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On August 19th 1 saw, in consultation with Drs. G. A. Shane and coupons for celebrex J. F. Whittaker, the following case : William P , a farmer, thirty years of age, weighing about one hundred and fifty pounds, muscular develop- ment good, while sliding from a haymow came in con- tact with a pitchfork which was standing tines upward against the contents of the mow. One of the prongs penetrated the right hip, at a point behind and on a level with the greater trochanter, and broke off close to the socket. Found him lying on the 200mg celebrex porch of the house, to which he had been taken, complaining of severe pain in his hip, abdomen, and back, and greatly frightened. On exami- nation we found a penetrating wound in the right hip, and just beneatli the surface a metallic substance was detected and removed, celecoxib celebrex being the lower portion of the fork-tine, one and three-quarter inch in length, and fit- ting accurately at its larger end, the stump remaining on the handle. Measurement of the remaining tine showed it to be thirteen inches in length, leaving about eleven inches yet to be accounted for. The patient complained greatly of his back, and a view of it disclosed an enlargement on the right side of the spinal column in the lumbar region, which was exquisitely sensitive. This apparent swelling showed no bruising or evidence of recent contusion, and inquiry elicited no- history of its existence previous to this time. We proceeded, under an anesthetic, to further explore for the missing steel, and found the direction of the wound to be upward, inward, and forward, and succeeded in fol- lowing its track for about five inches with a probe, but without detecting any foreign body, nor could we by en- larging the wound and making deep pressure determine its presence. He was allowed to come out from under the influence of the ether in order to get the benefit of his sensations under our manipulations, and his thigh was flexed on his abdomen, deep pressure again made, together with ab- duction and adduction of the thigh, producing no increase of pain in any region. After several hours he was again etherized, and tiie most critical examination made what is celebrex in the wound and by the rectum, and the swelling on the back laid open and thoroughly explored ; all to no purpose, and the wounds were left unclosed and dressed with water dressing. The case resolved itself into the following conditions : I. Head of the fork-tine penetrated and lodged in the body of the man ; if so, could it be removed? 2. If in his body, had it penetrated the pelvic cavity or was it buried in the dense muscular structure of the hip ' 3. Could it be possible that the first portion of the tine had, by the force of the falling body, broken off and by its elasticity tlew away, and, the fall being unbroken, the fork again came in contact with the body and penetrated with the remainder ? These questions were taken ui) and concluded upon : i. There was no positive evidence furnished by the examination that the tine was lodged in celebrex online his body, and, were it positive, an operation for its re- moval would involve a dissection of the muscular struct- ure of the hi)), and perhaps an opening of the abdominal cavity, both under the circumstances unjustifiable opera- tions. 2. The abdominal pain was taken as suspicious at least, and the bladder and rectum had not as yet acted, leaving their injury in doubt. 3. The cost celebrex possibility of this condition was acted celebrex celebrex upon, and tlie barn most thoroughly searched for the'missing tine, but it was not found. We now concluded to leave the case to nature, and the patient went on doing well, his bowels and bladder performing their functions normally, .\fter a few days, when his fright had subsided, he remembered that the in- jury to his back was of long ago, and always gave him trouble, and that his abdominal i>ain had preceded the 430 THE MEDICAL RECORD. [October i8, 1848. injury several days and had been accompanied with diar- rhcea, which continued. The wound in the back healed kindly, but the one in the hip continued to discharge profusely, and in the fourth week the whole Hmb became swollen, and later fluctuation was detected below the sore, which increased in size and extended down the ])os- terior aspect of the thigh, and on October ist, forty- three days after the accident, it (the tine) was removed, large end first, from celebrex coupons the upper portion of the popliteal space. It was eleven inches in length. The tine was evidently lodged either in the hip or had penetrated the pelvis, the heavy end being depend- ent, and the muscular action produced by the patient's walking across the floor daily caused it to descend and appear as described. Since its removal he is doing well, and the indications are that he will make a good recovery. SOME REMARKS ON THE ASSOCI.\TION OF , TUBERCULOSIS AND ACUTE PNEUMONIA. By EDMUND C. WENDT, M.D., The highly interesting case of tuberculous pneumonia, reported by Dr. Kinnicutt in the last issue of The Rec- ord, prompts the writer to offer a few remarks on the synchronous 200 celebrex occurrence of tuberculosis and pneumonia, particularly so as a case came under his observation four years ago, which was, in some respects at least, similar to the one observed by Dr. Kinnicutt. The writer con- sidered It at the time a rather puzzling instance of rapidly fatal croupous pneumonia, of an atypical kind. Having occurred before the era of the bacillus tuberculosis and the pneumonia-micrococcus, it will scarcely seem, in the light of our present knowledge, or at least widespread belief, a case observed with sufficient scientific accuracy to warrant any concise deductions. But it should not be forgotten that, despite the rapidly progressive researches of positive experimental pathology, the entire subject of pneumonia, and for that matter of tuberculosis as well, is still a debatable one. The writer's case, then, is to be regarded merely as a casuistical contribution to a subject