" REACTIONS " AND SIMILAR PHENOMENA 315 



serum anaphylaxis and the few cases that have occurred of sudden 

 death after the injection of antitoxin, since these have usually (not 

 invariably) occurred after the first dose. In some cases, if not 

 in all, they have happened in children the subjects of the lymphatic 

 diathesis, who are subject to sudden death on very slight provoca- 

 tion. And the remarkable lesions recorded by Gay and Southard 

 have never been seen after death from a single dose of antitoxin ; 

 nor do the extraordinary symptoms develop. 



This seems the most suitable place in which to discuss the 

 " serum disease," or series of unpleasant though transient pheno- 

 mena which may occur after the use of antitoxin, though it must 

 not be considered that it is necessarily a phenomenon having any 

 connection with those that have been already described. 



The symptoms have been carefully analyzed by von Pirquet, 

 and the following account is based very largely on his observations. 

 The most constant symptom is fever, which is usually remittent 

 in type. Next in frequency is a rash, which may be general or 

 confined to the vicinity of the region at which the injection was 

 made. The type of the rash varies in different cases, but all 

 forms are associated with the most unpleasant symptom of the 

 serum disease namely, severe itching. The types of rashes are 

 those included under the term " erythema multiforme." The 

 severest, which is associated with the greatest degree of fever, 

 is the morbilliform ; the scarlatiniform is associated with less ; 

 and the urticarial rash, which is the commonest, is usually accom- 

 panied with but little elevation of temperature. 



There is usually enlargement of the lymphatic glands corre- 

 sponding to the region where the injection was administered, and 

 this enlargement may be the first sign of the onset and of the cure 

 of the disease. The pains in the joints often form one of the most 

 unpleasant of the symptoms, and the articulations usually affected 

 are the metacarpo-phalangeal, wrist, and knee, in that order of 

 frequency. Albuminuria, not going on to nephritis, is occasionally 

 present, and slight oedema is common. The severity of the 

 disease is roughly proportioned to the amount of serum injected. 



According to von Pirquet and Schick the leucocytes are 

 increased in number until the symptoms develop, when a rapid 

 fall (due chiefly to a decrease in the polynuclears) takes place. 



The disease is painful, but not dangerous, complete recovery 

 invariably occurring. The few cases of sudden death that have 

 been recorded as taking place after an injection of serum appear 



