Charles Otto Dhonau

Infectious Diseases

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CHAPTER XIX. TREATMENT OF SPECIAL DISEASES.

Anthrax.

—Synonyms.—Malignant Pustule; Splenic Fever, Wool-sorter's Disease; Carbuncle; Charbons.

Definition.—An acute infectious, non-contagious disease, caused by the bacillus anthracis, and characterized by the formation of a boil with a circumscribed, infiltrated base and dark center, and a systemic infection of a severe type, the toxemia being of the gravest character.

Pathology.—The blood is dark, thick, diffluent, and rich in the spores of this disease.

Treatment.—Wash the body with 1 : 500 bichloride of mercury or 5% carbolic acid. Inject the arteries, using 64 ounces of half strength fluid followed by enough normal fluid to secure preservation. Inject the cavities with normal fluid. Drain blood from the veins, and disinfect the blood before disposing of it. Close the openings of the body. For transportation, govern yourself according to the provisions of the transportation rules.

Cerebro-spinal Fever.

—Synonyms.—Spotted fever; Cerebro-spinal meningitis; Typhus syncopalis; Malignant purpuric fever.

Definition.—An acute, infectious non-contagious disease, occurs sporadically, epidemically and endemically characterized by hyperemia of the brain and spinal cord, and sometimes attended by a petechial eruption.

Cause.—The meningococcus intracellularis of Weichselbaum.

Pathology.—In those cases that speedily prove fatal, there are little, if any, changes in the blood or tissues after death. Where the disease has continued for several days, however, we find the characteristic suppurative exudation. The sinuses of the brain contain blood clots. Sometimes pus is found in the internal ear, and the chamber of the eye. The liver, spleen and kidneys are usually slightly engorged and somewhat softened. There occurs in quite a number of cases a petechial eruption; the purpuric spots may be quite profuse, or but one or two may be seen.

Treatment.—As the means of ingress and egress of the infectious material is not known, it is best that we give these cases a thorough treatment; which should include a full arterial injection, drainage from the vein, injection of the cavities, and full care of the exposed portions of the body by washing same with a 1 : 500 solution of bichloride of mercury. The ears should be treated by packing them with absorbent cotton saturated with the fluid or with bichloride of mercury solution. The eyes should be carefully cleansed with a soft cloth or with cotton saturated with bichloride of mercury solution. The arterial injection should consume an amount of fluid equal to 10 per cent. of the body weight. Give full cavity injection. Govern yourself by the regulations of your district for transportation of these cases.

Erysipelas.

—Synonym.—St. Anthony's fire.

Definition.—An infectious, non-contagious disease, characterized by an acute and specific inflammation of the skin and subcutaneous tissues, attended by a shining redness, which spreads rapidly, marked swelling and pain, and which finally terminates in desquamation.

Cause.—This disease is supposed to be caused by the streptococcus erysipelatis.

Pathology.—The blood vessels are dilated and distended with blood, the cell infiltration may extend into the deeper tissues with suppuration. The cocci are found in the lymph spaces of the affected area, also in the lymph vessels. There is a true dermatitis, involving the skin, subcutaneous, and mucous surfaces.

Treatment.—Operator should wear rubber gloves. Wash the body externally with 1:500 solution of bichloride of mercury using absorbent cotton in the process. If crusts have formed bathe the spots with sweet oil, which will soften them and which will allow you to remove them; destroying them by burning would be the best means of disposal. If the face be the part affected, treat as above and then apply the following solution to the part with lintine (Moadinger) or by simple saturation: boric acid, one drachm; glycerine, one ounce; water, three ounces.

Inject the first 64 ounces of fluid at half the normal strength, gradually strengthening the fluid until the tissues become firm. Drain blood freely from a large vein and disinfect the drawn blood before disposing of it. Allow the softening solution mentioned above to remain on the face until you are ready to place the body in the casket, when the face can be dried and the usual cosmetic powders applied. Should the peritoneum or the pleura be affected, inject the proper cavities with very strong fluid. For transportation, govern yourself according to the provisions of your district rules.

Glanders.

—Synonyms.—Farcy.

Definition.—A specific, infectious, non-contagious disease of the horse, communicable to man by inoculation, and characterized by the formation of nodules in the mucous membrane of the nose-glanders; and also beneath the skin and lymph structures—farcy.

Cause.—In 1882, Loeffler and SchÜtz discovered the bacillus mallei which is the exciting cause of this disease. The infectious material is transmitted directly from horse to men, usually through an abraded surface, and occurs most frequently among hostlers, veterinarians, farmers, and those who come in contact with horses. It has been communicated from man to man, but this is rare.

Pathology.—There are found nodules located in the nose, in which case the disease is called glanders; or beneath the skin, in which case it is called farcy. These nodular masses discharge a yellow pus, which will infect any abraded surface.

Treatment.—Disinfect the oral and nasal openings, and wash the body with a good germicide. Give a thorough arterial injection, using half strength fluid in the first bottle and normal thereafter. Drain blood from a large vein, disinfecting the blood before disposing of it. Give a complete cavity injection. Close openings. For transportation, govern yourself according to the provisions of the transportation rules.

Hydrophobia.

—Synonyms.—Rabies.

Definition.—A specific infectious, non-contagious disease peculiar to animals, especially the dog, and communicable to man by inoculation, generally by a bite. It is characterized in many by melancholia; great fear of water; violent spasms of the pharynx and larynx, rendering deglutition and respiration very difficult; great prostration, a stage of paralysis, which generally terminates in death.

Cause.—The specific cause has not been determined, though bacteriologists agree that it is of microbic origin.

Pathology.—The blood vessels of the cerebrospinal system are congested.

Treatment.—Wash the body with 1:500 solution of bichloride of mercury, or 5% carbolic acid. Inject half strength fluid into a large artery for the first part, followed by enough normal fluid to secure preservation. Drain blood from the veins and disinfect the blood before disposing of it. If circulation to face and head is impaired through the cerebral congestion, open the common carotids and inject upward, draining from the internal jugular vein. Give thorough cavity injection. Close all openings of the body. For transportation, govern yourself according to the transportation rules.

Relapsing Fever.

—Synonyms.—Typhus recurrens; Bilious fever; Famine fever; Hunger pest; Spirillum fever.

Definition.—An acute, infectious and non-contagious disease, characterized by a series of exacerbations and remissions, each lasting from five to seven days, and prevailing epidemically.

Cause.—The spirillum of Obermeier.

Pathology.—There is no characteristic change in the solids of the body. There is sometimes icteric discoloration during the disease and the tissues are stained after death. The liver, kidneys and spleen are somewhat enlarged. The heart becomes soft. The body retains its heat a long time after death and the blood coagulates slowly if at all.

Treatment.—Arterial injection with half strength fluid, followed, in the second and third parts, with normal fluid. Drainage of blood. Spray fluid over abdominal viscera, through the usual puncture.

For transportation of bodies dead of this disease, govern yourself according to the provisions of the transportation rules.

Syphilis.

—Synonyms.—Pox; mal-venereal; lues venereal.

Definition.—A specific infectious, non-contagious disease, weeks or months are occupied in its development; contracted by inoculation which is known as acquired syphilis, or hereditary, which is congenital syphilis, and is characterized by three distinct stages; primary, secondary, tertiary.

History.—”In all probability syphilis is as old as the human race; for we can readily believe that illicit intercourse was practiced in the cities of the ancient world when the morals of the people were more lax than those of today. Our knowledge of the disease, however, dates from the fifteenth century. Breaking out among the troops of Charles VIII, King of France, it rapidly spread over Europe. From then to the present day our knowledge of the disease has grown, till today we are able to classify and separate the various lesions resulting from illicit and promiscuous intercourse. All forms of venereal disease were included under the name of syphilis till Ricord, in 1831, demonstrated that gonorrhea and syphilis were two distinct diseases.”

Etiology.—Predisposing causes are injuries or abrasions of the mucous surfaces of exposed parts, for the disease can originate in only one way, by inoculation.

Modes of Infection.—There are three modes of infection; illicit intercourse, heredity and accidental. Of these the embalmer need only consider the accidental form of infection.

Pathology.—The initial lesion is the chancre, the secondary lesions are ulceration of the mucous surfaces and cutaneous eruptions, and the tertiary lesions are inflammatory products known as gummata, and are found upon the bones and periosteum, or in the skin, muscles, liver, kidneys, lung, heart, brain; in fact in any of the viscera of the body.

Treatment.—Wash body thoroughly with 5% carbolic acid or 1:500 solution of bichloride of mercury. Work with rubber gloves. Inject half strength fluid for the first 64 ounces of fluid and follow that with normal fluid until disinfection and preservation are assured. Give the body a complete cavity injection with normal fluid. Drain blood from a large vein, and disinfect the blood before disposing of it. Close all openings of the body with absorbent cotton saturated with normal fluid. Bandage any large sores and saturate the bandage with normal fluid. When purpura (characterized by a blue spot on the face) exists, the discoloration cannot be removed. If anything is to be done at all for the discoloration, it must be of the nature of a covering for the spot, such as paint or other cosmetics. For transportation of the body, govern yourself according to the transportation rules.

Tetanus.

—Synonyms.—Lockjaw; Trismus.

Definition.—An acute infectious, non-contagious disease, characterized by painful spasmodic contraction of the voluntary muscles, most frequently those of the jaw, face, and neck; less frequently those of the trunk, the extensors of the spine and limbs.

Cause.—The cause is recognized as the bacillus tetanus.

Pathology.—The infection usually enters by way of a wound, especially of the hands and feet, and a punctured wound rather than an incised one. The post-mortem lesions are not constant.

Treatment.—The body should receive a complete arterial injection using half strength fluid for the first part of the injection, followed by sufficient normal fluid to secure preservation and disinfection. Blood should be drained from the veins and should be disinfected before being disposed of. Wash the wound with 1:500 solution of bichloride of mercury and bandage it to avoid infection from it. Inject the cavities of the body. Close the openings. For transportation, govern yourself according to the provisions of the transportation rules.

Actinomycosis.

—Synonyms.—Big Jaw; Lumpy Jaw.

Definition.—A specific infectious, non-contagious disease of domestic animals, particularly cattle, communicable to man, and caused by the ray-fungus.

