CHAPTER XVIII.

THE REMOVAL OF BLOOD.

=The Removal of Blood.=—In November 1882, Prof. J. H. Clarke and Dr. C. M. Lukens, while instructing a class in Philadelphia, in taking up the carotid artery, the internal jugular vein was injured and a flow of blood followed much to their dismay. This however turned out to be one of the greatest events that ever happened for the embalming profession, as it marked the beginning of the practice of the removal of blood from the body.

There are some very important reasons why blood should be removed from the body.

(1) There may be discolorations on the body, especially the face. This discoloration may be due to the presence of blood in the minute capillary system and other vessels which are near the surface skin. This discoloration may be due to the presence of the bile pigments in the blood, which would tend to give the body a yellowish hue. This discoloration may be due to the breaking up or disintegration of the blood corpuscles after death, which would tend to give the tissues of the body a light, pale, yellow color. Or this discoloration may be due to the presence of chromogenic bacteria, or color producing bacteria, in the blood, which might give to the tissues a characteristic green color.

(2) There may be blood in the arterial system after death, which certainly will have to be removed or else it may be pushed into the tissues of the face during the injection of the fluid and cause a discoloration. Besides if the arteries are congested with blood, this will have to be removed to make room for the embalming fluid, so that it will reach the capillaries and the tissues of the body.

(3) There may be the formation of tissue gas, and there is no doubt but that the removal of blood will greatly facilitate in the treatment, for without the blood, the fluid will have more chance to act on the parts containing the gas. This gas may be in the blood vessel itself, and the removal of that blood then will relieve the gas and the pressure exerted by the gas, which will aid in the injection of the fluid.

(4) To prevent a hasty decomposition. It may be that our subject is very heavy and fleshy which will mean that there is more tissue to be preserved and necessarily more fluid will have to be used. To make room for this increased amount of fluid, blood should be removed.

It may be that the body is in a hydropic condition. The tissues and the blood vessels will be filled with water. This will mean a hasty decomposition. The watery blood should be drawn from the blood vessels in order to make room for more fluid than ordinarily.

It may be that the body has died of a fever, which will also mean a hasty decomposition. This will mean that the blood will soon coagulate after death, and therefore the sooner it is removed, the better for the general cosmetic effect.

We do not however believe that blood should be removed from every subject, in order to get good cosmetic effect. Rather there are times when blood should not be removed, the conditions which are as follows:

(1) In the thin emaciated subject where there is no discoloration. An example of this condition would be in the tubercular subject, where before death the body has become very thin and emaciated. We would not remove blood when the subject is in this condition, for as a rule the body will take plenty of fluid, the arteries are as a rule empty after death, and besides we desire to leave the blood in the body, in order to give the skin of the face a more filled out healthy cosmetic effect.

(2) In the pale, marble-like, anemic subject. We would not remove blood in this case, first because it is not necessary, for there is a lack of blood in the surface capillaries showing that the arterial system is completely empty, and there is no congestion of the veins; secondly, experience teaches us that in these cases, you probably would not get any blood if you did try to remove it, and thirdly what little blood is in the surface capillaries is needed to build up a more healthy cosmetic effect.

There are times when blood should be removed from the subject after death which are as follows:

(1) Whenever blood is found in the arterial system. An example of this might be found in those cases of sudden death, such as drowning, suffocation, electric shock, or general heart failure. Whenever there has been a case of sudden death, the operator may expect to find blood in the arterial system. The last contraction of the heart normally would drive all the blood out of the arteries and arterial capillaries into the venous capillaries and veins, but this is not accomplished in the cases of sudden death. Whenever, on incising an artery, you find blood in the artery, and it runs freely, it indicates that there is a considerable quantity of blood in the arterial system. This blood then should be removed, because, were fluid to be injected into the artery, when it is full of blood and in this congested condition, all of this blood would be pushed ahead of the fluid toward the center of pressure, and from there large quantities would be pushed back into the tissues of the face, which would result in a greatly discolored face and a very poor cosmetic effect. DO NOT FORGET. Always remove blood when you find it in the arteries. The regular blood drainage tube should be placed in the artery, and all the blood removed that is possible, before attempting to inject. If this blood is not removed, the operator need not be surprised if he causes a decided blood discoloration of the face and a bad cosmetic effect. In these cases blood should be removed from the veins too, for that procedure will help to make room for what blood does remain in the arteries and capillaries, so that it can be pushed by the fluid into the veins rather than the tissues of the face.

