ARTERIAL EMBALMING.
=Making the First Call.=—There are some pertinent points to consider
regarding the procedure at the time the call is received. Many
embalmers have some particular rules that govern their inquiries at
this time. It is the consensus of opinion among professional men of
all kinds that a rule is a good thing to have to cover any regular
procedure. It matters not so much as to what the rule is, just so
the necessary information can be acquired in a uniform manner, thus
systematizing that part of the work and enabling the embalmer to
properly prepare for the case at hand before leaving the establishment.
The habit of inquiring about the sex, and age of the person, as well as
the cause of death, should be cultivated. The importance of knowing the
sex of the person lies in the fact that in some communities different
styles of door badges or decorations are more appropriate for one sex
than for the other. When the ruling decoration is some form of fresh
flowers, this should be ordered before the embalmer leaves for the
house of mourning if possible, unless the call should be received at
night or in the early hours of the morning, when this item is usually
left until the earliest business hour. The age of the person also
determines to a great extent the style of decoration which is to be
used.
The cause of death is vitally necessary. In some cases, the ordinary
contents of the embalmer's grip or hand bag are sufficient for the
usual needs. In other cases, extra material of various kinds are
necessary, for instance, the rubber floor covering for the carpet in
dropsical cases; the sanitary clothes in eruptive contagious diseases;
the fumigating outfit in the same diseases, (providing this duty is not
performed by the health authorities); and other articles needed only in
the treatment of special cases.
After obtaining the above information, examine your grip or hand bag
to see that you have all the equipment needed to care for the case in
the proper manner. This saves many cases for those who follow these
rules, as they are enabled to have just what is needed, and prevents
the slighting of a case for which there may be some excuse if the
proper materials are not in the outfit. From a professional standpoint,
it should be necessary for the embalmer to carry anything he may need,
otherwise carelessness may dictate his procedure and disaster may
result.
An ordinary case can be attended with the following material[1]:—
[1] NOTE—Many embalmers get along, some way, with much less in
their outfit than enumerated here. The authors believe that the
embalmer should have all the material needed to properly carry
out his work, and anything of necessity left from the outfit only
reduces the efficiency of the embalmer, and leaves him, at times,
without the proper assortment of material.
The couch embalming board.
The slumber robe, and face cover.
A rubber or oil cloth cover for the board.
A suit case grip, or hand bag.
Concentrated fluid (at least 4 bottles).
One or two empty 64-oz. bottles (for mixing fluid).
One bottle for blood drainage.
One injecting outfit (pump, tubes, etc.)
One blood drainage outfit.
One instrument wallet, containing:—
2 scalpels, 1 bone separator, 2 aneurism needles,
1 spool linen thread, 1 grooved director, 3 arterial
tubes (assorted diameters), 1 bistoury, 1 lock forceps,
1 spring forceps, 1 artery forceps, 1 case
needles, 1 6-inch child's trocar, 1 12 or 14-inch trocar,
1 chin rest, 1 hypodermic outfit, 1 roll absorbent
cotton, 1 sponge, 1 box face powder, 1 nail
file, 1 hair brush, 1 bottle bichloride of mercury
tablets, 1 shaving outfit.
For special cases it would be well to have on hand the following
articles:—
1 small can plaster of paris.
1 tube lip cement.
2 rubber bandages.
1 can hardening compound.
1 bottle Platt's chlorides or any other good deodorant.
1 outfit of formalin and permanganate of potash, or
any other standard gaseous germicide preparation for
fumigating.
1 small bottle of tincture of iodine as a preventive to
infection should you cut yourself.
After the outfit has been found correct for the case at hand, place
everything in the conveyance, and leave for the house. Upon arriving
at the house, enter alone and meet the member or members of the family
who have been delegated to talk to you. At this time it will be well
to ascertain the position of the body, the wishes of the family in
reference to where the body is to be placed after embalming and to
where the body is to rest in the casket until the time of the funeral.