Pathology.—Infection takes place, as a rule, through the mouth, through a cut or abrasion of the skin and rarely through the respiratory tract. The fungus produces a tumor, with a rapid proliferation of the neighboring connective tissue. The disease is not limited to any organ as the name lumpy jaw would imply; we may have actinomycosis of the lung, digestive tract, and of the skin.

Treatment.—Disinfect the outside of the body by washing with a good germicide. Care should be exercised against inoculation through an abrasion of the skin. Give the body a thorough arterial injection, draining blood, and disinfecting the blood before disposing of it. Close all openings. For transportation, govern yourself according to the provisions of the transportation laws.

Dengue.

—Synonyms.—Break-bone fever; dandy fever; broken-wing fever.

Definition.—An acute, specific, infectious, non-contagious fever, occurring epidemically in tropical and subtropical climates and characterized by two severe paroxysms of fever, separated by an intermission, great muscular pain, and usually attended by an eruption.

Cause.—The nature of the infection or contagion is not known. That it is infectious is shown by the rapidity with which it spreads when once it invades a section. In 1885, within a few weeks, sixteen thousand, in Austin, Texas, were stricken. Neither age, sex, race, nor position exert an influence in staying the disease.

Pathology.—As few cases prove fatal, but little opportunity has ever been given to study its pathological character. There has been found infiltration of the tissues about the joints. It is rare for a case to end fatally, only few succumbing to its influence. For this reason the embalmer will not have many of these cases to treat.

Treatment.—As this rarely comes excepting in the epidemic form, that form will be treated on. The body should be washed with a good germicide, and all openings should be closed with absorbent cotton. The body should then receive a very heavy arterial injection, with drainage of blood, and cavity injection. As is the case in epidemics, the body should be buried as soon as possible. While the mortality is light, yet the most strenuous treatment should be given to assist in the campaign of the health authorities against the disease and its spread. When more is known about the characteristics of the disease, it is likely that a more definite treatment can be advised.

Malarial Fever.

—Synonyms.—Ague; Chills and fever; Intermittent fever; Swamp fever; Marsh fever; Paludal fever.

Definition.—A specific, infectious, although non-contagious disease, caused by the hematozoa of Lavaran, and consisting of two distinct parts; first, a succession of exacerbations and intermissions, or a series of short fevers separated by short intervals of health; second, a continued fever made up of exacerbations and remissions, there being but one cold stage.

Cause.—The hematozoa of Lavaran.

Pathology.—There is a destruction of the red blood corpuscles, due to the action of the parasite. There is an increase of pigment, in the spleen, liver, kidneys, bone marrow, skin, and in fact, in all the tissues, due to the conversion of hemoglobin into pigment granules. The spleen is enlarged as are also the liver and the kidneys. The skin presents a jaundiced appearance in chronic malarial fever.

Treatment.—Arterial injection of 64 oz. 1% solution of borax or oxalic acid followed by 64 oz. of half strength fluid and then a sufficient quantity of normal fluid to complete preservation. Drainage of blood and solution to wash stain from capillaries. Application of full strength peroxide hydrogen to face, and massage during injection.

For transportation of bodies dead of this disease, govern yourself according to the provisions of the transportation rules.

Yellow Fever.

—Synonyms.—Typhus ichteroides; Febris flava; Black vomit; Yellow jack.

Definition.—An acute, infectious, though non-contagious disease of the tropics or sub-tropics, characterized by a high grade of fever, lasting from two to seven days, tenderness over the epigastrium (stomach), vomiting of black, broken down blood, and yellow discoloration of the skin.

Cause.—Not known, although it is definitely known that the infection is spread through the bite of a species of mosquito, the stegomyia fasciata.

Pathology.—The skin and the mucous membranes show a varying degree of jaundice, from a light yellow to a dark brownish or orange color; the color deepening over the course of the blood vessels. The stomach contains more or less of broken down blood, the so-called black vomit. The blood is dark and broken down.

Treatment.—Arterial injection of 64 oz., of half strength fluid followed by sufficient normal fluid to assure disinfection and preservation. Drainage of contents from vein and massage of face with full strength hydrogen peroxide in an attempt to clear the complexion. Full abdominal cavity treatment, and close orifices of the body.

For transportation of bodies dead of this disease, govern yourself according to the provisions of the transportation rules.

Diphtheria.

—Synonyms.—Diphtheritis; angina maligna; membranous croup.

Definition.—An acute infectious, contagious disease characterized by a grayish-white, fibrinous exudate, usually located on the tonsils or the neighboring tissues.

Cause.—This is the bacillus diphtheriae, although some still hold that the specific cause has not as yet been determined.

Pathology.—In the severe forms the deeper connective tissues are involved, and there may be extensive destruction of tissue, including the blood-vessels. There is more or less discoloration of the tissues from extravasation of the coloring matter. The kidneys and spleen may be enlarged. The blood is more or less broken down, the fibrin is deficient.

Treatment.—Disinfect the oral and nasal cavities with the embalming fluid. Wash the body externally with 1:500 solution of bichloride of mercury. Inject an amount of fluid equaling 10% of the body weight into the arteries, and give cavity injection. Drain blood and inject additional fluid to make up for that which will be lost in drainage. In young persons the strength of the fluid for the first 64 ounces of the injection should be cut to half of the normal strength. Close all openings of the body with absorbent cotton. Dress the body and then place it in the casket, drawing the glass slide and closing it, after which, it should not be re-opened. Abide by the regulations of your district concerning the amount of time to elapse between the time of death and of burial in these cases. For transportation govern yourself according to the provisions of your district rules.

Tuberculosis.

—Definition.—An infectious, slightly contagious disease, characterized by the formation of small nodules, tubercles, varying from the size of a millet-seed to that of a mustard-seed or even larger.

Cause.—Tubercle bacillus of Koch.

Pathology.—Any organ of the body may be the seat of the disease. In the adult the lungs are the most frequently affected, while in children the lymph glands, joints, and intestines are favorable seats for the disease. Probably the only form that will give the embalmer any trouble is tuberculosis of the lungs. Here either from the poison, developed by the bacilli, or from some other source, necrosis of the cells occurs, forming a cheesy condition known as caseation. At a later period this breaks down, forming an abscess, the cavity being filled with a purulent material. At other times there is a calcareous deposit, and the tubercular mass is said to undergo calcification.

Treatment.—In pulmonary tuberculosis, give the body a complete arterial injection using half strength fluid for the first part of the injection, followed by three-fourths strength for the latter part. Hohenschuh prefers to drain blood from all cases; the authors prefer to drain blood in tuberculosis, only when it is necessary as a means of preventing discolorations, and that would be in case the blood vessels contained much blood. Massage the face carefully with one of the commercial solutions, or, with water which of course has no bleaching action. For transportation, govern yourself according to the provisions of the transportation rules.

Typhoid Fever.

—Synonyms.—Typhus abdominalis; Typhus nervosus; Ileo-typhus and Autumnal fever, are the most common terms, although Murchison's list includes forty others.

Definition.—An acute, infectious and slightly contagious disease, derived from a specific cause and characterized by inflammation and generally sloughing of Peyer's glands, swelling of the mesentery, engorgement of the spleen and a rose colored eruption.

Cause.—A specific germ called the bacillus of Eberth or the bacillus typhosus.

Pathology.—The lesions resulting from this disease may be divided into two parts. First, the lesions of the intestinal canal, Peyer's patches, the solitary glands of the ileum and caecum, and more rarely of the colon and the rectum, and changes in the spleen. Secondly, those lesions resulting from sepsis occurring during the long period of fever, and affecting the tissues and organs at large. The first effect of the poison or bacilli is to cause hyperemia (swelling) of the lymphatics, the capillaries become engorged and cell infiltration takes place in the solitary glands of the intestines. Frequently the infiltration is so excessive that the capillaries become engorged and entirely choked with the infiltration. Ulcers form, which are shallow or deep, according to the amount of necrosis (sloughing), and when very deep, perforation of the bowel may follow, although this condition is rare. The spleen is nearly always involved, congestion takes place, followed by softening. The liver becomes hyperemic, swollen and soft, and often shows abscess formation. There is granular degeneration in the kidney, ulceration of the larynx and sometimes congestion of the lung. The heart muscles too often become weakened the result of the poison.

Treatment.—If death occurs early in the disease, the body will not be greatly emaciated, and the following treatment may be followed in detail:

If intense abdominal fermentation exists, relieve the accumulated gas with trocar, aspirate as much serous matter as possible from the pelvic cavity, introduce a strong fluid into the cavity, taking care to have as much of this fluid reach the cavities of the intestines as possible. Open one of the arteries commonly used in one of the drainage processes and inject 64 ounces of half strength fluid, draining blood from the vein simultaneously with the injection. Then inject a sufficient quantity of normal fluid to complete preservation. Close all openings of the body with absorbent cotton. Massage the face with water or a commercial solution during the injection.

If death occurs late in the disease, the abdomen may require a stronger treatment such as we would give in acute peritonitis. The trocar may not prove efficient in reaching the affected parts and in such a case we would make a 4 inch incision along the median line and between the umbilicus and the pubic arch, exposing the ileum and caecum, which should be incised, their contents removed, and then all replaced in the cavity thoroughly surrounded with hardening compound. After this the wound should be closed with stitches. After preservation has been completed in either this form of the disease or the one mentioned above, dust on a good quality of face powder to remove the moist appearance from the skin. When a body dead of this disease is to be transported, consult the state or local transportation rules in addition to these treatments.

Leprosy.

—Definition.—A chronic, infectious, contagious disease, which usually terminates fatally.

Cause.—The bacillus leprae. There are tuberculous growths in the skin, which push outward, form nodular masses, between which are seen areas of ulceration and cicatrization, which in the face, distort the features. These tubercular masses discharge a thick purulent material. The destruction of tissue proceeds gradually, years being occupied in destroying a patient. The deep, ulcerative process may amputate fingers and toes in its progressive march.

Treatment.—The body is rarely presentable for sometime before death, and this should not be a consideration in our treatment. If an arterial injection is possible, give it, using normal fluid for the injection. Work with rubber gloves. Give a complete cavity injection. Wrap the body in absorbent cotton and then in a sheet. For transportation, govern yourself according to the provisions of the transportation rules.

Influenza.

—Synonyms.—Epidemic catarrhal fever; la grippe.

