The Accidents Incidental to 
the Use of the Exploring 
Needle for Diagnosis. 
BY L'' 
HERMANN M. BIGGS, M.D., 
DEMONSTRATOR OF ANATOMY, BELLEVUE HOSPITAL MEDI- 
CAL COLLEGE J PATHOLOGIST TO CHARITY HOSPITAL 
AND THE NEW YORK CITY HEALTH BOARD J 
INSTRUCTOR IN THE CARNEGIE 
LABORATORY. 
REPBINTBD FROM 
artje Neto Yorft JHetncal journal 
for August 18, 1888. Reprinted from the Hew York Medical Journal 
for August 18, 1888. 
THE ACCIDENTS INCIDENTAL TO THE USE OE 
THE EXPLORING NEEDLE FOR DIAGNOSIS.* 
By HERMANN M. BIGGS, M. D., 
DEMONSTRATOR OF ANATOMY, BELLEVUE HOSPITAL MEDICAL COLLEGE ; 
PATHOLOGIST TO CHARITY HOSPITAL AND THE NEW YORK CITY HEALTH BOARD ; 
INSTRUCTOR IN THE CARNEGIE LABORATORY. 
The object of this paper, in response to the request of 
your president, is to present some facts to form the basis 
of a discussion regarding the grave accidents and secondary 
septic complications that sometimes follow the use of the 
exploring needle for diagnostic purposes. My own atten- 
tion was particularly directed to the subject recently by a 
case of pneumothorax followed by sudden death, produced 
apparently by an exploratory puncture with a hypodermic 
needle. This case was reported to this society in Decem- 
ber. 
I wish to say in advance that I would not be under- 
stood as in any way protesting against the use of the ex- 
ploring needle for diagnosis in properly selected cases with 
necessary precaution, nor as suggesting that in the vast 
majority of cases there is any considerable danger attend- 
ing its use; but I would protest against the routine indis- 
* Read before the New York Clinical Society, February 25, 1888. 2 
THE EXPLORING NEEDLE IN DIAGNOSIS. 
criminate and careless puncture of everything normal and 
abnormal upon insufficient grounds, when other signs and 
symptoms, and especially the physical examination, give 
more reliable information. The impression has arisen in 
the minds of a large number of the profession that this pro- 
cedure is absolutely free from any danger, however per- 
formed and under whatever conditions resorted to. This 
is especially the case among hospital men. A member of 
the house staff of one of the large city hospitals recently 
said to me, in speaking of the nature of a pulsating tumor 
of the chest: " I know it is an aneurysm because I intro- 
duced a hypodermic needle into it and moved it around in 
all directions, thus proving it was a large cavity, and then 
withdrew a syringeful of blood." That in this case por- 
tions of stratified fibrin from the aneurysmal wall were not 
separated and set free as emboli was not the fault of the 
operator. So general is the belief in the absolutely harm- 
less nature of this operation among the younger physicians 
that I believe few would think of ascribing to it any acci- 
dents occurring after its use, however close the relation to 
the operation. 
I wish in these remarks to simply call attention to the 
fact that serious results do sometimes unquestionably follow 
the use of an exploring needle, and to report a few of the 
accidents that have occurred from its use. 
I have made no attempt to collect a large series of cases 
or go carefully into the literature, scanty as it may be, as 
this was not necessary for my purpose, but have been con- 
tent with a few cases illustrating the different kinds of acci- 
dents and secondary complications following puncture of 
different parts of the body with an exploring needle. 
These may be divided into three classes: 
1. Those accidents resulting directly or indirectly from 
the traumatism produced by the needle. THE EXPLORING NEEDLE IN DIAGNOSIS. 
3 
2. Those cases of septic infection produced by the in- 
oculation of healthy tissues during the withdrawal of the 
needle through them after introduction into more deeply 
seated infectious matter. 