(2) When the venous blood vessels are congested with blood and gas. An example of this might be found in almost any case. When the operator makes the incision to disclose the vessels and finds the venous channels congested, or when over the body the surface veins show signs of congestion and distention with gases, then blood should be removed.

(3) In dropsical cases. Often in these cases the tissues throughout the body are in a hydropic condition (filled with water), the arteries as well as the veins are filled with a watery, bloody colored fluid. It will be best for the operator to remove all this watery blood from the arteries, veins, and the tissues also, in order to get the greatest amount of preservative action from his fluid.

(4) In heavy, fleshy subjects. Experience teaches us that these bodies are as a rule difficult to handle from a cosmetic, as well as from a preservative standpoint. It seems advisable to draw blood from these subjects whenever possible, and by so doing bring about a clear non-discolored cosmetic effect; also the removal of blood will give more room for a greater supply of fluid, and thus the tissues will be better preserved.

(5) When the face is discolored. Whenever the operator takes charge of a body and finds the face discolored, no matter what the cause of the discoloration may be, it is a good indication to remove blood from that body.

By removing blood from the larger venous channels, the operator will make room for the blood to leave the face, and in this way better cosmetic effect is assured. Massage the face toward the internal jugular vein, and push the discoloring blood from the tissues of the face, out into the larger channels, that have been emptied by the removal of blood.

(6) In fever. Whenever a body dies in a high state of fever, it indicates a hasty coagulation of the blood, and a tendency to a discoloration of the face. Whenever the operator knows that the subject has died of a fever, or when there has been considerable fever on the body before death, then blood should be removed.

(7) To make room for fluid. The average embalmer only injects a gallon to a gallon and a half of fluid into a body. There are times when the operator desires to use more fluid. It may be that the body will have to be shipped a long distance, perhaps to another country or a distant state. After a certain amount of fluid has been injected the vessels become filled up and there is a great resistance established. If the operator disregards this pressure, and forces still more fluid into the arterial system, the fine capillary network will be broken, especially in the lung where the result will be a leakage of fluid through the mouth and nose from the ruptured air cells in the lung, or in the tissues of the skin, where the result will be a leakage into a certain area of tissue later causing a condition known as leathery skin. To have prevented this the operator should not have forced the fluid beyond a certain maximum resistance. He could, though, have reduced this resistance by removing the blood from the venous system, and then succeeded in the further injection of fluid.

There are times when blood ought to be removed from a subject after death, but for some reason it seems impossible to remove any. The reasons may be stated briefly as follows:

(1) The blood may already be in a coagulated condition, owing to the fact that the body has died in a state of high fever.

(2) The blood may be in a coagulated condition owing to the fact, that the bacteria of decomposition and putrefaction, have so altered the blood as to make its removal impossible.

(3) Certain drugs may have been previously given, or taken during life which would cause a hasty coagulation of the blood.

(4) The body may still be in a condition of rigor, and although the operator may have released the rigor in the joints, still all the tissues are in that condition, a condition which might prevent the blood from draining from the veins no matter what method was used.

Arterial blood is removed from the aorta indirectly, and from the arteries, only when the arterial system contains blood after death.

Venous blood is removed from the right side of the heart directly or indirectly, and the veins, only when it is deemed necessary by the operator.

There are two methods of removing this arterial or venous blood from the body. These two methods are aspiration and drainage. Besides these two methods some modified methods or combinations of the two, are given.

Aspiration consists in actually pumping the blood from the heart, arteries or veins. In this method, if blood is to be taken from the heart directly, the trocar is used; if the blood is to be taken from the heart indirectly or from the arteries or the veins one of the drainage tubes is used. Either the trocar or the drainage tube is connected by rubber tubing, to the goose neck on the blood bottle, which in turn is connected by rubber tubing to the aspirator side of the aspirator and injector pump. When the air is drawn from the blood bottle, there is a vacuum formed, which will aspirate or draw the blood from the heart directly or indirectly from the arteries or veins. The one great disadvantage of this method is that if the vacuum is made too great, the artery or vein will collapse ahead of the drainage tube and thus prevent the successful aspiration of the blood.

