injuries ofthe heart and great vessels due to pins andneedles · injuries of the heart and great...

Thorax (1969), 24, 246.

Injuries of the heart and great vessels due topins and needles

DAVID CHAS. SCHECHTER' AND LAWRENCE GILBERT

From the Section of Cardiothoracic Surgery, Newark Beth Israel Hospital, Newark, N.J., U.S.A.

Three instances of cardiac injury from needles in two adults are described. Trauma was accidentalin one and due to suicidal attempts in the other two. The objects were removed. There are 157published accounts of wounding of the heart and/or great vessels by pins and needles. Thevictims have ranged from infants to the elderly. Causative agencies were accidents, suicide, andhomicide. A few were discovered at necropsy in presumably asymptomatic persons. Six of theaccidental injuries were iatrogenic. The objects reached the heart or great vessels from trans-thoracic insertion, ingestion, embolization, aspiration, or transabdominal penetration. The overallmortality incidence was about 50%. Acute cardiac tamponade was the dominant cause of death.Almost all individuals survived who were operated upon and from whom the object wasremoved. The right ventricle was hurt most often, but no region of the heart or of the greatvessels was spared. Occasionally multiple parts were affected. The primary damage occurredprincipally while the foreign body was extracardiac and relatively immobilized, from repetitivescratching or puncturing of the beating heart. Chest pain and unfolding patterns of tamponadewere inconsistent in onset, severity, and duration. Death ensuing days or weeks after the initialinjury was frequent. Progressive haemopericardium in somne cases was due to or aggravatedby laceration of a structure from within outward. Late complications-several fatal-wereconsequent upon inflammation, sepsis or thromboembolism. It is urged that all foreign bodies inthe heart or great vessels be retrieved, even if seemingly innocuous clinically.

'One discovers the heart under the unexpected aspectof a bric-a-brac shop, where may be found objects asdisparate as in the fabled stomach of the ostrich.'

Dr. Chas. Esmein (1910)

Cardiac wounding by foreign bodies poses prob-lems in management that are dissimilar from thoseof other pathological conditions. That the heartor great vessels may be severely damaged byobjects of unimpressive size or appearance is afact. In the main, preoccupation with this varietyof injury has pertained to bullets, shrapnel, andkindred projectiles. However, similar trauma hasalso occurred in consequence of strikingly diversi-fied items. A pot-pourri of objects has been in-culpated: the spine of a sting fish, metallicsplinters, tooth picks, dental plates, fish bones,pieces of ice-pick blades, bone spicules orsequestra, scraps or rods of wood, glass slivers, analuminium pipe stem, thorns, stud gun nails, metalfiles, drill fragments, fruit pips, vegetable fibres, anorthopaedic wire strut, a rubber catheter, a metal'Present address: Section of Cardiovascular and Thoracic Surgery,New York Medical College, New York, N.Y.

cannula, a false tooth, a straw from a broom, anda worm (Blaiha, 1935; Decker, 1939; Barrett,1950; Lowen, Fink, and Helpem, 1950; Bajardi,1953; Tinzer, 1953; Farber and Craig, 1956;Parmley, Mattingly, and Manion, 1958; Weekleyand Maltby, 1963 ; Gajdas, 1963; Leonard andGifford, 1965; Hudson, 1965).Over the past decade numerous accounts have

been published of iatrogenic mishaps resulting inpieces of diverse medical paraphernalia beingswept into the heart or great vessels. Disconcertingsituations have arisen from the breakage and lossinto the blood stream of venoclysis tubing,Pudenz-Holter valves for decompression in hydro-cephalus, and flexible steel stylets used durinigcardiac catheterization (Lillehei, Bonnabeau, andGrossling, 1965).Wounds of the heart and great vessels due to

pins and needles are not common: nor are theyharmless. This communication reports a personalexperience with three instances of sewing needleinjuries to the heart in two patients.

