CAVITY EMBALMING.
=Cavity Embalming.=—In shipping a body, cavity embalming must always be
resorted to and consists of introducing a trocar into the abdominal and
thoracic cavities and injecting sufficient fluid over the contents of
these cavities to thoroughly preserve them.
The scientific work in the embalming of to-day is being done on the
arteries, but cavity embalming should still hold an important place
with those embalmers who desire to get the best results. Although
the arteries have been injected, yet we find that sometimes the fluid
does not reach the cavities. Any cavity may contain gas or material
for decomposition, such as blood, pus, lymph, or as in perforation
of the intestines, feces in the abdominal cavity. Besides these we
always have the bacteria of decomposition, called saprophytes, which
have thoroughly invaded the organs and tissues of the body as soon as
sixteen hours after death. Then, if for any reason the fluid has not
reached a certain part, fermentation, and putrefaction will immediately
set in.
=The Cerebral Cavity.=—Gases may be generated in the cerebral cavity
soon after death, especially in drowned cases, where the gas forming
bacteria, the aerogenes capsulati, are distributed all over the body.
These bacteria work much more rapidly in fresh or shallow water, or in
the summer when the water is warm, than in the winter when the water
is cold, or the body is in salt water. The gases may penetrate every
tissue in the body, particularly the tissues about the eyes, which
gives the eyes their bulged appearance. The gases that are formed in
the brain and forced out into the tissues surrounding the eye do not
enter the eye ball. In these cases the eye ball may or may not be
pushed out of its socket, depending, of course, upon the amount of
gases that have been produced.
These gases may be removed by inserting a trocar inside the head at the
inner angle of the eye or in the nose through the turbinated process of
the ethmoid bone.
After the gases have been removed from the inside of the skull, about
one-half pint of strong formaldehyde fluid should be injected.
Another method of inserting the trocar into the brain would be to pass
it through the foramen magnum. This can be done by inserting the trocar
in the neck a little below and behind the lobe of the ear, directing
the needle upward and inward toward the opposite eyebrow, when the
needle will enter the subarachnoid space (Barnes Method).
In cases of hydrocephalus (water on the brain) where there may be from
one to two quarts of water inside the cranium, the water may be removed
by any of the above processes.
For ordinary cases we do not feel that it is necessary to make a cavity
injection in the head for the reason that the circulation there is
complete, only in rare instances do we find an obstruction.
=Purging.=—By purging, as the embalmer uses the term, is meant, the
fluid which emerges from the mouth and nose of the cadaver. If this
fluid is a brownish coffee-like substance, it signifies it is coming
from the stomach, but if it is a bloody frothy mixture it signifies it
is coming from the lungs.
The real cause of purging is the living and growing saprophytic
bacteria, which were normally in the body, or having gained access
later, produce as a result of their development, gas formations. These
gases confined as they are, press out from the stomach and lungs the
contained fluids of the color mentioned above.
Purging from the stomach may either be due to the presence of gases in
the stomach itself, or in the intestines or in both. If the gases have
formed in the intestines, they would dilate the canal sufficiently to
fill the entire abdominal cavity, thus pressing the stomach against the
diaphragm with enough force to cause the contents to escape through the
upper end of the alimentary canal.
Purging from the lungs is due to the presence of bacteria of
putrefaction, which begin to develope in the diseased portions. These
cause liquefaction of the lung substance and the formation of gas.
The gas will force the liquefied matter, of a bloody, frothy color out
through the respiratory tract.
Before embalming of the chest and the abdominal cavity is begun
the trachea and the esophagus should be treated in order to prevent
purging. There are two ways of doing this:
The first method consists of placing a ligature about the trachea and
the esophagus, this is done by making an incision through the skin and
tissues over the left edge of the trachea, one-half inch above the top
of the sternum. Insert the right forefinger, passing it to the right
side behind the trachea and the esophagus to separate the tissues from
them. In doing this great care should be taken so as not to injure the
carotid on the left and the innominate artery on the right side. Pass
the aneurism hook threaded with narrow tape (this must be very strong
tape) along the inner side of the finger, below the trachea and the
esophagus, to the point of entrance on the left side. You will have no
difficulty now in tying securely both the above tubes, and there will
be no possibility of purging from either the lungs or the stomach.
