CLINICAL SIGNIFICANCE OF ANAPHYLAXIS 429 



series of cases, found urticaria in all but 17 of 289 cases of serum 

 eruptions occurring between the first and tenth days after injection, 

 and in all but ten of ninety-four later eruptions. 



Rashes occurred in from 69.4 to 81.9 per cent, of the 600 anti- 

 toxin cases which Rolleston reports. 



Joint pains commonly accompany the appearance of the rash, and 

 frequently there is adenitis, involving the glands adjacent to the point 

 of injection, and even remotely in the submaxillary, axillary, or in- 

 guinal glands. Albuminuria is quite common, and with it oliguria 

 and relative concentration. Fever is rarely absent, though usually 

 slight, together with general malaise. Rolleston in his purely clini- 

 cal study does not classify his cases into those reacting after a first 

 injection and those showing symptoms after repeated treatment. He 

 states, however, that the serum-reaction may be extremely severe in 

 cases of "relapse or second attack of diphtheria" in which urticaria 

 with "pronounced edema surrounding the wheals, vomiting, rigors, 

 and collapse may ensue within a few hours of injection," and further 

 asserts that these severe symptoms are more apt to follow upon large 

 than upon small doses. 



Von Pirquet and Schick have studied the condition with careful 

 reference to a comparison between the symptoms occurring in sub- 

 jects after a first injection of serum and those following upon re- 

 peated treatments. Their studies revealed the very important fact 

 that the ill effects following a second injection were not only more 

 severe than those occurring after the first injection, but developed 

 after much shorter periods of incubation. In the ordinary "first 

 injection" case the symptoms appear usually in from one to twelve 

 days. After a second injection this incubation period may be con- 

 siderably shortened and symptoms may appear in from five to seven 

 days, the local and general reactions being much more marked than 

 those subsequent to a first injection. Indeed, in some of the cases re- 

 ported they may attain very alarming degrees of severity. This is 

 the so-called accelerated ("beschleunigte") reaction of von Pirquet 

 and Schick, and is different from the "first injection" symptoms only 

 in its greater severity and speedier onset. In addition to this, how- 

 ever, the "second injection" cases may show a train of immediate 

 symptoms 5 (sofortige Reaktion), which occur within twenty-four 

 hours after injection, and are characterized by marked local erythema 

 and edema with often urticaria and constitutional disturbance. Both 

 reactions may occur in the same individual, the "accelerated" reac- 

 tion setting in as the "immediate" reaction subsides. 



Again, one reaction or the other may occur alone. The analogy 

 between the immediate reaction and the anaphylaxis of animal ex- 

 periment is obvious. The cases may be classified on the basis of 



5 Rankin in the Lancet, Dec., 1911, reports a case of "immediate" reac- 

 tion 15 minutes after injection. 