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Injuries of the heart and great vessels due to pins and needles

CASE REPORTS

CASE 1

First admission B. B., a 29-year-old woman, was firstseen by one of us (L. G.) in December 1960 at herpsychiatrist's consulting-room. On the precedingevening, while sitting, she had partly pushed anordinary sewing needle into the front of her leftchest. The pain made her stand up, and with thissudden movement the remainder of the needle dis-appeared beneath the skin. The pain was relievedwhen she lay down in the prone position.There was a minute fresh puncture site in the 5th

intercostal space just left of the sternum. Fluoroscopyshowed the needle to be entirely within the cardiacsilhouette and moving synchronously with each beat.The deepest portion of the needle moved morevigorously than its superficial parts.

Operation was performed approximately 18 hoursafter injury. Thoracotomy was through a sub-mammary 5th intercostal incision. The hub of theneedle was palpated at a small ecchymotic area inthe pericardial fat over the right ventricle. On dis-secting the fat a glint of metal was perceived. Theneedle was found still projecting through the peri-cardium. It was grasped with a haemostat and with-drawn gently. Oozing of dark blood through thewound in the pericardium followed, and the latterwas opened widely anterior to the phrenic nerve.Approximately 50 ml. of blood was aspirated. Thepericardial sac was left open.The patient's recovery was uncomplicated. Radio-

logical studies on the seventh postoperative dayshowed a normal cardiac silhouette, no haemothorax,and no other foreign bodies in the chest wall or

cavity. On this same day the patient was transferredto an institution for psychiatric care.One week later the patient's physician announced

that chest radiographs taken that day had disclosedtwo foreign bodies. These films revealed a sewingneedle located in the lateral lung field, possibly inthe costophrenic sinus. A second, partially curved,broken needle was deep in the subcutaneous tissue,anterior to the sternum. The consensus was to leavethese objects in place.

Second admission In December 1965, B. B. (now 34years of age) was referred directly from the psychi-atrist's consulting-room after remarking that she hadplunged a needle into her chest five days previouslyduring a fit of mental depression. Radiography andffiluoroscopic examination showed the needle entirelywithin the cardiac silhouette and moving synchro-nously with each beat. In addition, the presence oftwo other foreign bodies, noted in the radiographstaken five years previously, was confirmed. Neitherof these foreign bodies had migrated.That same evening the left thorax was re-explored

through the former incision. The pericardium wasdensely fused to both the heart and retrosternaltissues. Over the anterior surface of the right ventricle,

an area of recent ecchymosis was seen; and soon,after dissection and search, about 1 mm. of the needlehub was found projecting free of the adherent peri-cardium. The needle was easily withdrawn. Therewas no bleeding from the puncture site. Explorationof the subcutaneous tissue exposed the 'old' needlefragment sequestered there. Probing in the costo-phrenic sulcus, hampered by considerable adhesions,did not reveal the needle anticipated in this area. Asit was considered to be harmless, no further attemptswere made to retrieve it.The patient's recovery was uncomplicated, and she

was discharged on the eighth postoperative day toanother institution for psychiatric treatment.

CASE 2 J. U., a 43-year-old roofer in the habit ofcarrying a needle in his left shirt pocket for removingsplinters from his fingers. was knocked on the chestby a ladder. Sharp pain was experienced over the leftbreast, but this grew less within an hour, and he wasable to resume work with no further discomfort. Henoticed a speck of clotted blood on his undershirtand was aware of the loss of his needle, but wasunconcerned about this until three days later, whenagain he received a glancing blow on the chest, thistime from a swinging door. Pain ensued and persisted.It was sharp, localized to the left breast, and notaltered by position or breathing.

Physical examination was normal; but a hard,tender, subcutaneous nodule, 0 75 cm. in size, waspalpable in the 5th intercostal space immediatelylateral to the left of the sternum. The electrocardio-gram was normal.

Radiography revealed a linear density in the regionof the cardiac ventricular septum, its outer enddirected towards the anterior chest wall, 4 cm. fromthe skin. By fluoroscopy the free end of the needlewas seen to vibrate synchronously with the heartbeat.

