CHAPTER XXI.

TREATMENT OF SPECIAL DISEASES.—Continued.

DISEASES OF THE CIRCULATORY SYSTEM.

=Pericarditis.=—_Definition._—An acute inflammation of the pericardium and the serous covering of the heart.

_Treatment._—Give the body a thorough injection of half strength fluid followed by normal fluid. Drain from the veins. Inject the abdominal cavity. For transportation of these cases, govern yourself according to the provisions of the transportation rules.

=Hydropericardium.=—_Synonym._—Dropsy of the pericardium.

_Definition._—Hydropericardium is a non-inflammatory condition of the pericardium, attended by an accumulation of sero-albuminous fluid.

_Pathology._—Hydropericardium is not a disease of itself, but it is always secondary. The accumulated fluid is usually clear, of an amber color, though it may become turbid by the presence of fibrin or red blood corpuscles. The fluid is alkaline in reaction.

_Treatment._—As this disease is always secondary to another, the treatment will also be secondary and all that can be said is that the heart sac should be relieved of its accumulated serous fluid, after the body has received the treatment necessary for the immediate cause of death. Transportation will also be covered by the disease causing death.

=Hemopericardium.=—_Definition._—Hemopericardium is an infiltration of blood into the pericardium. It is the result of a rupture of an aneurism of the aorta or coronary arteries, or in rare cases from rupture of the heart. It may also arise from injuries such as bullet wounds, fracture of the ribs, sternum, etc.

_Treatment._—This condition is usually secondary to another such as gun shot wound, aneurism of the aorta, etc., so that the treatment must be given under the heading of the immediate cause of death. For transportation requirements also refer to the immediate cause of death and the transportation rules.

=Pneumo-Pericardium.=—_Definition._—Pneumo-pericardium is an accumulation of air in the pericardium. Although this is a rare disease, it does occasionally occur, either through diseased processes, such as cancerous or tubercular ulceration or through injuries; thus a ruptured pulmonary cavity might result in this condition, or the perforation of the esophagus, by malignant processes would give rise to this lesion. Sometimes pus in the pericardium will generate gas.

_Treatment._—As the accumulation of air or gas is secondary to some other process of disease, the immediate cause of death will carry with it the proper treatment. The gas itself should be removed by piercing the pericardium with a small needle or trocar, after which a small quantity of fluid should be injected.

=Endocarditis.=—_Definition._—Endocarditis is an inflammation of the lining membrane of the heart, and is generally confined to the valves, though other parts may be affected.

_Pathology._—The morbid changes are, first, a reddened and injected appearance of the endothelium, which soon becomes opaque and swollen from congestion of the small blood vessels. This swelling or thickening of the membrane furnishes a favorable resting place for deposits of fibrin, and we have small, beady deposits from the size of a pin point to that of a pea, or even larger. These small, beady excrescences may become detached, and floating off in the general current, give rise to embolism in distant parts.

_Treatment._—An embolism means the obstruction of a blood vessel by some foreign material. If in the injection of fluid, there is an obstruction in one of the blood vessels, leading to one of the organs, you will never be any the wiser, but if the obstruction is in one of the vessels supplying a certain area of skin, the condition will show up sooner or later, when that certain part will have to be treated hypodermically. Slow arterial injection with drainage of blood should be given and when symptoms of fermentation are present, include special attention to the abdominal cavity.

=Aortic Incompetency.=—_Synonyms._—Aortic Insufficiency; Aortic Regurgitation.

_Definition._—Inability of the aortic valves to properly close an abnormally large aortic opening, or a change in the segments whereby they are shortened by curling of the leaflets, or by calcification.

_Treatment._—Bodies dead of this disease will be found with very much blood, and the elimination of the blood by drainage should be the first consideration along with the injection of fluid. The fluid should be diluted one-half for the first part of the injection, and sufficient fluid used to reach all parts of the circulatory system. It will be well to add fluid equal to the amount of blood and fluid taken from the vein to your normal injection in a body the size of the one to be operated on. A complete cavity injection should be given. For transportation, govern yourself according to the provisions of the transportation rules.

