounds and holds them together. Great care, then, should be taken to separate the artery from these veins before cutting the artery for injection.

The artery lies along the inner and under border of the large muscle on top of the arm known as the biceps. The biceps is the muscle used when lifting a weight. To those whose occupation is to exercise the muscular tissue of the body liberally, this muscle becomes quite large, and generally the artery is proportionally large.

Linear Guide.—The course of the brachial artery may be marked out by drawing a line from the middle of the axillary space (arm pit) to the center of the elbow, provided the palm of the hand be turned upward. This line will be immediately over the artery, which will be found by cutting through the skin at any point on the line, and dissecting through the subcutaneous tissue toward the center of the arm.

The Anatomical Guide.—In the upper third the artery lies between the biceps and coracobrachialis muscles which lie above the artery, and the triceps muscle which lies below the artery. In the upper third the nerve lies close to the muscle, the artery below and to the inner side toward the body, and the vein a little farther to the inside.

In the middle third the artery lies between the biceps which lies above the artery, and the triceps muscle which lies below the artery. In the middle third the artery will lie beneath the nerve.

In the lower third the artery lies between the biceps which lies above the artery, and the triceps which lies below the artery. In the lower third the artery lies next to the muscle and the nerve to the inner side next to the body, and the vein still farther to the inner side.

How to Raise the Artery.—First trace the inner border of the biceps muscle, feel for the median nerve, which will always be present. The artery in the middle and lower thirds will follow the border of the muscle. The palm of the hand should always be turned upward, and the linear guide, as stated above, will indicate the exact position of the artery. Make an incision through the skin, on the linear guide, pushing the fatty subcutaneous tissue to one side, if there be any, and with the handle of the scalpel, work through the superficial fascia. Reverse the blade, and at each end of the incision, cut forward and upward to make it clean. Now with the scalpel cautiously cut through the deep fascia, and remove this from the vessels below. This will expose to view the median nerve, and with the handle of the scalpel, separate the tissue between the artery and the muscle, and between the artery and the nerve. Having thus freed the artery, use the hook end of the aneurism needle and pass it under the artery toward the muscle, and raise the artery to the surface. Pass the bone separator or the forceps with the closed end, underneath, remove the sheath surrounding the artery and the deep brachial veins. The natural position will be, the artery on top, the larger deep brachial vein to the inner side and the smaller one underneath. It is very necessary to remove these deep brachial veins, for the reason that if they are not, in cutting the artery for injection, they will be cut also, resulting in a flow of venous blood into the incision.

Before the advent of formaldehyde fluids the radial artery offered more advantages to the embalmer than any other artery used for injecting. But at the present time almost all embalming fluids contain large quantities of formaldehyde, and when injected into this artery, which is very small, it is liable to constrict the vessel to such an extent as to sometimes make it difficult to inject the fluid.

Moreover, since both the radial and the ulnar arteries have many branches, a large quantity of fluid is liable to accumulate in the forearm, hardening it more than is necessary and giving the hand an undesirable color.

The radial artery is very superficially located, and can be secured without the possibility of error and with very little mutilation. The expert will, of course, choose that vessel which he believes will at the time and under the circumstances best serve his purpose.

The Linear Guide.—Is a line drawn from the center of the bend of the elbow to the center of the ball of the thumb.

The anatomical guide for the radial artery (in the wrist, where it should be raised) is the brachio-radialis muscle on the outside of the artery and the flexor carpi radialis muscle on the inside of the artery.

When about to raise this vessel, the embalmer should hold the arm at right angles with the body, with the palm up, and holding the hand of the body, with the hand, draw the arm tight. In most bodies this will show plainly the tendons of the muscles between which the vessel lies, thus affording an excellent guide for the incision. The arm should never be grasped and the tissues drawn out of their normal position, as that is very misleading. The vessel should be raised at a point about three inches above the wrist joint (the space where you would feel the pulse beat in life). The operator making an incision through the skin, superficial fascia, and fat, about one-half inch in length, will plainly see the artery lying in its sheath between the two tendons of the muscles. The cut should now be opened carefully, by placing the fingers on either side of it, and the fascia dissected from the artery, when it can easily be raised with the aneurism hook. There is no other vessel at this point that can be mistaken for the radial artery. Its two venae comites, or accompanying veins, are usually attached to the artery and need not be removed, as they are very small and can give the embalmer no trouble.

The Linear Guide.—Is a line drawn from the center of the bend of the elbow, to the inside of the pisiform bone in the wrist.

The Anatomical Guide.—The artery lies in a groove in the wrist, made by the flexor carpi ulnaris muscle on the outside, and the flexor digitorum sublimis on the inside.

To raise the ulnar artery, locate the valley in the lower third about one to two inches above the pisiform bone. Make an incision about an inch in length, cutting first the skin, superficial fascia, layer of fat, which will vary in thickness. The deep fascia is now reached, which should be split by means of the fascia needle and bistoury. Then separate with the handle of the knife or bone separator, the artery from its connective tissue on either side. Then with the hook raise it to the surface, and place the bone separator beneath, remove the hook, and tear off the individual sheath.