Operation was undertaken about eight hours afteradmission. A left 5th intercostal anterolateral incisionwas made and subsequently extended to the right.transsternally, without entering the right pleuralcavity. No track was visible in the intercostal tissuesor on the surface of the pericardium. Nor was thereany imprint on the heart itself to indicate the entryof the needle. The pericardial sac contained less than50 ml. of blood.

Methodical palpation and pressure on differentparts of the heart failed to uncover the site of nida-tion of the needle. Recourse to an electromagneticlocator was not fruitful, and neither was probing ofthe right ventricular chamber with a haemostatinserted through its apex.A finger was introduced into the right atrium,

through the appendage, and about 1 cm. of the pointof the needle was felt immediately above the medialcusp of the tricuspid valve. By combined pressureon the needle and quickly flattening the heart in theanteroposterior plane by manual pressure it waspossible to extrude the heel of the needle through

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David Chas. Schechter and Lawrence Gilbert

the anterior cardiac wall and to grasp it with a haemo-stat and remove it. The pericardial sac was left open.

There were no arrhythmias. The patient withstoodthe procedure well, and there were no untowardpostoperative sequelae from the manipulationsdescribed.

ANALYSIS OF THE WORLD LITERATURE

Cardciac injuries from pins are almost identicalwith those from needles. Some 157 cases ofwounds caused by these objects have been col-lected up to 1967. They, together with those we

have described, comprise the context of our re-

view. Recitals of the 'modes of injury, as well as

their nature, furnish rather provocative readingmatter.

HISTORICAL The earliest documentation on thissubject was made in 1600 by Paulus Zacchias, thefather of forensic medicine. A priest decided on

immolation by castrating himself and thrustingseveral stout needles into his body, including one

through the heart. He survived for six days.Zacchias was duly impressed by this-'. . . hicquidem mirabile auditu est . .'-for had notAristotle himself stated that touching the heartbrought about instantaneous death ? In 1782, a

Sardinian nobleman, at the court of KingAmadeos, was slain during sleep by his exasperatedwife. She plunged into his heart a needle whichwas made of gold. Admiral Pierre Charles Jean-Baptiste Silvestre, the Duke of Villeneuve, beingresponsible for tactical blunders at the Battles ofthe Nile and Trafalgar, fell into disfavour withNapoleon. Despondent, he purchased anatomicalplates to become acquainted with the arrangeimentof the thoracic viscera. Then, with precision, hepassed a needle into his heart. He survived severalyears and was captured by the English on 22 April1806.

It is surprising, considering the antiquity ofcardiac acupuncture and its widespread use even

in eastern European countries during the choleraepidemics of the last century, that only a singledeath is on record from this type of injury (Schiff,1965).

OBJECTS There are reports of 147 injuries fromneedles. Most were from plain household sewingor darning needles. In nine instances, two or moreneedles were used. In four, knitting needles ofvarious lengths were incriminated. In one, a 9-cm.needle for mending sails was used in a suicideattempt. The shortest needle resulting in a fatalitywas less than 2 cm. long. A gramophone needle

was discovered in a heart at necropsy. Five caseswere due to thoracentesis or to hypodermic needlesbreaking at the hub. One involved embolism ofa radium needle from the skin to the pulmonaryartery.The rest of the injuries were caused by assorted

pins. The shortest which resulted in death was lessthan 2 cm. long; the longest was an 8-in. hatpin.There were also a shawl pin, a brooch pin, twohairpins, and four safety pins. Multiple pins wereused for suicidal purposes in two instances, bybeing swallowed or thrust into the body. A blunt'bobby pin' was ingested accidentally and cameto rest in the heart in one case.

