46. Sophus Bang, Copenhagen.

Fever in gastrlc and duodenal ulcer.

Although the fact is not altogether unknown, that fever occasionally occurs in cases of gastric ulcer, hitherto the question has not attracted the attention it deserves; its diagnostic and practical significance has not been realized. The question is not mentioned in the general tert- books; even the special ulcer literature states, as a rule, merely the fact that h e m a t e m e s e s may be followed by fever, whereas fever as a complication of n o n-b 1 e e d i n g ulcers has been discussed - as far as I know - only by L o r e n z and K r o n e r . K r o n e r reports to have found fever in 17.5 O/O of his 300 ulcer cases; it should be men- tioned, however, that he regards one single rise of temperature to 37.5 as ,,fever”.

My material consists of 386 cases of ulcer from M u n i c i p a 1 H o- s p i t a l o f C o p e n h a g e n . As fever I have taken into account only fever p e r i o d s , in which a whole section of the temperature curve, covering several days, unquestionably stayed at a higher level than did the rest of the curve. I found such fever periods in 207 out of the 386 ulcer patients, that is in 51.5 o/o. But every case with merely a suspicion of some other cause giving the fever, has to be deducted from these 207 fever cases; and that applies t o 28 cases. When these arc deducted, I find fever in 179 out of 358 cases, o r 50 O/O . Although I am more strict in my requirements as t o the term ,,fever”, 1 stilE find fever in 50 0,’o of my cases as compared with K r o n e r ’ s 17 O/O; but this evidently is due to the fact, tha t my department by preference admits cases of a recent date, and thus has a proportionally large; num- ber of ulcers immediately after their occurrence (for this reason, too, my material comprises 41.7 O/O of manifest bleedings, while K r o n e r has only 8 ”0). And it is just in ulcer hemorrhages that fever is s9 frequent. While fever in non-bleeding ulcers so far, as mentioned has been a subject of very parsimonious treatment in the literature is fever subsequent to hemorrhage more often discussed; it was stu- died in particular by L e i c h t e n s t e r n in 1891. In my material I find fever present in manifest hemorrhages (i. e. hematemeses and melma,

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but not occult bleeding) in 121 cases out of 138, or 87.5 o/o'. The au- thors who have worked on th is subject have usually considered the fever due to absorption or to decomposition 6f the bliiod evacuated into the intestines. If this explanation were correct, one would expect a fever to develop from blood which entered the intestines from some other source, f. inst. bleeding oesophageal varices or epistaxis. How- ever, a preliminary investigation of my hospital material of this nature has demonstrated that a large number of such cases develop no fever; hence the mere accumu'fation of a large amount of blood in ihc intesti- nes does n o t necessarily cause a rise of temperature. If the blood in the intestines of a patient with bleeding gastric ulcer were the sole cause of the fever, one also would expect a certain proportionality between the rise of temperature and the retention of the blood in the intestines. And it cannot be denied that such a proportionality does exist in one definite respect, namely with regard t o the h e i g h t of the fever. The highest fever is generally found in that period the patient is kept mn- s'tipated after the hemorrhage; and I find it very likely for other rea- sons, too, that decomposition of the blood which is retained in the in- iestines, can give rise to fever or, a t least, increase a pre-existing fever from other cause. But the fever is by no means proportional to the amount of blood in the intestines when considered from a different point of view, namely with regard to the j u n c t u r e s, when the fever abates, and the blood is evacuated in the stools. If the fever were due to decomposition of the blood, one would expect the temperature to be- come normal as soon as the blood had been discharged from the in- testines; but the fever persists in many cases for a long time after the last trace of blood has disappeared from feces - when even the sen- sitive benzidin reaction gives a negative result. Such was the condition in no less than 68 out of the 138 cases mentioned. A still stronger proof is furnished by t h e fact, that fever occurs in many cases which never showed any signs of manifest hemorrhage, but merely minimal amounts of blood in the intestines, amounts that were so ,small they could be demonstrated only by means of the benzidin reaction, and1 where an ,,absorption fever" was inconceivable. In 28 cases of such occult bleeding 1 find 21 cases or 75 O/O to be febrile. After this, one does not get surprised at finding cases in which there has been no he- morrhage whatever, neither manifest nor occult bleeding, and which still were febrile. My material comprises 13 cases of that kind, or 6.5 ,O/O of the non-bleeding ulcers. - It turns out, that febrile hemorrhages are more frequent in ulcers of a recent date than in old ones. In 13 non-febrile hemorrhages, the ulcer symptoms of the 12 had lasted several years (2-13 years), 1 patient only stated that the symptoms had ,la- sted but 2 months. In contrast herewith, all the apparently quite recent ulcers were associated with fever, namely 19 cases, in which the first

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dyspeptic symptoms were 1 week old at most. If I sum up all ,the fe- brile cases in which the first symptoms appeared a t most 2 months pre- vious to the admission, I have 92 patients in this group, or 76 O/O of the 121 febrile hemorrhages. Thus all the really recent ulcers belong to the febrile group; the old ulcers are sometimes febrile, sometimes afebrile.

How then is this fever to be explained? The classical conception of the gastric ulcer as an ,,uIcus ,simplex”,

a loss of substance in the mucous membrane without any inflammatory phenomena worth mentioning, can evidently not explain the fever. But in the later years, investigations - and particularly the study of fresh material from the stomach resections - show more and more clearly that the ulcer develops in a mucous membrane which has undergone inflammatory changes ( A s k a n a z y, K o n j e t z n y, K a I i m a, B o h- m a n s s o n , S c h m i n c k e , and many others), and then it is an ob- vious surmise, tha t it is this gastritis - and not the ulcer as such - which causes the fever.

From these investigations I feele entitled to draw the conclusion, that many cases of gastric and duodenal ulcer develop a rise \of tem- perature which is independent of hemorrhages. It appears as large accumulations of blood in the intestines are capable of increasing this fever; and the decomposition of the blood can, perhaps independently cause a rise of temperature, but this question requires further inve- stigation. I

It will be of practical value, I think, to pay attention to these temperatures. In many of my cases a slight elevation of the tempe- rature was t h e only tangible sign in an otherwise latent period. Even though all other symptoms were absent, the temperature showed that either the ulcer itself o r its fundamental cause had not yet been cured. Since 1 have realized this fact, I give my directions as to diet and the question of the patient staying in bed accordingly. Sometimes a slight rise of temperature persists for weeks; and I cannot conceive it being immaterial to the question of relapse, whether one takes this temperature into consideration or not in treating the patient. There is just as much reason to pay attention to the temperature in these cases as there is - or ought t o be - in t h e treatment of tuberculosis. It ,is questionable whether this temperature can become of differential diagnostic value ; but it a n hardly be altogether worthless to know that ulcer can be asso- ciated with a fever not unlike that in tuberculosis. At any rate, %the presence of fever can no longer be used as a criterion as to whether a hemorrhage is due to pulmonary tuberculosis or to a gastric ulcer.