The two ulnar veins will be separated from the artery by taking away the individual sheath, which should be allowed to drop back into the incision. Proceed now to open and inject the artery the same as you would the radial or the brachial. While this artery may seem just a little more difficult to raise, still at times it has its place in arterial embalming.

It is believed quite commonly, that by the injection of the femoral artery, there is a great danger of flushing the face. This belief is erroneous. Flushing of the face will result from the injection of any artery if it is full of blood and if it is found that the femoral artery contains blood, and likewise any other artery, this blood should be removed before injection takes place, and what little then remains, will not discolor the face, since it will be greatly diluted.

The internal long saphenous vein is mistaken frequently for the femoral artery. It is a superficial vein and is usually found empty after death. It lies a short distance to the inner side of the femoral artery in Scarpa's triangle. This vein is taken up frequently, not only by the younger members of the profession, but by the older as well, when the guides are not followed closely, and when this mistake does occur, and fluid is injected through it, flushing of the face results.

Next to the common carotid artery the femoral artery is the largest branch artery used in embalming. The femoral artery commences immediately behind Poupart's ligament and is a continuation of the external iliac artery.

It passes down the forepart and inner side of the thigh, terminates at the opening in the adductor magnus, at the junction of the middle with the lower third of the thigh, where it becomes the popliteal artery. In the upper third the artery is contained in a triangular space called Scarpa's triangle and in the middle third of the thigh it is contained in an aponeurotic canal called Hunter's canal.

At a point about one and one-half to two inches below Poupart's ligament, the femoral artery gives off a branch to the outer and under side, known as the deep femoral artery, or the profunda femoris, which courses the thigh downward, and connects with branches coming off the popliteal and the anterior tibial arteries, thus forming the collateral circulation to the lower leg and foot.

As the femoral artery leaves the body, it is accompanied by the femoral vein, which for two inches down, lies along side the femoral artery to the inner and under side. At about this juncture, however, it passes underneath the artery and continues its course in that position until it passes below where we have occasion to use the artery.

The femoral artery can be used all the way from where it leaves the body at Poupart's ligament until it reaches Hunter's canal. At Poupart's ligament the artery is very superficial, being covered only by the skin, superficial fascia and superficial lymphatic glands, but it gets deeper further down, being covered not only by the above named tissues, but also by muscles, making it very difficult to raise in the middle and lower thirds of the thigh. About five to seven inches below Poupart's ligament the artery passes under the adductor magnus muscle, and enters what is known as Hunter's canal. Because this artery does get deeper as it courses down the thigh, it is generally raised in the upper third.

A knowledge of the anatomy of the vessels of the thigh and leg will be of value in treating accidents when this member is injured.

Scarpa's triangle is a triangular space, the apex of which is directed downward, and the sides formed externally by the sartorius muscle, internally by the inner border of the adductor longus muscle, and above by Poupart's ligament. The floor of the space is formed from without inward by the ilio-psoas pectineus and the adductor longus muscles. The space is divided into two nearly equal divisions by the femoral vessels, which extend from the middle of its base to its apex, the artery giving off in this situation the superficial and profunda branches, and the vein receiving the deep femoral and the internal saphenous veins. Besides the vessels and nerves this space contains some fat and lymphatics.

Hunter's canal is the aponeurotic space in the middle third of the thigh, extending from the apex of Scarpa's triangle to the femoral opening in the adductor magnus muscle. Hunter's canal contains the femoral artery and vein inclosed in their own sheath of areolar tissue, the vein being behind and on the outer side of the artery, and the long saphenous nerve lying at first on the outer side and then in front of the vessels.

Linear Guide.—The guide for the femoral artery is represented by a line drawn from the center of Poupart's ligament to the inner side of the knee joint.

Poupart's ligament extends from the crest of the ileum bone to the top of the pubic bone. To determine the center of Poupart's ligament for the right leg, get on the right side of the body and with the left hand, place the second finger on the top of the pubic bone and the thumb on the crest of the ileum bone, then let the index finger drop down between the two which will represent the commencement of the femoral artery.

Anatomical Guide.—The artery runs through the center of Scarpa's triangle from the center of its base to its apex. In the middle third of the thigh the artery passes beneath the vastus medialis muscle and enters Hunter's canal.

Relation of the Artery, Vein and Nerve.—The femoral vein at Poupart's ligament lies close to the inner side of the artery, separated from it by a thin fibrous partition; but two inches down the vein runs behind the artery and then to its outer side.

There is no nerve in relation to the artery in the upper third, the anterior crural nerve lies about half an inch to the outer side of the femoral artery, being separated from the artery by the ilio-psoas muscle. In the middle third of the thigh the internal saphenous nerve is situated on the outer side of the artery, but not usually in the same sheath with the artery.

To raise the femoral artery in its proper place, is to measure down from Poupart's ligament from one and one-half to two inches in the linear guide, and there begin the incision, making it two inches or less in length. This will bring the incision below the point where the collateral branches are given off. Cut through the skin, then the fat, which will vary in thickness with the subject. Underneath the fat are several layers of deep fascia, which must be split the length of the incision.

The femoral artery will then be seen, and underneath it will be the femoral vein. Both will be in the same common sheath of fascia, which may be removed with a hook by gently tearing the sheath loose over the artery. When the artery has been loosened the length of the incision, raise it to the surface, placing a bone separator underneath for a bridge.