Drainage or gravity consists in opening one of the principle arteries or veins of the body, inserting a blood drainage tube into the artery or vein as far as it seems practical, and then connecting the blood drainage tube to the blood bottle by means of rubber tubing. The blood bottle should be placed considerably lower than the body in order to have the blood drain successfully. If the femoral artery or vein is used, the body ought to be on a considerable incline, the head at least one foot higher than the feet in order to get the maximum amount of blood.

If the axillary, brachial, or carotid, or their corresponding veins are used, the body ought to be on a level or turned to the side of the opening veins.

Simple drainage in itself is not a very successful method of getting the maximum amount of blood from the body.

The process can be modified in three ways which are as follows:

(1) By placing the blood drainage tube in the vein and the arterial tube in the corresponding artery. Inject fluid into the arteries which will tend to push the blood in turn from the capillaries into the veins, and out into the drainage tube into the blood bottle. This modified method has been called by Robbins “Displacement.” This is a good name and one which should be generally adopted.

(2) By placing the blood drainage tube in the artery or vein, preferably the femoral, and connect it by means of rubber tubing to the blood bottle. The operator now stands at the head of the subject, he reaches over, takes hold of each hand of the subject, raises the arms of the subject to right angles with the subject, then crosses the arms and with a steady gentle pressure bears down on the chest of the subject over the heart region.

If the axillary is used the operator is able to manipulate but one arm, the one opposite. Raise this arm to right angles with the body then fold down on the chest, exerting an even steady pressure. By raising the arms the blood will leave the hands, and each time pressure is exerted on the chest blood begins to flow from the artery or the vein, and will continue to flow as long as the even pressure is exerted.

(3) By the combination of number one and two. The operator opens the artery, preferably the femoral, inserts the arterial tube, and injects a pint of fluid to exert a pressure on the venous system. He then opens the vein, inserts the blood drainage tube which is connected with the blood bottle. With the pump in his right hand (granting that he is using the aspirator and injector pump), he stands at the head of the subject and slowly injects the fluid. If at any time the blood ceases to flow, by taking hold of the hands, raising both arms at right angles to the subject, crossing, and while in this position injecting a few ounces of fluid, then bear down gently on the chest with a steady pressure. If the blood will not flow by this method and the operator is using either the axillary or the femoral, there is hardly any use of trying any other method. The operator will be able to draw the maximum amount of blood with this method, if it is at all possible to draw blood.

Often when the blood stops flowing, there is a blood clot formation ahead of the drainage tube. By injecting just a few ounces of fluid or salt water through the tube into the vein, the clot may be pushed to one side, and the blood will continue to flow.

=Removal of Blood from the Right Auricle of the Heart. Direct Method.=—Insert the trocar in the third intercostal space, just to the right edge of the sternum or the breastbone. The trocar should be inserted obliquely, the point of the trocar is to pass in the general direction of the left hip joint, while the open end of the trocar is to point in the general direction of the right ear. A general knowledge of the anatomy as far as the location of the heart is absolutely necessary to master this procedure. The object is to have the point of the trocar pierce the right auricle of the heart. When the trocar has pierced the right auricle, which the operator will have to judge through practice, attach rubber tubing to the gooseneck of the blood bottle and by the use of the aspirator pump, draw the blood from the heart into the blood bottle. This is removal of blood by aspiration.

=Removal of Blood from the Right Ventricle of the Heart. Direct Method.=—Insert the long thin twelve or fourteen inch trocar two inches above and two inches to the left of the navel and pierce the abdominal wall, pass the trocar keeping the point close to the abdominal wall, in the general direction of the right shoulder as far as the lower border of the third intercostal space, without fear of breaking any circulation. The right ventricle will thus be reached from which blood can be aspirated as in the previous method. Here again a general knowledge of the anatomy as far as the location of all the organs in the upper abdominal and thoracic cavity is necessary to perform a successful operation. This is removal of blood by aspiration.

=Removal of Blood from the Right Auricle of the Heart. Indirect Method.=—Make the incision for the femoral artery and vein.

