The wandering needle

In 1889 a surgeon from the Adelaide Hospital in Dublin, Kendal Franks, wrote a notable case report for the British Medical Journal. His subject was renal calculus, otherwise known as kidney stones. During an operation in October that year he had removed a stone which was quite unlike anything he’d seen before.

The specimen is composed chiefly of phosphate of lime, with a small amount of carbonate of lime, and in this respect agrees with nearly all the renal calculi which I have myself removed, or which I have seen removed by operation.

It sounds as if this was a type of calculus known as a struvite stone, which often contain calcium carbonate and calcium phosphate. They are typically caused by bacterial infection, which would fit with the other circumstances, as we’ll see. The paper includes an illustration, which reveals an unusual detail:

The smaller fragment was accidentally broken off by the forceps during the process of extraction, and it was the separation of this piece which revealed the point of the nucleus, jutting out from the end of the larger fragment, and which is clearly the point of an ordinary sewing needle.

A needle! How on earth had it ended up in his kidney?

The patient from whom this specimen was obtained was a young man, aged 22, who first consulted me on October 14th, 1889, for a sinus in the right loin.

A ‘sinus’ is an abnormal passage caused by the destruction of tissue. This was an unpleasant and painful hole in his side, just below the ribcage.

This sinus was daily discharging large quantities of pus, sometimes amounting to nearly a pint.

Not a predicament one would enjoy.

He told me that in January last (1889) he went to South Africa. Whilst there he developed a train of symptoms which led the doctors in Durban to diagnose a stone in the right kidney, and for which they proposed an operation. With this object he entered the hospital in Durban. He informed me that several punctures were made previous to operation, on several occasions, in order to ascertain the presence of a stone, but all with negative results.

The South African surgeons made an incision just above his pelvis, but found no stone; Dr Franks believed they had failed even to locate the kidney, let alone explore it for signs of disease.

He remained in hospital for three months, and about the end of August returned to his native air near Dublin.

Not even the fresh air of Ireland could succeed in curing the nasty wound in his side, so he again sought medical attention.

When I first saw him he was a fine-looking well-built young man, presenting, nevertheless, the cachectic appearance of one suffering from prolonged suppuration.

‘Cachectic’ means wasting away. Chronic infection had badly affected his health.

There were two small openings in the loin, in the scar which I have mentioned. An unusually long probe passed readily in to its full length without meeting with obstruction. I advised him to undergo another operation, and to this he at once consented.

It is notable that the procedure Dr Franks was about to undertake was pretty much the height of surgical sophistication in 1889. The first successful operation to remove a renal calculus had been performed just nine years earlier, when the London surgeon Henry Morris removed a small kidney stone from a young woman.

After administering chloroform, Dr Franks made an incision through the scar in the young man’s side.

I soon came upon a large cavity filled with pus, situated immediately behind the right kidney, and in this cavity I found the stone. The posterior surface of the kidney could be felt, and, as it appeared quite healthy, it was not further interfered with. The abscess cavity was found to have burrowed downwards and forwards, and a probe passed down into this pouch could be felt in the swelling in the groin.

When you consider the size of the pus-filled cavity, it’s not difficult to see why the patient was emaciated.

A drainage tube was inserted in the loin and the wound well irrigated and dressed in the usual way. The patient made an excellent recovery; the wound quickly cicatrised [healed], and the old sinus, which had been thoroughly scraped and cleaned, has been closed for nearly three weeks.

The operation was a total success. But the surgeon still had a mystery to clear up.

Now, the interesting question in this case is, How did the needle get into the kidney and thus induce the formation of a stone? When I first discovered the needle, it was a few days after the operation. At first it occurred to me that it might have been left there during the operation in May.

This was obviously not the case, because the needle was an ordinary sewing needle and not one suitable for surgery – and also because the kidney stone had undoubtedly been there even before the first operation.

Dismissing, therefore, this hypothesis, I carefully questioned the patient, but he could not remember having in any way introduced a needle into his body. However, he related the circumstance to his sister, and she at once reminded him that in 1872, when he was a little boy, he had been sent home from school and was kept home for some days because he had swallowed a needle. As, however, it failed to produce any symptoms or to give rise to any sort of annoyance, no more was thought of it, and he was sent back to his studies.

Amazing. The needle had been in his body for at least a decade, probably longer. It might easily have caused a problem even worse than a kidney stone.

Now, the probable solution of the problem seems to me to be this: That in the well-known erratic peregrinations of needles introduced into the body, the one in question, after wandering about for a time, found a resting place in the cortical portion of the right kidney. It there became encrusted by the deposit of phosphates from the urine and so formed a stone, and this very encrustation served to protect the needle from itself being destroyed by a slow process of oxidation.

Eventually the presence of the stone had caused inflammation, infection had set in and a large pus-filled abscess was the result. Not only an impressive operation for this early date, but an unusual tale of a wandering sewing needle.