If it is desired to remove the blood, the femoral vein should then be raised.

CHAPTER XVII. CAVITY EMBALMING.

The scientific work in the embalming of to-day is being done on the arteries, but cavity embalming should still hold an important place with those embalmers who desire to get the best results. Although the arteries have been injected, yet we find that sometimes the fluid does not reach the cavities. Any cavity may contain gas or material for decomposition, such as blood, pus, lymph, or as in perforation of the intestines, feces in the abdominal cavity. Besides these we always have the bacteria of decomposition, called saprophytes, which have thoroughly invaded the organs and tissues of the body as soon as sixteen hours after death. Then, if for any reason the fluid has not reached a certain part, fermentation, and putrefaction will immediately set in.

These gases may be removed by inserting a trocar inside the head at the inner angle of the eye or in the nose through the turbinated process of the ethmoid bone.

After the gases have been removed from the inside of the skull, about one-half pint of strong formaldehyde fluid should be injected.

Another method of inserting the trocar into the brain would be to pass it through the foramen magnum. This can be done by inserting the trocar in the neck a little below and behind the lobe of the ear, directing the needle upward and inward toward the opposite eyebrow, when the needle will enter the subarachnoid space (Barnes Method).

In cases of hydrocephalus (water on the brain) where there may be from one to two quarts of water inside the cranium, the water may be removed by any of the above processes.

For ordinary cases we do not feel that it is necessary to make a cavity injection in the head for the reason that the circulation there is complete, only in rare instances do we find an obstruction.

The real cause of purging is the living and growing saprophytic bacteria, which were normally in the body, or having gained access later, produce as a result of their development, gas formations. These gases confined as they are, press out from the stomach and lungs the contained fluids of the color mentioned above.

Purging from the stomach may either be due to the presence of gases in the stomach itself, or in the intestines or in both. If the gases have formed in the intestines, they would dilate the canal sufficiently to fill the entire abdominal cavity, thus pressing the stomach against the diaphragm with enough force to cause the contents to escape through the upper end of the alimentary canal.

Purging from the lungs is due to the presence of bacteria of putrefaction, which begin to develope in the diseased portions. These cause liquefaction of the lung substance and the formation of gas. The gas will force the liquefied matter, of a bloody, frothy color out through the respiratory tract.

Before embalming of the chest and the abdominal cavity is begun the trachea and the esophagus should be treated in order to prevent purging. There are two ways of doing this:

The first method consists of placing a ligature about the trachea and the esophagus, this is done by making an incision through the skin and tissues over the left edge of the trachea, one-half inch above the top of the sternum. Insert the right forefinger, passing it to the right side behind the trachea and the esophagus to separate the tissues from them. In doing this great care should be taken so as not to injure the carotid on the left and the innominate artery on the right side. Pass the aneurism hook threaded with narrow tape (this must be very strong tape) along the inner side of the finger, below the trachea and the esophagus, to the point of entrance on the left side. You will have no difficulty now in tying securely both the above tubes, and there will be no possibility of purging from either the lungs or the stomach.

The second method of preventing purging from the lungs and stomach consists in plugging the pharynx through the mouth, there-by plugging the trachea and the esophagus. The only disadvantage of this method is that it can not be done successfully after the body has been embalmed arterially. And for this reason, after arterial embalming, the lower jaw will be firmly set and to use this method, it would mean that the lower jaw must be pried back in order to gain access through the mouth. Then it will be found very difficult and in some cases impossible to set the lower jaw again in its proper position. If this method is to be used at all, it is advised that you do the plugging of the pharynx before the arterial embalming has been done.

To do this, take your position at the head of subject on the right side, and open the mouth wide enough to admit two fingers. Roll several pieces of dry cotton, the size of an English walnut, and holding the corner of the mouth back with the left hand, insert a ball of cotton with the right hand and shove it hard down behind the tongue (this can best be done with a pair of clamp forceps). Continue to do this until the pharynx is well and firmly filled, but avoid bulging out the side of the cheek. If properly done this plug will prevent an ordinary amount of purging and dry cotton seems much better to use for this purpose than absorbent. It must be borne in mind that simply filling the mouth is of no use; nothing is plugged by this procedure, as it leaves the opening into the nose open.

If you had not anticipated purging in the beginning, and the body has been embalmed arterially it will be necessary to stop the purging by the first method.

A third method of preventing purging from the lungs and stomach is in the use of plaster of paris. In this method the plaster of paris is mixed thinly, then by means of a paper funnel, pour the liquid into the nose and mouth, then plug tightly with absorbent cotton as in method two. It requires only a short time for the plaster of paris to set and it has been found quite successful. Probably the only disadvantage of this method is that it is mussy and because of the rapid drying qualities of the plaster of paris the operator must work very quickly.

Again in certain other diseases, especially pneumonia, the fluid cannot reach the diseased lung, either through the nutrient arteries or by the respiratory tract, because of the resistance offered. The nutrient arteries will be filled with coagulated blood and the bronchi, to a certain extent, with a bloody mucous.

This being the case, the bacteria of putrefaction will begin to develop within the diseased portions of the lungs, and will be the cause of the purging so much dreaded by the embalmer.

