Normal Rectal, Auditory Canal,

Sublingual and Axillary

Temperatures in Elderly Afebrile
Patients in a Warm Environment

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A. DAROWSKI, J. R. WEINBERG, A. GUZ

Summary
Fifty hospital inpatients were selected, who, on the basis of their history and on clinical and laboratory
findings, were believed not to have a febrile illness. Body temperature was measured simultaneously at
four sites, in order to compile a normal range of temperature at each site for patients under these
conditions. The observed range of rectal temperature was 36.7-37.S°C, auditory canal temperature 36.4-
37.2°C, sublingual temperature 36.2-37.0°C, and axillary temperature 35.5-37.0°C.

Introduction Body temperature in elderly people probably

Thermometers have been used in clinical prac-
tice for over 100 years. Despite this, there is a
paucity of data about normal body tempera-
tures in hospital inpatients, and about the
differences between temperatures measured at
various sites. There is no clear definition of
what levels of temperature at each site consti-
tute a fever.
There have been several previous studies of
sublingual temperature in elderly subjects [ 1 -
4]. Two of these studies have been of elderly
patients at home in the winter [1, 2], and one
was of hospital inpatients, but was performed
over a wide range of ambient temperatures [3].
They have shown that the range of sublingual
temperature at low ambient temperatures is
wide, 32.6-37.2°C in one study, with one-third
of patients having a sublingual temperature of
less than 35°C [3]. A study comparing body
temperatures in patients at home with those in
local authority homes found lower sublingual,
but not urinary temperatures, in the winter in
patients living at home [4].
varies to some extent with ambient tempera-
ture. We therefore assume that there must be
several normal ranges of temperature in elderly
people, depending upon the temperature of
their surroundings. For the purposes of diag-
nosing and treating hospital inpatients, the
important normal range of body temperature is
that of patients in the ward environment, at
ambient temperatures in the range 21-26°C.
We have been unable to find normal ranges of
body temperature at various sites for elderly
patients in a warm environment. We have
therefore measured simultaneously rectal, axil-
lary, auditory canal and sublingual tempera-
tures of 50 subjects thought not to have a febrile
illness in order to establish normal ranges for
elderly patients who have been in ward tem-
peratures for at least 24 hours.
Methods
National Health Service (NHS) mercury-in-glass
thermometers (Zeal) were used to measure axillary
Age and Ageing 1991.20.113-119
 A. DAROWSKI ET AL
and rectal temperatures. Subhngual temperature was
measured twice; once with a mercury-in-glass ther-
mometer, and once with an I VAC Temp Plus II
electronic thermometer with a thermistor probe, set
on 'monitor mode'. This thermometer can either
measure temperature at the tip of the probe (monitor
mode), or can register a temperature more rapidly by
estimating the final temperature from the initial rate
of rise of temperature (predictor mode). These two
readings differ, and the former was found to be the
accurate reading, giving an equivalent value to that
obtained with other electronic or mercury-in-glass
sublingual thermometers.
Auditory canal temperatures were measured with
a zero-gradient auditory canal thermometer [5]
in the left ear, and an Ellab C T D 85 electronic
thermometer, with an AE-15 auditory canal thermo-
couple probe in the right ear.
The zero-gradient auditory canal and the Ellab
thermometers were calibrated electronically by the
manufacturers at the beginning and at the end of the
study, and found to be accurate. The mercury-in-
glass thermometers, and the probes of the electronic
thermometers were calibrated by immersion in a
water bath together with a mercury-in-glass ther-
mometer with a certificate of accuracy from the
National Physical Laboratory, Teddington. Over the
range 35-39°C, they were found to be accurate to at
least 0.1 °C, the limit of discrimination of the digital
displays on the thermometers.
Four I VAC Temp Plus II thermometers were
calibrated in a water-bath at 36.0°C, 37.0°C and
38.0°C. On monitor mode all read correctly at 36 0°
and 37.0°C, but over-read by 0.1°C in 10 of 12
measurements at 38.0°C. On predictor mode they
over-read by 0.4-0.5 C C at all three water tempera-
tures. When they were used to measure sublingual
temperature, predictor mode consistently gave a
reading O.2-O.3°C higher than monitor mode in all
four thermometers. Sublingual temperature mea-
sured simultaneously with other thermometers (mer-
cury in glass and Ellab C T D 85 with AE 15 probe)
gave an equivalent reading to that produced on
monitor mode. The introduction of a cold ther-
mometer into the sublingual area causes local cool-
ing, which can be felt by the subject, and which can
be measured by a second thermometer which has had
time to equilibrate at or near that site. This cooling is
of the order of 0.2°C. It takes several minutes for
sublingual temperature to return to its previous level.
Accurate rapid measurements of sublingual tem-
perature are probably not possible with equipment
that causes local cooling.
The rectal thermometer was inserted to a depth of
5 cm from the anus. The patient then lay on her back
while other thermometers were placed. The zero-
gradient auditory canal thermometer was positioned
in the left ear, and the proximal auditory canal
thermocouple in the right ear. The auditory canal
probes were inserted into the auditory canal until the
subject felt slight discomfort as they touched the
tympanic membrane. They were then withdrawn 1-2
mm, until the subject was comfortable. The external
auditory meatus was then closed off with a cotton
wool plug.
All thermometers were left in situ until the zero-
gradient auditory canal thermometer had equili-
brated—approximately 1 5 to 20 minutes. After the
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sublingual mercury-in-glass thermometer was
removed, sublingual temperature was measured
again using the I VAC Temp Plus II on monitor
mode for 3 minutes. Blood samples for full blood
count, erythrocyte sedimentation rate and C-reactive
protein (CRP) were taken at the end of the measure-
ment period.
All subjects had been in hospital for at least 24
hours, and were studied at least half an hour after
their last meal or drink. All measurements were made
between 10 h 00 and 18 h 00.
Hospital inpatients, aged 70 years or over, with no
clinical suspicion of an infection or any other febrile
illness on that admission, and whose diagnosis was
not one usually associated with fever, were studied.
Typical patients studied included those with a diag-
nosis of anaemia, angina, vertebrobasilar ischaemia,
or mild stroke.
All patients admitted to wards for the elderly at
Edgware General Hospital were considered for entry
into the study. The study population represents
about 2% of patients admitted over the period of the
study.
Patients were excluded if they had any bruising, if
they had a history of chronic obstructive airways
disease, a history of previous urinary tract infections
or an indwelling urinary catheter, or if blood or
sputum cultures had been sent.
All subjects were examined and had a chest
radiograph, mid-stream urine sample and a full
blood count performed before entry. Any patient
with white cells or any bacterial growth in the urine,
or who had a blood neutrophil count greater than
75OO/mm3 at any time on that admission was not
entered into the study.
Patients were examined immediately before being
studied. Patients with clinical signs suggesting that
fever might be present—feeling warm or flushed, a
tachycardia or a bounding pulse—were excluded.
The study was approved by the District Ethics
Committee. Verbal consent was obtained from all
subjects.
 TEMPERATURES IN ELDERLY AFEBRILE PATIENTS