The second method of preventing purging from the lungs and stomach
consists in plugging the pharynx through the mouth, there-by plugging
the trachea and the esophagus. The only disadvantage of this method is
that it can not be done successfully after the body has been embalmed
arterially. And for this reason, after arterial embalming, the lower
jaw will be firmly set and to use this method, it would mean that the
lower jaw must be pried back in order to gain access through the mouth.
Then it will be found very difficult and in some cases impossible to
set the lower jaw again in its proper position. If this method is to
be used at all, it is advised that you do the plugging of the pharynx
before the arterial embalming has been done.
To do this, take your position at the head of subject on the right
side, and open the mouth wide enough to admit two fingers. Roll several
pieces of dry cotton, the size of an English walnut, and holding the
corner of the mouth back with the left hand, insert a ball of cotton
with the right hand and shove it hard down behind the tongue (this
can best be done with a pair of clamp forceps). Continue to do this
until the pharynx is well and firmly filled, but avoid bulging out the
side of the cheek. If properly done this plug will prevent an ordinary
amount of purging and dry cotton seems much better to use for this
purpose than absorbent. It must be borne in mind that simply filling
the mouth is of no use; nothing is plugged by this procedure, as it
leaves the opening into the nose open.
If you had not anticipated purging in the beginning, and the body has
been embalmed arterially it will be necessary to stop the purging by
the first method.
A third method of preventing purging from the lungs and stomach is in
the use of plaster of paris. In this method the plaster of paris is
mixed thinly, then by means of a paper funnel, pour the liquid into the
nose and mouth, then plug tightly with absorbent cotton as in method
two. It requires only a short time for the plaster of paris to set and
it has been found quite successful. Probably the only disadvantage
of this method is that it is mussy and because of the rapid drying
qualities of the plaster of paris the operator must work very quickly.
=The Thoracic or Chest Cavity.=—Cavity embalming must be resorted to
frequently in the chest or thoracic cavity for the reason that in
certain diseases, especially tuberculosis, fluids cannot enter the
diseased cavities, as the capillaries and small vessels are destroyed
by the disease and the ends of the arteries securely plugged. If
this were not so, the patient would have died of hemorrhage of those
arteries, a thing which seldom takes place.
Again in certain other diseases, especially pneumonia, the fluid cannot
reach the diseased lung, either through the nutrient arteries or by
the respiratory tract, because of the resistance offered. The nutrient
arteries will be filled with coagulated blood and the bronchi, to a
certain extent, with a bloody mucous.
This being the case, the bacteria of putrefaction will begin to develop
within the diseased portions of the lungs, and will be the cause of the
purging so much dreaded by the embalmer.
The thoracic cavity may be treated by one of several methods.
A first method consists in passing a curved trocar into the trachea
just above the sternum and injecting a strong embalming fluid into
the bronchi. In cases of gangrene of the lung, the sputum has a very
offensive odor, which may be disinfected by this method. But it must
be remembered that the ends of the bronchioles which enter the diseased
parts of lungs will be closed (from the nature of the disease), so that
any fluid injected into the bronchi from the trachea will not reach the
diseased part of the lungs. You will thus see that it is absolutely
necessary to use a method in treating the thoracic cavity, whereby
any mass of rotten tissue, which may be present, may become thoroughly
saturated with the disinfectant.
A second method written about the Robbins, is accomplished by inserting
the trocar on both the right and left sides at the tops of the lungs,
and at the bases. At the top of the lungs the trocar is introduced two
inches outside the sternum just below the clavicle. The trocar may then
be pushed in any direction, except toward the sternum, without injury
to any of the larger vessels.
The arch of the aorta passes a little to the right of the sternum and
as high as the lower border of the first rib, then makes a turn to
the left and goes directly back to the left side of the fifth dorsal
vertebra. The superior vena cava lies a little to the right of the
arch of the aorta. The advantage of inserting at this point rather
than above the clavicle is that there are no vessels in the location
in danger of perforation. If the trocar is inserted above the clavicle
on either the right or the left side there is danger of perforating
the subclavian artery or vein, while if the insertion is made next
to the sternum, the aorta may be perforated, in either case breaking
the circulation. Disease fluids are seldom found at the top or apexes
of the lungs, but in consumption, breaking down of the lung substance
usually begins at this point, especially in young cases. To insure a
perfect embalming of the lungs, you should inject at the apexes, about
a half-pint of strong formaldehyde on each side. It should, however, be
remembered that the injection at the tops of the lungs, as suggested,
gives no fluid to the lower parts of the lungs where it is often most
necessary.