The thoracic cavity may be treated by one of several methods.

A first method consists in passing a curved trocar into the trachea just above the sternum and injecting a strong embalming fluid into the bronchi. In cases of gangrene of the lung, the sputum has a very offensive odor, which may be disinfected by this method. But it must be remembered that the ends of the bronchioles which enter the diseased parts of lungs will be closed (from the nature of the disease), so that any fluid injected into the bronchi from the trachea will not reach the diseased part of the lungs. You will thus see that it is absolutely necessary to use a method in treating the thoracic cavity, whereby any mass of rotten tissue, which may be present, may become thoroughly saturated with the disinfectant.

A second method written about the Robbins, is accomplished by inserting the trocar on both the right and left sides at the tops of the lungs, and at the bases. At the top of the lungs the trocar is introduced two inches outside the sternum just below the clavicle. The trocar may then be pushed in any direction, except toward the sternum, without injury to any of the larger vessels.

The arch of the aorta passes a little to the right of the sternum and as high as the lower border of the first rib, then makes a turn to the left and goes directly back to the left side of the fifth dorsal vertebra. The superior vena cava lies a little to the right of the arch of the aorta. The advantage of inserting at this point rather than above the clavicle is that there are no vessels in the location in danger of perforation. If the trocar is inserted above the clavicle on either the right or the left side there is danger of perforating the subclavian artery or vein, while if the insertion is made next to the sternum, the aorta may be perforated, in either case breaking the circulation. Disease fluids are seldom found at the top or apexes of the lungs, but in consumption, breaking down of the lung substance usually begins at this point, especially in young cases. To insure a perfect embalming of the lungs, you should inject at the apexes, about a half-pint of strong formaldehyde on each side. It should, however, be remembered that the injection at the tops of the lungs, as suggested, gives no fluid to the lower parts of the lungs where it is often most necessary.

It is not an unusual condition to find a whole lobe rotten and broken down at the base of the lung, and when such a diseased condition exists the lungs become firmly attached to the chest walls, and unless fluid is placed below these adhesions it does not reach the diseased parts. The intelligent embalmer, will never trust to the fluid passing from the tops of the lungs to the base, as in almost all cases the adhesions between the lungs and the walls absolutely prevent this taking place.

It is necessary first to draw off by aspiration, at the bases of the lungs, the fluids which have accumulated and which may be either water, pus or blood. This is done by inserting a curved trocar of small size, between the fifth and sixth ribs on the axillary line. The thoracic cavity extends in the back as low as the last rib and the twelfth dorsal vertebra and it may be necessary to pass the trocar down into this part of the cavity in order to remove the fluids.

As soon as the fluids are removed, inject from a pint to a quart of strong formaldehyde on either side. By so doing the gangrenous and decomposed part of the lung will be put to soak in the embalming fluid, which will insure perfect disinfection and an absence of bad odors.

To prevent the formation of gas now which has arisen, a second injection will do no good. More drastic measures will have to be used. One method that has long been in vogue is the use of the trocar.

The Trocar Method.—In this method a trocar varying in length from six to fourteen inches is used. It may either pierce the abdominal wall through the umbilicus, or two inches above and two inches to the left of the umbilicus. Then after the trocar has entered the abdomen the secret of removing gases successfully depends very largely upon the operator having a very correct idea of the location of all the abdominal organs. It is difficult to know when the trocar has pierced the interior of the stomach, or in fact even to make it pierce the stomach at all for the peritoneum which is a covering for all the organs of the abdominal cavity contains a serous fluid which makes the organs slippery, and even the sharp pointed trocar often does not take hold as it should. Again it must be remembered that the stomach is a hollow organ, and for example let us try to pierce a soft rubber ball, containing air and a small opening, a condition resembling the stomach, with a trocar, we know that the one wall, will have to be pushed up against the other wall, and then placed against something firm, before the trocar will pass through. Just this condition happens with the stomach when the trocar tries to pierce the arterial wall of the stomach there is nothing solid to bear against and consequently the front wall will be pushed up against the back wall and then if enough pressure is now used to push the trocar through, it is very liable to pass all the way through both walls.

Again it must be remembered that the descending aorta passes very close behind the stomach and should the trocar go all the way through the aorta might be pierced and the circulation in a measure ruined. The one main disadvantage of this trocar method is that the operator is always working blindly, it is always impossible to tell just how much damage may be done to the internal organs and the circulation, and again should the operator desire to place fluid in a certain part—say the inside of the intestines or the inside of the stomach or the colons, will the operator have assured knowledge that he has actually placed the fluid in the part desired. From the number of experiments that have been carried out in our anatomical rooms, the proof seems to be in every case that the fluid has not reached the part it was supposed to reach.

The advantage of this method is the fact that by introducing the trocar into the abdominal cavity two inches above and two inches to the left of the navel that after the abdomen has been treated that the trocar then can be directed upward into the thoracic cavity and fluid there distributed to the several parts, but this is seldom necessary. After the trocar has been removed or better, just before the trocar is entirely pulled out the operator should sew a circular stitch about the wound and then as soon as the trocar is pulled out, pull the stitch closely together as if it were a draw string, and tie. This will prevent any further leakage from the part.