Definition.—An acute, infectious disease, the contagion of which is questionable occurring pandemically.

Cause.—The bacillus influenza.

Pathology.—There is no characteristic lesion in the uncomplicated case. When death occurs it is usually from complication.

Treatment.—Disinfect the oral and nasal cavities with embalming fluid. Inject as much fluid as you can into the arteries and cavities. The usual 10% of the body weight must be given for transportation. If blood vessels are filled with blood, drain from a large vein, and add more fluid to your injection, to make up for the loss of blood to the blood bottle. Close all openings with absorbent cotton. For transportation, govern yourself according to the provisions of your district rules.

Cholera.

—Synonyms.—Cholera Algida; Cholera Asiatica; Cholera maligna.

Definition.—Cholera is an acute, specific, infectious slightly contagious disease, occurring epidemically and endemically, and characterized by severe vomiting and copious watery stools, violent cramping of the muscles and collapse.

Cause.—The exciting cause is now generally recognized as the comma bacillus of Koch, or spirillum cholerae.

Pathology.—The tissues after death are shrunken and drawn, and the extremities are inclined to be mottled; in some cases there is a postmortem rise of temperature. Rigor mortis sets in very early. Spasmodic contractions sometimes occur for some moments after death; hence the eyes and jaws have been seen to move after life was extinct. Owing to this marked contraction, the limbs have been distorted and the partial turning of the body is thus accounted for, and is not, as many have supposed, the result of being buried alive. The tissues are dry, having been drained of these fluids before death, hence some time elapses before decomposition begins after death. The chief visceral lesion is that of the intestinal canal. The intestines contain a more or less quantity of rice-water, fluid rich in the comma bacillus. The blood is very dark, but slightly coagulable and robbed of its salts and fluids.

Treatment.—Arterial and cavity embalming, closing all orifices of the body. Any discharges from the bowels should be disinfected before being disposed of. In epidemics, cosmetic effect is a non-essential and in that case the most thorough treatment must be given without regard to appearances.

For transportation of bodies dead of this disease, govern yourself according to the provisions of the transportation rules.

Bubonic Plague.

—Synonyms.—The Pest; Black Death; Plague of Egypt.

Definition.—A specific, infectious, contagious disease, running a rapid course, and characterized by inflammation of the glands (buboes), carbuncles, ecchymoses, and petechiae upon the surface. It is endemic on the eastern coast of the Mediterranean Sea and the Oriental countries adjacent. Epidemics occur when it spreads to other parts of the world, traveling along the great thoroughfares of travel and commerce.

Cause.—To Kitasato belongs the honor of discovering the specific cause, the bacillus pestis. On entering the body, either by inoculation or by way of the digestive or respiratory tracts, it multiplies with great rapidity. It is found in the blood, in the internal organs, in the intestinal canal, lymphatic glands and in great numbers in the suppurating buboes.

Pathology.—Rigor mortis occurs early, and often there is elevation of temperature immediately after death. Petechiae, ecchymoses, and carbuncles are generally found upon the skin. The lymphatic system is generally affected, the lymph glands of the groin and axilla showing evidence of inflammation.

Treatment.—Wash the body thoroughly with a good germicide, close all openings, first however, disinfect the oral and nasal openings. Nothing should be done for the ecchymotic spots, the cosmetic effect in these cases being secondary to disinfection. The arteries should receive a heavy injection of normal fluid, blood being drained from the veins. The blood should be disinfected before being disposed of. The cavities should receive a heavy injection of normal fluid. For transportation of these cases, govern yourself according to the provisions of the transportation rules.

Scarlet Fever.

—Synonyms.—Scarlatina; scarlet rash.

Definition.—An acute, contagious disease, characterized by a bright scarlet colored eruption, diffused over the entire body, terminating by desquamation of the skin.

Cause.—Not definitely known, although thought by Klein and Gordon to be the streptococcus scarlatinae.

Pathology.—The blood is dark, diffluent, and does not coagulate readily, owing to a defect in the fibrin. The eruption disappears after death, except in those malignant cases where the eruption failed to appear during life, and appears upon the death of the patient.

Treatment.—First protect yourself by wearing a bandage of surgical gauze over your mouth and nose, then enter the room of death and wash the body thoroughly with a 1:500 solution of bichloride of mercury. Inject an amount of fluid equaling 10% of the body weight into the arteries and inject into the cavities. Drain blood through one of the drainage processes, and add an amount of fluid to the arterial injection equal to that which is lost to the blood bottle. Close all openings with absorbent cotton, dress the body, and then place it in the casket, drawing the glass slide and closing it, after which, it should not be reopened. Abide by the regulations of your district concerning the amount of time to elapse between the time of death and of burial in these cases. For intra-state and inter-state transportation, govern yourself according to the provisions of your district rules.

Variola.

—Synonyms.—Small-pox; German Blattern; French, La Petite Verole.

Definition.—A specific, infectious, highly contagious febrile disease, characterized by a dermatitis, in which the eruption passes from the papule to vesicle, and this in turn into pustule, finally dessicating.

Cause.—The true nature of the virus is not known, and although certain microorganisms have been described which are found in the pock, there is no proof that they are responsible for producing the poison. All that is positively known is, that it is developed in the system and reproduced in the pustule.

Pathology.—The most marked change occurs in the skin, where an eruption takes place, finally with the formation of scabs or crusts. The blood does not reveal any microscopic changes, although darkened in color.

Treatment.—No one but an immune should handle these cases, and he should first wash the body with a 1:500 solution of bichloride of mercury. After this has been done, inject an amount of fluid equal to 10 per cent. of the body weight, distributing same by arterial injection. If blood is drained, and it is proper to do so, add fluid to the injection to make up the loss into the blood bottle. Give full cavity injection. Bodies dead of this disease should be buried within a reasonably short length of time, so that the apartments may be rendered safe by fumigation, and under no circumstances should a public funeral be held. After the body has been placed in the casket, the slide, preferably of glass, should be closed and should not be reopened under any circumstances. Govern yourself by the regulations of your district for transportation of these cases.

Measles.

—Synonyms.—Morbilli; rubeola.

Definition.—An acute, infectious, contagious fever, characterized by a general papular eruption.

Cause.—The efforts to isolate a specific germ which will produce the disease has thus far failed, though many organisms have been found in the secretions.

Pathology.—There is a lack of coagulability of the blood, which is dark in color. The internal organs are congested and softened. The lesion of the skin consists of an acute hyperemia with exudation in the vascular papillae of the corium, the sebaceous and sweat glands.

Treatment.—Bodies rarely die from this cause; the usual immediate cause of death is exhaustion. An injection of half strength fluid for the first part of the injection followed by normal fluid for the balance of the injection, with full cavity injection, closing the orifices is all that is necessary. For transportation, govern yourself according to the provisions of the transportation rules.

Parotitis.

—Synonyms.—Mumps, epidemic parotitis.

Definition.—An acute, infectious, and contagious disease, characterized by an inflammation of one or both of the parotid glands.

Cause.—The specific cause is a contagion generated during the course of the disease, the exact nature of which is not known, although thought by some to be the tetrad of mumps.

Pathology.—The parotid glands become swollen and hard. Death very seldom occurs from this disease.

Treatment.—Disinfect the oral cavity with embalming fluid. The swelling cannot be reduced, so that the next concern to the embalmer will be to preserve the body. This should be done by injecting 64 ounces of half strength fluid, followed by enough normal fluid to secure preservation. If blood vessels contain much blood, drain from a large vein, and then inject additional fluid to make up for that lost by drainage. Close all openings with absorbent cotton. Abide by the regulations of your state governing the transportation of these cases.

Pertussis.

—Synonyms.—Whooping-cough; tussis convulsiva.

Definition.—A specific infectious, contagious disease occurring epidemically, and characterized by a peculiar, spasmodic cough, ending in a whoop.

Cause.—The cause of whooping-cough has always been a matter of conjecture.

Pathology.—In the uncomplicated form there is no lesion which can be said to be characteristic. There might in complications be hemorrhage from the lung.

Treatment.—Disinfect the oral and nasal cavities with embalming fluid. Inject 64 ounces of half strength fluid followed by enough normal fluid to secure preservation. If blood vessels contain much blood, drain from a large vein, and then inject additional fluid to make up for that lost by drainage. Close all openings with absorbent cotton. Discourage public funerals in these cases. For intra-state or inter-state transportation of these cases, govern yourself according to the provisions of your district rules.

Typhus Fever.

—Synonyms.—Famine fever; Ship fever; Jail fever; Hospital fever; and Putrid fever.

Definition.—An acute, infectious, very contagious, endemic, and also epidemic disease, characterized by a high grade of fever and a peculiar rash.

Cause.—Not known.

Pathology.—The blood is dark and diffluent the result of the intense fever and rapid work of the poison. The liver is somewhat enlarged and softened, as are also the kidneys and spleen. There is an extravasation into the pericardium which gives it an ecchymotic appearance. There is also a slight engorgement and infiltration of the capillaries. The muscular tissues are of a dark red color. The skin shows a characteristic rash and ecchymotic spots are found on the more dependent parts of the body after death.

Treatment.—Slow arterial injection and drainage of blood. On account of rash, apply bichloride of mercury 1:500. In the presence of fermentation, give the abdomen a special treatment.

For transportation of bodies dead of this disease, govern yourself according to the provisions of the transportation rules.

Varicella.

—Synonym.—Chicken-pox.

Definition.—An acute, specific, and infectious disease, characterized by an eruption that rapidly passes through the stage of papule, vesicle, and pustule, and terminates by dessication.

Cause.—This is not known. All attempts to isolate the microorganisms or the contagium, whatever that may be, have failed.

Pathology.—The only pathological lesion is the eruption that appears on the skin.

Treatment.—These cases should be thoroughly washed with 1:500 solution of bichloride of mercury, after which a thorough arterial and cavity injection should be given, consuming for this purpose an amount of fluid equal to 10 per cent. of the body weight in the arteries. Blood should be drained from the veins, and an amount of fluid equal to what is lost to the blood bottle should be injected in addition to the 10 per cent. mentioned above. After the body is placed in the casket, close the slide which should be of glass, and do not reopen again. Public funerals of these cases should be discouraged, to avoid the indiscriminate transfer of the disease.

Septicemia.