If you meet with any objection as to embalming, it will be well for
you to consider the sanitary aspect of the case in speaking to those
interested. In this case the sanitary aspect should always take
precedence over the preservative aspect, since you can count on the
assistance of the physicians in supporting embalming on that account.
Should your wishes be overruled after you have presented the facts in
the matter, it would be well for you to place the entire responsibility
for the condition of the body upon the family, since without embalming
you are unable to know the final condition of the body, and should not
be held responsible for it regardless of what the condition may be in
that case.
After this short talk with the family, return to your conveyance and
carry your outfit to the room of death. Everything that you carry
should be properly covered, as there is nothing quite as indecorous
as the display of an embalming board without a cover. When you have
placed the outfit in the room, call for everything that you will need
from the family, which will include such things as a pail, warm water,
soap, towels, etc. Do all of this before touching the body; and after
securing all the necessary items, close the door, and do not open it
again until the work has been completed.
Should unforeseen circumstances cause you to re-open the door,
present yourself with a coat on, and never, under any circumstances,
appear before any one in your shirt sleeves, as that is another
indecorous procedure. After the preservation has been completed,
dust a little face powder on the face and hands, to remove the moist,
clammy appearance which may have been left on those parts. Place the
undergarments on the body and then any other garments which may have
been given to you by the family. Cover the body with the slumber robe,
and then call in as many members of the family as may wish to view the
body, asking them to criticize your work. Before calling in the family
it would be well to put everything out of sight and not have any grips
open.
If favorable comment is heard from the family, your work is done for
the time being. If unfavorable comment is heard, ascertain the cause
of the comment and do not leave the house until the proper appearance
has been secured. If your work has been pleasing to the family, you can
rest assured that the case is a success and that you have done your
work well. When you are satisfied in your own mind that all is well
with the body, make arrangements for the selection of the casket, and
then retire from the house. If the door decoration has not been placed
in position before you leave, you will place it in position yourself.
Some funeral directors set the time for the funeral during the first
call, and some wait until later. The same for the other arrangements,
such as newspaper notices, minister, singers, church or chapel
services, number of conveyances, etc. Whatever method you choose to
use in your community should be carried out systematically so that
at no time, will anything be left undone to cause confusion at some
inopportune time.
=The Position of the Body on the Embalming Board.=—The position of
the body on the embalming board is regulated by the adjustment of the
movable head end of the board.
After much experience with various classes of bodies, we find that
the adjustment mentioned is a very valuable aid in securing the best
results both as to completeness of the circulation and amount of blood
drained.
In anemic, tubercular, cancer of the stomach and exhaustion cases,
together with other conditions resulting in emaciation, the head end
of the board should be raised to the height that seems suitable for the
position of the upper part of the body when placed in the casket during
the injection of the first bottle of fluid. When the first bottle of
fluid has been injected, lower the head end of the board until the
entire board is level, and leave it in that position until you have
completed the injection, when you will again raise the end of the board
until the position of the body is just as it will be in the casket.
When pneumonia and other non-emaciated bodies are to be injected, with
drainage, use the same procedure as is stated above for the emaciated
bodies.
In dropsical cases, raise the head end of the board only for the first
bottle of the injection; then for the second bottle, lower the head end
to about half of its first height, and set the foot end of the board
on some object that will raise it five and six inches. In this way you
will have a slight elevation at both ends of the body, and drainage
can better be obtained from the center of the circulation. When the
operation is complete, lower the foot end again and raise the head end
so that the body occupies the proper position for the casket.
These adjustments are practical methods of overcoming gravity handicaps
in the distribution of the fluid, and of accelerating the amount of
drainage obtainable by keeping the level of the drainage tube below the
blood level in the body, thus accomplishing a universal distribution
of fluid, and securing a greater quantity of undiluted blood from the
vein.
It is very important to remember when you are through injecting the
body that you are to place the body in the exact position on the
cooling board which you want it to have in the casket. After a little
time the body will become more or less rigid due to the action of the
preservative fluid used, and will set in the position you have placed
it which condition will be hard to change later.