Raise the artery and inject about a pint of fluid in order to cause a pressure on the venous system. Open the vein and insert the flexible rubber drainage tube, known on the market as the Red Seal drainage tube or the Worsham drainage tube. Push this tube up through the femoral, external iliac, the ascending vena cava, through the eustachian valve, and into the right auricle of the heart.

In order to determine when the tube is inside the right auricle, the operator should have laid the tube on the external surface of the body from the point of entrance to the point where the right auricle normally should be, allowing for the bend of the vein in its course. Mark the tube, then when it has been pushed into the vein to that point the operator is reasonably sure that the end is in the right auricle.

In order to make the tube slip easily it should be greased with a liquid solution of vaseline.

After the tube has reached the right auricle the blood may be allowed to drain, or it may be aspirated.

Either femoral may be used, but the left femoral is preferable owing to the fact that, the angle at the bifurcation of the ascending vena cava is more obtuse.

If the operator desires to remove blood from the heart, we believe that the indirect method is the better way. By the use of the direct method to draw blood from the right auricle by means of the trocar there is always danger of rupturing the circulation. The aorta may be accidently pierced. When the trocar is inserted from below to reach the right ventricle the stomach may be punctured and the liver and diaphragm will have to be pierced which, too, may mean an injured circulation. If any accidental damage has been done, it can not be remedied. The direct method is a blind procedure and is always uncertain. On the other hand if the flexible rubber drainage tube is inserted into the vein it must follow the channel of that vein. It is more certain than the trocar method and there is no danger of rupturing the circulation.

The basilic or axillary vein may be used to remove blood from the heart instead of the femoral. These veins should be used on the left side of the body owing to the fact that the angle at the junction of the subclavian and internal jugular veins is not so acute as on the right side.

=Removal of Blood by the Use of the Femoral Vein.=—The use of the femoral vein is considered by some operators a very good method. The femoral should be employed in the upper third. Make the incision in the center of Scarpa's triangle, just below Poupart's ligament. The incision should be about two inches in length, the length of the incision usually depends upon the size and thickness of the thigh and the depth of the vein in the tissue. Expose the artery and the vein. The vein at this point will lie to the inside of and a little below the femoral artery. Open the artery and inject about a pint of fluid to cause a pressure on the venous system.

Have all the blood drainage outfit in readiness then open the vein and quickly insert the drainage tube. Any of the drainage tubes now commonly sold on the market are good. For the femoral, though, the flexible rubber drainage tube seems to be the best, because the femoral vein dips deep down into the posterior part of the abdomen after it leaves the Poupart's ligament. The flexible rubber drainage tube will follow this bend and can be pushed as far as is desired by the operator, in contrast the steel drainage tube could only be pushed into the vein for a few inches.

Blood ought to drain out into the blood bottle, if it does not, inject a little more fluid to cause more pressure on the venous system, and if it will not flow by the drainage method or any of its modifications try the aspirator. If blood still will not flow, it may mean that there is a clot ahead of the drainage tube. Pump some fluid through the drainage tube into the vein, to see if the tube is open, then let the fluid drain out which usually will bring some blood. After you have tried all the methods, if blood still does not flow, it will indicate that the blood is either in a coagulated condition, or there is not very much blood in that particular vein, which in this case is the femoral. The blood may be more in the dependent parts of the body.

=Removal of Blood from the Axillary Vein.=—The axillary vein is of large size, and is formed by the junction of the venae comites or deep brachial veins with the basilic. The axillary vein begins at the lower part of the axillary space, increases in size as it ascends by receiving tributaries corresponding in name with the branches of the axillary artery and terminates immediately beneath the clavicle at the outer margin of the first rib where it becomes the subclavian vein. To remove blood from the axillary vein, raise the vein to the surface, and insert the drainage tube. The Eckels-Genung steel drainage tube will perhaps be the best tube to use. Insert the drain tube high up in the arm pit, pass through the subclavian, to beyond the valve located in the subclavian vein outside the point at which the internal jugular vein unites with the subclavian to form the innominate. There being no more valves the blood should pass out freely. If the blood does not flow, raise the axillary artery, begin the injection of fluid which will tend to cause a pressure through the capillaries on the venous system pressing the blood back to the right auricle of the heart as in life, and as there is no obstructed passage the blood should flow freely from the tube. The vein tube is of metal having a plunger rod within, and a Y attachment at the upper end. The blood runs from the Y shaped attachment into a rubber tube which is connected with the blood bottle. A flexible arterial tube should be used in the artery, which will measure eight to ten inches in length and constructed with a shut-off valve. The tube will reach the innominate artery close to the arch of the aorta. With these arterial and drainage tubes the arms can be folded and placed in position, with the hands over the abdomen and the tubes will extend out over the upper border of the arm. This method will enable the operator to inject the body and have the arms in their natural position. If a short circuit through the internal mammary vessels occurs, and this will be evidenced by the premature flow of thin blood, close the vein tube now and then during the operation, continuing the injection until the proper results are obtained.

