usual fashion but was unable to retrieve it.

She was first seen

Clinical ÍN otes, Suggestions and
INew Instruments
FOREIGN BODY IN THE BLADDER
Removal of Thermometer with Stern-McCarthy Resectoscope
WALTER A.
SCHLOSS, M.D.
and
MARK SOLOMKIN, M.D.
Hartford, Conn.
The story of foreign bodies in the urinary bladder is an old
one, varied and fascinating. Brewer and Marcus 1 state that
the medical literature from 1880 to 1946 contains reports of no
less than 566 foreign bodies in the urinary bladder. The
following objects are among those that have been found2:
lead pencils, slate pencils, knitting needles, nails, hairpins,
button hooks, feathers, paint brushes, kidney beans, watch
chains, leather shoe laces, straw, chewing gum, chalk, slippery
elm, paraffin, tallow, bougies and catheters. Also reported are
a perfume bottle, a hog's penis (in female urethra), a condom,
a toothbrush handle, a squirrel's tail, a thermometer, a snail, a
candiru (a species of fish that penetrates the urethra and
enters the bladder), candles, a sponge, a wasp and paraffin from
the treatment of hernia by injection. Geyerman3 reported
removing a decapitated garter snake 18 inches (46 cm.) long
from the bladder. Hoberg 4 removed, by suprapubic cystotomy,
23 inches (58 cm.) of insulated electric wire from the bladder
of a man. Bond "' found several dozen nails and tacks, two
screws, glass, a stone, a piece of animal bone and enamel from
a tooth, as well as feces and pus, all in the bladder of a man
who had an ileovesical fistula.
Hankinson l; reported the case of a woman who, while taking
her vaginal temperature for birth control purposes, accidentally
slipped the thermometer into the bladder. Removal was accom-
plished by placing the patient in a- partial Trendelenberg
position, passing the smallest size infant proctoscope through
the urethra, passing an Eve nasal snare around "the con-
striction of the bulb and extracting the thermometer.
Aspinall T reported a similar incident in which the patient
accidentally passed the thermometer into her bladder while
attempting "to take her temperature in the vulva." As the
patient was thin, it was possible to palpate the thermometer
between the hands, one on the abdomen and one in the vagina.
With the patient under anesthesia, the thermometer was
extracted by manual manipulation (one hand on the abdomen,
one finger in the urethra and an assistant's finger in the rectum).
As might be expected, Aspinall reports that it was a tedious
maneuver. The patient made an uninterrupted recovery.
In a general article on removal of foreign bodies from the
bladder, Jeck 8 does not mention the use of the proctoscope or
the resectoscope or manual removal. It is the use of the
resectoscope in the case reported here which is of interest.
REPORT OF CASE
The patient, a 29 year old white nulligravida, had been
married for one and one-half years and had failed to become
pregnant, although no contraception was practiced. In an effort
to determine her time of ovulation a gynecologist in another
city had instructed the patient to take and chart her vaginal
temperature each morning. On the morning when she was first
seen by us, she had inserted the thermometer (an ordinary oral
thermometer made by Taylor) in what she thought was the
1. Brewer, A. C., and Marcus, R.: Foreign Body in the Urinary
Bladder: An Unusual Case, Brit. J. Surg. 35: 324 (Jan.) 1948.
2. Winsbury-White, H. P., cited by Brewer and Marcus.1
3. Geyerman, P. T.: Medical Curiosities [Snake in Bladder], J. A.
M. A. 108:1409 (April 24) 1937.
4. Hoberg, J. E.: An Unusual Foreign Body in the Urethra and
Bladder: Case Report, Urol. & Cutan. Rev. 50: 678 (Nov.) 1946.
5. Bond, S. P.: Foreign Bodies in the Bladder, J. A. M. A. 83:
1163 (Oct. 11) 1924.
6. Hankinson, J.: A Complication of Birth Control [Thermometer
Accidentally Passed into Bladder], Brit. M. J. 2: 574 (Oct. 11) 1947.
7. Aspinall, A.: Thermometer in Bladder, M. J. Australia 2: 454
(Oct. 10) 1931.
8. Jeck, H. S.: Removal of Foreign Bodies from the Urethra and
Bladder, Am. J. Surg. 36: 197 (April) 1937.
at home, where vaginal and rectal examination failed to dis-
close the thermometer. A diagnosis of probable foreign body
in the urinary bladder was made. This was confirmed in the
office, where a 16 F Brown-Buerger convex cystoscope was
easily introduced into the bladder without anesthesia and the
intact thermometer was visualized lying transversely on the
floor of the bladder.
The patient was hospitalized. Cystoscopic examination was
again performed, this time with the patient under thiopental
sodium anesthesia. Several attempts were made to guide the
end of the thermometer into the sheath of a 28 F McCarthy
foroblique panendoscope with the foreign body grasping forceps.