It is not an unusual condition to find a whole lobe rotten and broken
down at the base of the lung, and when such a diseased condition exists
the lungs become firmly attached to the chest walls, and unless fluid
is placed below these adhesions it does not reach the diseased parts.
The intelligent embalmer, will never trust to the fluid passing from
the tops of the lungs to the base, as in almost all cases the adhesions
between the lungs and the walls absolutely prevent this taking place.
It is necessary first to draw off by aspiration, at the bases of the
lungs, the fluids which have accumulated and which may be either water,
pus or blood. This is done by inserting a curved trocar of small size,
between the fifth and sixth ribs on the axillary line. The thoracic
cavity extends in the back as low as the last rib and the twelfth
dorsal vertebra and it may be necessary to pass the trocar down into
this part of the cavity in order to remove the fluids.
As soon as the fluids are removed, inject from a pint to a quart of
strong formaldehyde on either side. By so doing the gangrenous and
decomposed part of the lung will be put to soak in the embalming fluid,
which will insure perfect disinfection and an absence of bad odors.
=Abdominal Cavity.=—Often it will be found necessary to do cavity work
in the abdominal cavity. Gases may arise causing a distention of the
abdominal wall, resulting in purging from the mouth and nose. This gas
is the result of putrefaction and fermentation in the alimentary canal.
When one of the principle arteries is injected, the fluid finds its
way to the minute capillaries of the organs of the abdominal cavity,
including the stomach and the intestines. It must be remembered that
often there is a great amount of undigested food and fecal matter in
the stomach and intestines. The only way the fluid which is in the
minute capillary circulation of the stomach and intestines, is able
to reach the inside of those organs and come in contact with the
undigested food and the fecal matter is by soaking through the mucous
wall. No doubt a certain quantity of the fluid does soak through, and
when it does, if there is not much undigested food or fecal matter
in these parts, disinfection will be accomplished and it is in these
cases that we do not have any trouble with distentions of the abdomen.
When however, there is a great amount of undigested food and fecal
matter inside the stomach and the intestinal tract, it is only obvious
that enough fluid can not possibly soak through to disinfect, and
consequently a host of putrefactive, and fermentative germs will begin
their work, with the formation of gases and the distended abdomen, and
perhaps purging from the mouth and nose.
To prevent the formation of gas now which has arisen, a second
injection will do no good. More drastic measures will have to be used.
One method that has long been in vogue is the use of the trocar.
_The Trocar Method._—In this method a trocar varying in length from
six to fourteen inches is used. It may either pierce the abdominal
wall through the umbilicus, or two inches above and two inches to the
left of the umbilicus. Then after the trocar has entered the abdomen
the secret of removing gases successfully depends very largely upon
the operator having a very correct idea of the location of all the
abdominal organs. It is difficult to know when the trocar has pierced
the interior of the stomach, or in fact even to make it pierce the
stomach at all for the peritoneum which is a covering for all the
organs of the abdominal cavity contains a serous fluid which makes
the organs slippery, and even the sharp pointed trocar often does not
take hold as it should. Again it must be remembered that the stomach
is a hollow organ, and for example let us try to pierce a soft rubber
ball, containing air and a small opening, a condition resembling the
stomach, with a trocar, we know that the one wall, will have to be
pushed up against the other wall, and then placed against something
firm, before the trocar will pass through. Just this condition happens
with the stomach when the trocar tries to pierce the arterial wall of
the stomach there is nothing solid to bear against and consequently the
front wall will be pushed up against the back wall and then if enough
pressure is now used to push the trocar through, it is very liable to
pass all the way through both walls.
Again it must be remembered that the descending aorta passes very close
behind the stomach and should the trocar go all the way through the
aorta might be pierced and the circulation in a measure ruined. The one
main disadvantage of this trocar method is that the operator is always
working blindly, it is always impossible to tell just how much damage
may be done to the internal organs and the circulation, and again
should the operator desire to place fluid in a certain part—say the
inside of the intestines or the inside of the stomach or the colons,
will the operator have assured knowledge that he has actually placed
the fluid in the part desired. From the number of experiments that
have been carried out in our anatomical rooms, the proof seems to be in
every case that the fluid has not reached the part it was supposed to
reach.
