AN
On physical examination the patient was markedly dyspneic
UNUSUAL CASE OF A NEEDLE FOUND IN
THE HEART AT NECROPSY
Charles Rea, M.D., and Philip A. Hoover, M.D.
York, Pa.
Although descriptions of foreign bodies in the heart are not
common, neither are they unique. The literature contains
reports of articles such as toothpicks, pins, needles, fish bones,
bullets, shell fragments and in one case of a pipe stem ' being
lodged in the cardiac structure.
Bullets, especially in the post-war literature, are the foreign
bodies most often reported. Keith records eight cases in
which fibrin-covered bullets were found free in the left ventricle.
-
Needles rank second in prevalence. We reviewed at least a
dozen cases in the English literature, and Cope3 described a
case in which the needle was successfully removed.
A recent death caused by a needle in the heart presents several
interesting features. There was no definite history of the
Needle inposition in the heart exactly as found at autopsy. A 1 shows
the needle extending through the outer wall of the left ventricle and
outlined against the tip of the white arrow. B 1 demonstrates the other
end of the needle in the inner wall of the left ventricle. A 2 represents
the blood clot on the parietal pericardium and marks the point at which
the needle transfixed that tissue. B2 demonstrates the same point
on the visceral pericardium. A3 and B3 both represent the small pleural
tear that provided a mechanism for the subcutaneous emphysema noted
clinically. These points together mark the course of the needle as it
entered the heart.
entrance of a needle into the body ; an interstitial emphysema
involving the neck and chest was the presenting symptom.
Pneumothorax and lung collapse followed. The needle was
discovered at autopsy. We have not found an identical case
in the literature.
A white man aged 70, admitted to the York Hospital. Oct. 28,
1936, had suffered from severe cough and vertigo for four
years. For three weeks past there was severe pain in the left
side of the chest when he coughed. Dyspnea developed.
October 26, coughing ceased but the pain in the chest became
worse. A physician, called October 28, noted interstitial emphy¬
sema involving the left anterolateral surface of the neck and the
upper part of the chest anteriorly.
From the York Hospital.
1. Hunter, W. C.; Staub, R. R., and Lunsford, W. B.: Penetration
of Heart by an Aluminum Pipe Stem, Arch. Path. 6:807 (Nov.) 1928.
2. Keith, Arthur: Loose Bullets and Foreign Bodies in the Heart,
Brit. M. J. 1: 278, 1917.
3. Cope, Zachery: Extraction of a Sewing Needle from the Heart,
Lancet 1:813 (April 10) 1920.
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and
apparently acutely ill. We have recorded only the positive
physical changes. The blood pressure was 144 systolic, 80
diastolic. The temperature was 100.6 F., pulse rate 130 and
respiration rate 40. The left anterolateral portion of the neck
and upper part of the chest revealed crepitation on palpation.
The left lower lobe was dull to percussion and almost silent
on auscultation. Bubbling râles could be heard at the upper
margin of the area of dulness. Over the left upper lobe breath
sounds were exaggerated and the percussion note was hyper-
resonant. No cardiac abnormalities were noted, although the
heart sounds were poor.
Blood studies revealed red blood cells 4,210,000, hemoglobin
75 per cent, white blood cells 19,450. The Kahn reaction was
negative. The urine showed a heavy trace of albumin.
By the fourth day after admission the interstitial emphysema
was disappearing. A thoracentesis on the sixth day yielded
no fluid. Bronchoscopy did not reveal a malignant condition
of the lung. On the seventh day the heart action became very
irregular. Digitalis was given and the rhythm improved.
On the eleventh day the chest was roentgenographed. The
roentgenologist reported interstitial emphysema throughout the
tissues of the neck and chest wall, left pleural effusion and
displacement of the cardiac shadow to the left suggesting atelec-
tasis of the left lung. He observed that increased radiopacity
at the periphery of the lung field suggested slight pneumothorax.
The following day the patient was obviously sinking. The
temperature rose and the heart rate and respiration rate
increased. Death occurred on the evening of the fifteenth day.
Autopsy showed that the left pleural cavity contained 375 cc.
of blood. No puncture wound was found on the pleural sur¬
faces nor in the fibromuscular tissues of the thoracic wall.
The left lung presented an aerated upper lobe except for a
small V-shaped area, about 8 mm. wide, at the lower margin
of the upper lobe, which overrode the pericardium. This
V-shaped area consisted of pleura presenting a perforation
from 2 to 3 mm. long, occurring at the margin of angulation
with collapse and retraction of the underlying alveolar struc¬
ture. A mechanism for production of the interstitial emphysema
noted clinically here was seen. The parietal pleura covering
the pericardium at a point opposite this defect presented an
area of hemorrhage of approximately 6 mm., to which area thin
fibrinous strands were attached. The left lower lobe was
extensively collapsed.
The parietal pericardium, opposite the area of hemorrhage
on the parietal pleura, was covered with coagulated blood. In
the midst of the mass adherent to the visceral pericardium,
which similarity was covered with coagulated blood, the end
of a hard sharp object, such as that of a needle, could be pal¬
pated. This occurred at a point 5 cm. from the apex of the
heart and was in general alinement with the perforation of the
visceral pleural and pericardial lesions. Close inspection revealed
the end of the hard object to be the broken eye end of a thin
needle, now black. On dissection, the point of the needle with
approximately 1 cm. of its length was found projecting into the
cavity of the left ventricle after transversing the interventricular
septum. The needle was 1 mm. thick and 34 mm. long.
COMMENT
On the basis of the autopsy and a subsequent history obtained
from the patient's widow, it is possible to reconstruct a modus
operandi which fits the clinical picture fairly well.
The widow states that the patient stepped on a sharp object
in the dark with his left foot in 1932. No foreign object
could be discerned in the morning, although there was some
pain and tenderness of the plantar surface for some days. It
would appear probable that this was the point of entrance of
the needle, which gradually worked its way upward, penetrat¬
ing the pleura and lodging in the heart ; the pleural tear caused
the interstitial emphysema, while the point in the clinical his¬
tory at which the heart became irregular probably marked the
beginning entrance of the needle into the cardiac structure.
The fact that the needle only recently penetrated the pleuro-
pericardial surface was confirmed by the necropsy. It must be
considered, however, that the needle may have been driven into
the chest recently during one of the falls incident to the patient's
vertigo.