This was unsuccessful, but we did succeed in turning the
thermometer so that instead of lying transversely in the bladder
it pointed toward the internal urethral opening. We then
thought that we would make a gentle and cautious attempt to
grasp the thermometer end with the Lowsley visualizing grasp-
ing forceps, realizing full well that the power of the jaws of
this instrument was sufficient to break the thermometer if not
properly handled. Dr. D. Dillon Reidy, attending urologist at
St. Francis Hospital, suggested the use of the 28 F Stern-
^fcCarthy resectoscope instead of the Lowsley instrument.
This was done. The tip of the thermometer was guided into
the electrotome loop and thus into the resectoscope opening by
Diagrammatic representation of the technic used in removing the ther-
mometer from the bladder with the Stem-McCarthy resectoscope.
numerous excursions of the electrotome loop and manipulation of
the resectoscope (the accompanying figure). When the tip of
the thermometer was inside the electrotome loop, pointing
straight into the urethra, pressure was made on the bladder
suprapubically by an assistant and at the same time the resecto-
scope was gently and easily withdrawn. The thermometer
came out intact, still within the loop, with its tip inside the
resectoscope sheath.
The patient withstood the procedure well and went home the
following morning, complaining only of slight burning of the
external meatus at the end of micturition.
COMMENT
The value of the daily determination of basal body tempera-
ture in determining the probable time of ovulation and in
planning pregnancy has been established.8 In the early work
on basal body temperature, the taking of the vaginal tempera-
ture was suggested. It was soon discovered that rectal tem-
peratures were equally accurate. However, it is now apparent
that changes in gonadal function can be determined in most cases
by the careful recording of oral temperatures. Nevertheless,
there are still those who persist in the use of the vaginal method
of determining temperature. This unnecessary procedure is
fraught with danger and can expose the patient to much risk
and harm.
9. Mazer, C., and Israel, S. L.: Diagnosis and Treatment of
Menstrual Disorders and Sterility, ed. 2, New York, Paul B. Hoeber,
Inc., 1946.

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 Whenever there are breakable objects in the bladder, such as
thermometers, glass rods and tubes, there is great risk of
breakage in removing them transcystoscopically. The method
described here, with the use of the Stern-McCarthy resectoscope,
obviates the danger of using a grasping or crushing instrument
in extracting these objects from the bladder transcystoscopically.
Dilatation of the urethra also is avoided. The advantages of
removing foreign bodies from the bladder via the urethra are
obvious.
CONCLUSIONS
1. The danger of using the vaginal method to determine
basal body temperature is again stressed.
2. A method of recovering a loose object from the urinary
bladder by the use of the resectoscope is described.
RESUSCITATION AFTER APPARENT DEATH FROM
SPINAL ANESTHESIA
Effectiveness of Cardiac Massage and a New Method of
Artificial Respiration
T. L. HYDE, M.D.
and
LEO V. MOORE, M.D.
The Dalles, Ore.
Resuscitation of a patient after her apparent death from spinal
anesthesia with piperocaine hydrochloride (metycaine hydro-
chloride\s=r\) is reported herein; cardiac massage and a new
method of artificial respiration were used.
REPORT OF CASE
History and Induction of Anesthesia.\p=m-\A slender woman aged
26 in otherwise excellent health was found to have gallstones.
In the past she had had two normal pregnancies and typhoid.
She was admitted to the hospital, given pentobarbital sodium
100 mg. at 8 p. m. and again at 6 a. m. Thirty minutes
before being brought to the operating room at 9 a. m. she was
given a hypodermic injection of morphine sulfate 0.016 mg. and
scopolamine hydrobromide 0.0003 mg., which produced an
agreeable sedation. She was placed in right lateral level
recumbency with the back arched, and a 22 gage spinal needle
was easily introduced into the dural space between the third
and fourth lumbar vertebrae. Spinal fluid dropped readily from
the needle. Two cubic centimeters of spinal fluid was aspirated
into a syringe containing 150 mg. of piperocaine hydrochloride
and 45 mg. of ephedrine sulfate in 3 cc. of water. The 5 cc.
volume of fluid was then introduced with moderate speed and
the needle withdrawn. The patient was then turned onto her
back with the operating table horizontal. The abdomen was
prepared with cleansing and antiseptic solution and draped for
operation. Ten minutes after introduction of the anesthetic
solution the patient had anesthesia to the level of the lower
end of the sternum, and a transverse incision was made over
the gallbladder region. The liver edge overhung, so the gall-
bladder rest on the table was raised. The table was otherwise
left flat. The patient conversed freely; her pulse and color were
normal and respiration quiet, and the operation proceeded. An
anomaly of the junction of the cystic and common bile ducts
caused some delay in the operation.