Results
Rectal
12
Data for sublingual and auditory canal tem-
10
peratures are based on the higher of the two
available readings where they differed. The
No
normal ranges of temperature at different sites
are presented in the Figure. Mean temperatures
and the observed and calculated ranges of
temperature at each site are summarized in
Table I. The mean differences between tem- 36 0 36 5 37 0
peratures at different sites are summarized in Temperature (°C)
Table II.

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The means of rectal, auditory canal, sub-
lingual and axillary temperatures differed from Auditory canal
12.
each other significantly. No significant differ-
ence was found between temperatures meas- 10.

ured with the zero-gradient auditory canal

thermometer and the proximal auditory canal
thermometer. No significant difference was
found between sublingual temperatures meas-
ured with a mercury-in-glass and an IVAC
Temp Plus II Electronic thermometer on
36 0 36 5 37 0
monitor mode. Temperature (°C)
The mean CRP level was 8.9 mg/1 (95%
confidence interval 7.1-10.7 mg/1, n = 42). Only
three patients had CRP levels > 20 mg/1; all had Sublingual
temperatures near the middle of the observed
range, and none had any obvious cause for a
raised CRP.

Discussion
In this study we have compiled normal ranges
of temperature at four sites in patients believed 365
Temperature (°C)
not to have a febrile illness. We excluded
patients who might have such an illness as far as
possible on clinical and laboratory grounds.
Only 2% of patients admitted during the study- Axilla
period were suitable for entry into the study.
Most were excluded on the basis of a presen-
tation compatible with a febrile illness; other No
patients were excluded if they were considered
subjectively to be warm or flushed to the touch,
or to have a tachycardia or a bounding pulse.
It is nevertheless difficult to be certain that all
infected patients were excluded from the study. n 365 n nn
Routine laboratory tests may remain normal Temperature i •C)
with mild infections. Many elderly women have
bacterial colonization of the urinary tract [6]
which is usually asymptomatic, but which may Figure. The normal ranges of body temperatures at
still cause an increase in body temperature. various sites in elderly hospital inpatients.
n6 A. DAROWSKI ET Ah.