—Definition.—A morbid process commonly known as blood poisoning, in which there is an invasion of the blood by bacteria or their toxins.

Cause.—Any bacteria or its toxin.

Pathology.—The blood is found to be dark, diffluent, and rich in bacteria. The liver and spleen are soft, dark in color, and show swelling. The lymphatics are also swollen.

Treatment.—The operator should approach these cases with unbroken skin on his hands, or if that be impossible, with rubber gloves, as the disease is disseminated through abrasions. Take up a large artery and vein, inject half strength fluid for the first bottle and normal fluid thereafter in the arteries, and drain from the veins. Disinfect the blood obtained from the vein before disposing of it. Give the body a complete cavity injection. Massage the face to stimulate capillary circulation while the arterial injection is being made. For transportation, govern yourself according to your district transportation rules.

Pyemia.

—Definition.—An infectious disease due to the absorption of animal poisons, principally pyogenic organisms, and characterized by the formation, in the various tissues and organs, of multiple metastatic abscesses.

Cause.—One of the forms or a combination of pyogenic micrococci are held to be responsible, for this condition. The streptococcus and the staphylococcus are the forms most common, though it is not uncommon to find the micrococcus lanciolatus, the gonococcus, the bacillus coli communis, bacillus typhosis, bacillus pyocyaneus, and many others.

Pathology.—The body does not undergo putrefaction as rapidly as in septicemia. The first effects of the morbid changes are found in the veins, which result in thrombi. These thrombi are found in the various organs and tissues of the body.

Treatment.—Use the precautions observed in the treatment for septicemia. Give the body a complete arterial injection using half strength fluid for the first bottle of the injection. Drain as much blood from the veins as possible. Thrombi may complicate the drainage, and if none can be obtained from several of the larger veins, tap the heart as a last resort. Disinfect the blood before disposing of it. Streptococcus infection of the embalmer from abrasions of the skin is very dangerous and every possible precaution should be carefully taken. Give the body a complete cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

CHAPTER XX. TREATMENT OF SPECIAL DISEASES.—Continued. DISEASES OF THE RESPIRATORY SYSTEM.

Gangrene of the Lung.

—Definition.—A putrefactive necrosis of the lung.

Cause.—Many putrefactive bacteria thrive in the necrotic soil, but whether they are the cause or the result is not known.

Pathology.—When the gangrene is due to the plugging of one of the large branches of the pulmonary artery, a large part of the lung becomes dark, greenish brown, or a black fetid mass, softening rapidly in the center, forming an irregular cavity, containing a foul-smelling disgusting, greenish fluid.

Treatment.—Give complete arterial injection. Inject the pleural sac on the affected side through the first intercostal space or through the apex of the cavity. Spray fluid into the mouth and nose and close them with absorbent cotton. For shipment of these cases govern yourself according to the transportation rules.

Pulmonary Hemorrhage.

—Synonyms.—Hemoptysis; Broncho-pulmonary hemorrhage; Bronchorrhagia; Pneumorrhagia.

Definition.—An expectoration of blood, due to hemorrhage from the mucous membrane of the bronchi, trachea, or larynx and from erosion or rupture of capillaries in lung cavities.

Cause.—The hemorrhage may result from congestion of the lungs, due either to pulmonary lesions or from cardiac derangements. It may accompany malignant affections, infectious fevers, scurvy, cancer of the lung, gangrene, and abscess of the lung.

Pathology.—There is, in most cases rupture of the capillaries of the bronchial mucous membranes. If tubercular cavities are formed, a ruptured aneurism is sometimes seen, or large blood vessel eroded by ulceration. If pulmonary apoplexy has existed, the parenchyma may be lacerated.

Treatment.—Some operators wait until fluid passes from the mouth before taking steps to stop the hemorrhage due to the injection of fluid. We prefer to use plaster of paris and cotton, making a paste of them and forcing the paste down upon the epiglottis to prevent the waste of fluid from that source. When the cause of death is known, this operation must be done before the injection is begun or the throat will have to be dried out before the plaster of paris will set properly. Another treatment to prevent the leakage of fluid would be to tie off the trachea just above the upper border of the sternum.

The body is usually emaciated and should be injected arterially with comparatively mild fluid, in order to avoid drying or dessication of the features. Whenever fermentation exists in the abdomen, the cavity should be injected; otherwise it is not usually necessary. The amount of fluid for the injection should be based on the amount that will be taken by the vessels of a body the size of the one being injected. For transportation of these cases the provisions of the transportation rules should be your guide.

Pulmonary Abscess.

—Synonyms.—Abscess of the lungs; Suppurative pneumonitis.

Definition.—A collection of pus in the lung, accompanied by degeneration of tissue.

Pathology.—The abscess may involve one or more lobules, or engage almost the entire lobe, or the abscesses may be scattered throughout the whole lung.

Treatment.—Should hemorrhage occur, treat this case the same as for pulmonary hemorrhage. If no hemorrhage occurs, give the body a complete injection with a mild fluid and inject the pleural sacs from the first intercostal space or the apex of the cavity. For transportation, govern yourself according to the provisions of the transportation laws.

Pneumonia.

—This disease is divided into different subdivisions as follows: Lobar Pneumonia, broncho-pneumonia, and chronic interstitial pneumonia.

(A) Lobar Pneumonia.—Synonyms.—Croupous or Fibrinous Pneumonia; Pneumonitis; Inflammation of the lungs; and Winter fever.

Definition.—This is an acute infectious disease characterized by an inflammation of the lung tissue in which there is, first, congestion and engorgement, second, exudation or consolidation; and third, resolution or suppuration.

Pathology.—The right lung is more frequently affected than the left, and one lobe, or one entire lung, rather than both lungs at the same time.

Treatment.—Should suppuration occur, turn the body on its side, press on the sternum and cause the suppurative matter to leave the windpipe by purging it into the folds of a towel which should be placed at the mouth. Spray the mouth with fluid and close the oral and nasal cavities with absorbent cotton.

Give the body a thorough arterial and cavity injection, paying especial attention to the pleural sacs, which should be injected independently from the first intercostal space on each side or from the apex of the cavity. Drain blood and disinfect the contents of the blood bottle before disposing of same. For transportation, govern yourself according to the provisions of the transportation laws.

(B) Broncho-Pneumonia—Synonyms.—Capillary Bronchitis; Lobular Pneumonia; Catarrhal Pneumonia.

Definition.—An inflammation of the terminal bronchi, air vesicles, and interstitial tissue of a few or many of the lobules.

Pathology.—The interstitial tissue between the air cells and the capillaries are greatly weakened. In most cases the lung will float when placed in water, though the small mahogany-colored nodules found distributed throughout the lung when excised sink in water.

Treatment.—The nature of the disease is such that preservation is comparatively simple, the disease affecting the extremities of the respiratory system. Arterial injection together with special attention to the pleural sacs will suffice for the cases. For transportation, govern yourself according to the provisions of the transportation rules.

(C) Chronic Interstitial Pneumonia.—Synonyms.—Cirrhosis of the lungs; Fibroid Pneumonia.

Definition.—A chronic inflammation of the lungs, in which the normal air cells are replaced by fibrous or connective tissue, followed by induration and atrophy of the lung.

Pathology.—The disease is nearly always confined to one lung, though, in very rare cases, both lungs may be involved, while localized areas are the rule. The affected lung becomes atrophied and in extreme cases, may be no larger than the closed hand. As a result of the shrinkage of the lung tissue, the heart undergoes hypertrophy. When tuberculosis exists, cavities of varying size and number are found, and the interstitial tissue between the capillaries and the air cells is very much weakened.

Treatment.—Should this disease be followed by a rupture of the capillaries during the injection, thereby causing a hemorrhage from the oral and nasal openings, treat it as you would a case of pulmonary hemorrhage. Otherwise give the body a thorough arterial and cavity injection with special attention to the pleural sacs. For transportation, govern yourself according to the provisions of the transportation laws.

Hydrothorax.

—Synonyms.—Thoracic dropsy; Dropsy of the chest; Dropsy of the pleura.

Definition.—A collection of serous fluid within the pleural cavity without inflammation.

Pathology.—Hydrothorax, unless due to cardiac affections, is usually bilateral. The quantity of fluid varies, and is generally greater on one side than on the other. The fluid is free, and of a low specific gravity, alkaline in character, clear, and of an amber color.

Treatment.—To prevent the formation of blisters on the posterior surface of the thorax, aspirate the serous fluid from the pleural sacs, introducing the trocar through the apex of the cavity, and extending it into the cavity until it has almost reached the diaphragm. This must be done with both the right and left sacs. Give the body a complete injection, using normal fluid throughout the entire injection. Inject the pleural sacs after the serous fluid has been withdrawn. For prevention of post-operative dangers such as bursting blisters, etc., line the casket with rubber for a distance of 3 inches above the bottom. For transportation of these cases, govern yourself according to the provisions of the transportation laws.

CHAPTER XXI. TREATMENT OF SPECIAL DISEASES.—Continued. DISEASES OF THE CIRCULATORY SYSTEM.

Pericarditis.

—Definition.—An acute inflammation of the pericardium and the serous covering of the heart.

Treatment.—Give the body a thorough injection of half strength fluid followed by normal fluid. Drain from the veins. Inject the abdominal cavity. For transportation of these cases, govern yourself according to the provisions of the transportation rules.

Hydropericardium.

—Synonym.—Dropsy of the pericardium.

Definition.—Hydropericardium is a non-inflammatory condition of the pericardium, attended by an accumulation of sero-albuminous fluid.

Pathology.—Hydropericardium is not a disease of itself, but it is always secondary. The accumulated fluid is usually clear, of an amber color, though it may become turbid by the presence of fibrin or red blood corpuscles. The fluid is alkaline in reaction.

Treatment.—As this disease is always secondary to another, the treatment will also be secondary and all that can be said is that the heart sac should be relieved of its accumulated serous fluid, after the body has received the treatment necessary for the immediate cause of death. Transportation will also be covered by the disease causing death.

Hemopericardium.

—Definition.—Hemopericardium is an infiltration of blood into the pericardium. It is the result of a rupture of an aneurism of the aorta or coronary arteries, or in rare cases from rupture of the heart. It may also arise from injuries such as bullet wounds, fracture of the ribs, sternum, etc.