=Removal of Blood from the Basilic Vein.=—To withdraw blood from the basilic vein the left arm should be employed, because of a more direct route to the right auricle. Make the incision in the middle or the upper third of the arm. The basilic vein lies in the upper arm and extends from the elbow to the shoulder, and can be found a short distance from the brachial artery, either above or below, but generally below and toward the body. Its position is not always the same, owing to the many anomalies that might occur. As a rule the vein is quite large and prominent and when secured, raise to the surface freeing it from the surrounding tissues.

Prepare two ligatures, make the incision in the vein and pass gently the basilic drainage tube upward toward the heart. Either a steel or rubber tube may be used. If the flexible rubber tube is used, it will find its way to the right auricle of the heart, its course is through the basilic, axillary, sub-clavian, innominate, superior vena cava, to the right auricle. Either the aspiration or the drainage methods may be used. If these fail try the displacement method.

The use of the basilic for the removal of blood is fast disappearing from general practice. Larger veins can be used, which will always insure greater success.

=The Removal of Blood from the Internal Jugular Vein.=—The internal jugular vein is the largest tributary vein in the body, and accompanies the carotid artery. The operator will cut through the skin at a point from one half inch above the clavicle or collar bone and in the valley formed by the sterno-mastoid muscle to the outside and the muscles of the wind pipe to the inside, cut upward making the perpendicular incision. Raise both the artery and the vein according to the usual method. It seems best to raise the artery and the vein together, and by so doing this will tend to give added strength to the vein which is very large but has quite thin walls.

Direct the hook around the vein first then around the artery toward the wind pipe or trachea, raise both to the surface, place on the bone separator, and remove the sheaths. Use any of the drainage tubes. Insert the vein drainage tube and the arterial tube, the point of both tubes being directed toward the heart. The injection should be made slowly, which will cause the blood to flow from the vein through the tube and into the blood bottle.

This vein is not as much used as the axillary or the femoral for the removal of blood.

It is true that it is very close to the center of circulation and a gateway for the blood from the face. The chief disadvantage is that the vein lies quite deep, is very large and has such thin walls, that it is almost impossible to raise it without a rupture.

About one-thirteenth of the body's weight is calculated to be blood. Granting for the sake of argument that the average body that we would desire to draw blood from would weigh 208 pounds, then that average body would contain 16 pounds of blood. One pound of blood is practically equal to one pint, making the average body to contain about 16 pints of blood.

After death about one-fourth of the blood of the body is found in the portal system. The portal system has capillaries at both ends so that it is impossible to draw this blood.

After death about one-fourth of the blood of the body is found in the tiny capillaries and tissues, blood which by the ordinary methods used today the embalmer is unable to draw.

After death about one-fourth of the blood of the body is found in the azygos system, and points dependent in the body, which blood, too, it is impossible to draw.

This leaves about one-fourth of the blood of the body, which we are able to draw. One-fourth of 16 pints, is 4 pints which is the maximum we can draw from the average body.

The point of this argument is that if from the average body you have taken from two to four pints of pure undiluted blood, then you should be satisfied. If the majority of this blood has been taken from the face you will get the desired cosmetic effect. The claims by some that they are able to draw a gallon or more of blood is in our judgment erroneous, as we feel the blood has been greatly diluted. We have tested this out many times with the aid of control solutions and have found that what the embalmer would ordinarily call thin blood was composed of from 10 to 30% blood and from 70 to 90% fluid.