CAUSATION The pins and needles entered the heartmuscle or its cavities chiefly by transthoracic pene-tration or by ingestion. In 88 authenticated casesthe injury was accidental. The transthoracic routeaccounted for 68 of these, the invariable mechan-ism being a fall, a blow or an embrace, with theobject stuck originally in the victim's or someoneelse's clothes. In one instance a man nearly diedwhen a needle in the bodice of a barmaid withwhom he was engaged in coitus traversed his chestwall. Six of the accidents were iatrogen.ic. Theloss of a radium needle on that basis has pre-viously been cited. The others were from break-age of a needle during thoracentesis, intracardiacinjection, and intravascular embolization duringperformance of venoclysis. In one child, the needleentered the thorax across the abdominal wall, andonly in a single case was it aspirated. In theremainder, the object was swallowed.There were 52 injuries consequent on suicide or

suicidal design. All but seven, in which the objectswere swallowed, were transthoracic wounds. Insome of these there were concomitant self-destruc-tive actions, such as insertion of glass into thevagina, amputation of genitalia, slashing the throatwith a razor, drinking laudanum, and cutting thewrist. One woman swallowed an entire packet ofneedles. Another, to avoid drawing attention,feigned prayer, meanwhile surreptitiously pressing30 pins and needles into her chest with a Bible,until haemiorrhage from the superior vena cavaended her life. One woman both swallowed needlesand thrust several more into diverse parts of herbody.

Pins and needles were used as weapons formurder on five occasions. The most macabre inci-dent concerned a neonate who was mutilatedalmost beyond recognition by being stabbed 20times with a knitting needle and 40 times with apen-knife.

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In six cases, the object was discovered fortui-tously at necropsy. The mechanism of injury wasnot identified in the last nine.

AGE AND SEX There were 76 males and 60 femalesin the series. The sex of the other 24 was notstated. The youngest victim was the infant justmentioned; two patients, the oldest, were 82 yearsof age.As might be anticipated, all the infants and

children were hurt accidentally, either in a fall orby being clasped against the bosom of a motheror nurse whose frock contained the object. About45 of the accidental injuries took place in personsover the age of 20 years, the oldest being 82 years.The proportion of accidents in males was 43 to35 in females. The sex of the remaining 10 acci-dent victims was not stated.

In the suicidal group of 52 cases, the youngestwas a 17-year-old adolescent, and the oldest was82 years of age. There were 25 men and 22women. The sex of the five others was not stated.

PHYSICAL SIGNS The quality, onset, duration, andtemporal relationship of the symptoms variedwidely. The most consistent was precordial orretrosternal pain. This was sharp, lancinating ordull. It was clamant uniformly at the start, be-coming degravescent after irregular periods, andoften recurring with different qualitative charac-teristics as a terminal event. Deep-seated pain andoccasionally dysphagia were early but temporarymanifestations of swallowed foreign bodies. Thetype of secondary pain arising after a relativelysymptom-free interval, and described as an'angoisse' or oppressive in intensity, is recognizableas characteristic of cardiac compression fromhaemopericardium. The severity of the initial painwas greater when the object was stil extracardiac,as in the pericardium or soft tissues of the chestwall. The pain usually disappeared after completeentry of the object into the heart.Dyspnoea preponderated next. It usually devel-

oped later and in association with increasing peri-cardial effusion. When it was pronounced, a senseof suffocation was complained of. Palpitationswere rare.Very early, the foreign bodies were either visible

or palpable in the skin, depending on the forcewith which they had been driven in. Needles eitherleft no trace of puncture on the skin or a smallarea of ecchymosis. The ingress of pins wasordinarily halted by their broadened end, but thiswas inconsistent. When there was a subcutaneousprotrusion, it throbbed rhythmically with the heart

beat. Cessation of this movement was usually anominous sign, inferring that relay of the cardiacpulsations was stilled because of an interposedenlarging mass of blood. A cardiac murmur orpericardial friction rub was audible in a fewpatients.

Incidental symptoms such as retching, vomiting,weakness, cough, and syncope were ordinarilynonspecific accompaniments of trauma. Fever,sweats, and tachycardia usually indicated suppura-tive pericarditis, carditis or pleuritis.

Diagnosis was difficult in many of the infantsand children, especially when information abouttrauma was vague or wanting. Several displayedunexplained lassitude, restlessness or anorexia.Others were given to recrudescent syncope or con-vulsions. A few showed cardiac decompensation.