of universal interest to tlie profession in the past, the present, and, it is»to be hoped, the future. Quite briefly stated the case was as follows : A. M , male, aged thirty-six, married, the father of healthy children, himself the child of healthy parents, was seized with a rigor on a Monday, in March, 1880. He posi- tively denied celebrex 100 any previous serious illness, but admitted a tendency to " take cold " easily during changeable weather. He also stated that he had lost one sister from phthisis, at the age of twenty-two. Soon after the chill the patient developed the signs of croupous pneu- monia on the right side, which soon spread throughout the entire middle and lower lobes. It was thought to be even encroaching on the upper lobe, when, on the third day, after the rigor had marked the incipience of severe illness, he suddenly died. Clinically the unusual signs had been an excessively high temperature (io6|° to 107^ F., in the rectum), associated with a pronounced typhoid condition. On the last day of his illness the patient also became intensely jaundiced. fcjAt the autopsy the right lung was found hepatized in the middle celebrex purchase and lower lobes. The hepatization, however, was grayish only in a few places, the prevailing color being a dark maroon. In the upper lobe, there was merely moderate congestion, some firm old pleuritic ad- hesions, a few slate-colored nodules with chalky centres, and a rather abundant crop of miliary tubercles. Besides this there were in both lungs quite a number of purulent foci, resembling the well-known multiple abscesses of py.-emia. ^The left lung was congested, celebrex 100mg oedematous, and showed in its upper lobe a condition quite similar to what ob- tained on the right side, '^except that there were relatively fewer miliary tubercles and purulent collections. The latter in no instance exceeded in size that of a cherry-pit. The abdominal organs were in general much congested, especially the spleen, which was soft, large, and pulpy. The liver was found in the first stage of icteric hepatitis. The intestines were only moderately hypersmic, other- wise normal. The common bile-duct was easily per- vious. The brain was not examined. There were no miliary tubercles in any other organs, save those already mentioned, viz., the upper lobes of both lungs. The questions that suggest themselves in tliis case, as well as in the one reported by Dr. Kinnicutt, are these : Was there a latent unrecognized tuberculosis upon which, as a suitable soil, a fatal croupous pneumonia became engrafted ? or was there rather a primary lobar coupon for celebrex pneu- monia, that afforded a fertile soil for the rapid develop- ment of acute tuberculosis ? Without stopping to weigh arguments pro and contra, the writer would simply state his belief that in his own case the tuberculosis preceded, for weeks or months, the pneumonia ; but that the latter would not have proved so rapidly fatal without the coexist- ence of the former. In Dr. Kinnicutt's case the se- quence of events seems less clear. And it is much to be regretted that the microscopical examination of the spu- tum failed to make matters any clearer. One thing may be learned from these cases. If croup- ous pneumonia is an infectious disease, caused by the in- vasion of a specific micro-organism, and if pulmonary tuberculosis similarly depends upon the entrance into the lungs of peculiar bacilli, then it follows that the growth and multiplication of these two typical and vastly dis- similar varieties of germs within the same organ, so far from being mutually antagonistic, may be reciprocally 200 mg celebrex stimulating, and thus prove doubly dangerous to the host carrying the parasites. In conclusion, the writer may be permitted to suc- cinctly refer to a case of so-called " mixed infection through tubercular bacilli and pneumonia-micrococci," celebrex coupon which was recently reported by Dr. Samter [Berliner Klin. Wochenschrift, June 23, 1884), and which seems to have escaped Dr. Kinnicutt's notice. A weak and marantic-looking old man, aged sixty-five, was admitted to the Posen hospital on March 13, 1884. The patient had a slight, innocent-seeming cough, and a physical examination led only to the diagnosis of senile bronchitis. The patient cost of celebrex improved visibly at first. But on April 19th he began to complain of great weakness, and showed an increased tendency to cough. His tem- perature, however, was below the normal. The scanty viscid sputum resembled somewhat that of ordinary lobar pneumonia. Microscopical examination, however, elic- ited the interesting fact that, in addition celebrex buy to the abundant presence of tubercle bacilli, the sputum contained a few of the characteristic micrococci of pneumonia. The physical signs of the latter affection subsequently became more marked, and the patient died in a few days from heart-failure. From the record of the post-mortem ex- amination the following points, having a direct bearing on the subject under discussion, may be cited : celebrex price In the apex of the left lung there were some old cheesy de- posits, the entire right lung was intensely congested and in the first stage of pneumonia. Scattered throughout all the lobes celebrex mg of this lung there was found an abundant crop of recent miliary tubercles, but not a single cheesy or purulent mass was discover- able in that lung. In the small intestine numerous ul- cers existed, but there was no evidence there of miliary tuberculosis. It would seem, therefore, that this case resembled my own in several important respects. Dr. Samter is inclined to believe that his patient had latent tuberculosis ; and further, that a sudden invasion of the specific germs of pneumonia wrought such changes in al- ready damaged lungs that, an acute miliary tuberculosis was lit up where before there had only existed the slowly smouldering process of chronic tuberculosis. In the light of the experience of his own case, the writer would fully concur in the above opinion.

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