Table I. Body temperatures measured at different young [8] and in fit elderly adults. Theoretically
sites the upper limit of normal sublingual tempera-
ture should be the same as that for auditory
canal temperature, 37.2°C. No patients with
Body temperature (°C) sublingual temperatures in the range 37.1 —
Site of
measurement Range Mean Mean±2SD 37.2°C were found in this study. A definition of
fever as a sublingual temperature greater than
Rectal 36.7-37.5 37.2 36.8-37.6 37.0°C might therefore result in a small number
Auditory canal 36.5-37.2 36.8 36.5-37.1 of afebrile patients being considered febrile
Sublingual 35.6-37.0 36.6 36.1-37.2 (although the majority of patients with sub-
Axillary 35.5-37.0 36.3 35.5-37.0 lingual temperatures in this range would prob-
ably be found to be febrile if their temperature

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In clinical practice, temperature is measured
to determine whether or not a patient has a
febrile illness. If we define fever as a tempera-
ture higher than that normally found at that site
under similar conditions, then any tempera-
tures higher than those in our series would
constitute a fever.
The issue is, however, more complex. There
is one range of temperature found at each site in
normal subjects, and another found at that site
in patients who have a febrile illness (and who
have a fever either at that site or at another).
These ranges overlap to a varying degree at each
site. A febrile patient with a rectal temperature
greater than 37.5°C may have an auditory canal
temperature of only 37.0°C, a sublingual tem-
perature as low as 35.9°C, and axillary tempera-
ture of 36.2°C [7].
In another study we have found that careful
measurements of sublingual and auditory canal
temperatures result in equivalent values in
were measured in the rectum or auditory canal).
We propose, therefore, that patients be consi-
dered febrile if they have a rectal temperature
>37.5°C, an auditory canal temperature
> 37.2°C, or a sublingual or axillary tempera-
ture > 37.0°C. Where the sublingual tempera-
ture is 37.1°C or 37.2°C the febrile state should
be confirmed by measuring the rectal tempera-
ture.
Patients cannot be said to be afebrile on the
basis of normal sublingual or axillary tempera-
ture measurements, as these measurements do
not distinguish between febrile and afebrile
patients if they are within the normal range. An
afebrile patient is one who has a rectal tempera-
ture of 37.5°C or less. It does appear, however,
that this might include a small percentage of
subjects with low-grade fevers at other sites,
but with rectal temperatures of 37.4-37.5°C.
Body temperature varies according to the site
at which it is measured. At any given site, body
temperature is dependent upon local blood

Table 11. Temperature differences between sites of measurement and between

different thermometers at the same site (°C)