=Selection of an Artery.=—Great care should be taken in the selection
of an artery. Never make a practice of using the same artery on
all cases. Acquaint yourself with the location of them all, and on
different occasions, as different conditions arise, use the artery most
likely to give the best results for the condition in hand.
Convenience usually governs the operator as to the artery he is to
use. If blood is to be removed it is best to raise one of the larger
blood vessels, such as the carotid artery and the internal jugular
vein, or the femoral artery and femoral vein, or the axillary artery
and axillary vein. If it is desired to draw the maximum amount of
blood, the femoral artery and vein should be selected, as they are more
dependent, and control more of the blood, when the body is placed on
an incline. A drainage tube sufficiently long to reach above Poupart's
ligament as far as the common iliac is all that is necessary as there
are no valves intervening between the bifurcation of the common iliac
and the right auricle. However if you can, extend the tube up through
the ascending vena cava and eustachian valve into the right auricle.
This will give you a chance to draw blood from the right auricle and is
a much better procedure than tapping the right auricle with the trocar.
If the body is already dressed and the hands or feet need to be
re-injected, the radial or posterior tibial likely will be most
convenient as their use will not necessitate the removal or cutting of
the clothing.
Oftimes there is but a single window to admit light and the operator
should be so skilled as to be able to raise the arteries either on the
right or left side without having to turn the cooling board.
In emaciated subjects the linear and anatomical guides are always
plain but in fleshy subjects this is not always the case. Look over
the subject and see which artery will be the most convenient to raise.
Usually in fleshy subjects the femoral is hard to raise as there is
a great amount of fat in Scarpa's triangle making the artery lie very
deep, but in these subjects the guide for the brachial is quite plain,
a distinct groove being seen between the biceps and triceps muscles.
In a short necked subject it is never advisable or convenient to raise
the carotid as there is not much room to work and the incision is very
liable to show. Another artery will be found much more advantageous in
these subjects.
In accident cases the seat of injury will determine the artery to be
raised, using the one through which you can give the body the greatest
supply of fluid to all parts. Often it will be necessary to raise
several arteries to complete the injection.
There is no necessity for undue exposure in either sex, however it is
hardly ever advisable to inject the femoral in the female, as some
mischief-maker might without any real cause influence others in the
community against your methods.
When selecting the brachial and femoral arteries always raise them at
a place below the point where collateral circulation is given off or in
other words raise them in the middle third. By so doing the fluid will
reach, by means of collateral circulation, the tissues of the arm and
leg below the point of injection.
As far as the injection of fluid is concerned, one artery is just as
good as another. All arteries are parts of the same channel branches of
the aorta. No valves exist in any part of their course.
=How to Raise an Artery.=—With the scalpel make an incision an inch
long in the average size arm, cutting through the skin and then through
the fat. Reverse the blade and at each end of the wound cut forward
and upward to make it clean. Take the grooved director and with the
small end puncture the deep fascia, then reverse ends of the director
and force the blunt end up the wound, underneath this deep fascia,
one-fourth to one-half an inch longer than the wound. Now take the
scalpel with the edge of the blade upward and split the fascia as far
up as the needle extends and cut the tissue (fascia and fat) up to the
skin, being careful not to cut the skin. Reverse the needle and cut the
lower end of the wound the same way. This will give you an incision one
inch long on top and one and one-half or two inches at the bottom of
the wound, and none of the vessels will be injured.
With the handle of the aneurism needle separate the tissues between the
muscles, artery, vein and nerve, then use the hook end of the aneurism
needle, pass it under the artery and raise it to the surface, passing
the bone separator or the forceps with the closed end underneath.
Remove the individual sheath surrounding the artery. Likewise raise the
vein to the surface.
If the artery and vein lie side by side and it is desired only to raise
the artery, hook down between the two, away from the vein, sliding
the hook forward and backward underneath the artery, then raise to the
surface.