3. Those cases of septic infection produced by the intro- 
duction of needles not properly disinfected into healthy or 
diseased tissues or fluids. 
Under the first head, the accidents following from the 
traumatism produced by the puncture, the following cases 
should be recorded: 
Cases of Pneumothorax.-The first case of this kind that 
came under the writer's notice was reported to this society 
in December. 
In that case a patient came under observation for some pul- 
monary affection, and the physician in charge introduced a hy- 
podermic needle into both sides of the chest. From the right 
side he obtained two or three drops of pus and blood. From 
the left nothing was obtained. The following morning the pa- 
tient was found dead in bed. The autopsy revealed the pres- 
ence of a very extensive interstitial pneumonitis with tubercular 
deposits in the left lung. The lung was very much contracted 
and occupied not more than half the space ordinarily filled by 
the normal lung. The heart was drawn to the left of the me- 
dian line. The right pleural cavity was exceedingly large and 
was filled with air. The right lung was collapsed and com- 
pressed against the spinal column and contained scarcely any 
air. There were no adhesions between the two layers of the 
pleura, and there was no fluid of any kind in the pleural cavity. 
The lung was very carefully removed and inflated. Then, after 
placing it under water, an exceedingly small pin-hole perforation 
was found in the lower lobe near the free border. There were 
a few small tubercular nodules scattered through the lung, and 
extensive emphysematous changes. The tissues around the 
puncture seemed to be normal with the exception of a slight 
haemorrhage at the point of puncture and the emphysematous 4 
THE EXPLORING NEEDLE IN DIAGNOSIS. 
condition found elsewhere. I believe that this perforation and 
the subsequent pneumothorax were due to the puncture of an 
emphysematous vesicle that, as was shown by the drops of pus, 
was situated over more deeply seated diseased tissue. The 
puncture remained patent and the pneumothorax followed. 
This interpretation, of course, is not susceptible to proof. 
Dr. G. F. Lloyd, of the Flatbush Hospital, Brooklyn, 
has given me the history of the following case, which was 
apparently one of the same nature : 
The patient was a Hungarian laborer, aged forty-one, and 
was admitted to the hospital with the following history: He fell 
on the ice a day or two before admission, and struck the right 
side of his chest against a curb-stone. On admission, the diag- 
nosis was made of simple pleurisy with effusion, situated on the 
right side. There were ecchymoses in the skin over this side 
where he had struck against the stone. His temperature was 
101-50 F. and his pulse 80. The patient did not seem to be very 
sick. A day or two after his admission a hypodermic needle 
was introduced into the right side and then into the left side. 
Serum was obtained from the right side. The left side appeared 
to be normal, and nothing was withdrawn through the needle. 
Four hours later the physician was called to see the patient 
because of severe dyspnoea. On examining the chest he found 
the intercostal spaces on the left side bulging, with tympanitic 
resonance over the whole side. Stimulation by hypodermic in- 
jections and by the stomach was resorted to without avail, and 
the patient died half an hour later with symptoms of intense 
dyspnoea and cyanosis. No autopsy could be obtained. 
It seems to me that there is no way of accounting for 
the symptoms and signs in this case except by assuming 
the presence of pneumothorax. This followed immediately 
after puncture of the lung with a hypodermic needle in a 
man suffering apparently only from a simple pleurisy on the 
opposite side. The needle used was an ordinary hypoder- 
jnic needle. THE EXPLORING NEEDLE IN DIAGNOSIS. 
5 
Dr. Thacher reported a similar case at the December 
meeting of this society. The history of his case was as 
follows: 
" A child had some infectious disease, some pulmonary symp- 
toms developed, and, in order to settle the diagnosis between 
broncho-pneumonia and pleurisy, the hypodermic needle was 
inserted on both sides. Within two or three hours intense 
dyspnoea developed, and the child soon died. The speaker made 
an autopsy. Both lungs were collapsed, and a puncture was 
found through the lower edge of both at the site where the 
physician said he had introduced the hypodermic needle. There 
was a slight amount of broncho-pneumonia. The speaker 
could account for the pneumothorax in no other way than on 
the supposition of puncture of the lungs by the hypodermic 
needle." 