In both adults and the young, ingravescence ordissolution followed an abrupt pattern, withsudden death or a rapid sequence of heart failure,jugular venous distension, shock, and coma pre-saging death from acute cardiac tamponade. Thistook place both early and late after injury.DIAGNOSIS Immediate death has been uncommon.In most, the correct diagnosis was made, or wasat least attainable, within a few hours from theprecipitating trauma. On 10 occasions it was ob-vious, the article being seen transfixing the skin.In 14 others, the object was subcutaneous, andpalpable, usually with transmitted cardiac pulsa-tions.When information about injury was volunteered

by the patient or by an interested party, leadingto speedy medical evaluation, the chief diagnosticaid was radiology. The shadow cast by a needlewas unmistakable, and its intimate relationship tothe heart was corroborated by its oscillations beingvisualized with fluoroscopy. Cardiac arrhythmiaswere rare, save as a terminal event; electrocardio-graphy was generally not helpful except to cor-roborate clinical suspicion of cardiac tamponadeor pericarditis.

Diagnostic perplexities were presented by thoseinfants regarding whom there was no foreknow-ledge of injury. The customary picture in thesecases was one of mystifying physical deteriora-tion lasting for days or weeks, culminating infrank cardiac tamponade. Often, without ante-cedent clinical portents, children became gravelyil and were admitted to hospital, after which anintracardiac foreign body was discovered byradiography.Two people, a young boy and a middle-aged

woman, insisted that they had a needle in theheart; neither was believed and both died.

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MANAGEMENT The object was removed with thefingers nine times out of the 10 that it jutted abovethe skin. In one case a needle broke when a childtried to take it out, and in another, the manipula-tion resulted in its being pushed further into thechest, necessitating thoracotomy. Death occurredin three of the cases when the object was pulledout with the fingers.The foreign body was subcutaneous in 14 cases,

once with an attached cotton thread trailing overthe skin. In 11 of these, the object was removedafter incising the skin over it. In three othersthese manceuvres were unsuccessful, and majoroperation followed. One patient died afterremoval of the object from the subcutaneoustissues.

Mediastinotomy, pericardiotomy, or formalthoracotomy, each of varying magnitude, wasundertaken 53 times, and extraction by oesophago-scopy once. Six of these operations failed, theforeign body being left behind. Four otherpatients in whom emergency thoracotomy wasundertaken died on the operating table or soonafter.

In three cases, the object was extruded spon-taneously by the heart. In one, it appeared after10 days beneath the ensiform cartilage, and in asecond, at a superior intercostal space after threeweeks. Both were simply removed by incising theskin over them. In the third, a needle which hadtravelled from the antecubital vein to the left lungvia the ipsilateral pulmonary artery over a periodof eight years was removed by wedge resectionof the lung.

FINDINGS AT OPERATION OR NECROPSY The affecte-danatomical structures were distributed thus:

Right ventricle 66Haemopericardium 46Focal or diffuse

pericarditis 20Ventricular septum 16Right atrium 12Lung 11Intracavitary

thrombus 8Left atrium 7Both ventricles 7Papillary muscles 7Diaphragm 6Pleuritis 6Coronary vessels 6Mediastinitis or media-

stinal haematoma 5

Left ventricleOesophagus

StomachTricuspid valvePulmonary arteryAorta

474

HaemothoraxMitral valveSuperior vena cavaPulmonary infarctionBronchusVertebraeInferior vena cava

Liver

Not infrequently, the foreign body causeddamage by wounding adjacent structures, eitherby perforating them individually in transit or byimpaling them concomitantly 'en brochette'.

FATE Apart from the cases discovered coinci-dentally at necropsy, and those patients who diedfrom unrelated or intercurrent disease, the mor-tality in the series was 85 cases, or roughly 50%.

