CHAPTER XXII.

TREATMENT OF SPECIAL DISEASES.—Continued.

DISEASES OF THE DIGESTIVE SYSTEM.

=Jaundice.=—_Synonym._—Icterus.

_Definition._—Jaundice is a symptom rather than a disease, and is found in the various affections of the liver. It is characterized by a deposit of bilirubin in the various structures and fluids of the body, which gives them a yellow or jaundiced hue.

_Etiology._—Most pathologists agree that all the forms of jaundice can only come from obstruction. The obstruction is due to inflammation tumefaction of the duodenum or bile-ducts; to foreign bodies, such as gall stones or parasites, within the ducts; tumors within the duct or by pressure from without, such as tumors, gravid uterus, or fecal matter; or to stricture or obliteration of the duct.

=Catarrhal Jaundice.=—_Definition._—Catarrhal inflammation of the lining membrane of the biliary ducts, and the duodenum, and attended with discoloration of the skin and tissues from the consequent retention and absorption of the bile.

_Pathology._—That portion of the duct lying in the intestines is more frequently and seriously affected, though the inflammation may extend to the cystic and even the hepatic duct. The membrane lining the ducts is swollen and inflamed. The liver is usually congested, slightly enlarged, and of a deep yellow color. The gall bladder is usually distended with bile. The ducts are occluded by the swollen mucosa and plugs of inspissated mucous.

Discoloration of the skin and conjunctiva occurs. The yellow tinge begins in the eyes, forehead, and neck, gradually extending over the body, the color being the deepest in the wrinkles and folds of the skin. The color is generally of a lemon hue, becoming darker and assuming a bronze or greenish tint as the hepatic lesion assumes a graver character.

=Infantile Jaundice.=—_Etiology._—It is not known positively what causes give rise to temporary jaundice in the new-born. Some say it is due to a reduction of blood pressure in the hepatic capillaries, while others say it is due to a stasis in the smaller bile ducts, which are compressed by the distended radicles of the portal vein. The severe form may be due to congenital closure or absence of the common or hepatic duct, to hepatic syphilis of congenital form, or to septic infection due to phlebitis of the umbilical vein.

In the child the skin becomes a yellowish hue of various shades. In the severe form the hue increases in intensity, the skin assuming a bronze or yellowish-green color. The abdomen becomes full and tumid, owing to the congestion of the liver and spleen. When due to syphilis, there is usually skin eruption.

=Malignant Jaundice.=—_Synonyms._—Acute Yellow Atrophy of the Liver.

_Definition._—A grave form of jaundice characterized by neurosis of the hepatic cells and atrophy of the liver.

_Pathology._—The liver shows marked atrophy, being not more than two-thirds or one-half of the normal size, is thin, flabby. On making a section a yellow or a reddish yellow surface is presented. The hepatic cells are found in every stage of necrosis. Most of the organs are bile stained, as well as the skin, and hemorrhages are frequent.

_Treatment for Jaundice._—Since the conditions are similar and since the conditions after death are identical in reference to pigmentation, we will consider the treatment of infantile, malignant, and catarrhal jaundice under one head.

The pigmentation of the skin, no matter how small, is the condition which presents itself most forcefully, and is the most annoying to the embalmer. Much study has been given to the subject, but with little success. It is claimed by some that certain fluids will bleach and bring out the natural color.

A small amount of bile is sufficient to tint the surface of the body. Bile is composed of salts, fats, organic matter, acids, and also coloring matter, called the bile pigments. Bilirubin is the principal coloring matter, and when dissolved in alkali, forms, when coming in contact with the air and also in the dead body, a green precipitate known as biliverdin. The bile pigments in the blood are carried with the serum from the capillaries to the tissues, being deposited in the internal coat or deep layer of the epidermis as well as the papillary of the dermis. The amount deposited regulates the extent of the pigmentation.

One of the most beneficial things to do, where pigmentation is present is to wash out the arterial system, draw blood from the veins, massage the exposed parts. Inject a diluted fluid at first, follow with a fluid of full strength, until complete disinfection and permeation of the tissues has taken place. Keep up constant massaging during the whole course of injection. This may bring fair results, with the addition of face tints and showing the body under artificial light.

Strong solutions of formaldehyde when used at first are deleterious, causing the skin to become green. This greenness is more pronounced when chemicals such as methylene blue have been administered by the attending physician before death. Bilirubin is a red yellow color, and alkalies precipitate the bilirubin and form biliverdin. Biliverdin is a greenish color.

All fluids contain alkalies, and are mostly alkali in reaction, and this may account for the greenish color of the skin after the injection of fluid. Acids do not precipitate the biliverdin and there is a tendency to dissolve it and keep it in solution.

Moadinger suggests that a weak solution of some acid be injected into the arterial system before the injection of embalming fluid. He prefers a two per cent. solution of oxalic acid.