These cases of pneumothorax, it seems to me, are of 
special interest. So far as I know, attention has not been 
previously called to the occurrence of this condition after 
the use of an exploring needle. It probably would never 
follow the introduction of a needle into a perfectly normal 
lung. The conditions under which it would, perhaps, be 
most likely to occur are when the pleura is quite normal 
and the lung is diseased, and especially when there is a pro- 
cess of softening in the lung near the pleural surface, but 
not involving it. 
It seems to me probable that there are cases of pneumo- 
thorax of less extent due to this cause, which do not pro- 
duce symptoms marked enough to attract attention, and 
that there are other cases which are recognized, and in 
which recovery takes place, that may also be produced in 
this manner. A moderate degree of pneumothorax, exist- 
ing on one side and gradually developed, would not be 
likely to produce very urgent symptoms, and, as the open- 
ing would probably be soon closed as the lung became 6 
THE EXPLORING NEEDLE IN DIAGNOSIS. 
partially collapsed and the air in the pleural cavity absorbed, 
the condition might easily escape recognition, and, if rec- 
ognized, soon disappear. In all the cases reported above, 
where death occurred, it will be noticed that both lungs 
were involved and rendered practically useless. 
I have obtained the notes of a number of cases of gen- 
eral peritonitis produced by oozing along the track of the 
needle after puncture of a distended gall-bladder. The first 
one was reported by Dr. A. B. Pope. The case occurred 
in the service of Dr. Ball in Bellevue Hospital : 
A fluctuating tumor was found in the region of the gall- 
bladder, which was supposed to be a distended gall bladder. A 
hypodermic needle was introduced, and immediately after its 
withdrawal the patient complained of intense pain in the abdo- 
men. He said to the physician, "You have done me up this 
time, doctor." He died in three days of general peritonitis. 
At the autopsy, bile was found mingled with the peritoneal ex- 
udation. 
Dr. Wylie, in the " Trans, of the New York Obstet. 
Society," March 2, 1886, described a similar case. Dr. 
Roosevelt reported a third case at the December meeting of 
the Clinical Society, and Dr. Janeway has given me notes of 
a fourth case of the same kind that he saw in consultation 
in private practice. 
Dr. Wylie has also reported a case of fatal peritonitis 
produced by oozing of pus along the track of the needle in 
a case of perityphlitic abscess. A hypodermic needle was 
used for the puncture. Dr. Munde has reported, in the 
"Trans, of the New York Obstet. Soc.," a case of suppu- 
rating dermoid cyst which he punctured with a hypodermic 
needle after opening 'the abdominal cavity, and on with- 
drawing the needle a drop of pus escaped. If this had 
been punctured through the abdominal wall, death would THE EXPLORING NEEDLE IN DIAGNOSIS. 
7 
have certainly followed from general peritonitis. It illus- 
trates well the mode of occurrence of such accidents. 
Cases of peritonitis have also been reported as following 
puncture of pyosalpinx and encysted pockets of pus in the 
abdominal cavity. 
Gerster ("Aseptic and Antiseptic Surgery," p. 247) has 
reported a case in which death occurred from general peri- 
tonitis after puncture of a perityphlitic abscess, the needle 
having passed through the peritonaeum. 
The "Medical News" for January 1st contains the re- 
port of a case of sudden death following the introduction 
of an aspirator needle occurring in the practice of Dr. J. C. 
Reeve, of Dayton, Ohio. 
The patient was suffering from abscess of the liver and it 
was decided to aspirate the liver. Immediately after the intro- 
duction of the needle the patient suddenly began to breathe 
heavily, and in a moment was dead. No anaesthetic was used. 