=Aortic Stenosis.=—_Definition._—Aortic stenosis is an obstruction of the aortic orifice, due to changes in the segments of the semilunar valves, or arterio-sclerosis, or atheromatous deposits.

_Treatment._—Give same treatment advised for aortic incompetency, with special care in the injection. Sclerotic conditions may complicate the injection, and in that case as many arteries should be injected as possible together with full blood drainage.

=Mitral Incompetency.=—_Synonyms._—Mitral Regurgitation; Mitral Insufficiency.

_Definition._—This condition is an incomplete or imperfect closure of the auriculo-ventricular opening, permitting the regurgitation of blood during the contraction of the left ventricle, and due to an abnormal condition of the leaflets or an enlarged opening.

_Treatment._—Give same treatment as advised for aortic incompetency, with special care to remove as much blood as possible, which, with massaging the face downward, should relieve any blood discolorations.

=Mitral Stenosis.=—_Definition._—Mitral stenosis is a constriction of the left auriculo-ventricular orifice, usually due to valvular endocarditis.

_Treatment._—Give this body the same treatment as advised for aortic incompetency, with special care indicated in mitral incompetency.

=Tricuspid Incompetency.=—_Synonym._—Tricuspid Regurgitation.

_Definition._—This condition is an imperfect closure of the tricuspid valves, due to dilation of the right ventricle or to disease of the valves.

_Treatment._—Drain as much blood as possible from this case. Massage the face downward, and inject the maximum amount of fluid; diluting the first bottle to half strength. In obstinate cases of blood discoloration, open the common carotid arteries and internal jugular veins, inject upward in the arteries and drain from the veins, so as to wash out the vessels of the face. For facial injection use nothing stronger than half strength fluid. Give thorough cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

=Tricuspid Stenosis.=—_Definition._—Tricuspid stenosis is an obstruction of the tricuspid opening, usually congenital, though it may be acquired.

_Treatment._—Treat the same as for tricuspid incompetency.

=Pulmonary Incompetency.=—_Synonym._—Pulmonary Insufficiency.

_Definition._—Pulmonary incompetency is an imperfect closure of the pulmonary orifice of the right ventricle due to changes in the pulmonary valves.

_Treatment._—Treat the same as for tricuspid incompetency.

=Pulmonary Stenosis.=—_Definition._—Pulmonary stenosis is an obstruction of the pulmonary opening of the right ventricle, due to congenital defects or to endocarditis.

_Treatment._—Treat the same as for tricuspid incompetency.

=Cardiac Thrombosis.=—_Definition._—Cardiac thrombosis is the formation of blood clots in the cavities of the heart.

_Pathology._—The blood clots are found most frequently in the right side of the heart. They vary in size, from that of a pin head to that of a hen's egg. When degeneration takes place, softening follows, and sometimes particles become dislodged and float off to set up thrombi in other viscera.

_Treatment._—Remove the maximum amount of blood by drainage along with the injection of fluid. The fluid in this case should be not more than half strength for the first part of the injection, to be followed by enough normal fluid to secure preservation. If thrombi have lodged in any of the larger arteries, the circulation to the part reached by the branches of the artery will be affected. This can be overcome by injecting an artery close to the part which is not receiving the fluid. Massage the face downward to assist capillary circulation. Give a complete cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

=Hypertrophy of the Heart.=—_Definition._—Hypertrophy of the heart is an enlargement of the organ, due to an increase in the volume of its muscular fibers, and usually also to dilatation of its cavities.

_Treatment._—Secure full drainage from the veins. Drainage will be stimulated by an injection of half strength fluid for the first part of the injection and a massage of the face. Follow the first part of the injection with enough normal fluid to secure preservation. Give a complete cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

=Cardiac Dilatation.=—_Definition._—Cardiac dilatation is an increase in the size of the cavities of the heart, due either to thickening or thinning of the walls.

_Treatment._—Treat the same as for hypertrophy of the heart.

=Cardiac Atrophy.=—_Definition._—Cardiac atrophy is a decrease in the size, strength, weight, and activity of the heart.