The advantage of this method is the fact that by introducing the
trocar into the abdominal cavity two inches above and two inches to
the left of the navel that after the abdomen has been treated that the
trocar then can be directed upward into the thoracic cavity and fluid
there distributed to the several parts, but this is seldom necessary.
After the trocar has been removed or better, just before the trocar is
entirely pulled out the operator should sew a circular stitch about the
wound and then as soon as the trocar is pulled out, pull the stitch
closely together as if it were a draw string, and tie. This will
prevent any further leakage from the part.
=The Direct Incision.=—Sometimes before the body is embalmed or a day
or two after the body has been embalmed, there is a distention of the
abdominal wall indicating gases and there may or may not be purging
from the mouth and nose. From the great number of cases that have been
posted in our anatomical laboratories, it has been found that the gas
that has accumulated is as a rule located in either the stomach, the
transverse colon, or the colons in general, but rarely in the small
intestines to the extent that it would do much damage. By the use
of the direct incision, make a cut with a sharp scalpel, about three
inches long in the median line of the body over the abdomen. Start the
cut about one inch below the ensiform process of the sternum and cut
toward the navel. After a cut has been made three inches in length on
the skin, direct the scalpel downward so that it enters the abdomen.
Place the index and second finger in the incision thus made pressing
the organs from the abdominal wall, and carefully cut upward between
the two fingers. This will prevent the operator cutting any of the
underlying intestines.
The incision having been made, it is evident now that the part
containing the gas will come up into the incision. If the stomach
contains the gas it will come up, if the transverse colon contains
the gas it will come up, but that makes no difference, for it is the
part with the gas that the operator is after. Usually the transverse
colon will be the first to come up into the incision, now take hold
of the part with your artery forceps and with a pair of scissors make
a clip through the wall, this will let the gas escape. Do not let
the gas escape into the room not deodorized, so place over the hand
quickly after you have made the clip, a towel, or absorbent cotton
that has been saturated with formaldehyde, this will both deodorize and
disinfect the gas. Keep hold of the part until all the gas has escaped,
and then pick up the arterial tube and inject a small quantity of fluid
in the colon, and then sew up with the circular stitch. Then locate the
stomach, which can easily be found if it contains gas and treat it in
the same way, relieving the gases and then placing a small amount of
fluid inside. Treat the other several parts of the intestines in the
same way if gas be present and it is remarkable how quickly the abdomen
sinks to its normal level. After this has been done place hardening
compound or common salt in the cavity, and placing a layer of absorbent
cotton in the abdomen under the incision, sew up neatly.
The one great advantage of this method is that you can actually see
what you are doing, you can see the part that contains the gas and
treat that part particularly, the operator is not working blindly, but
is able to place the fluid in the part that he desires and is assured
of the fact that it is in the part for his eyes do not deceive him as
the sense of feel and touch sometimes do. By this method the operator
is able to surround the parts of the abdominal cavity with a hardening
compound, and thus feel sure that his case if it is to be shipped,
will be received in proper condition, at least it will be as far as the
abdomen is concerned, if it is treated under this method. This method
is one sure cure for purging, for the gases once properly relieved from
the stomach and the contents disinfected, there is no chance for them
to recur. If the stomach is found to be full of liquid as well as of
gas, as is the condition during purging, the liquid can be taken from
the stomach with a drainage tube or a stomach pump, and lastly every
part is deodorized and disinfected properly.
A seeming disadvantage might be that a critic might suggest that you
are mutilating the body with your abdominal incision. Let a fair
question be asked. If it were your sister that was to be embalmed
and gases had to be removed, which would you rather see some operator
running a trocar here and there through the abdomen, relieving gases
and injecting fluid here and there, or, the use of the neat surgical
incision, made as a surgeon would make it.
=Embalming of the Subcutaneous Tissue.=—It is not always possible to
fill the tissues of the body through the arterial system, the arteries
may be full of blood in a coagulated condition so that it can not
be removed, the walls of the arteries may be diseased, or they may
be severed at many places the result of accidental death, such as
railroad accident, etc. If any of the above conditions be present or
other similar conditions, it will be impossible to inject the arterial
system, or it may be that arterial injection is only partly possible.