Thirteen of the 85 deaths followed some formof major surgical intervention. Infection wasresponsible for three, iatrogenic errors for two,acute tamponade for three, the moribund state ofthe patients at operation for four, and an inade-quate procedure for one. Closer scrutiny of thecauses of these deaths disclosed that, except asregards the individuals who were operated uponwhile desperately ill, all the fatalities could havebeen prevented. Thus, one of the iatrogenic mis-chances consisted of laceration of a coronary ves-sel. In none of the three who developed tamponadehad drainage of the pericardium been effected,the surgeons being lulled into false security by theabsence of demonstrable haemopericardium whenthe object was removed.The foreign body was taken out by some

surgical means, major or minor, in 51 of the 56survivors, and left in the heart in five. Of thelatter, two died from unrelated ailments after 18months, the third was reported to be in goodhealth a few years later, the fourth was barelysalvaged after incurring empyema and suppura-tive pericarditis, and in the last the needle wasextruded eventually from the heart. Another per-son, from whom a needle was withdrawn but thepericardium was sutured, suffered in the post-operative period from pleuritis, pericarditis,cardiac arrhythmias, and spontaneous drainagethrough the wound of bloody pericardial fluid.

DISCUSSION

4 Foreign bodies may reach the heart by any of the3 following pathways: through the chest wall-4 directly through the sternum, ribs, or an inter-4 space, or indirectly after traversing the pleural

cavity and/or lung; across the oesophagus or from4 the duodenum into the vena cava; across the dia-3 phragm, from the abdominal wall or the peri-2 toneal cavity; across the respiratory tract; or by2 transport in the bloodstream from a distant region.2 The commonest route is through the chest wall.2 Sundry aspects of injuries from pins and needles1 distinguish them from other varieties of cardiac

trauma. The principal distinction concerns their1 dimensions and configuration, the significance of

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which was apparently appreciated a few centuriesago. During the scientific renaissance, many peopledisproved Aristotle's dictum about cardiac inviol-ability by sticking pins and needles into the heartsof animals. They demonstrated that such woundingwas reimarkably well tolerated and compatiblewith life. Moreover, exsanguination did not hap-pen, as had been supposed, except when lessfleshly, non-sealing portions of the heart werepricked. These trials were made directly on theorgan, and it was not until much later, whenclinical accounts were published, that notabledifferences from the experimental setting becameevident. Paradoxically, the most obvious of thesedifferences has not been em,phasized in the litera-ture. It concerns the fact that the heart is morevulnerable to serious injury while the foreign bodyis extracardiac than when it is intracardiac.

It is clear that the major damage is caused whenthe object is partially immobilized-in the thoracicparietes, for example. Then, repetitive woundingresults from the unceasing motion of the heartagainst the sharp point of the fixed foreign body.The danger to life of rigidly held objects is exhi-bited in the cases surveyed. Quite often the heartshave borne marks denoting continuous punctur-ing, scraping in saw-tooth pattern, or slicing alonga semilunar or elliptical arc. Intact pins have beenprime offenders in this connexion, since theirbroadened end has ordinarily restrained free pas-sage into the thorax. In one particullarly strikingcase, the heart shredded itself against a brooch-pinrendered immovable by an ornate handle. Ofcourse, the longer the foreign body, the less likelyis this mechanism to become operative, but thenthe greater are the risks of simultaneous skeweringof several portions of the heart. This is especiallytrue in younger subjects, in whom the easy com-pressibility and small size of the chest magnifythe importance of even a 2-cm. needle.The next feature of interest regarding this cate-

gory of foreign body is that the sleek and narrowcontour allows fairly swift migration into theheart. Because of incessant movements of the ribcage and cardiac contractions, needles and frac-tured pins caught by one end in the myocardiumdo not remain stationary in the soft tissues forlong. They are pulled gradually, but inexorably,into the substance of the heart. By then the bulkof the damage has been done. Haemopericardiumis the principle cause of complication and death,and is due mainly to rents on the surface of theheart rather than to the slender, self-obliteratingpath left by the object as it passes through thewall of the heart. If the object is delivered with

great impact, it is more likely to be forced intothe heart at once, so that the phase of scratchingor cutting of the cardiac surface is circumventedand haemopericardium is minimal or absent. Infact, such trauma seems to be associated with amore favourable outcome. This remarkable pro-cess has been noticed on several occasions, espe-cially when the object possesses free mobility. Insome instances the steadily forward course intothe heart has been visualized by means of success-sive radiographs. In others, needles have been seento move or have disappeared from sight prior toor at operation because of vigorous contractionsof the heart. In one case the advance of a pinthrough the heart wal was followed on serialradiographs until the head of the object halted itsfurther transit.