The incision having been made, it is evident now that the part containing the gas will come up into the incision. If the stomach contains the gas it will come up, if the transverse colon contains the gas it will come up, but that makes no difference, for it is the part with the gas that the operator is after. Usually the transverse colon will be the first to come up into the incision, now take hold of the part with your artery forceps and with a pair of scissors make a clip through the wall, this will let the gas escape. Do not let the gas escape into the room not deodorized, so place over the hand quickly after you have made the clip, a towel, or absorbent cotton that has been saturated with formaldehyde, this will both deodorize and disinfect the gas. Keep hold of the part until all the gas has escaped, and then pick up the arterial tube and inject a small quantity of fluid in the colon, and then sew up with the circular stitch. Then locate the stomach, which can easily be found if it contains gas and treat it in the same way, relieving the gases and then placing a small amount of fluid inside. Treat the other several parts of the intestines in the same way if gas be present and it is remarkable how quickly the abdomen sinks to its normal level. After this has been done place hardening compound or common salt in the cavity, and placing a layer of absorbent cotton in the abdomen under the incision, sew up neatly.

The one great advantage of this method is that you can actually see what you are doing, you can see the part that contains the gas and treat that part particularly, the operator is not working blindly, but is able to place the fluid in the part that he desires and is assured of the fact that it is in the part for his eyes do not deceive him as the sense of feel and touch sometimes do. By this method the operator is able to surround the parts of the abdominal cavity with a hardening compound, and thus feel sure that his case if it is to be shipped, will be received in proper condition, at least it will be as far as the abdomen is concerned, if it is treated under this method. This method is one sure cure for purging, for the gases once properly relieved from the stomach and the contents disinfected, there is no chance for them to recur. If the stomach is found to be full of liquid as well as of gas, as is the condition during purging, the liquid can be taken from the stomach with a drainage tube or a stomach pump, and lastly every part is deodorized and disinfected properly.

A seeming disadvantage might be that a critic might suggest that you are mutilating the body with your abdominal incision. Let a fair question be asked. If it were your sister that was to be embalmed and gases had to be removed, which would you rather see some operator running a trocar here and there through the abdomen, relieving gases and injecting fluid here and there, or, the use of the neat surgical incision, made as a surgeon would make it.

With these difficulties then in view, the best operation for filling the tissues, that is the subcutaneous tissue covering the bony framework of the body, is the direct injection of fluid into the part by means of (1) the hollow needle trocar, and (2) the hypodermic needle.

The hollow needle trocar is to be used for the rough work, so called. Inserting the trocar into the center of the popliteal space it can be pushed through the tissues of the foreleg, and fluid injected; then reversing, push the trocar through the tissues of the leg proper, and inject fluid. Inserting the trocar into the center of the bend of the elbow it can be pushed into the tissues of the forearm, and fluid injected; then reversing, push the trocar through the tissues of the arm proper and inject fluid. Turn the body over so as to trocar the back. Insert the trocar above the sacrum bone in the middle line of the back, and push the trocar through the fleshy parts of the gluteal regions, and inject fluid. Again insert the trocar in the middle line of the back between the two scapulae bones, and inject fluid into the region of the shoulders and the small of the back.

After each puncture, before the trocar is removed a circular stitch should be thrown around the trocar and when the trocar is removed draw the puncture shut, the circular stitch acting as a draw string.

A large amount of fluid may be injected in this manner, it being possible to inject several gallons into a body of average size. The fluid transudes through the tissues very readily filling them up completely, but of course, not as certainly as if the fluid were injected arterially. It is an easy matter to inject from two to three gallons of fluid into the soft tissues on the outside of the skeleton of a body weighing from 130 to 140 pounds.

This procedure is only to be used if it is impossible to inject the body by the ordinary arterial embalming. The cavity work in the cerebro-spinal, the thoracic, and the abdominal cavity, should be done first, and then follow with this subcutaneous tissue outside the bony framework.

This procedure may be used in dropsical cases and in certain cases, where for some reason the fluid does not reach a certain part, or where a certain part is not completely supplied with fluid, by the arterial injection.

The hypodermic needle is to be used for the more delicate work, such as the hands and the face. Insert the needle at the wrist and direct it into the palm of the hand, inject a very small quantity of fluid; then into the back of the hand and inject a small quantity of fluid.

To reach the tissues of the face insert the needle into the muscles and tissues of the face from the inside of the mouth. The region about the temple can be reached by inserting the needle into the tissues in the hair line, which will hide the puncture.

With the use of the hypodermic needle fluid can be placed in contact with all the tissues of the hands and face, and the cosmetic effect will be almost perfect if the operator is careful as to the amount he injects, and is careful to see that, the fluid is equally distributed throughout the part.

In the male it is wise to tie a string about the penis just back of the head, or glans, while in the female it is best to plug the meatus of the urethra and the vagina with cotton.

CHAPTER XVIII. THE REMOVAL OF BLOOD.

There are some very important reasons why blood should be removed from the body.

