- Email: [email protected]
Fever chart
Perspectives
Object lessons Fever chart
www.thelancet.com Vol 389 January 28, 2017
and collated the data. We have selected one chart from the many in his archives, and reading it reveals several things. First, his charts were prepared on printed forms, part of the burgeoning supply of medical stationary that helped make clinical care more systematic. Admission forms, laboratory results (Rogers was an adept microscopist), and discharge summaries were standardised from the late 19th century, serving to produce a common medical language. Second, the diagnostic notations at the top of the chart were both a throwback to an older qualitative tradition felt by the hand (“low” fever was a condition where the temperature never reached very far above “normal”—a figure agreed on only after routine use of the thermometer), and an example of the quantitative specificity now applied to illnesses with a febrile element. Of the latter, “heatstroke” was regular in its pattern, along with the “malarious fevers” so common in India. Third, Rogers’ fever charts well illustrate the transition between the older clinical ways and a new era dominated by bacteriology and the notion of specific fevers. “Low fever” belonged to the past, but his other fever charts documented more specific diagnoses, such as typhoid fever or amoebic liver abscess, on which he recorded the clinical course of a disease, pretty sure of its origin. So much for Rogers. For the patient, a 20-year-old woman, this was a discreet episode forming part of her unique medical record. It could inform her doctors for the rest of her life, but in the early 20th century it was a private document for the doctor, not one that she could expect necessarily to have access to, as she could today.
For more on Object lessons see Comment Lancet 2015; 386: 939, Perspectives Lancet 2015; 386: 945, 1525, 1933, Lancet 2016; 387: 113, 1046, 1607, 2281, and Lancet 2016; 388: 119, 859, 2107
*Bill Bynum, Helen Bynum [email protected]
Wellcome Library, London
“Fever” has long been a medical preoccupation. For most of its history, fever has been a disease in itself, further differentiated by modifiers such as malignant, low, intermittent, or putrid. It was diagnosed by the patient’s history, the prevalent disease in the neighbourhood, the pulse, the condition and feel of the skin, and other signs and symptoms that an experienced doctor would recognise. The clinical course would have further helped in its differentiation. With the development of the thermometer, Santorio Sanctorius (1561–1636) occasionally used them in his clinical practice, and temperature gradually became a number, to be measured, not just estimated, part of a new mechanical objectivity. Numbers appealed to those seeking out the mysteries of nature during what is generally called the “Scientific Revolution” of the 16th and 17th centuries. Our two main scales, Fahrenheit and Celsius, take their name from naturalists working in the early 18th century. To be used routinely, thermometers needed to be smaller and more responsive. Despite some fascination with measuring temperature in the late 18th century, their widespread clinical use dates from the work of the German clinical scientist Carl Wunderlich (1815–77), who showed how important regular measurement of temperature could be for diagnosis of disease patterns, and for following the clinical course of a disease. For Wunderlich, measuring temperature was a skilled business, to be done only by the doctor. His thermometers were long (20–30 cm), and when placed under the arm they took about 20 min to register a result. Further improvements in design and speed made thermometers common and promoted the temperature or fever chart, so common a feature of the records at the foot of hospital beds. The fever chart shown here is one from the papers of Sir Leonard Rogers (1868–1962), an expert in tropical medicine who helped set up the Calcutta School of Tropical Medicine and Hygiene and spent over 20 years in the Indian Medical Service. Rogers’ goal was to ensure that the latest scientific medicine was practised everywhere. Fever charts were part of this enterprise, giving as they did graphic records of temperature over time. Such records were central to experimental physiology and their deployment at the bedside helped make clinical medicine that much more scientific. Rogers’ fever charts were part of patient care but also provided data for his books, including Fevers in the Tropics (first edition, 1908). Rogers was officially a pathologist but he bicycled around Kolkata visiting the city’s hospitals in the early mornings, and thus immersed himself in the sheer volume of sick humanity that only hospitals can offer. He meticulously recorded the patients’ progress in shorthand
Fever chart Leonard Rogers used a standard Lewis’s Clinical Chart, published by H K Lewis of London, to record the clinical course of patients in the Calcutta European Hospital 1904–06. It is preserved in his papers at the Wellcome Library.