Treatment.—This condition is usually secondary to another such as gun shot wound, aneurism of the aorta, etc., so that the treatment must be given under the heading of the immediate cause of death. For transportation requirements also refer to the immediate cause of death and the transportation rules.

Pneumo-Pericardium.

—Definition.—Pneumo-pericardium is an accumulation of air in the pericardium. Although this is a rare disease, it does occasionally occur, either through diseased processes, such as cancerous or tubercular ulceration or through injuries; thus a ruptured pulmonary cavity might result in this condition, or the perforation of the esophagus, by malignant processes would give rise to this lesion. Sometimes pus in the pericardium will generate gas.

Treatment.—As the accumulation of air or gas is secondary to some other process of disease, the immediate cause of death will carry with it the proper treatment. The gas itself should be removed by piercing the pericardium with a small needle or trocar, after which a small quantity of fluid should be injected.

Endocarditis.

—Definition.—Endocarditis is an inflammation of the lining membrane of the heart, and is generally confined to the valves, though other parts may be affected.

Pathology.—The morbid changes are, first, a reddened and injected appearance of the endothelium, which soon becomes opaque and swollen from congestion of the small blood vessels. This swelling or thickening of the membrane furnishes a favorable resting place for deposits of fibrin, and we have small, beady deposits from the size of a pin point to that of a pea, or even larger. These small, beady excrescences may become detached, and floating off in the general current, give rise to embolism in distant parts.

Treatment.—An embolism means the obstruction of a blood vessel by some foreign material. If in the injection of fluid, there is an obstruction in one of the blood vessels, leading to one of the organs, you will never be any the wiser, but if the obstruction is in one of the vessels supplying a certain area of skin, the condition will show up sooner or later, when that certain part will have to be treated hypodermically. Slow arterial injection with drainage of blood should be given and when symptoms of fermentation are present, include special attention to the abdominal cavity.

Aortic Incompetency.

—Synonyms.—Aortic Insufficiency; Aortic Regurgitation.

Definition.—Inability of the aortic valves to properly close an abnormally large aortic opening, or a change in the segments whereby they are shortened by curling of the leaflets, or by calcification.

Treatment.—Bodies dead of this disease will be found with very much blood, and the elimination of the blood by drainage should be the first consideration along with the injection of fluid. The fluid should be diluted one-half for the first part of the injection, and sufficient fluid used to reach all parts of the circulatory system. It will be well to add fluid equal to the amount of blood and fluid taken from the vein to your normal injection in a body the size of the one to be operated on. A complete cavity injection should be given. For transportation, govern yourself according to the provisions of the transportation rules.

Aortic Stenosis.

—Definition.—Aortic stenosis is an obstruction of the aortic orifice, due to changes in the segments of the semilunar valves, or arterio-sclerosis, or atheromatous deposits.

Treatment.—Give same treatment advised for aortic incompetency, with special care in the injection. Sclerotic conditions may complicate the injection, and in that case as many arteries should be injected as possible together with full blood drainage.

Mitral Incompetency.

—Synonyms.—Mitral Regurgitation; Mitral Insufficiency.

Definition.—This condition is an incomplete or imperfect closure of the auriculo-ventricular opening, permitting the regurgitation of blood during the contraction of the left ventricle, and due to an abnormal condition of the leaflets or an enlarged opening.

Treatment.—Give same treatment as advised for aortic incompetency, with special care to remove as much blood as possible, which, with massaging the face downward, should relieve any blood discolorations.

Mitral Stenosis.

—Definition.—Mitral stenosis is a constriction of the left auriculo-ventricular orifice, usually due to valvular endocarditis.

Treatment.—Give this body the same treatment as advised for aortic incompetency, with special care indicated in mitral incompetency.

Tricuspid Incompetency.

—Synonym.—Tricuspid Regurgitation.

Definition.—This condition is an imperfect closure of the tricuspid valves, due to dilation of the right ventricle or to disease of the valves.

Treatment.—Drain as much blood as possible from this case. Massage the face downward, and inject the maximum amount of fluid; diluting the first bottle to half strength. In obstinate cases of blood discoloration, open the common carotid arteries and internal jugular veins, inject upward in the arteries and drain from the veins, so as to wash out the vessels of the face. For facial injection use nothing stronger than half strength fluid. Give thorough cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

Tricuspid Stenosis.

—Definition.—Tricuspid stenosis is an obstruction of the tricuspid opening, usually congenital, though it may be acquired.

Treatment.—Treat the same as for tricuspid incompetency.

Pulmonary Incompetency.

—Synonym.—Pulmonary Insufficiency.

Definition.—Pulmonary incompetency is an imperfect closure of the pulmonary orifice of the right ventricle due to changes in the pulmonary valves.

Treatment.—Treat the same as for tricuspid incompetency.

Pulmonary Stenosis.

—Definition.—Pulmonary stenosis is an obstruction of the pulmonary opening of the right ventricle, due to congenital defects or to endocarditis.

Treatment.—Treat the same as for tricuspid incompetency.

Cardiac Thrombosis.

—Definition.—Cardiac thrombosis is the formation of blood clots in the cavities of the heart.

Pathology.—The blood clots are found most frequently in the right side of the heart. They vary in size, from that of a pin head to that of a hen's egg. When degeneration takes place, softening follows, and sometimes particles become dislodged and float off to set up thrombi in other viscera.

Treatment.—Remove the maximum amount of blood by drainage along with the injection of fluid. The fluid in this case should be not more than half strength for the first part of the injection, to be followed by enough normal fluid to secure preservation. If thrombi have lodged in any of the larger arteries, the circulation to the part reached by the branches of the artery will be affected. This can be overcome by injecting an artery close to the part which is not receiving the fluid. Massage the face downward to assist capillary circulation. Give a complete cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

Hypertrophy of the Heart.

—Definition.—Hypertrophy of the heart is an enlargement of the organ, due to an increase in the volume of its muscular fibers, and usually also to dilatation of its cavities.

Treatment.—Secure full drainage from the veins. Drainage will be stimulated by an injection of half strength fluid for the first part of the injection and a massage of the face. Follow the first part of the injection with enough normal fluid to secure preservation. Give a complete cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

Cardiac Dilatation.

—Definition.—Cardiac dilatation is an increase in the size of the cavities of the heart, due either to thickening or thinning of the walls.

Treatment.—Treat the same as for hypertrophy of the heart.

Cardiac Atrophy.

—Definition.—Cardiac atrophy is a decrease in the size, strength, weight, and activity of the heart.

Treatment.—Remove blood by drainage, and inject half strength fluid for the first part of the injection. The amount of fluid need not be as great as in the acute disease of the heart. Massage the face downward. Give cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

Arterio-Sclerosis.

—Synonyms.—Endarteritis; Atheroma; Arterial Sclerosis.

Definition.—Arterio-sclerosis is an inflammatory and degenerative condition of the arterial system, primarily of the intima, although later degenerative changes may involve the whole structure. Calcarine deposits are quite common.

Pathology.—As a result of proliferation, infiltrated areas begin in the middle and outer coats. These nodules vary in size from that of a small shot to that of a large coin. As they increase in size, the intima loses its smoothness and becomes thickened and rough. As these changes progress, the middle and outer coats are weakened. Calcification may also occur in the wall.

In the diffuse form the change in the coats of the vessels extends throughout the greater part of the arterial system, and in some cases invades the capillaries and veins.

In the senile arterio-sclerosis calcareous deposits occur, which render the vessels rigid. Where these tissue-changes involve the capillaries, there may be complete obliteration of their lumen in some places.

Treatment.—In some cases the artery appears to be closed at a point ahead of the tube and will resist the injection of fluid. Usually, however, the injection can be made without resistance. Blood should be drained from these cases so as to allow as full capillary penetration as possible. When no arterial injection can be made, open the internal jugular and several other large veins, drain blood from them and then inject fluid while the tube is within the vessel. If necessary add a complete hypodermic injection to all parts of the body excepting the face. Give the cavities full treatment. For transportation, govern yourself according to the transportation rules.

Fatty Degeneration of the Arteries.

—In the fatty degeneration of arteries the process consists in the gradual replacement of certain parts of the muscular cells by fat droplets. The fat makes its appearance as minute droplets or granules in the cells. These granules, which are characterized by their dark color, gradually increase in number and ultimately the whole of that part of the cell may be transformed. During the process the granules coalesce, and in this manner form distinct drops of fat. As the process proceeds the cell is increased in size and becomes more globular in shape. The cell wall is destroyed and the cell may thus be converted into a mass of granular fat. Ultimately the matter between the granules of fat liquify. The corpuscles break up and the fat becomes distributed in the surrounding tissues. The immediate effect of this fatty degeneration is to produce more or less softening of the fatty part, which will impair or destroy its function. In the case of the artery, the internal, middle and external coats may be affected, but the external is the one usually first attacked. The inner layer or endothelium, and the connective tissue cells in the deeper layers of the inner coat may become affected in various parts of the vessel. The process may involve a great portion of the inner coat, even the whole thickness of the intima may be destroyed. The walls of the artery may be entirely solidified, the canal being closed completely with a soft, yellowish substance as a result of the disease. The artery might appear to be a solid mass when the dissecting knife is passed through. We have seen the anterior and posterior tibial, the popliteal, radial, ulnar, the aorta arteries, and especially the arch of the aorta thus affected. Calcification may be present at many places. These cases are frequently met with in old age.

A body of this kind, where there is fatty degeneration of the arteries, is sometimes hard to embalm. The walls of the artery will be very much weakened, and too much pressure must not be made on them while injecting fluid. Inject the fluid so that it will take several hours to fill the tissues. The pressure should be gentle and regular when the aspirator and injector pump is used. If this precaution is taken often the whole body can be embalmed without a rupture of the arterial system, the fluid reaching all the extremities by means of collateral circulation.

If the embalmer should be so unfortunate as to rupture the circulation then he will have to resort to cavity embalming, and the subcutaneous tissues will have to be embalmed by the hollow needle trocar.

Aneurism.

—Definition.—An aneurism is a circumscribed dilatation of an artery, formed by the giving away of one or more of its coats. A false aneurism is where there is a rupture of the coats, and the blood is found in the adjacent tissues.

Treatment.—Drain blood from a large vein. Inject half strength fluid for the first part of the injection, followed by enough normal fluid to secure preservation. The aneurism itself, will not affect the circulation of fluid to any great extent. Massage the face downward. Give a complete cavity injection. For transportation, govern yourself according to the transportation rules.