It is noteworthy that the progress of haemoperi-cardium has been unpredictable, numerouspatients dying many days or weeks after the trau-matic incident. Necropsy descriptions make itprobable that some of these late deaths from tam-ponade have been from a secondary haemoperi-cardium subsequent to realignment of the object,accompanied by grazing or laceration of the heartfrom within outward. The evolution of this pheno-menon depends in large part on the axis ofentrance of the object and where inside the heartchambers it becomes situated. For instance, if aneedle becomes embedded in a straight line in theventricular septum, further travel would tend to beimpeded. Conversly, were it not thus stabilized,but floated loose in the left atrium, it would bemore likely to migrate, as do needles and pins inother parts of the body where there is muchmovement. In -the series there are only threeexamples of a needle being extruded by the heartback into the pleural cavity, and thence to betweenthe ribs.

Needles which become fixed in the substance ofthe heart may remain clinically harmless for a longtime, as attested by their having been found inci-dentally at necropsy. The longest asymptomaticinterval has been 37 years. These are exceptionalsituations, however. The inflammatory reactionprovoked after the object has been encompassedeventually results in its becoming 'encysted'. Onthe other hand, this walling-off may be hinderedby infection or by thrombosis. That a silentforeign body need not necessarily signify benignencapsulation is exemplified by a multiplicity ofcomplications arising at a remote period after theinitial trauma.

Both focal pericarditis and chronic constrictivepericarditis have been described from weeks to

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years following injury. At times they have endedin death. Often se.psis has featured prominentlyas the agency of morbidity or in hastening thepatient's death. Clot has frequently been foundattached to parts of pins and needles exposed tointracardiac blood currents. Death has ensued insome patients from embolization of fragments ofsuch thrombi, especially the suppurative ones. Afew of the objects have even become rusty orcorroded from contact with blood.

TREATMENT The outcome of cardiac injuries dueto pins and needles has been characterized in thepast by a high mortality, which should serve as awarning against any misconception that theseforeign bodies are innocuous. Death in most caseshas been due to cardiac tamponade.

There is little quibbling about the necessity forprompt surgical intervention when an intracardiacforeign body of any sort produces symptoms ormenaces life. Emergencies from pin and needleinjuries are predominantly instigated by cardiactamponade. Pericardiocentesis is permissible-indeed, probably desirable-as a prelude to anoperation intended to retrieve the foreign bodyand repair whatever damage it has inflicted whenhaemopericardium is present. Undue temporizingin such situations is ill-advised, for, as a numberof the reviewed cases have 'shown, death mayfollow quite quickly on the heels of demonstrablehaemopericardium. Precise radiographic localiza-tion of the foreign body is desirable but is notessena.al. This information can be secured byfilms taken while the patient is in the operatingroom, with all necessary equipment at hand inthe event of precipitous deterioration in his con-dition. Moreover, it sometimes happens that theobject will have migrated by the time operation isbegun. Once the foreign body has been identifiedon admission to hospital, the goal should be torermove it as soon as possible without delaysentailed by additional non-contributory studies.

Pericardiotomy should suffice in most instancesfor evacuating the haemopericardium, withdraw-ing the object, and performing cardiorrhaphy. Theexposure must be adequate since unsuccessfuloperations in the series have been associated withinadequate procedures or limited manceuvrabilitythrough 'key-hole' incisions. It is immaterialwhether a vertical sternotomy or an anterolateralthoracotomy approach is selected, providing thereis unhampered accessibility to all regions of theheart and great vessels. Ancillary aids, such aselectromagnetic localizers, have not been usefulin these cases.

