HYSTERICAL pyrexia. 
Read at the Semi-Annuae Meeting of the Medicae and Chirurgicae Facuety of 
Maryeand, heed at Cumbereand, Md., Nov. 21 and 22, 1894. 
By George J. Preston, M. D., 
Professor of Physiology and Clinical Professor of Nervous Diseases, College of Physicians 
and Surgeong,x®Sltimore. 
Reprinted from the Maryland Medical Journal, December 8,1894. 
In considering the subject of hysteri- 
cal pyrexia there are two questions that 
naturally arise. First, is it possible to 
have any considerable rise of body tem- 
perature which is due solely to some 
disturbance in the heat regulating appa- 
ratus; and second, are the recorded clin- 
ical observations free from error ; have 
all other possible causes which might 
be operative in inducing fever been 
rigorously excluded ? 
It is not within the limits of this pa- 
per to discuss the theories of fever; 
upon purely physiological grounds we 
know that in the central nervous system 
there are centers whose function it is 
to regulate probably both heat produc- 
tion and heat dissipation. This con- 
clusion would seem almost inevitable 
when we consider the practically con- 
stant body temperature in health. It is 
inconceivable that the coarse adjustment 
of heat production and heat dissipation, 
oxidation and frictional movements, on 
the one hand, and conduction, radiation, 
heating of air and food, the heat lost 
by becoming latent in the evaporation 
of water, and the conversion of heat 
into mechanical energy, the heat unit 
being converted into the work unit, on 
the other hand, can possibly maintain 
an exact and practically unvarying equi- 
librium. 
There necessarily must exist some 
means of fine adjustment, some delicate 
regulating apparatus, and from a physio- 
logical point of view this must be looked 
for in the central nervous system. That 
the central nervous system possesses 
heat centers there can no longer be any 
doubt. Numerous experiments upon 
animals have amply confirmed this. 
The number and exact location of these 
centers is not however absolutely deter- 
mined upon. There are certainly a 
number of such centers in the spinal 
cord, in the basal ganglia, and probably 
in the cortex of the brain. It is not 
absolutely certain whether these centers 
are merely regulative, thermotaxic, or 
aid in the actual production of heat, 
thermogenetic. Again we are largely 
in the dark as regards the modus operandi 
of these centers. Section of sympathetic 
nerves shows us that the ensuing rise of 
temperature is probably due to vaso- 
dilatation. But even this method of 
heat regulation would seem a rather 
coarse one. Observations upon the hu- 
man subject show that injury to the 
cord and brain will produce enormous 
rise of temperature. 
Since, as we have seen, mechanical 
irritation and injury of certain parts of 
the central nervous system bring about a 
rise of body temperature, it would seem to 2 
be a perfectly logical deduction that dis- 
ordered, irregular, inco-ordinate action 
of these centers would have the same 
effect. Take for example the familiar 
illustration of blushing. Here we have 
an instance of the inhibition of the 
lower vaso-motor centers by the higher 
or intellectual centers. This illustration 
is a very apt one for our purpose, since 
it is evident that vaso-motor paralysis 
plays some part in heat regulation. 
Much valuable and interesting work has 
been done upon this subject by Tsclie- 
schichin, H. C. Wood, Fulenburg, Ivan- 
dois, Richet, Ott and Rosenthal. 
Having thus answered the first ques- 
tion in the affirmative, namely, that upon 
physiological grounds, there is no reason 
why the temperature should not be 
elevated by disturbance of the heat 
regulating centers, and that this disturb- 
ance may arise from the higher brain 
centers. We pass to the consideration 
of the clinical aspect of the question. 
Among the older writers on hysteria 
(Pomme, Sydenham) we find hysterical 
pyrexia described, but it is doubtful 
whether these observations should be 
received as exact, since the etiology of 
fever was far from clear at that day, and 
certain causes which are now well- 
known to be active in the production of 
fever were not recognized and consequent- 
ly not excluded. Recent literature on 
hysteria contains frequent reference to 
hysterical pyrexia, and the subject 
would perhaps obtain still further recog- 
nition if clinical observation were more 
frequently directed to this symptom. 