359
Object lessons Fever chart
www.thelancet.com Vol 389 January 28, 2017
and collated the data. We have selected one chart from the many in his archives, and reading it reveals several things. First, his charts were prepared on printed forms, part of the burgeoning supply of medical stationary that helped make clinical care more systematic. Admission forms, laboratory results (Rogers was an adept microscopist), and discharge summaries were standardised from the late 19th century, serving to produce a common medical language. Second, the diagnostic notations at the top of the chart were both a throwback to an older qualitative tradition felt by the hand (“low” fever was a condition where the temperature never reached very far above “normal”—a figure agreed on only after routine use of the thermometer), and an example of the quantitative specificity now applied to illnesses with a febrile element. Of the latter, “heatstroke” was regular in its pattern, along with the “malarious fevers” so common in India. Third, Rogers’ fever charts well illustrate the transition between the older clinical ways and a new era dominated by bacteriology and the notion of specific fevers. “Low fever” belonged to the past, but his other fever charts documented more specific diagnoses, such as typhoid fever or amoebic liver abscess, on which he recorded the clinical course of a disease, pretty sure of its origin. So much for Rogers. For the patient, a 20-year-old woman, this was a discreet episode forming part of her unique medical record. It could inform her doctors for the rest of her life, but in the early 20th century it was a private document for the doctor, not one that she could expect necessarily to have access to, as she could today.
For more on Object lessons see Comment Lancet 2015; 386: 939, Perspectives Lancet 2015; 386: 945, 1525, 1933, Lancet 2016; 387: 113, 1046, 1607, 2281, and Lancet 2016; 388: 119, 859, 2107
*Bill Bynum, Helen Bynum [email protected]
Wellcome Library, London
“Fever” has long been a medical preoccupation. For most of its history, fever has been a disease in itself, further differentiated by modifiers such as malignant, low, intermittent, or putrid. It was diagnosed by the patient’s history, the prevalent disease in the neighbourhood, the pulse, the condition and feel of the skin, and other signs and symptoms that an experienced doctor would recognise. The clinical course would have further helped in its differentiation. With the development of the thermometer, Santorio Sanctorius (1561–1636) occasionally used them in his clinical practice, and temperature gradually became a number, to be measured, not just estimated, part of a new mechanical objectivity. Numbers appealed to those seeking out the mysteries of nature during what is generally called the “Scientific Revolution” of the 16th and 17th centuries. Our two main scales, Fahrenheit and Celsius, take their name from naturalists working in the early 18th century. To be used routinely, thermometers needed to be smaller and more responsive. Despite some fascination with measuring temperature in the late 18th century, their widespread clinical use dates from the work of the German clinical scientist Carl Wunderlich (1815–77), who showed how important regular measurement of temperature could be for diagnosis of disease patterns, and for following the clinical course of a disease. For Wunderlich, measuring temperature was a skilled business, to be done only by the doctor. His thermometers were long (20–30 cm), and when placed under the arm they took about 20 min to register a result. Further improvements in design and speed made thermometers common and promoted the temperature or fever chart, so common a feature of the records at the foot of hospital beds. The fever chart shown here is one from the papers of Sir Leonard Rogers (1868–1962), an expert in tropical medicine who helped set up the Calcutta School of Tropical Medicine and Hygiene and spent over 20 years in the Indian Medical Service. Rogers’ goal was to ensure that the latest scientific medicine was practised everywhere. Fever charts were part of this enterprise, giving as they did graphic records of temperature over time. Such records were central to experimental physiology and their deployment at the bedside helped make clinical medicine that much more scientific. Rogers’ fever charts were part of patient care but also provided data for his books, including Fevers in the Tropics (first edition, 1908). Rogers was officially a pathologist but he bicycled around Kolkata visiting the city’s hospitals in the early mornings, and thus immersed himself in the sheer volume of sick humanity that only hospitals can offer. He meticulously recorded the patients’ progress in shorthand
Fever chart Leonard Rogers used a standard Lewis’s Clinical Chart, published by H K Lewis of London, to record the clinical course of patients in the Calcutta European Hospital 1904–06. It is preserved in his papers at the Wellcome Library.
359