CHAPTER XV.

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.