Original Articles.

THE DISTINCTIVE CHARACTER OF THE TEMPERATURE CURVE OF MEASLES AND OF SCARLET FEVER; AND THE TREATMENT OF HYPERPYREXIA IN THESE DISEASES BY BATHS OF INCREASING

TEMPERATURE.*

BY HENRY W. BERG, M.D.,

NEW YORK.

VISITING PHYSICIAN TO THE WILLARD PARKER AND RIVERSIDE HOSPITALS;
ADJUNCT PHYSICIAN TO MOUNT SINAI HOSPITAL; INSTRUCTOR IN IN-
FECTIOUS DISEASES, COLUMBIA UNIVERSITY.

THE clinical observation of measles and scarlet fever in hospital and private practice has led me to the conclusion that the temperature curve in these two acute infectious diseases is as characteristic and distinctive for each of them as are the respective curves of typhoid, typhus, and smallpox. I am well aware that this is not the view of the vast majority of writers on measles and scarlet fever, and it becomes all the more important that each of us who sees much of these diseases in a systematic way should add his quota of observation to the recognition of the normal course of the temperature curve in these extremely common affections.

The temperature curve of the acute infectious diseases is divisible into three stages: (1) That of accession, including the beginning and rise of the temperature to its maximum; (2) the fastigium or stage during which the temperature continues at its height before the positive decline has set in, which forms (3) the stage of defervescence. The first stage may be an acute steep rise to a high temperature in the course of a few hours, or a gradual rise, continuing for days before the fastigium or period of maintenance is attained. The second stage, or fastigium, also varies in duration in different diseases. In some the temperature is maintained for some days, in others the fastigium is scarcely attained before the third stage of the temperature, or that of defervescence, begins. Of the third stage, there are two types. When t declines rapidly, as in pneumonia, the temperature is said to resolve by crisis; when it declines gradually by a slow diurnal descending staircase movement, the resolution is by lysis.

Before discussing the temperature curve of the two diseases to which these observations are limited, I wish to object to the customary description of the symptoms of measles and scarlet fever under the head of the stage of invasion or prodromal stage, the stage of eruption, and the stage of desquamation. The stage of invasion or prodromal stage corresponds with the appearance of the enanthematic eruption upon the mucous membranes, those of the conjunctiva, the nasal fossæ, buccal cavity and inside of the lips and cheeks in measles, and the pharynx, tonsils, and tongue in scarlet fever. This stage is as much a part of the eruptive stage as is the exanthema itself. The so-called prodromal tempera*Read before the New York Academy of Medicine, May

19, 1904.

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ture is the temperature of the enanthematic stage of the eruption. The conception of the desquamative stage as synonymous with that of defervescence is also faulty, in that it would give the impression that desquamation begins with defervescence or disappearance of the eruption, which is rarely true even in measles, and is never true in scarlet fever. Every one who sees much of the latter disease knows that, as far as the skin lesion of this disease is concerned, there is in a large proportion of cases a period of three to eight days or more after the eruption has entirely disappeared and the skin has become normal to the eye and touch before desquamation begins. During this period the most expert clinician could not, in many cases, affirm from the presence of any positive symptoms that the patient had suffered from scarlet fever, and when the history points to that disease he awaits the appearance of the characteristic desquamation. While this is not true of measles, in which the skin does not return to its normal color or appearance until after desquamation is completed, yet even here the fading of the characteristic eruption is not, as a rule, immediately followed by desquamation, but there is generally a period of some days before desquamation sets in. If these diseases must be described clinically under the head of stages, it would be more logical and true to write of them as (1) the eruptive stage, including the enanthematic and exanthematic periods; (2) the stage of defervescence; (3) the stage of desquamation.

The pyrexia of measles and scarlet fever, due to the respective specific infectious cause of these diseases occurs during the eruptive stage as thus defined and the stage of defervescence. By that I do not mean that the rise and fall of temperature that occurs during these stages of all cases of measles and scarlet fever is due to the specific virus of these diseases, emphatically not; for very many suffer during the earliest as well as the latest stage from a variety of complications and mixed infections, each of which causes modifications and deviations from the temperature curves characteristic of measles and scarlet fever when these diseases are uncomplicated. What is meant is that the characteristic temperature curve of measles as well as the characteristic temperature curve of scarlet fever covers the stage of eruption and the stage of defervescence.

Let me then describe the characteristic temperature curve of an uncomplicated case of measles in which there is pyrexia. During the enanthematic period of the eruptive stage the pyrexia is moderate; it rises toward night, it declines about a degree toward morning. It lasts for from two to five days. There is a slight increment of pyrexia every evening as compared with that of the evening before. There is, however, a sharp decline, sometimes to within a degree of the normal, on the morning of the day when the skin eruption (face) is to appear. Synchronous with the appearance of the exanthema, the pyrexia becomes greater and the temperature rises rapidly, generally to a higher point than any