CHAPTER XVII.

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.