Apparent Death and Resuscitation.—At about twenty-five min-
utes the anesthesist announced that the anesthesia level was at the
clavicles, but the patient's condition otherwise was not changed.
The cystic duct had just been severed and tied when the anes-
thetist announced that the patient's color was poor and that
she had ceased to breathe. This was forty minutes after the
introduction of the spinal anesthetic solution. The patient's
color was indeed poor. There was no arterial pulse nor
palpable cardiac impulse. The anesthesia machine mask was
applied with 100 per cent oxygen in the bag. Artificial respira-
tion was induced by rhythmic pressure on the chest. Some
respiratory exchange was produced without improvement in
the patient's color. The patient had died by all ordinary
criteria of stoppage of heart beat and respiration.
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The left hand of the surgeon was introduced into the abdomen
through the incision and up under the diaphragm to feel of
the heart. A desperate massage of the heart was begun, poking
at the heart every second or so. Soon it was found that the
heart could be squeezed between the palmar surface of the hand
and the anterior chest wall. After about 90 seconds of such
massage the skin of the forehead was noticed to become
definitely pink. This was encouraging ; an intratracheal rubber
air way tube was then introduced and the mask reapplied.
Artificial respiration by intermittent pressure on the bag of
the anesthesia machine seemed difficult to perform, but it was
noticed that the upward pressure of the massaging hand on
the heart would produce some respiratory exchange. The
rapid massage of the heart was continued, with the left hand in
the abdomen, and adequate respiration was produced by slow,
alternate lifting" and depressing of the lower end of the sternum
with the right hand. The fingers were hooked around the
manubrium sternum through the abdominal incision. The color
of the skin became nicely pink over the face and arms of
the patient. Circulation was being maintained, although there
was no suggestion of any respiratory effort on the part of
the patient or of any cardiac contraction. Stimulants (1 mg.
of epinephrine chloride, 0.5 Gm. of caffeine and sodium benzoate
and 2 cc. of 25 per cent nikethamide solution) were introduced
into the left cubital vein followed by 5 per cent dextrose in
isotonic sodium chloride solution.
Twelve minutes after the anesthetist announced the cessation
of pulse the heart was felt to give a single powerful contrac-
tion. Ten seconds later there was another powerful con-
traction, then several more such contractions, and soon the
heart began a rapid, regular beating which persisted. The
surgeon's left hand was practically stiff with fatigue. Respiration
still had to be maintained, but this was accomplished easily by
the rhythmic alternate lifting and depressing of the sternum.
After thirty-two minutes of artificial respiration sporadic
spontaneous respiratory efforts were noticed ; these soon became
regular and adequate.
Operation and Subsequent Course.—The gallbladder was then
removed and the abdomen closed. A pint (500 cc.) of type O
refrigerated blood was given and 2 pints (1,000 cc.) of dried
plasma. The blood pressure soon rose to 100 systolic and 60
diastolic, with a pulse rate of 140 and a variable respiratory
rate of 12 to 22 per minute. The patient remained unconscious
for five days. She had several clonic convulsions in the first
thirty-six hours, some of which were exceedingly severe and of
several minutes' duration. Cyanosis during convulsions became
pronounced. The spinal fluid ten hours after operation was
normal. Mass reflexes, including micturition, were present to
painful stimuli. Her temperature rose only to 101 F. and she
was not anemic, but there was leukocytosis (20,000 cells
per
cubic millimeter). The electrocardiogram indicated myocardial
injury with an isoelectric T wave in lead 1 and slight inversion
of the T wave in lead 2. Voltage was a low normal. Tachy-
cardia continued above 110 for several days. There was no
distention or other complication of the abdomen. Nutrition
was maintained intravenously at first and then
by indwelling
gastric nasal catheter. The patient became noisy on the third
day and required sedation. She would grimace and cry out if
disturbed. On the fifth day it became apparent that she had
some awareness of her surroundings. She would smile easily
and seemed serene and happy. She would swallow water and
food. Catamenia occurred. Tendon reflexes were present
normally throughout, but some stiffness of the legs persisted
for eight days. It then became possible for her to sit on the
side of the bed. Her hands moved slowly and stiffly. She
gradually improved. First speech appeared on the tenth day
and was very slow, as were her other motions. She was able
to leave the hospital on the twenty-second day but required
attention for three weeks longer before she could be trusted
to walk alone without falling. There was neither persistence
of the stiffness nor spasticity, but her motions were slow and
somewhat clumsy. She remained remarkably patient and cheer-
ful throughout her convalescence. This had been her dis-
position before her illness. Sexual appetite returned during
the third month, and the electrocardiogram was normal at the