(1) There may be discolorations on the body, especially the face. This discoloration may be due to the presence of blood in the minute capillary system and other vessels which are near the surface skin. This discoloration may be due to the presence of the bile pigments in the blood, which would tend to give the body a yellowish hue. This discoloration may be due to the breaking up or disintegration of the blood corpuscles after death, which would tend to give the tissues of the body a light, pale, yellow color. Or this discoloration may be due to the presence of chromogenic bacteria, or color producing bacteria, in the blood, which might give to the tissues a characteristic green color.

(2) There may be blood in the arterial system after death, which certainly will have to be removed or else it may be pushed into the tissues of the face during the injection of the fluid and cause a discoloration. Besides if the arteries are congested with blood, this will have to be removed to make room for the embalming fluid, so that it will reach the capillaries and the tissues of the body.

(3) There may be the formation of tissue gas, and there is no doubt but that the removal of blood will greatly facilitate in the treatment, for without the blood, the fluid will have more chance to act on the parts containing the gas. This gas may be in the blood vessel itself, and the removal of that blood then will relieve the gas and the pressure exerted by the gas, which will aid in the injection of the fluid.

(4) To prevent a hasty decomposition. It may be that our subject is very heavy and fleshy which will mean that there is more tissue to be preserved and necessarily more fluid will have to be used. To make room for this increased amount of fluid, blood should be removed.

It may be that the body is in a hydropic condition. The tissues and the blood vessels will be filled with water. This will mean a hasty decomposition. The watery blood should be drawn from the blood vessels in order to make room for more fluid than ordinarily.

It may be that the body has died of a fever, which will also mean a hasty decomposition. This will mean that the blood will soon coagulate after death, and therefore the sooner it is removed, the better for the general cosmetic effect.

We do not however believe that blood should be removed from every subject, in order to get good cosmetic effect. Rather there are times when blood should not be removed, the conditions which are as follows:

(1) In the thin emaciated subject where there is no discoloration. An example of this condition would be in the tubercular subject, where before death the body has become very thin and emaciated. We would not remove blood when the subject is in this condition, for as a rule the body will take plenty of fluid, the arteries are as a rule empty after death, and besides we desire to leave the blood in the body, in order to give the skin of the face a more filled out healthy cosmetic effect.

(2) In the pale, marble-like, anemic subject. We would not remove blood in this case, first because it is not necessary, for there is a lack of blood in the surface capillaries showing that the arterial system is completely empty, and there is no congestion of the veins; secondly, experience teaches us that in these cases, you probably would not get any blood if you did try to remove it, and thirdly what little blood is in the surface capillaries is needed to build up a more healthy cosmetic effect.

There are times when blood should be removed from the subject after death which are as follows:

(1) Whenever blood is found in the arterial system. An example of this might be found in those cases of sudden death, such as drowning, suffocation, electric shock, or general heart failure. Whenever there has been a case of sudden death, the operator may expect to find blood in the arterial system. The last contraction of the heart normally would drive all the blood out of the arteries and arterial capillaries into the venous capillaries and veins, but this is not accomplished in the cases of sudden death. Whenever, on incising an artery, you find blood in the artery, and it runs freely, it indicates that there is a considerable quantity of blood in the arterial system. This blood then should be removed, because, were fluid to be injected into the artery, when it is full of blood and in this congested condition, all of this blood would be pushed ahead of the fluid toward the center of pressure, and from there large quantities would be pushed back into the tissues of the face, which would result in a greatly discolored face and a very poor cosmetic effect. DO NOT FORGET. Always remove blood when you find it in the arteries. The regular blood drainage tube should be placed in the artery, and all the blood removed that is possible, before attempting to inject. If this blood is not removed, the operator need not be surprised if he causes a decided blood discoloration of the face and a bad cosmetic effect. In these cases blood should be removed from the veins too, for that procedure will help to make room for what blood does remain in the arteries and capillaries, so that it can be pushed by the fluid into the veins rather than the tissues of the face.

(2) When the venous blood vessels are congested with blood and gas. An example of this might be found in almost any case. When the operator makes the incision to disclose the vessels and finds the venous channels congested, or when over the body the surface veins show signs of congestion and distention with gases, then blood should be removed.

(3) In dropsical cases. Often in these cases the tissues throughout the body are in a hydropic condition (filled with water), the arteries as well as the veins are filled with a watery, bloody colored fluid. It will be best for the operator to remove all this watery blood from the arteries, veins, and the tissues also, in order to get the greatest amount of preservative action from his fluid.

(4) In heavy, fleshy subjects. Experience teaches us that these bodies are as a rule difficult to handle from a cosmetic, as well as from a preservative standpoint. It seems advisable to draw blood from these subjects whenever possible, and by so doing bring about a clear non-discolored cosmetic effect; also the removal of blood will give more room for a greater supply of fluid, and thus the tissues will be better preserved.

(5) When the face is discolored. Whenever the operator takes charge of a body and finds the face discolored, no matter what the cause of the discoloration may be, it is a good indication to remove blood from that body.

By removing blood from the larger venous channels, the operator will make room for the blood to leave the face, and in this way better cosmetic effect is assured. Massage the face toward the internal jugular vein, and push the discoloring blood from the tissues of the face, out into the larger channels, that have been emptied by the removal of blood.

(6) In fever. Whenever a body dies in a high state of fever, it indicates a hasty coagulation of the blood, and a tendency to a discoloration of the face. Whenever the operator knows that the subject has died of a fever, or when there has been considerable fever on the body before death, then blood should be removed.