CHAPTER XXII. TREATMENT OF SPECIAL DISEASES.—Continued. DISEASES OF THE DIGESTIVE SYSTEM.

Definition.—Jaundice is a symptom rather than a disease, and is found in the various affections of the liver. It is characterized by a deposit of bilirubin in the various structures and fluids of the body, which gives them a yellow or jaundiced hue.

Etiology.—Most pathologists agree that all the forms of jaundice can only come from obstruction. The obstruction is due to inflammation tumefaction of the duodenum or bile-ducts; to foreign bodies, such as gall stones or parasites, within the ducts; tumors within the duct or by pressure from without, such as tumors, gravid uterus, or fecal matter; or to stricture or obliteration of the duct.

Pathology.—That portion of the duct lying in the intestines is more frequently and seriously affected, though the inflammation may extend to the cystic and even the hepatic duct. The membrane lining the ducts is swollen and inflamed. The liver is usually congested, slightly enlarged, and of a deep yellow color. The gall bladder is usually distended with bile. The ducts are occluded by the swollen mucosa and plugs of inspissated mucous.

Discoloration of the skin and conjunctiva occurs. The yellow tinge begins in the eyes, forehead, and neck, gradually extending over the body, the color being the deepest in the wrinkles and folds of the skin. The color is generally of a lemon hue, becoming darker and assuming a bronze or greenish tint as the hepatic lesion assumes a graver character.

In the child the skin becomes a yellowish hue of various shades. In the severe form the hue increases in intensity, the skin assuming a bronze or yellowish-green color. The abdomen becomes full and tumid, owing to the congestion of the liver and spleen. When due to syphilis, there is usually skin eruption.

Definition.—A grave form of jaundice characterized by neurosis of the hepatic cells and atrophy of the liver.

Pathology.—The liver shows marked atrophy, being not more than two-thirds or one-half of the normal size, is thin, flabby. On making a section a yellow or a reddish yellow surface is presented. The hepatic cells are found in every stage of necrosis. Most of the organs are bile stained, as well as the skin, and hemorrhages are frequent.

Treatment for Jaundice.—Since the conditions are similar and since the conditions after death are identical in reference to pigmentation, we will consider the treatment of infantile, malignant, and catarrhal jaundice under one head.

The pigmentation of the skin, no matter how small, is the condition which presents itself most forcefully, and is the most annoying to the embalmer. Much study has been given to the subject, but with little success. It is claimed by some that certain fluids will bleach and bring out the natural color.

A small amount of bile is sufficient to tint the surface of the body. Bile is composed of salts, fats, organic matter, acids, and also coloring matter, called the bile pigments. Bilirubin is the principal coloring matter, and when dissolved in alkali, forms, when coming in contact with the air and also in the dead body, a green precipitate known as biliverdin. The bile pigments in the blood are carried with the serum from the capillaries to the tissues, being deposited in the internal coat or deep layer of the epidermis as well as the papillary of the dermis. The amount deposited regulates the extent of the pigmentation.

One of the most beneficial things to do, where pigmentation is present is to wash out the arterial system, draw blood from the veins, massage the exposed parts. Inject a diluted fluid at first, follow with a fluid of full strength, until complete disinfection and permeation of the tissues has taken place. Keep up constant massaging during the whole course of injection. This may bring fair results, with the addition of face tints and showing the body under artificial light.

Strong solutions of formaldehyde when used at first are deleterious, causing the skin to become green. This greenness is more pronounced when chemicals such as methylene blue have been administered by the attending physician before death. Bilirubin is a red yellow color, and alkalies precipitate the bilirubin and form biliverdin. Biliverdin is a greenish color.

All fluids contain alkalies, and are mostly alkali in reaction, and this may account for the greenish color of the skin after the injection of fluid. Acids do not precipitate the biliverdin and there is a tendency to dissolve it and keep it in solution.

Moadinger suggests that a weak solution of some acid be injected into the arterial system before the injection of embalming fluid. He prefers a two per cent. solution of oxalic acid.

Dhonau prefers the use of a one or two per cent. solution of borax, to be injected into the arterial system, followed by half strength fluid, and this followed by full strength fluid. Dhonau also applies full strength peroxide of hydrogen to the skin while massaging the face.

Eckels prefers the use of a fluid containing a peroxide.

If methylene blue has been administered by the attending physician and you have learned this fact before hand, it is then not advisable to use a formaldehyde fluid. There is a chemical action set up between the methylene blue and the formaldehyde which will give to the tissues a greenish color which is quite objectionable. In this case you would inject some fluid which does not contain formaldehyde. A benzoate of soda or borax, or peroxide solution would do.

A good formula to use, when you know methylene blue has been used by the attending physician is:

For transportation, govern yourself according to the transportation rules.

Definition.—A chronic disease of the liver, characterized by an increased connective tissue, a reduction in the size of the organ, and a degeneration of the parenchymatous constituents.

Etiology.—In a great majority of cases the disease is due to alcohol, syphilis, highly spiced and very rich foods. Cirrhosis may result from chronic obstruction of the bile ducts, due to gall stones, or tuberculosis. Cirrhosis frequently occurs between the ages of thirty and sixty years, though it may be found in the extremes of life. Men are more liable to contract the disease, owing to greater dissipations.

Pathology.—The liver is increased in size by the increase of connective tissue, and hyperaemic. On the surface it exhibits a knobbed appearance (hobnailed liver) and these knobs present through the capsule a yellowish appearance. The granulations vary in size from a pinhead to a pea. As a rule there is a little jaundice, as there is a decrease in the production of bile, instead the skin takes on an earthy, sallow tint. There is generally ascites, swelling of the feet and legs, which increases until the abdomen and the lower extremities become of an enormous size. The nutrition of the body suffers, the skin is dry and harsh. The blood is altered in quantity, and coagulates quickly. Ecchymotic spots appear on the skin, about the face and nose.

Treatment.—There are probably not many other cases of death, which need greater skill and intelligence in their treatment than does cirrhosis. The condition that presents itself is a distended abdomen with gas and liquid. The limbs are also distended and the upper part of the body is wasted away and is greatly discolored as death was caused by asphyxia.

Place the body on the board, open the femoral vein, and insert your drainage tube. It is better to use this vein as it is larger, and there is more control of the removal of blood, and we would advise in this case the use of the flexible rubber drainage tube, which can be pushed up in the vein till it reaches the right auricle of the heart if you wish. Drain all the blood possible. Use the trocar method, see page 255, or the direct incision, see page 257, to remove the gases and ascitic fluid from the abdomen. Use the bandage method, see page 339 to remove the water from the tissue of the extremities.

Raise the femoral artery and inject slowly a diluted fluid and massage the face gently toward the jugular vein, using some recognized face bleacher. Then follow with an injection of fluid of full strength until you are sure the fluid has permeated every tissue of the body. Do not be afraid to use plenty of fluid. Inject the cavities.

For transportation, govern yourself according to the transportation rules.

Pathology.—Jaundice is present in most cases and where the portal circulation is seriously compressed, ascites developes. The liver is greatly enlarged, and the surface is nodular.

Treatment.—As in all chronic affections of the liver, where the skin takes on a yellowish or bronze hue, due to pigmentation, it is almost impossible to bring about the desired cosmetic effects. The pigment is not only in the blood vessel but also in the tissues of the skin.

We would advise the washing out of the tissues, by the use of the oxalic or borax solution, injecting the axillary artery and draining from the femoral artery or raising both the carotid arteries, injecting upward on one side and draining from the other.

For transportation, govern yourself according to the transportation rules.

Pathology.—The pathology will depend to a great extent upon the degree of the inflammation. Ulceration may take place or there may be perforation.

Treatment.—If, after an operation, reopen the incision made by the surgeon, relieve the gas pressure on the intestines by incising them; surround the intestines with hardening compound; then inject an artery, using half strength fluid for the first 64 oz., followed by enough normal fluid to secure preservation. Drain the blood during the injection by one of the drainage processes.

If no operation has been made, insert a trocar into the caecum to relieve the gas pressure, then inject normal fluid into the same place, using sufficient fluid to neutralize the process of putrefactive fermentation. The trocar can be first inserted in the usual place passing it to the caecum, or through the abdominal wall directly over the caecum. The arterial injection and drainage should be made as is mentioned above. For transportation, govern yourself according to the transportation rules.

Pathology.—There is nearly always present more or less fluid in the abdominal cavity.

Treatment.—Drain blood from a large vein, and inject half strength fluid for the first part of the injection, following this with enough normal fluid to preserve the tissues of the body. After the arterial injection and drainage have been completed, pierce the abdominal cavity in the usual place and draw off all the fluid that you can reach, paying especial attention to the lower part of the cavity. Then inject normal or supernormal fluid into the cavity to neutralize the process of putrefactive fermentation. Pierce the colons and inject fluid into them as well. If fermentation resists this treatment, make a small incision along the median line and above the umbilicus, examine the stomach and intestines, incising them if they contain the gas. After eliminating the gas, inject fluid directly into them, or, surround the organs of the cavity with good hardening compound; sew up the incision and the body should not deteriorate in any way. For transportation, govern yourself according to the transportation rules.

Dropsy of the abdomen is called ascites.

Dropsy of the chest is called hydrothorax.

Dropsy of the peritoneum is called hydroperitoneum or ascites. General dropsy of the cellular tissues is called anasarca.

Definition.—An accumulation of serous fluid in the peritoneal cavity.

Etiology.—Any obstruction of the portal circulation is a possible cause of ascites, the most frequent being cirrhosis of the liver. Pressure from tumors or neighboring organs may also give rise to it. Peritonitis and valvular diseases of the heart are also responsible for ascites, and chronic pulmonary affections may impair the portal circulation to the extent of producing it.

Pathology.—The quality and character of the fluid show great variation, from a few pints to several gallons, and from a straw or lemon tint to a brownish or greenish hue. It may be blood stained, and occasionally clean and transparent. It is usually watery in character.

Treatment.—Use the trocar method. Insert the trocar through the umbilicus and draw off all the ascitic fluid from the abdomen, then surround the organs with a quantity of fluid sufficient to preserve them. Or if you desire, use the direct incision and after the ascitic fluid has been drawn off, surround the organs with a hardening compound.