_Treatment._—Remove blood by drainage, and inject half strength fluid for the first part of the injection. The amount of fluid need not be as great as in the acute disease of the heart. Massage the face downward. Give cavity injection. For transportation, govern yourself according to the provisions of the transportation rules.

=Arterio-Sclerosis.=—_Synonyms._—Endarteritis; Atheroma; Arterial Sclerosis.

_Definition._—Arterio-sclerosis is an inflammatory and degenerative condition of the arterial system, primarily of the intima, although later degenerative changes may involve the whole structure. Calcarine deposits are quite common.

_Pathology._—As a result of proliferation, infiltrated areas begin in the middle and outer coats. These nodules vary in size from that of a small shot to that of a large coin. As they increase in size, the intima loses its smoothness and becomes thickened and rough. As these changes progress, the middle and outer coats are weakened. Calcification may also occur in the wall.

In the diffuse form the change in the coats of the vessels extends throughout the greater part of the arterial system, and in some cases invades the capillaries and veins.

In the senile arterio-sclerosis calcareous deposits occur, which render the vessels rigid. Where these tissue-changes involve the capillaries, there may be complete obliteration of their lumen in some places.

_Treatment._—In some cases the artery appears to be closed at a point ahead of the tube and will resist the injection of fluid. Usually, however, the injection can be made without resistance. Blood should be drained from these cases so as to allow as full capillary penetration as possible. When no arterial injection can be made, open the internal jugular and several other large veins, drain blood from them and then inject fluid while the tube is within the vessel. If necessary add a complete hypodermic injection to all parts of the body excepting the face. Give the cavities full treatment. For transportation, govern yourself according to the transportation rules.

=Fatty Degeneration of the Arteries.=—In the fatty degeneration of arteries the process consists in the gradual replacement of certain parts of the muscular cells by fat droplets. The fat makes its appearance as minute droplets or granules in the cells. These granules, which are characterized by their dark color, gradually increase in number and ultimately the whole of that part of the cell may be transformed. During the process the granules coalesce, and in this manner form distinct drops of fat. As the process proceeds the cell is increased in size and becomes more globular in shape. The cell wall is destroyed and the cell may thus be converted into a mass of granular fat. Ultimately the matter between the granules of fat liquify. The corpuscles break up and the fat becomes distributed in the surrounding tissues. The immediate effect of this fatty degeneration is to produce more or less softening of the fatty part, which will impair or destroy its function. In the case of the artery, the internal, middle and external coats may be affected, but the external is the one usually first attacked. The inner layer or endothelium, and the connective tissue cells in the deeper layers of the inner coat may become affected in various parts of the vessel. The process may involve a great portion of the inner coat, even the whole thickness of the intima may be destroyed. The walls of the artery may be entirely solidified, the canal being closed completely with a soft, yellowish substance as a result of the disease. The artery might appear to be a solid mass when the dissecting knife is passed through. We have seen the anterior and posterior tibial, the popliteal, radial, ulnar, the aorta arteries, and especially the arch of the aorta thus affected. Calcification may be present at many places. These cases are frequently met with in old age.

A body of this kind, where there is fatty degeneration of the arteries, is sometimes hard to embalm. The walls of the artery will be very much weakened, and too much pressure must not be made on them while injecting fluid. Inject the fluid so that it will take several hours to fill the tissues. The pressure should be gentle and regular when the aspirator and injector pump is used. If this precaution is taken often the whole body can be embalmed without a rupture of the arterial system, the fluid reaching all the extremities by means of collateral circulation.

If the embalmer should be so unfortunate as to rupture the circulation then he will have to resort to cavity embalming, and the subcutaneous tissues will have to be embalmed by the hollow needle trocar.

=Aneurism.=—_Definition._—An aneurism is a circumscribed dilatation of an artery, formed by the giving away of one or more of its coats. A false aneurism is where there is a rupture of the coats, and the blood is found in the adjacent tissues.

_Treatment._—Drain blood from a large vein. Inject half strength fluid for the first part of the injection, followed by enough normal fluid to secure preservation. The aneurism itself, will not affect the circulation of fluid to any great extent. Massage the face downward. Give a complete cavity injection. For transportation, govern yourself according to the transportation rules.