(7) To make room for fluid. The average embalmer only injects a gallon to a gallon and a half of fluid into a body. There are times when the operator desires to use more fluid. It may be that the body will have to be shipped a long distance, perhaps to another country or a distant state. After a certain amount of fluid has been injected the vessels become filled up and there is a great resistance established. If the operator disregards this pressure, and forces still more fluid into the arterial system, the fine capillary network will be broken, especially in the lung where the result will be a leakage of fluid through the mouth and nose from the ruptured air cells in the lung, or in the tissues of the skin, where the result will be a leakage into a certain area of tissue later causing a condition known as leathery skin. To have prevented this the operator should not have forced the fluid beyond a certain maximum resistance. He could, though, have reduced this resistance by removing the blood from the venous system, and then succeeded in the further injection of fluid.

There are times when blood ought to be removed from a subject after death, but for some reason it seems impossible to remove any. The reasons may be stated briefly as follows:

(1) The blood may already be in a coagulated condition, owing to the fact that the body has died in a state of high fever.

(2) The blood may be in a coagulated condition owing to the fact, that the bacteria of decomposition and putrefaction, have so altered the blood as to make its removal impossible.

(3) Certain drugs may have been previously given, or taken during life which would cause a hasty coagulation of the blood.

(4) The body may still be in a condition of rigor, and although the operator may have released the rigor in the joints, still all the tissues are in that condition, a condition which might prevent the blood from draining from the veins no matter what method was used.

Arterial blood is removed from the aorta indirectly, and from the arteries, only when the arterial system contains blood after death.

Venous blood is removed from the right side of the heart directly or indirectly, and the veins, only when it is deemed necessary by the operator.

There are two methods of removing this arterial or venous blood from the body. These two methods are aspiration and drainage. Besides these two methods some modified methods or combinations of the two, are given.

Aspiration consists in actually pumping the blood from the heart, arteries or veins. In this method, if blood is to be taken from the heart directly, the trocar is used; if the blood is to be taken from the heart indirectly or from the arteries or the veins one of the drainage tubes is used. Either the trocar or the drainage tube is connected by rubber tubing, to the goose neck on the blood bottle, which in turn is connected by rubber tubing to the aspirator side of the aspirator and injector pump. When the air is drawn from the blood bottle, there is a vacuum formed, which will aspirate or draw the blood from the heart directly or indirectly from the arteries or veins. The one great disadvantage of this method is that if the vacuum is made too great, the artery or vein will collapse ahead of the drainage tube and thus prevent the successful aspiration of the blood.

Drainage or gravity consists in opening one of the principle arteries or veins of the body, inserting a blood drainage tube into the artery or vein as far as it seems practical, and then connecting the blood drainage tube to the blood bottle by means of rubber tubing. The blood bottle should be placed considerably lower than the body in order to have the blood drain successfully. If the femoral artery or vein is used, the body ought to be on a considerable incline, the head at least one foot higher than the feet in order to get the maximum amount of blood.

If the axillary, brachial, or carotid, or their corresponding veins are used, the body ought to be on a level or turned to the side of the opening veins.

Simple drainage in itself is not a very successful method of getting the maximum amount of blood from the body.

The process can be modified in three ways which are as follows:

(1) By placing the blood drainage tube in the vein and the arterial tube in the corresponding artery. Inject fluid into the arteries which will tend to push the blood in turn from the capillaries into the veins, and out into the drainage tube into the blood bottle. This modified method has been called by Robbins “Displacement.” This is a good name and one which should be generally adopted.

(2) By placing the blood drainage tube in the artery or vein, preferably the femoral, and connect it by means of rubber tubing to the blood bottle. The operator now stands at the head of the subject, he reaches over, takes hold of each hand of the subject, raises the arms of the subject to right angles with the subject, then crosses the arms and with a steady gentle pressure bears down on the chest of the subject over the heart region.

If the axillary is used the operator is able to manipulate but one arm, the one opposite. Raise this arm to right angles with the body then fold down on the chest, exerting an even steady pressure. By raising the arms the blood will leave the hands, and each time pressure is exerted on the chest blood begins to flow from the artery or the vein, and will continue to flow as long as the even pressure is exerted.

(3) By the combination of number one and two. The operator opens the artery, preferably the femoral, inserts the arterial tube, and injects a pint of fluid to exert a pressure on the venous system. He then opens the vein, inserts the blood drainage tube which is connected with the blood bottle. With the pump in his right hand (granting that he is using the aspirator and injector pump), he stands at the head of the subject and slowly injects the fluid. If at any time the blood ceases to flow, by taking hold of the hands, raising both arms at right angles to the subject, crossing, and while in this position injecting a few ounces of fluid, then bear down gently on the chest with a steady pressure. If the blood will not flow by this method and the operator is using either the axillary or the femoral, there is hardly any use of trying any other method. The operator will be able to draw the maximum amount of blood with this method, if it is at all possible to draw blood.

Often when the blood stops flowing, there is a blood clot formation ahead of the drainage tube. By injecting just a few ounces of fluid or salt water through the tube into the vein, the clot may be pushed to one side, and the blood will continue to flow.

