94 T/z-e Philippine Journal of Science 1920 
apparently improved, and he was voluntarily taking nourishment. 
His mental condition had markedly changed, he now being 
seemingly rational and cooperative. 
The blood cultures showing a diminishing growth, and with 
the apparent improvement in the general condition of the patient 
with no new involvements recently having occurred, it was 
thought that the infection had pretty well localized itself; so 
it was deemed advisable to stimulate antibody production by 
the administration of an autogenous vaccine. This vaccine was 
duly prepared and an initial dose of 2,000,000 given, and a 
second dose of 4,000,000. The serum was continued as before. 
About eight hours after the last dose of vaccine, the temperature 
suddenly rose to 104°, the pulse became very rapid, and the 
patient was in extreme condition. 
The following morning, signs of fluid were demonstrated in 
the right chest and proven by aspiration. The fluid showed 
streptococcus. The next day, pus was obtained from the left 
chest. This also showed streptococcus. 
Upon examining the patient the next morning, about the sev- 
enteenth day of the disease, a large swelling was noted over 
the anterior aspect of the left chest, extending from the upper 
border of the seventh rib to the nipple, and laterally from the 
edge of the sternum to 2 centimeters inside the anterior axillary 
line. This mass was about the size of a small grapefruit, and 
in it a distinct fluctuation was obtained. 
An impulse was also distinctly evident in the mass, syn- 
chronous with each heartbeat and was transmitted all through 
the mass. The area of cardiac dullness, and the dullness in 
the mass, and the fluid in the right and left chests, all merged 
together. The heart sounds were barely audible. A diagnosis 
of a large pericardial effusion was made. A needle was inserted 
through the skin over the mass and pus obtained. The surgeon, 
from this evidence, considered the condition to be that of' a 
large superficial abscess and advised incision, which was per- 
formed in the sixth interspace about the nipple line. Approx- 
imately 200 cubic centimeters of pus were obtained. The abscess 
evacuated itself in spurts, and each spurt apparently corresponded 
to each heartbeat. The incision was enlarged and the cavity 
explored, with the result that an irregular hole, about the size 
of a fifty-cent piece, was discovered through the intercostal 
muscles in the fifth interspace about the location of the costo- 
chondral junction of the fifth rib, which was necrotic. 
The opening led directly into the pericardial cavity, and by 