Dhonau prefers the use of a one or two per cent. solution of borax, to be injected into the arterial system, followed by half strength fluid, and this followed by full strength fluid. Dhonau also applies full strength peroxide of hydrogen to the skin while massaging the face.

Eckels prefers the use of a fluid containing a peroxide.

If methylene blue has been administered by the attending physician and you have learned this fact before hand, it is then not advisable to use a formaldehyde fluid. There is a chemical action set up between the methylene blue and the formaldehyde which will give to the tissues a greenish color which is quite objectionable. In this case you would inject some fluid which does not contain formaldehyde. A benzoate of soda or borax, or peroxide solution would do.

A good formula to use, when you know methylene blue has been used by the attending physician is:

Rx Carbolic acid 5 oz. Borax 12 oz. Glycerine 1 oz. Water, qs. 1 gal.

For transportation, govern yourself according to the transportation rules.

=Cirrhosis of the Liver.=—_Synonyms._—Interstitial Hepatitis; Sclerosis of the Liver; Nutmeg Liver; Hobnailed Liver.

_Definition._—A chronic disease of the liver, characterized by an increased connective tissue, a reduction in the size of the organ, and a degeneration of the parenchymatous constituents.

_Etiology._—In a great majority of cases the disease is due to alcohol, syphilis, highly spiced and very rich foods. Cirrhosis may result from chronic obstruction of the bile ducts, due to gall stones, or tuberculosis. Cirrhosis frequently occurs between the ages of thirty and sixty years, though it may be found in the extremes of life. Men are more liable to contract the disease, owing to greater dissipations.

_Pathology._—The liver is increased in size by the increase of connective tissue, and hyperaemic. On the surface it exhibits a knobbed appearance (hobnailed liver) and these knobs present through the capsule a yellowish appearance. The granulations vary in size from a pinhead to a pea. As a rule there is a little jaundice, as there is a decrease in the production of bile, instead the skin takes on an earthy, sallow tint. There is generally ascites, swelling of the feet and legs, which increases until the abdomen and the lower extremities become of an enormous size. The nutrition of the body suffers, the skin is dry and harsh. The blood is altered in quantity, and coagulates quickly. Ecchymotic spots appear on the skin, about the face and nose.

_Treatment._—There are probably not many other cases of death, which need greater skill and intelligence in their treatment than does cirrhosis. The condition that presents itself is a distended abdomen with gas and liquid. The limbs are also distended and the upper part of the body is wasted away and is greatly discolored as death was caused by asphyxia.

Place the body on the board, open the femoral vein, and insert your drainage tube. It is better to use this vein as it is larger, and there is more control of the removal of blood, and we would advise in this case the use of the flexible rubber drainage tube, which can be pushed up in the vein till it reaches the right auricle of the heart if you wish. Drain all the blood possible. Use the trocar method, see page 255, or the direct incision, see page 257, to remove the gases and ascitic fluid from the abdomen. Use the bandage method, see page 339 to remove the water from the tissue of the extremities.

Raise the femoral artery and inject slowly a diluted fluid and massage the face gently toward the jugular vein, using some recognized face bleacher. Then follow with an injection of fluid of full strength until you are sure the fluid has permeated every tissue of the body. Do not be afraid to use plenty of fluid. Inject the cavities.

For transportation, govern yourself according to the transportation rules.

=Carcinoma of the Liver.=—_Definition._—A cancerous growth in the liver.

_Pathology._—Jaundice is present in most cases and where the portal circulation is seriously compressed, ascites developes. The liver is greatly enlarged, and the surface is nodular.

_Treatment._—As in all chronic affections of the liver, where the skin takes on a yellowish or bronze hue, due to pigmentation, it is almost impossible to bring about the desired cosmetic effects. The pigment is not only in the blood vessel but also in the tissues of the skin.

We would advise the washing out of the tissues, by the use of the oxalic or borax solution, injecting the axillary artery and draining from the femoral artery or raising both the carotid arteries, injecting upward on one side and draining from the other.

For transportation, govern yourself according to the transportation rules.

=Appendicitis.=—An inflammation, acute or chronic, of the appendix.

_Pathology._—The pathology will depend to a great extent upon the degree of the inflammation. Ulceration may take place or there may be perforation.

_Treatment._—If, after an operation, reopen the incision made by the surgeon, relieve the gas pressure on the intestines by incising them; surround the intestines with hardening compound; then inject an artery, using half strength fluid for the first 64 oz., followed by enough normal fluid to secure preservation. Drain the blood during the injection by one of the drainage processes.

If no operation has been made, insert a trocar into the caecum to relieve the gas pressure, then inject normal fluid into the same place, using sufficient fluid to neutralize the process of putrefactive fermentation. The trocar can be first inserted in the usual place passing it to the caecum, or through the abdominal wall directly over the caecum. The arterial injection and drainage should be made as is mentioned above. For transportation, govern yourself according to the transportation rules.

=Peritonitis.=—An acute or chronic inflammation of the peritoneum either local or general.

_Pathology._—There is nearly always present more or less fluid in the abdominal cavity.