In order, in arterial embalming, to have the tissues embalmed the
fluid must reach the capillaries, and to fill the capillaries it is
first necessary to fill the larger arteries. So if for any reason it
is impossible to reach all or certain tissues by arterial embalming, it
becomes necessary to resort to some other means.
With these difficulties then in view, the best operation for filling
the tissues, that is the subcutaneous tissue covering the bony
framework of the body, is the direct injection of fluid into the
part by means of (1) the hollow needle trocar, and (2) the hypodermic
needle.
The hollow needle trocar is to be used for the rough work, so called.
Inserting the trocar into the center of the popliteal space it can be
pushed through the tissues of the foreleg, and fluid injected; then
reversing, push the trocar through the tissues of the leg proper,
and inject fluid. Inserting the trocar into the center of the bend of
the elbow it can be pushed into the tissues of the forearm, and fluid
injected; then reversing, push the trocar through the tissues of the
arm proper and inject fluid. Turn the body over so as to trocar the
back. Insert the trocar above the sacrum bone in the middle line of
the back, and push the trocar through the fleshy parts of the gluteal
regions, and inject fluid. Again insert the trocar in the middle line
of the back between the two scapulae bones, and inject fluid into the
region of the shoulders and the small of the back.
After each puncture, before the trocar is removed a circular stitch
should be thrown around the trocar and when the trocar is removed draw
the puncture shut, the circular stitch acting as a draw string.
A large amount of fluid may be injected in this manner, it being
possible to inject several gallons into a body of average size. The
fluid transudes through the tissues very readily filling them up
completely, but of course, not as certainly as if the fluid were
injected arterially. It is an easy matter to inject from two to three
gallons of fluid into the soft tissues on the outside of the skeleton
of a body weighing from 130 to 140 pounds.
This procedure is only to be used if it is impossible to inject
the body by the ordinary arterial embalming. The cavity work in the
cerebro-spinal, the thoracic, and the abdominal cavity, should be done
first, and then follow with this subcutaneous tissue outside the bony
framework.
This procedure may be used in dropsical cases and in certain cases,
where for some reason the fluid does not reach a certain part, or where
a certain part is not completely supplied with fluid, by the arterial
injection.
The hypodermic needle is to be used for the more delicate work, such
as the hands and the face. Insert the needle at the wrist and direct it
into the palm of the hand, inject a very small quantity of fluid; then
into the back of the hand and inject a small quantity of fluid.
To reach the tissues of the face insert the needle into the muscles and
tissues of the face from the inside of the mouth. The region about the
temple can be reached by inserting the needle into the tissues in the
hair line, which will hide the puncture.
With the use of the hypodermic needle fluid can be placed in contact
with all the tissues of the hands and face, and the cosmetic effect
will be almost perfect if the operator is careful as to the amount he
injects, and is careful to see that, the fluid is equally distributed
throughout the part.
=Plugging Orifices of the Body.=—The proper manner in which to plug the
orifices of the body is to use a pledget of absorbent cotton dipped in
your embalming fluid and forced into all the orifices, following this
up with a pledget of dry absorbent cotton. In this the fluid disinfects
the surface with which it comes in contact and the dry cotton prevents
the outgoing of the germs from the body or the passage inward of
bacteria. It must be understood that absorbent cotton filters out germs
from the air, even though air passes through it, they become entangled
in the meshes of the cotton and there remain.
=Removal of Urine.=—As a rule, in the last throes of death, the bladder
is emptied, but in some instances this is not done and then it becomes
necessary for the embalmer to remove the urine. This may be done in
two ways. Use the steel catheter, insert it in the bladder through
the urethra, and draw off the urine, or use the trocar and insert it
through the abdominal wall in the median line just above the pubic
bone, directing the end of the trocar into the bladder which lies just
below the pubic bone and draw off the urine. It is seldom necessary to
inject the bladder with fluid, as after the urine has been removed, we
find from general experience that it is well supplied with fluid from
the arterial injection.
In the male it is wise to tie a string about the penis just back of the
head, or glans, while in the female it is best to plug the meatus of
the urethra and the vagina with cotton.