There was nothing found at the autopsy to account for the sud- 
den death. 
A German surgeon, whose name I have forgotten, has re- 
cently reported a case of removal of a large pancreatic cyst in 
which, previous to the removal, an exploring needle was intro- 
duced into the cyst for diagnostic purposes. A general perito- 
nitis, lasting about a week, immediately followed, although the 
patient recovered, and the cyst was later removed. 
Dr. Janeway has given me notes of the following case : 
In a patient with suspected pericarditis with effusion an ex- 
ploratory puncture of the pericardium was made by the physi- 
cian in charge. The patient died soon after, and at the autopsy 
laceration of the heart was found, with haemorrhage into the 
pericardium. , 
In the "Australian Medical Gazette" of June, 1887, a 
series of cases are reported where unfortunate results fol- 8 
THE EXPLORING NEEDLE IN DIAGNOSIS. 
lowed puncture of hydatid cysts. These are with the 
report of a case in which symptoms of collapse terminating 
fatally followed immediately upon puncture of a hydatid 
cyst of the spleen. Only a few drops of fluid had escaped, 
when the patient went into collapse and died. Among the 
cases included in this paper are the following : 
In the " St. Bartholomew's Hospital Reports," vol. xvi, 
the following case is reported : 
A small hydatid cyst of the liver was punctured with a very 
fine trocar. Only a few drops of fluid escaped, when the patient 
died suddenly with the symptoms of shock. 
In the " Lancet," vol. xxi, the following case was re- 
ported : 
A very fine trocar was introduced into a hydatid cyst of 
the liver, and a few drops of fluid escaped, when the patient went 
into collapse and died in twenty minutes. 
A number of cases are on record of death following 
puncture of hydatid cysts of the lungs. In most of these 
death has followed from escape of fluid into the lung and 
drowning; in others, as in the foregoing, collapse and death 
have directly followed the puncture. 
Dr. Tingley, of the house staff of Bellevue Hospital, has 
given me notes of the following case : 
A hypodermic needle was introduced into a large ovarian 
cyst; the following day the cyst was removed by operation, when 
a thin layer of colloid matter was found at the site of puncture 
between the abdominal wall and the cyst wall. Had not an 
operation been performed early, peritonitis would probably have 
followed. 
Not properly belonging here, perhaps, is a case of con- 
tinued oozing following puncture of an ovarian cyst with 
the aspirator needle reported by Dr. Lusk. THE EXPLORING NEEDLE IN DIAGNOSIS. 
9 
A case of circumscribed pleurisy following breaking of 
a hypodermic needle in the chest wall is also reported by 
Dr. Tingley. 
Dr. A. A. Smith has called attention to the occurrence 
of cough with bloody sputum for several days after explora- 
tory puncture of the lung, and Dr. F. S. Dennis has referred 
to a case of continued oozing from an aneurysm after punct- 
ure with a hypodermic needle. 
It is possible that some of the cases included in this 
class properly belong in the second class. 
The second class includes those secondary septic com- 
plications following the inoculation of healthy tissues in 
the withdrawal of the needle after its introduction into more 
deeply seated infectious material. 
A case was reported at the December meeting of the 
Clinical Society by Dr. Roosevelt: 
When, in the exploration of the chest in a case of empyema, 
the needle was introduced into the peritoneal cavity, through 
the diaphragm, and into the pleural cavity, a general perito- 
nitis followed the exploration, probably produced by the infec- 
tion of the peritoneal cavity by material remaining on the 
needle in its withdrawal, or perhaps by oozing along the needle 
track. 
Dr. Janeway has referred to two cases of cellulitis of 
the back that had fallen under his observation which fol- 
lowed the introduction of an exploring needle into the lung 
in cases of foetid bronchitis : 
The cellulitis was of the gangrenous type, accompanied by 
subcutaneous emphysema, and was probably produced by the 
infection of the tissues with the material from the bronchiec- 
tatic cavities remaining on the needle when it was withdrawn. 