If the artery and vein lie side by side and it is desired to raise
both, pass the hook around the vein first, as by hooking around the
artery toward the vein the point of the hook will often rupture the
vein.
=How to tell an Artery from a Vein or a Nerve.=—Raise the suspected
vessels to the surface, placing a bone separator underneath to form a
bridge, which will cause the blood to recede on every side. If you are
in doubt which is the artery, remove the individual sheath from each
one.
The nerve will appear as a glistening white cord, very solid to the
touch and showing bands of nerve fibres which can be separated by the
aneurism hook. It will not have any central opening.
The vein will appear as a dark blue color and collapsible because of
the fact that they have thinner walls than the arteries, lacking the
middle circular layer of fibres. Veins have a central opening. As a
rule the vein contains blood after death, which gives it the dark blue
color but should it not contain blood, it resembles the artery very
closely as to color.
The vein contains valves which can be seen distinctly, if the blood be
pushed the opposite way from which it runs in life.
The artery is of a creamish white color and non-collapsible because of
the fact that it has heavy walls and a middle circular layer of fibres.
The arteries feel firm to the touch while the veins are soft and
velvety. Arteries have a central opening and as a rule do not contain
blood after death. They likewise do not have valves. The artery is
usually more constant than the vein.
Should all these not convince you, raise the one you think is the
artery with the hook, pass the forceps underneath, spread these and
pass the bone separator under for a bridge and with the scalpel incise
the artery about one-fourth the way. Attach the arterial tube and if
there is blood present, allow it to drain by lowering the arm. When
it has ceased to flow, inject very gently and slowly. If you get a
half-pint of fluid in the body, you may be assured of its being the
artery.
Another way to tell the artery from the vein is to roll them lightly
between the fingers. If it feels like a thin rubber tube, and does not
roll together in a little bundle, the supposition is that the vessel
is an artery. This however is not certain, as phlebitis, or some other
diseased condition of the veins may result in the thickening of the
walls of those vessels, to such an extent as to make it impossible to
distinguish in this way between the artery and the vein.
The anatomical and the linear guides for the arteries and veins, and
their relation to the accompanying nerve, will help also to tell them,
one from the other.
=How to Cut an Artery for Injection.=—After the artery has been located
it should be freed from the surrounding tissues and then raised to the
surface. After it has been raised to the surface the bone separator
which is to act as a support while cutting the artery, should be placed
underneath the artery.
The artery may be cut in several ways as follows—a T shaped incision
may be made. This is a very old method, one of the first to be used
for this purpose. To make this kind of an incision in the artery, the
scalpel is placed point down about one-fourth the distance from the
edge of the artery, and then by forcibly bearing down on the scalpel
cut the artery crosswise. Rotating the artery the cut will now be on
the upper surface. Now from the middle of the crosswise cut, extend a
longitudinal cut lengthwise of the artery, for almost one half inch.
We have no comment to make on this kind of an incision, excepting to
say that the method is old and obsolete, and no longer used, and that
a much better method is now used.
Another method suggested by some authors is the longitudinal incision.
With the belly of the scalpel cut the artery lengthwise for a distance
of a little less than one half inch. The disadvantage of this kind of
a cut is that the operator does not know when he has cut to the center
of the artery and no more than the center. If the cut has been made to
a distance beyond the center, then the inside wall on the opposite side
will be cut and if the wall is in the least diseased, the arterial tube
when it is inserted may get between the walls which will mean that no
fluid can be injected.
Another method is to cut the artery crosswise, placing the point of the
knife on the artery about one fourth the distance from the edge of the
artery, bearing down so that the point will come through to the bone
separator which is beneath, then forcibly bearing down cut outward with
the belly of the knife. Now rotate the artery and the cut will be on
the front of the artery.
Another better method is the same as the above, but instead of cutting
outward perpendicular to the artery, cut outward diagonally, then when
the artery is rotated there will be a V—shaped cut. The point of the V
should be made opposite the way the operator is to inject the fluid.
