144 ANAPHYLAXIS, ALLERGY OR HYPERSENSITIVENESS 
2. Servm Sickness or Serum Disease.— Attention was first directed 
to serum sickness by von Pirquet and Schick/ who noticed that there 
occasionally developed in individuals who had received an injection 
of antitoxic sera, usually after ten to fourteen days, fever and a rash 
which might be urticarial, scarlatinal, or, in the more severe cases, 
morbilliform; enlargement of lymph glands, particularly those near 
the site of inoculation, and joint pains, more frequently of the meta- 
carpal joints. A slight edema, frequently of the angioneurotic type, 
was also occasionally observed. The fever was usually slight and there 
were signs of respiratory embarrassment, not as a rule marked, but 
occasionally severe. These reactions, sudden death and serum sick- 
ness, are more common in asthmatics who frequently have an hyper- 
trophied bronchial musculature,- and in those individuals presenting 
the pathological syndrome known as status lymphaticus. 
According to Moschowitz,^ these individuals, particularly the 
asthmatics, present an eosinophilia. The exact cause of sudden death 
following the administration of diphtheria antitoxin is not definitely 
known, but it has been assumed that respiratory involvement is a 
potent factor. The appearance of serum disease seven to fourteen 
days after the administration of antitoxin is supposed to depend upon 
the fact that some of the alien protein (serum) remains in the body 
during the period of preanaphylaxis (period of sensitization), and 
that this residual protein is broken down by the mature specific 
enzyme or enzymes with the liberation of a poisonous substance 
which causes the anaphylactic shock. 
3. Arthtis Phenomenon.'^— T>UT\ng the course of immunization against 
rabies by the Pasteur method it is frequently observed that after 
seven to ten daily injections a subsequent injection causes symptoms 
of inflammation at the site of the first injection, and that this phe- 
nomenon is repeated, usually, but not always, with diminishing 
intensity at the site of earlier injections as the treatment progresses. 
This inflammatory reaction at the site of injection is not due to bacterial 
infection ordinarily, but is rather an expression of anaphylaxis. It is 
comparable to the Arthus phenomenon produced in rabbits by suc- 
cessive injections of serum referred to above. Also in revaccination 
(vaccinia) a so-called accelerated reaction may occur the second time 
the individual is vaccinated. This accelerated reaction again is 
suspected to be a mild replica of the Arthus phenomenon. 
4. Prophylaxis.— At first sight it might appear that the administra- 
tion of diphtheria or tetanus antitoxin for therapeutic purposes would 
be a dangerous procedure. If there is reason to suspect that the 
patient would react unfavorably to the injection of antitoxic serum, 
it is advisable to inject 0.1 or 0.2 cc. subcutaneously and wait one-half 
' Die Scrumkraukheit, Leipzig, 1905. 
■^ Huber and Koessler: Arch. Int. Med., 1922, 30, 68P. 
3 New York Med. Jour., 1911, 93, 15. 
^ Compt. rend. Soc. biol., 19(W, 55, >S17, 1478. 