_Treatment._—Drain blood from a large vein, and inject half strength fluid for the first part of the injection, following this with enough normal fluid to preserve the tissues of the body. After the arterial injection and drainage have been completed, pierce the abdominal cavity in the usual place and draw off all the fluid that you can reach, paying especial attention to the lower part of the cavity. Then inject normal or supernormal fluid into the cavity to neutralize the process of putrefactive fermentation. Pierce the colons and inject fluid into them as well. If fermentation resists this treatment, make a small incision along the median line and above the umbilicus, examine the stomach and intestines, incising them if they contain the gas. After eliminating the gas, inject fluid directly into them, or, surround the organs of the cavity with good hardening compound; sew up the incision and the body should not deteriorate in any way. For transportation, govern yourself according to the transportation rules.

=Dropsy.=—_Definition._—Dropsy is the accumulation of serous fluid in a cavity or in the tissues.

Dropsy of the abdomen is called ascites.

Dropsy of the chest is called hydrothorax.

Dropsy of the peritoneum is called hydroperitoneum or ascites. General dropsy of the cellular tissues is called anasarca.

=Ascites.=—_Synonyms._—Dropsy of the Peritoneum; Abdominal Dropsy.

_Definition._—An accumulation of serous fluid in the peritoneal cavity.

_Etiology._—Any obstruction of the portal circulation is a possible cause of ascites, the most frequent being cirrhosis of the liver. Pressure from tumors or neighboring organs may also give rise to it. Peritonitis and valvular diseases of the heart are also responsible for ascites, and chronic pulmonary affections may impair the portal circulation to the extent of producing it.

_Pathology._—The quality and character of the fluid show great variation, from a few pints to several gallons, and from a straw or lemon tint to a brownish or greenish hue. It may be blood stained, and occasionally clean and transparent. It is usually watery in character.

_Treatment._—Use the trocar method. Insert the trocar through the umbilicus and draw off all the ascitic fluid from the abdomen, then surround the organs with a quantity of fluid sufficient to preserve them. Or if you desire, use the direct incision and after the ascitic fluid has been drawn off, surround the organs with a hardening compound.

The body in general should be preserved through an arterial injection of normal fluid for the first 64 ounces, then one and one-quarter strength for all subsequent bottles. This, if attended by copious drainage from a large vein, will preserve all portions of the body excepting possibly the epidermis of the posterior abdominal wall, which, by gravitation of the ascitic fluid, will become separated from the derma, producing skin slip, and causing the formation of blisters.

Previously to placing the body on the embalming board for treatment, a rubber cover should be placed over the board so that drippings of all kinds can be made to flow into a bucket at the lower end of the embalming board. When the above mentioned blisters are cut and their contents disposed of by gravitation into the bucket, a strong solution of formaldehyde should be applied to the affected skin to harden it and to prevent any further progress toward decomposition.

In ascitic cases the casket should be lined with rubber or oil cloth to a point three or four inches above the bottom. In addition to this precaution, the use of sawdust is favored so that any unlooked for breaking of blisters may not be attended by a flow of the ascitic liquid from the casket. Many embalmers do not protect themselves against contingencies of this kind and are frequently criticized by the friends and family of the deceased.

=Anasarca.=—_Definition._—Anasarca is a general dropsy of the cellular tissues.

_Treatment._—_Bandage Method._—Bandage the extremities of the body, commencing at the toes and finger tips, bandaging upward to the hip and shoulder, using a rubber bandage. Relieve the water as you go along, then rebandage, and by the third application you will have removed most of the water from the extremities. Do not leave the bandage on while injecting.

_Bandage Method._—Bandage the lower limbs, commencing with the thighs. Bandage as tight as possible down to the toes and make an incision in the heel, from which drainage of the serous fluid can be secured. In this method no laps are left between the bandaging so that the serous fluid can be forced toward the opening at the heel. (This method is said to be reliable, although we have had but little experience with it.)

Any accumulation of ascitic fluid in the cavities should be removed by aspiration with the trocar, as described in the treatment of ascites and hydrothorax. The rubber cover for the embalming board as described in the treatment for ascites, should not be omitted.

After the water has been eliminated as far as possible, the arterial injection should be made, using 64 ounces of normal strength fluid, followed by enough one-fourth strength fluid to secure preservation. Copious drainage will help to clear the blood vessels and allow a better distribution of the fluid, thereby assuring good preservation of all parts excepting the epidermis, which is practically closed off to the fluid by the accumulation of water in the subcutaneous tissue.

In these cases the skin should receive a good application of strong formaldehyde fluid before and after the principle operation, so as to strengthen it against the putrefactive tendencies of the rete mucosum.

These cases should be watched closely between the time of embalming and the funeral, as the most thorough preparation is sometimes unequal to the task of preserving the entire body in such a way as to prevent the formation of blisters.

For transportation of all dropsical conditions, govern yourself according to the provisions of the transportation rules.