Approaching cardiac weakness is always indicated by failure of capillary circulation, which may be easily and instantly estimated by making pressure upon the finger-nails. The rapidity with which the blood will return to give them a natural appearance, after such pressure is made, will be the index as to whether or no stimulation is necessary. Tardiness in return of color, or absence, is a better indication of the approach of shock than is coldness of the nose or moisture of the skin. It often precedes acceleration of the pulse.
Respiration may be interfered with by a variety of causes. Not infrequently the tongue is allowed to drop backward into the pharynx as the patient lies upon his back, which, by its pressure, causes the epiglottis to fall backward upon and close the glottis. The indication here is to lift the tongue forward and carry the epiglottis upward so as to restore the air channel. Extension of the head and neck will accomplish much in this direction, as well as holding the lower jaw forward and upward by well-regulated pressure exerted behind the angle and at the same time by upward and forward traction upon the hyoid bone. But when it is necessary in cases of emergency to carry out this maneuver forcibly and extensively, then the tongue should be drawn upward and forward in the direction indicated in [Figs. 41] and [42].
Tongue forceps are often resorted to for this purpose, and can be procured in various forms and shapes. To the writer their employment has always seemed far more barbarous than the much simpler expedient of passing a curved needle, armed with silk, through the tongue in either direction, 3 to 5 Cm. back of its tip. The suture thus drawn through is knotted and made into a loop, and may be employed through a long operation to make all the traction that will be required. This really makes the tongue less sore and produces less swelling and after-discomfort than does the use of forceps.
Fig. 42
Showing how dragging the tongue over the teeth fails to pull on the epiglottis. (Hare.)
Respiration may also be impeded or suddenly checked by the presence of a foreign body. This may possibly be a plate which the anesthetizer has failed to require the patient to remove, or it may be material ejected from the stomach; this latter is especially likely to happen when emergency has required anesthesia without due preparation. When this happens the fingers should be passed behind the epiglottis and the obstructing body removed. In rare instances some portion of food may have been so impacted in the glottis as to completely obstruct it. If such an emergency arise the trachea should be opened and relief thus afforded. Only in this way can life be saved. Embarrassment of respiration is caused at other times by the patient apparently “forgetting to breathe” or by his taking such shallow inspirations that nothing is accomplished. This may be combated in several ways. In the former instance the use of ether or injections of atropine will frequently afford the necessary stimulus to the respiratory centres. In the latter class of cases especially the most valuable expedient is the dilatation of the sphincter ani, which may be stretched with a speculum, or with the fingers. Long-drawn, even gasping inspirations may follow this expedient.
Finally in certain cases artificial respiration will be required, combined with rhythmical traction upon the tongue. The tongue should be grasped, or controlled by a suture, and retracted from the mouth at the rate of at least sixteen times a minute, while the chest is compressed at the same rate, the traction being made at the moment of relaxation of chest pressure. Tongue traction alone will sometimes renew respiratory movements in extreme cases.[9] [Figs. 43] and [44] from Hare, show the combined manipulation of inverting the patient in order that the brain may not lack for blood supply, and carrying out artificial respiration.
[9] Freudenthal has called attention to the extreme irritability of both surfaces of the epiglottis, and advises to pass the index finger down upon it, irritating it by friction. This causes a powerful reflex effect, as the glossopharyngeal supplies its anterior surface and the inner branch of the superior laryngeal its posterior surface.
While these measures are to be regarded as emergency expedients, they will often need to be supplemented by others, the use of adrenalin and of salt solution, either beneath the skin or in the veins, and the use of the Crile pneumatic rubber suit described in the chapter on Shock.