With the aneurism hook, pick up the point of the V, which will mean
that the hook will have to be inside of the artery, and using the hook
as a guide insert the arterial tube. The only disadvantage of this
method is that the tensil strength of the artery is to a certain extent
weakened, but if the artery is not cut too deep, this is not a serious
disadvantage. The advantage is that the operator is always certain that
he is in the center of the artery, that if his knife is sharp, that he
will always cut all three walls of the artery at once, and thus prevent
a ruffling up of the inner wall of the artery should it be diseased.
=The Injection of Fluid.=—One very important point to be taken into
consideration when embalming, is the slowness with which the fluid
should be injected.
Upon this one thing will depend very largely the success you will have
with the perfect circulation of the fluid and cosmetic effects.
Some authorities on the art and science of embalming have made the
claim that it makes no difference how rapidly a body is injected as the
fluid is so widely distributed through so many branches of the artery
that no harm can come from this source. This is very erroneous for when
the fluid is forced rapidly through the arteries, it also flows rapidly
through the capillaries into the veins, thereby enlarging the quantity
of fluid in those vessels and often forcing the blood into the exposed
parts of the body, causing serious discolorations.
The capillaries are sometimes ruptured by the rapid injection of fluid,
causing spots to appear on the face that would never have been there
had the body been injected more slowly.
A further reason for slow injection is that the disinfecting fluid is
given an opportunity to be absorbed by the tissues as it passes into
the capillaries and not be forced through those little vessels into
the veins, as it is by the absorption of the fluid that the body is
disinfected. This is especially true when the drainage tube is being
used as the fluid, seeking the course of least resistance, passes
through the artery, into the capillaries, through those vessels to the
veins and out through the drainage tube.
As it takes but little blood to color a large quantity of embalming
fluid, many embalmers are led to believe that they are removing large
quantities of blood, while in reality perhaps one-half of the colored
liquid which flows from their drainage tube is the fluid which is being
injected. Many failures have resulted from this error.
Fluid should always be injected into the body very slowly, and the more
slowly it is injected the more perfect will be the cosmetic effect.
If necessary make a second injection. An embalmer who makes the
proper charge for his services as a professional can afford to make
two injections if necessary. He can let it be known that he will
not be content with anything but perfect work, and patrons will not
only cheerfully pay for it, but will have a better opinion of his
professional standing. Thorough drainage and slow injection are the
best safeguards against discoloration.
Dr. Erdman before the Minnesota association suggests that the amount of
fluid that fills the arteries is not enough to percolate through the
capillaries and into the tissues, and saturate all the parts of the
body. He favors the gravity injection by merely allowing the fluid to
flow naturally into the arteries from an elevated vessel, and would use
no force or pressure in injection. Ideal embalming would be a series
of gravity injections at intervals of several hours. While the gravity
injection such as the doctor describes will undoubtedly be a sure
method of getting a perfect circulation, and while it is the process
generally pursued in morgue work where the apparatus is convenient, it
is in the majority of cases in the home impractical.
All bodies to be shipped must be thoroughly arterially embalmed, that
is, to have introduced into the arterial system sufficient amount of
disinfecting fluid to thoroughly sterilize every particle of matter in
the dead body. This can only be done by introducing into the arteries
an approved disinfecting fluid.[2]
[2] The quantity to be injected of course varies, but a fair
estimate would be that the quantity should be three-fourths of
the capacity of the blood vessels of the body. This would require
approximately one and one-eighth gallons of fluid to every 150
pounds of tissue. The latest transportation rules demand the
injection of an amount of fluid equal to 10% of the body weight
into the arteries.
=Approved Disinfectants.=—This is construed by most states to mean a
fluid which is sufficient in strength to kill all the germs on the
surface of the body or on the interior. An approved disinfectant
for the external surface of a dead body is a solution of 1 : 1000
bichloride of mercury. An embalming fluid which has the official
approval should contain 5% formaldehyde.