The body in general should be preserved through an arterial injection of normal fluid for the first 64 ounces, then one and one-quarter strength for all subsequent bottles. This, if attended by copious drainage from a large vein, will preserve all portions of the body excepting possibly the epidermis of the posterior abdominal wall, which, by gravitation of the ascitic fluid, will become separated from the derma, producing skin slip, and causing the formation of blisters.

Previously to placing the body on the embalming board for treatment, a rubber cover should be placed over the board so that drippings of all kinds can be made to flow into a bucket at the lower end of the embalming board. When the above mentioned blisters are cut and their contents disposed of by gravitation into the bucket, a strong solution of formaldehyde should be applied to the affected skin to harden it and to prevent any further progress toward decomposition.

In ascitic cases the casket should be lined with rubber or oil cloth to a point three or four inches above the bottom. In addition to this precaution, the use of sawdust is favored so that any unlooked for breaking of blisters may not be attended by a flow of the ascitic liquid from the casket. Many embalmers do not protect themselves against contingencies of this kind and are frequently criticized by the friends and family of the deceased.

Treatment.—Bandage Method.—Bandage the extremities of the body, commencing at the toes and finger tips, bandaging upward to the hip and shoulder, using a rubber bandage. Relieve the water as you go along, then rebandage, and by the third application you will have removed most of the water from the extremities. Do not leave the bandage on while injecting.

Bandage Method.—Bandage the lower limbs, commencing with the thighs. Bandage as tight as possible down to the toes and make an incision in the heel, from which drainage of the serous fluid can be secured. In this method no laps are left between the bandaging so that the serous fluid can be forced toward the opening at the heel. (This method is said to be reliable, although we have had but little experience with it.)

Any accumulation of ascitic fluid in the cavities should be removed by aspiration with the trocar, as described in the treatment of ascites and hydrothorax. The rubber cover for the embalming board as described in the treatment for ascites, should not be omitted.

After the water has been eliminated as far as possible, the arterial injection should be made, using 64 ounces of normal strength fluid, followed by enough one-fourth strength fluid to secure preservation. Copious drainage will help to clear the blood vessels and allow a better distribution of the fluid, thereby assuring good preservation of all parts excepting the epidermis, which is practically closed off to the fluid by the accumulation of water in the subcutaneous tissue.

In these cases the skin should receive a good application of strong formaldehyde fluid before and after the principle operation, so as to strengthen it against the putrefactive tendencies of the rete mucosum.

These cases should be watched closely between the time of embalming and the funeral, as the most thorough preparation is sometimes unequal to the task of preserving the entire body in such a way as to prevent the formation of blisters.

For transportation of all dropsical conditions, govern yourself according to the provisions of the transportation rules.

CHAPTER XXIII. TREATMENT OF ACCIDENT CASES.

Under this head are treated those deaths which are the result of accident.

Raise both the artery and the vein to the surface, and insert the arterial tube in the artery toward the face, and inject a small quantity of fluid in order to cause a pressure on the venous system, then open the vein, insert the drainage tube and begin to remove the blood, and as the blood drains from the drainage tube inject slowly into the artery. This will help to push the blood out of the capillary system and into the blood bottle and thus clear up the face of its discoloration.

In these cases the raising of only one common carotid would hardly suffice, and it would be far better to operate on both carotids to get the best results. For this reason then the circular incision would be the best operation, and perhaps the use of the Y shaped drainage tube. With the Y shaped drainage tube both sides of the face could be injected at the same time, and the blood could be removed from both internal jugular veins, and the operator could not help but get good results. The removal of blood from the internal jugulars in this direct way will relieve the pressure in the capillaries and smaller veins and induce a better circulation to all the immediate tissues.

If the body is severed below the diaphragm remove and cleanse all the loose and injured organs and tissues, place them in a bucket or pan and cover with fluid. Ligate all the injured arteries and veins in the upper and lower parts.

Inject the lower extremities from inside the abdominal cavity using the common iliac artery, observing the presence of the remaining united arteries and veins, which you can now see, for fluid will leak from them. The lock forceps will enable you to pick them up and with the aneurism needle dissect around the end of the vessel and tie each one tight.

Treat the upper extremity in the same way injecting either from the inside or the outside, according as the severity of the accident may lead you to decide. Inject from the inside upward through the aorta, or from the outside either through the radial, brachial, axillary or carotid.

The trunk may now be sewed together, beginning at the middle of the back. Sew each side up leaving the top open to receive the organs and the tissues which were removed. After these are placed more or less in position sprinkle hardening compound throughout the cavity. Now sew up the front and then place a strong bandage around the body.

The remaining body can then be injected through the opposite carotid, brachial or femoral, and when the leakages begin to occur at the stub end of the arm they can be found and tied off or if the leakage is too great plaster of paris may be used and a tight bandage placed about the stub end.

After both the arm and the body have been injected the arm can now be sewed on in its natural position, plaster of paris put around and a strong bandage placed around or a splint may be used on both sides.

The remaining body can then be injected through the carotid, brachial, axillary, or the opposite femoral and when the leakages begin at the stub end of the leg they can be found and tied off, or if the leakage is too great plaster of paris may be used and a tight bandage placed about the stub end.

After both the leg and the body have been injected, the leg can be sewed on in its natural position, plaster of paris put around and a strong bandage placed around, or a splint may be used on both sides.

To inject the body, the four principle arteries to be tied are the two common carotids and the two vertebrals, besides numerous veins and small vessels. If it is impossible to tie all the severed vessels plaster of paris may be used, and then by injecting either through the brachial, axillary or femoral a thorough injection may be obtained. The stub end of the carotid might also be used for injection, but would not advise it as in most cases we find that it would be hard to get especially if the head were cut off close to the shoulders.

When both the head and the body have been injected, bring the two parts together by using a splint in the vertebral column, and having plastered well together sew the skin. Demi-surgery can be practiced to the fullest extent in this case, with great cosmetic effect.

The lower part of the body, if it is not injured, can be injected now through the abdominal aorta, but if there has been any damage done below the diaphragm, it would probably be best to further open up the cavity and inject each lower extremity through the common iliacs.

Now replace all the organs and surround them with hardening compound, and sew up the cavity incisions, with great care and neatness. It would be well to practice demi-surgery here, so that you would become more proficient in the art, and thus be able to do more efficient work on the exposed parts, should the occasion ever demand it.

A scald is an injury produced by the application of a liquid heated above a certain temperature.

Injuries resulting from corrosive liquids such as sulphuric acid, nitric acid, caustic potash, carbolic acid, etc., are properly termed burns. A heated solid such as iron may produce a burn of great intensity from the blistering of the skin to the charring of the underlying tissues. Metals heated above 212 degrees Fahrenheit will produce redness, vesication and coagulation of the blood. Molten metals cause burns or scalds very similar to those produced by heated solids. Boiling oil produces severe burns. If a part is severely scalded with boiling water, the skin may appear sodden, blistered, and of an ash grey color, but never produces blackening or charring of the cuticle. Phosphorous burns are usually very severe and of great depth, while the area of skin destroyed is usually small. Gunpowder burns caused by explosions are often of great superficial extent, extensive scorching and numerous carbon particles are commonly found imbedded in the true skin. Petroleum burns are generally severe, as usually all or nearly all the body is scorched and blackened. Burns from flame, extensive scorching with burnt hair is a usual feature in a flame burn. Burns from explosions of fire damp in coal mines are frequently of great extent and present the appearance of great scorching, and very often a quantity of coal dust will be found imbedded in the true skin. There are six degrees of burns as follows: (a) Simple hyperemia of the skin, (b) dermatitis, with vesicles or bullae, (c) necrosis of the superficial layer of the skin, (d) complete necrosis of the skin, (e) necrosis of the skin, superficial fascia and muscles, and (f) complete carbonization of the part.

Treatment.—The embalmer does not treat these cases according to the cause as much as to what is left of the part after burning has been accomplished. After observing the part to note whether the condition can be bettered by a replacement of tissue by artificial means and finding such to be the case, I would use a form of paste commonly used for filling in cuts and restoring the features and with this paste thoroughly cover the burned part. If the affected part covers the entire face or most of it, an entire new surface will have to be built up with the paste. If the burning of the skin has left particles of epidermis adhering to the derma, I would use sweet oil and bath the entire face with it, thus softening the skin and allowing the removal of the small particles. Any small desiccated spots should be covered with the paste. After carefully blending the paste with the skin so as to produce a smooth even complexion, which can best be done by the use of a brush to smooth it with, apply a good quality of face powder (flesh color) to the part. If the color is too striking, or too white, destroy the contrast with carmine rouge. This form of operation is commonly known as demi-surgery. We find that the face powder is best applied with a pad made of surgical gauze especially when applied with a patting movement. This gives a good imitation of the pores of the skin, and if any further smoothing is necessary the brush can be used again. The principal result wanted is a good imitation of the natural parts. If the operator will use the utmost care to give the parts gentle, fine touches here and there, a most artistic effect will be produced. If the eye brows have been destroyed, imitate them with charcoal, carbon, or dark theatrical paint. A good make-up outfit is indispensable for an embalmer handling many railroad cases during the year, and as such can be had at any dealer in theatrical supplies, we advise the securing of a few varieties of pastes, and some good face powder together with carmine rouge.

If the face is damp or moist, the theatrical paste above mentioned will not adhere properly, and in that case alcohol applied to the skin will cause it to dry. One of the most important considerations in these cases, is the placing of the body in the casket. The body should be placed as low as possible, the silk slide should be closed and a view of the body only secured through it, the light in the room should be tempered so that no striking rays of light serve to distort any portion of the features. Wonderful work has been accomplished by the authors and by others in rescuing cases of this kind from non-presentability to presentability, but in all cases, the ingenuity of the operator is taxed to the utmost, and the case never looks just right until the last touch is applied. With the above information, you have only the rudiments of the work. Your success or failure will depend upon how hard you try to make good in each individual case, and your success in matching colors, which can only be acquired with much patience.

Give burned bodies a very thorough arterial injection, using half strength fluid for the first part of the injection. The cavities should also receive a good injection of normal fluid. The peculiar odor present about a burned body can be lessened by the use of false deodorizers such as flowers, perfume, etc.

CHAPTER XXIV. TREATMENT OF POSTED CASES.