An instance of mild septic infection of a similar nature 
has fallen under my observation. 10 
THE EXPLORING NEEDLE IN DIAGNOSIS. 
In a case of encysted peritonitis attended with little rise of 
temperature the introduction of an exploring needle was followed 
by a chill and a temperature of 104° that continued for several 
days. A similar case is reported by Dr. Tingley. Following the 
introduction of a needle into a perinephritic abscess the tem- 
perature ran up to 106°. The infection in these cases may also 
have been produced by oozing along the track of the needle. 
The third class includes the cases of infection of normal 
or diseased tissues or collections of fluid by inoculation of 
them with a septic needle. These cases occur most fre- 
quently, and are those most generally recognized and most 
easily avoided. But little requires to be said about them. 
There are but few clinicians of considerable experience who 
have not had the misfortune to see one or more cases of 
simple pleurisy changing into suppurative pleurisy after 
puncturing with a hypodermic needle. Several such cases 
have fallen under my own observation. I do not refer, of 
course, to those cases that become suppurative after aspira- 
tion, but to those that become suppurative after simple ex- 
ploratory puncture. In some of these cases certainly, if not 
in all, the occurrence is not a mere coincidence, but is due 
to the infection of the serous fluid by a septic needle. 
Similar cases of suppurative peritonitis following the intro- 
duction of a needle into the abdominal cavity in peritonitis 
have been observed. Dr. Lusk has reported two cases of 
suppuration in ovarian cysts following the introduction of 
an aspirating needle. 
A similar result would be likely to result from this 
procedure under the same conditions in any form of cystic 
neoplasm or retention cyst, or in cases of collection of 
serous fluid in any pre-existing cavities. The occurrence 
of suppuration under such conditions is simply a ques- 
tion of inoculation of the tissues or fluids with septic 
organisms. THE EXPLORING NEEDLE IN DIAGNOSIS. 
11 
Reference should be made to the dangers and accidents 
following puncture of intestines distended with gas or liquid 
contents. There are numerous cases recorded where a gen- 
eral peritonitis has resulted from the oozing of faecal matter 
through the wounds thus produced. 
I especially desire not to seem to exaggerate the dan- 
gers following the use of the exploring needle or to over- 
estimate their importance. The following remarks, how- 
ever, are suggested and seem to be justified by the cases 
reported: 
1. The employment of the exploring needle is not infre- 
quently attended by considerable danger, and a number of 
deaths have directly resulted from its use. 
2. The indiscriminate, careless, and routine resort to 
exploration with a needle should be condemned. This pro- 
cedure should not be resorted to without careful considera- 
tion of the conditions obtaining in each case and the results 
that may follow the puncture. The site for the puncture 
should be thoughtfully chosen, the puncture carefully made 
with complete antiseptic precautions, and the smallest needle 
that will answer the purpose employed. 
3. The puncture of collections of fluids with tense walls 
in relation with serous surfaces should be, as far as possible, 
avoided, and, if it is resorted to, sufficient fluid should be 
withdrawn to relieve the tension upon the walls of the sac. 
In many cases certainly an exploratory operation would be 
attended by less danger. 
4. In the introduction of the needle into deeply seated 
infectious matter the nature of the intervening tissue should 
be carefully considered. 
5. The needle before use should be always thoroughly 
disinfected, preferably by heating in the flame of an alcohol 
lamp or a Bunsen burner. 
6. The skin where the puncture is to be made should 12 
THE EXPLORING NEEDLE IN DIAGNOSIS. 
be rendered thoroughly aseptic by first scrubbing with soap 
and water and then washing with an antiseptic solution. 
7. The dangers attending the use of this valuable adju- 
vant in diagnosis should not in the slightest interfere with 
its employment in properly selected cases, where due pre- 
cautions are observed as to its use. REASONS WHY 
Physicians Should 
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