Temperature differences
Sites of
measurement Range Mean 95% Confidence interval

Rectal-auditory canal 0-0.7 0.38 0.34-0.42

Rectal-sublingual 0-1.4 0.55 0.49-0.61
Rectal-axillary 0.3-1.5 0.91 0.87-0.95
Zero-gradient vs
proximal auditory canal - 0 . 1 - + 0.2 0.0073 -0.013 to +0.027
Mercury vs IVAC
Temp Plus II
sublingual - O . 2 - + O.3 0.032 0-0.06
 TEMPERATURES IN ELDERLY AFEBRILE PATIENTS
flow, local cooling and heat production, and
upon the temperature of arterial and venous
blood flowing through the area. Areas of heat
production (the liver, intestines [9], and poss-
ibly the brain [10]) have temperatures higher
than those of surrounding tissues, and higher
than that of blood in the great vessels [11].
When there is a stimulus that results in an
increase in body temperature, it acts on these
areas in such a way as to increase local heat
production. The rectum is the only one of these
areas readily accessible to measurement. It
might therefore be expected that rectal tem-
perature would reflect whether the body was in
a state of neutral temperature homoeostasis, or
of increased heat production, and that it would
be a sensitive and early indicator of fever.
Sublingual temperature is often a poor esti-
mate of body temperature in elderly afebrile
subjects [12], and may be even less useful in
febrile patients. It has been shown that at the
onset of fever sublingual temperature may fall,
owing to the vasoconstriction that accompanies
fever, at a time when there is an increase in
rectal temperature [13], and that the rectal-oral
temperature difference is increased in febrile
patients [14, 15], possibly owing to local heat
production in the gut during fever.
The sublingual area may be regarded as being
part of both the skin and the respiratory tract.
Sublingual temperature appears to be
influenced by local vasoconstriction and vasodi-
latation in a similar way to skin temperature [13,
16]. Sublingual temperature is also lower in
cold environments (below 24°C) [17], and poss-
ibly in patients who are tachypnoeic [18].
In fit subjects in a warm environment (24-
26°C) auditory canal temperatures are equiva-
lent to sublingual temperatures in young volun-
teers [8] and fit elderly patients [Darovvski et al.,
unpublished]. The relationship between audi-
tory canal and sublingual temperatures seems to
depend upon the patients' level of fitness. In the
present study of fit patients, the mean differ-
ence between auditory canal and sublingual
temperatures was only 0.2°C. In a previous
series, including more-dependent elderly
patients [12], we reported a much wider range
of sublingual temperature (34.9-37.0°C) in
patients with a similar range of auditory canal
•17
temperature (36.4-37.2°C). In that study con-
fusion, previous stroke, parkinsonism, absent
dentures and micrognathia were found to be
associated with a larger difference between
auditory canal and sublingual temperatures.
In cold environments, or during the onset of
fever, body heat is conserved by the skin, while
at warmer ambient temperatures the skin and
the respiratory tract may serve as organs of heat
dissipation [19]. The range of temperatures
measured at superficial sites (axilla, sublingual
area, and, to a lesser extent, the auditory canal)
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is wider, and the temperatures lower than those
measured in the rectum. They may be
influenced by diminished local blood flow and
low ambient temperatures to a greater extent
than is rectal temperature. Local heat produc-
tion at these sites is not significant [14], and they
are warmed passively by circulating blood.
The Figure shows the ranges of body tem-
peratures measured at various sites. These
ranges, particularly those for rectal and audi-
tory canal temperatures, are narrower than any
previously reported for body temperature in
elderly subjects, suggesting that under these
environmental conditions body temperature is
very precisely controlled. We have found that in
this environment elderly subjects have rectal
temperatures of at least 36.7°C, and in this and
two pilot studies of auditory canal temperature,
totalling 122 patients [12, 20], no normal
patient has been found to have an auditory canal
temperature below 36.4°C (although three
patients with poikilothermia, persistently low
body temperatures, and recurrent symptomatic
hypothermia had rectal temperatures in the
range 34.5-35.5°C [12, 20, 21]). We believe that
this is the first description of a lower limit of
normal temperature under fixed environmental
conditions in elderly people.
This precise control of body temperature is
necessary for the normal working of biological
systems, many of which, particularly those of
the immune system, are very sensitive to
changes in temperature [22]. The biological
role of fever may be to enhance their activity in
the face of an infection.
We have reported previously that equivalent
auditory canal temperatures can be measured
with the proximal auditory canal thermometer
118 A. DAROWSKI ET AL.
and the zero-gradient auditory canal ther-
mometer [8]. This was confirmed in the present
study, in which these two temperatures were
equivalent in 56% of 41 cases, and differed by
more than 0.1 °C in only one case. The zero-
gradient auditory canal thermometer takes
more than 15 minutes to equilibrate, whereas
the proximal auditory canal thermometer equi-
librates in about 5 minutes. The use of auditory
canal temperatures has been criticized because
of the temperature gradient down the length of
the auditory canal [23]; this gradient is suppo-
sedly made negligible by the heater applied to
the external ear in the zero-gradient ther-
mometer [5]. Although abolishing this gradient
should make the zero-gradient thermometer
more accurate than the proximal auditory canal
thermometer, we have found both ther-
mometers to be equally highly sensitive to
probe position; the highest temperature is
invariably measured with the probe as close as
possible to the tympanic membrane. It may also
be that the insertion of a cotton wool plug into
the ear is as effective a way of abolishing the
gradient as is external heating.
Neither of these thermometers is likely to
find widespread clinical applications. They are
uncomfortable in long-term use, and it is some-
times difficult to obtain and maintain optimum
probe placement. At ward temperatures the
zero-gradient thermometer has no advantages
over the proximal auditory canal thermometer,
and its use is limited by its long equilibration
time. It is probably of greater value in cold
environments, for which use it was originally
designed [5].
From a consideration of the physiology of
temperature, it might be expected that the
rectum would be the most sensitive of the
readily available sites of temperature measure-
ment in which to distinguish accurately
between fever and a state of neutral temperature
homoeostasis. This is borne out by our finding
that it has the smallest overlap in the ranges
found in febrile and afebrile patients, that it has
a higher and narrower afebrile range than other
sites, and that it is almost invariably raised in
the presence of significant infection. It is far
more logical to measure body temperature at a
site of heat production than in the sublingual
area, which is a site of heat loss.
Acknowledgements
J.R.W. is a Wellcome Trust Lecturer. This study
was supported by a British Geriatrics Society Senior
Registrar Research Start-up Grant.
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Authors' address
A. Darowski*
Department of Medicine for the Elderly
Edgware General Hospital, Edgware,
Middlesex HA8 OAD
J. R. Weinberg, A. Guz
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Department of Medicine,
Charing Cross and Westminster Medical School,
Fulham Palace Road, London W6 8RF
*Address correspondence to Wexham Park Hospital,
Slough, Berkshire SL2 4HL
Received in revised form 20 June 1990