Treatment.—Place the body on the cooling board and undo all the stitches made by the physician in sewing up the body after the post-mortem. Remove all the organs, that have been previously removed by the physician, and place same in a bucket or other container. Clean out thoroughly all the blood from the cranial, thoracic and abdominal cavities. Now try to tie off the arteries in the cranial cavity which will be the vertebrals or the basilar and the common carotids. If these have been cut too short to be tied, then mix up some plaster of paris and cover them securely so that there will be no leakage. While the plaster of paris is setting raise the common iliac artery, which you will find at the back of the abdomen just over the ilio-psoas muscle, represented by a line drawn from the body of the fourth dorsal vertebra to the center of Poupart's ligament. Inject the right and left common iliac arteries downward which will take care of the lower extremities. Here the only artery you need to tie off is the deep epigastric artery which is a branch of the external iliac just a short distance above Poupart's ligament and which takes a course upward over the abdominal muscles finally to anastomose with the deep mammary artery.

By the time you have injected the lower extremities, the plaster of paris will be set. Work from the inside of the thoracic cavity, and tie off the innominate, left common carotid and the left subclavian arteries, and when this has been accomplished inject each one separately. Here the only leakage you will have will be through the mammary or intercostal arteries which you will tie off as the leakage occurs.

Now turn the body over and hypodermic the back, then turn body over again. Fill the cranial cavity with sawdust, place the skull cap in position and sew up the scalp. Wash all the organs and place them back in the cavities in their proper positions or as nearly so as possible and as you do so fill in with hardening compound. Sew up the abdomen and wash the body with a disinfecting solution and apply outward cosmetics.

CHAPTER XXV. TREATMENT OF MISCELLANEOUS CASES.

Pathology.—Where death is the result of acute alcoholism, the mucous membrane of the gastro-intestinal canal is engorged, injected, and dark red in color, and covered with a sticky, mucoid exudate. The brain and the kidneys show the same characteristic changes. In chronic alcoholism, changes of a more permanent character take place, depending somewhat upon the quantity, quality and kind of alcoholics consumed, and the length of time used. While all the bodily tissues are more or less impaired, the brain, kidneys, and digestive system suffer most. There may be connective tissue changes, fatty degeneration, sclerosed kidneys, liver or arteries, and a more or less dilatation of the stomach.

Treatment.—In acute alcoholism, the blood should be drained from a large vein, while fluid is being injected into a large artery. After draining a sufficient amount of blood from the body, the vein tube should be shut off and the arterial injection should continue until the capillaries have been filled to their utmost capacity. This strong treatment is advised on account of the early tendencies toward putrefaction, which is sometimes in an advanced state shortly after death. The cavities should receive a thorough treatment with normal or supernormal fluid. Myers advises the re-injection of the cavity in 6 or 8 hours after removing the fluid remaining in the cavity from the first injection. As a preventive treatment, this last is a wise precaution. While the cavity treatment is being given the stomach should be entered by the trocar, relieved of its contents and injected, thus preventing post-operative purging.

In chronic alcoholism, the greatest circulation difficulties will be encountered. The capillaries will not receive the fluid, the putrefactive processes causing the formation of tissue gas early in the case, which, when coupled to many natural impediments to the circulation in cases of this kind, virtually nullifies the circulation for fluid distribution. Inject as many arteries as possible, and if necessary the veins also. Use the hollow needle or trocar and give the unexposed portions of the body a heavy hypodermic injection. The fluid used in this case should be not less than normal in strength and in most cases should be at least ¼ over normal. Give the cavities a very heavy injection, paying special attention to the food passages. This is one of the cases coming to the attention of the embalmer where every emphasis must be laid upon the injection of a sufficient amount of fluid, through as many channels as possible. Do not count the cost of the fluid in this case, if you value the securing of satisfactory results. Cosmetic effect will be enhanced by injection of the carotids upward with drainage from the internal jugular veins. Finish the case with the use of good face powder, unless a discoloration is present, when this should be obliterated with one of the improved methods mentioned in the chapter on discolorations.

Pathology.—There are no characteristic tissue changes, other than that due to indigestion and malnutrition. At death the patient is anemic, the skin dry, sallow and inelastic, the heart and blood vessels show the effects of poor nutrition, and the tissues generally present a starved appearance. The blood disintegrates, causing a discoloration of a brownish color, one or two days after death.

Treatment.—Drain blood from these cases using half strength fluid for the first part of the injection. The more blood obtained, the less the danger of discoloration will be. Give the body a thorough cavity injection in addition to the arterial injection. If your treatment does not eliminate the blood as a factor, the discoloration will occur and then it cannot possibly be removed. In this case the use of cosmetics, if in the hands of a patient operator, will overcome the color.

Definition.—A chronic intoxication due to absorption of lead.

Pathology.—The muscles are atrophied and pale in color. Arteriosclerosis of the cerebral blood vessels is found. There may be softening of the brain and hemorrhage.

Treatment.—Drain blood from the veins while injecting fluid in the arteries. The fluid should be used half strength for the first bottle of the injection. Massage the face downward to help eliminate any discoloration of blood origin from cerebral hemorrhage. Give the body a thorough injection both as to arteries and cavities. If the face is unduly pale from this treatment, carmine rouge, judiciously applied will lessen the paleness.

Treatment.—Same as for plumbism.

Pathology.—There is an acute inflammation of the mouth, stomach, and intestines. The kidneys are inflamed and the liver is degenerated.

Treatment.—Drain blood from a large vein while the injection is going on. The first bottle of fluid for the injection should be half strength. The cavities should be injected, as intense inflammation takes place in the alimentary tract.

Definition.—Heat-stroke is the result of exposure to intense heat, either from the direct rays of the sun, or the radiation of blasts or furnaces, or to an overheated atmosphere.

Pathology.—Owing to the excessive heat of the body, putrefactive changes occur very early. If a post-mortem examination is made very soon after death, the left heart will be found contracted, while the right heart will be engorged, and the venous trunks filled with dark semi-fluid blood. There is also venous engorgement of the brain, spinal cord, and lungs. Ecchymoses and extravasations of blood are found in the skin and mucous membranes.

Treatment.—Drain blood from a large vein during the injection. The first two bottles of the injection should be of half strength fluid. The face should be massaged to assist in the securing of capillary circulation and in the elimination of the blood discoloration. The body should be treated as soon as possible after death, as putrefaction begins early. The cavities should have a very thorough treatment, eliminating the gases and injecting normal fluid therein. Should ecchymosis occur, obliterate the color by an application of cosmetics.

Treatment.—Drain blood from these cases, injecting the first bottle of fluid half strength followed by normal fluid for the balance of the injection. Massage the face downward during the injection. Inject the cavities, with special attention to the stomach and intestines. For transportation of these cases, govern yourself according to the provisions of the transportation laws.

Treatment.—Drain blood from these cases and inject normal fluid sufficient enough in quantity to secure preservation. For long time preservation, supplement the foregoing treatment by a special injection into the thickened extremity, either through an artery leading directly to the part or by trocar or hollow needle inserted under the skin. Give the body a thorough cavity treatment, using normal fluid throughout. For transportation, govern yourself according to the provisions of the transportation laws.

Treatment.—The body is distended with gases in the cavities, tissues and capillaries, putrefaction is in an advanced state, and a vile odor will be present. If body is to be shipped, aspirate all the gas possible from the tissues with the hollow needle, injecting strong fluid in the same openings. Open the body from the base of the neck to the pubic bone, relieve the gases in the alimentary tract and lungs, and fill cavity thoroughly with hardening compound, after which it should be sewed up. Inject as many arteries as possible with very strong fluid. Dress the body and place it in a metallic casket. Pour the contents of two pound bottles of Platt's chlorides on the underclothing to assist in deodorizing the body. Do not open the casket after it is once sealed.

If the body is not to be shipped, it will be advisable to deodorize it as much as possible and bury it without delay.

After the three months stage, the circulation, by direct flow, is stopped and fluid could only reach the foetus by absorption from the placenta. This is naturally insufficient to preserve the child, which by this time is immersed in the liquor amnii (water of the womb) and which is subject to early putrefaction in that situation. The trocar should be directed to the uterus or womb from a point on the median line, half way from the umbilicus to the pubic arch, care being taken to reach the water which surrounds the foetus. Withdraw the water, and inject as much strong fluid as possible so that the foetus will be surrounded with fluid, and in that way preserved. If the trocar enters the body of the child, this will not occur, so the instrument should be carefully manipulated to reach the space between the child and the uterine wall. The mother should receive a very heavy arterial and cavity injection, with full drainage of blood. The vulva should be closed with absorbent cotton. The face should be massaged thoroughly toward the heart.

Definition.—A state of decline in an aged person characterized by progressive atrophy of all the tissues and organs.

Pathology.—Excessive shrinking and obliteration takes place among the capillaries. The skin becomes diminished in thickness. When this occurs, it is easily seen why in old age there will follow, after the injection of fluid into the arterial system, greenish, brownish, and soft spots, in the different parts of the body, especially notable in the face, neck and hands. The products of degeneration may accumulate in the tissues and cause them to be thicker than they are in health, as is seen in the vessels, the walls of which are much thicker than normal. The blood contains fewer corpuscles and solid constituents, is more watery, and coagulates more readily; also the total quantity is less. The pericardium, endocardium, and the capsules of the liver and spleen are opaque and toughened. Degeneration of the cardiac substance may lead to a state of asthenia, which generally produces death. Dilatation of the orifices of the heart may be the prominent lesion, or they may be contracted by atheroma, or by thickening of the vales or rings. The lungs are changed more or less, increasing the bronchial secretions, which during life have been attended by severe paroxysms of coughing.

Treatment.—Inject half strength fluid for the first bottle, following that with ¾ strength for the second and normal for the third and all thereafter if more be necessary. Blood may be drained from the vein if the operator thinks it advisable. The commercial face solution or water should be used on the face while massaging in order that the skin may be kept moist and to prevent dessication from the action of the fluid. The cavity should be injected as a matter of precaution.

Definition.—Putrefactive fermentation of dead tissue, from various causes.

Treatment.—The extremities are affected in senile gangrene. They should be wrapped with absorbent cotton which should then be saturated with fluid. The body itself should receive the same treatment accorded in the paragraph on senility.