=Embalming Fluids.=—At the present time only a few states have placed
restrictions on fluids. These restrictions are that they contain
neither mercury, arsenic, antimony or any of their compounds. These
poisons when used to inject a body make it almost impossible to detect
from a chemical analysis whether death was caused by a poison or
the poison was from the embalming fluid. Iowa recommends a fluid the
formula consisting of formaldehyde, glycerine, borax, boracic acid,
salt petre and water.
=Wrapping a Body in Cotton.=—In certain diseases, when a body is to be
shipped, the law compels the embalmer to wrap the body in cotton. This
may be the ordinary cotton purchased from a dry goods store. The cotton
should be cut in strips at least one to one and one-half feet longer
than the body. Two layers are laid side by side upon a sheet, the body
then placed thereon and the whole wrapped about the body will envelope
the body in a satisfactory manner. This means that the entire body is
to be enveloped, so that the face head or feet will not be exposed, and
the wrapping should never be removed. Absorbent cotton may be used for
this work, but it is more expensive and not as good as dry cotton for
this purpose.
=[3]The Charge of Embalming.=—This subject is one that has
long been forcing itself upon the thought and attention of
progressive undertakers, principally because of the many abuses and
misunderstandings that have grown out of the manner in which members of
the profession regard the value of their services and the careless and
indifferent systems used in conducting the business side of our work.
[3] Extracts from a paper written by F. W. Alexander, Conrad,
Iowa.
In order to succeed in a chosen calling one must first have a liking
and a natural adaptation for the work; second, he must prepare himself
by obtaining a thorough working knowledge of the profession or business
he expects to follow. He must educate himself for the work. This is
fundamental and has been proven many times with the successes in every
profession. It is fair to presume then that the great majority of men
entering this profession have considered the probabilities of success
and have met the requirements needed to qualify them to follow this
calling and to receive the support of any who through necessity need
their services.
Without going into the non-essentials showing the rights of individuals
holding a license as an embalmer to practice, we may naturally come to
the next question in this connection, the value of his services and
how they should be charged for. Charge what your work is worth,
and do not conceal the amount in the price made on the casket or any
other part of the funeral expenses. Make it a specific charge in every
instance for there is a good and sufficient reason why you should.
An explanation of these reasons may be summed up as follows: the
conscientious effort in qualifying yourself to meet the needs of your
calling and the requirements of the state, the cost of your training
and education in time and money, the years spent in the hard school of
practical experience and self development.
Next your business equipment and investment, the care of the case on
which you are called, its peculiar requirements and how it taxes your
skill in doing the work, the risk from infection, the distance you must
travel and the expense of the trip. All of these considerations enter
into the cost and should be the basis on which to formulate a charge
for the work.
Just as the well equipped surgeon of wide experience and training
skillfully performs operations relieving suffering, saving and
prolonging life, naturally allows the difficulties of the case and
the distinctive personal service rendered to govern him in the amount
of the fee, so in a very similar sense the services of the embalmer
should hold a certain ratio of value to the conditions under which he
works and the ability he employs in its performance. Therefore let me
again urge that you make it a specific charge showing it a distinctive
personal service.
In the matter of the value of personal services the question is
often raised: “Which is the more important part of the work in our
profession, directing and managing the funeral or the embalming and
care of the body.” In answer to this let me say that the care and
the embalming of the body is first importance because the law says
so, because the education of the embalmer is paramount to other
considerations and so regarded by the national association, because
sanitary science demands it, because without a body properly embalmed
and prepared for burial the funeral is a failure from whatever
standpoint you wish to judge it.
A director may bungle the arrangements and at the most it is but a
matter of annoyance to the family. However, let him fail to properly
fit and prepare the body so that the relatives can see restored to
them the face of their beloved one, beautified in the last long sleep
of death, and they will never forgive him. They secured his services
first as an embalmer and incidentally as a director of the funeral,
naturally, therefore, the greater importance of his work centers around
his services to the family in that capacity. Now in all candor, why
should he not make a specific charge for his work? He is rendering the
greater service in caring for the body, it should be the first item
charged for on the funeral bill.