Deliberate drainage of the pericardial sac,regardless of the presence or absence of haemo-pericardium, should be accomplished always.Failure to do so, or tight re-suture of the peri-cardium, has been accompanied at times by thereaccumulation of pericardial fluid. In the samecontext, even if a pin or needle is amenable tosimple removal, i.e., digitally or by incising theskin over it, the physician is not relieved of re-sponsibility for protracted management of thecase. Rather, the patient should be admitted tohospital and kept under physical and radiologicalsurveillance to forestall cardiac tamponade fromdelayed bleeding. In a not inconsiderable numberof cases, the insidious progression of haemo-pericardium after the aforementioned simplemanoeuvres, or fresh haemopericardium due toother unsuspected foreign bodies, have been over-looked with fatal consequences.Whereas there is no equivocation about the

urgency for operating in acute symptomaticphases olf cardiac wounding by foreign bodies,doubts exist in some quarters regarding propercriteria for surgically 'molesting' chronic intra-cardiac foreign bodies. There is no denying thatsome pins and needles of long standing in theheart may not cause any demonstrable harm. Butthese are medical curiosities. The dangers of lateembolic, inflammatory, and septic sequelae fromretained pins and needles are real, and transcendthe risks from striving for surgical retrieval ofthese objects. While acknowledging that general-izations in medicine are incautious, we neverthe-less wish to express our conviction that allintracardiac foreign bodies should be removed,even if silent clinically. That is surely a reasonablecourse to adopt, for not only does it effectivelysafeguard against the eventuality of organicdisease, but it also dispels uneasiness or otheremotional stress which the patient is likely tohave about being the bearer of a potentially deadlyobject in the heart.

REFERENCESBajardi, F. (1953). Ueber einen Fall von Pflanzenzellembolien im

Koronargefasssystem. Wien. klin. Wschr., 65, 815.Barrett, N. R. (1950). Foreign bodies in the cardiovascular system.

Brit. J. Surg., 37, 416.Blaha, J. (1935). Embolische Verschleppung eines Fremdkorpers

(Gummikatheter) ins Herz bei einem kriminellen Abortus. Zbl.Gynuk., 59, 746.

Decker, H. R. (1939). Foreign bodies in the heart and pericardium-should they be removed? J. thorac. Surg., 9, 62.

Farber, S., and Craig, J. M. (1956). Clinical Pathological Conference,Children's Medical Center, Boston, Mass. J. Pediat., 49, 330.

Gajdas, J. (1963). Rib fracture in a 4-year-old child with perforationof the lung and right cardiac atrium by an ossal sequester. Pat.pol., 14, 521. (In Polish: English summary.)

Hudson, R. E. B. (1965). Cardiovascular Pathology, Vol. 2, p. 1611.Arnold, London.

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Leonard, J. W., and Gifford, R. W., Jr. (1965). Migration of a Kirsch- Parmley, L. F., Mattingly, T. W., and Manion, W. C. (1958). Pene-ner wire from the clavicle into the pulmonary artery. Amer. J. trating wounds of the heart and aorta. Ibid., 17, 953.Cardiol., 16, 598. Schiff, A. F. (1965). A fatality due to acupuncture. Med. Tms (N. Y.),

Lillehei, C. W., Bonnabeau, R. C., Jr., and Grossling, S. (1965). 93, 630.Removal of iatrogenic foreign bodies within cardiac chambers Tanzer, A. (1953). Intrakardiale abgebrochene Injektionskanule.and great vessels. Circulation, 32, 782. Fortschr. Rontgenstr., 78, 357.

Lowen, H. J., Fink, S. A., and Helpern, M. (1950). Transfixion of the Weekley, A. S., Jr., and Maltby, G. L. (1963). More stud-gun injuriesheart by embedded ice pick blade with 8 months' survival. Ibid.. (letters). New Engi. J. Med., 269, 110, 111.2,426. Zacchias, P. (1600). Quaestiones medico-legales, I (5), 375.

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