Raise the artery and inject about a pint of fluid in order to cause a pressure on the venous system. Open the vein and insert the flexible rubber drainage tube, known on the market as the Red Seal drainage tube or the Worsham drainage tube. Push this tube up through the femoral, external iliac, the ascending vena cava, through the eustachian valve, and into the right auricle of the heart.

In order to determine when the tube is inside the right auricle, the operator should have laid the tube on the external surface of the body from the point of entrance to the point where the right auricle normally should be, allowing for the bend of the vein in its course. Mark the tube, then when it has been pushed into the vein to that point the operator is reasonably sure that the end is in the right auricle.

In order to make the tube slip easily it should be greased with a liquid solution of vaseline.

After the tube has reached the right auricle the blood may be allowed to drain, or it may be aspirated.

Either femoral may be used, but the left femoral is preferable owing to the fact that, the angle at the bifurcation of the ascending vena cava is more obtuse.

If the operator desires to remove blood from the heart, we believe that the indirect method is the better way. By the use of the direct method to draw blood from the right auricle by means of the trocar there is always danger of rupturing the circulation. The aorta may be accidently pierced. When the trocar is inserted from below to reach the right ventricle the stomach may be punctured and the liver and diaphragm will have to be pierced which, too, may mean an injured circulation. If any accidental damage has been done, it can not be remedied. The direct method is a blind procedure and is always uncertain. On the other hand if the flexible rubber drainage tube is inserted into the vein it must follow the channel of that vein. It is more certain than the trocar method and there is no danger of rupturing the circulation.

The basilic or axillary vein may be used to remove blood from the heart instead of the femoral. These veins should be used on the left side of the body owing to the fact that the angle at the junction of the subclavian and internal jugular veins is not so acute as on the right side.

Have all the blood drainage outfit in readiness then open the vein and quickly insert the drainage tube. Any of the drainage tubes now commonly sold on the market are good. For the femoral, though, the flexible rubber drainage tube seems to be the best, because the femoral vein dips deep down into the posterior part of the abdomen after it leaves the Poupart's ligament. The flexible rubber drainage tube will follow this bend and can be pushed as far as is desired by the operator, in contrast the steel drainage tube could only be pushed into the vein for a few inches.

Blood ought to drain out into the blood bottle, if it does not, inject a little more fluid to cause more pressure on the venous system, and if it will not flow by the drainage method or any of its modifications try the aspirator. If blood still will not flow, it may mean that there is a clot ahead of the drainage tube. Pump some fluid through the drainage tube into the vein, to see if the tube is open, then let the fluid drain out which usually will bring some blood. After you have tried all the methods, if blood still does not flow, it will indicate that the blood is either in a coagulated condition, or there is not very much blood in that particular vein, which in this case is the femoral. The blood may be more in the dependent parts of the body.

Prepare two ligatures, make the incision in the vein and pass gently the basilic drainage tube upward toward the heart. Either a steel or rubber tube may be used. If the flexible rubber tube is used, it will find its way to the right auricle of the heart, its course is through the basilic, axillary, sub-clavian, innominate, superior vena cava, to the right auricle. Either the aspiration or the drainage methods may be used. If these fail try the displacement method.

The use of the basilic for the removal of blood is fast disappearing from general practice. Larger veins can be used, which will always insure greater success.

Direct the hook around the vein first then around the artery toward the wind pipe or trachea, raise both to the surface, place on the bone separator, and remove the sheaths. Use any of the drainage tubes. Insert the vein drainage tube and the arterial tube, the point of both tubes being directed toward the heart. The injection should be made slowly, which will cause the blood to flow from the vein through the tube and into the blood bottle.

This vein is not as much used as the axillary or the femoral for the removal of blood.

It is true that it is very close to the center of circulation and a gateway for the blood from the face. The chief disadvantage is that the vein lies quite deep, is very large and has such thin walls, that it is almost impossible to raise it without a rupture.

About one-thirteenth of the body's weight is calculated to be blood. Granting for the sake of argument that the average body that we would desire to draw blood from would weigh 208 pounds, then that average body would contain 16 pounds of blood. One pound of blood is practically equal to one pint, making the average body to contain about 16 pints of blood.

After death about one-fourth of the blood of the body is found in the portal system. The portal system has capillaries at both ends so that it is impossible to draw this blood.

After death about one-fourth of the blood of the body is found in the tiny capillaries and tissues, blood which by the ordinary methods used today the embalmer is unable to draw.

After death about one-fourth of the blood of the body is found in the azygos system, and points dependent in the body, which blood, too, it is impossible to draw.

This leaves about one-fourth of the blood of the body, which we are able to draw. One-fourth of 16 pints, is 4 pints which is the maximum we can draw from the average body.

The point of this argument is that if from the average body you have taken from two to four pints of pure undiluted blood, then you should be satisfied. If the majority of this blood has been taken from the face you will get the desired cosmetic effect. The claims by some that they are able to draw a gallon or more of blood is in our judgment erroneous, as we feel the blood has been greatly diluted. We have tested this out many times with the aid of control solutions and have found that what the embalmer would ordinarily call thin blood was composed of from 10 to 30% blood and from 70 to 90% fluid.