One is rather surprised, in looking 
through the immense number of records 
of cases in Richet's classic work, to find 
how rarely the thermometer was used. 
Briquet in his well-known treatise on 
hysteria mentions a number of cases of 
hysterical pyrexia; Charcot, on the other 
hand, rarely alludes to it, and seems to 
have assigned it no definite place in the 
symtomatology of hysteria. 
During the past three or four years 
the subject has attracted a good deal of 
attention, and many perfectly authentic 
and carefully observed cases have been 
recorded. Thebest and most exhaustive 
paper on the subject is that of Sarbo of 
fur Psychiatric, xxiii, 
2). His conclusions are as follows : 1. 
There is a genuine hysterical fever, which 
may be (a) continuous, (b) paroxysmal. 
2. Hysterical fever is a functional fever. 
3. It occurs either in simple hysteria or 
in hystero-epilepsy. In the elaboration 
of these conclusions the author describes 
first a form of pseudo-hysterical fever, 
in which are present tachycardia, vaso- 
motor disturbances, headache, thirst 
and other symptoms of fever, with no 
actual rise of temperature; and second, 
true fever, which may present itself as a 
continued or as an intermittent, irregu- 
lar or paroxysmal symptom. 
There was recently under my care 
a very good example of the first type ; 
a young woman of a marked hysterical 
temperament, without any very decided 
stigmata, presenting all the phenomena 
of hysterical fever without any actual 
rise of temperature. The pulse ranged 
from 120 to 160, respiration was rapid, 
skin dry, face rather flushed ; the heart 
sounds were perfectly normal, and there 
was no rise of temperature. This con- 
dition continued for a week or more and 
gradually improved. The continued 
fever may be mild or severe ; it has no 
settled type ; it may appear and disap- 
pear suddenly. Differences in the tem- 
perature of the two sides of the body are 
often observed, and there may be high 
morning and low evening temperature. 
This fever often closely resembles ty- 
phoid, tuberculosis, meningitis and the 
like. The fever may follow, but is in- 
dependent of, convulsive attacks. 
* Pucci (fjrazetta degli ospitali, No. 91) 
concludes : 1. That there is a true hys- 
terical fever. 2. It generally follows 
other hysterical symptoms, yet it may 
be the first symptom of hysteria. 3. It 
always accompanies other symtoms of 
hysteria which may become aggravated 
during the period of the highest temper- 
ature. 4. It may assume the quotidian 
or tertian, intermittent type, or the 
remittent or subcontinuous type. 5. It 
is accompanied by the ordinary symp- 
toms of fever, and may rise to a high 
degree, and during the apyrexia the 
temperature may fall to 350 C. (94.6° F). 
6. The fever may undergo notable inter- 3 
ruptions of days or months. 7. Nutri- 
tion remains good but the mental condi- 
tion may be disturbed. 8. The fever is 
refractory to antithermic remedies. 
Hale White {Lancet, February, 1886) 
says : Hysterical fever always occurs in 
girls. 2. Other symptoms of hysteria 
are present. 3. It occurs at the hysterical 
age. 4. Ovarian tenderness is observed 
and rigors may be present. 5. The 
character of the fever is irregular. 
As opposed to the first conclusion of 
this author, namely, that hysterical fever 
always appears in girls, and it may be 
noted in passing that most English writ- 
ers seem rather unwilling to admit the 
occurrence of hysteria in the male, Bo- 
nardi {Gazetta degli ospitali) mentions a 
case of intermittent hysterical fever in a 
soldier 21 years of age. 
J. O. Affleck {Edinburgh Medical Jour- 
nal, xxxviii) relates an interesting case 
of hysterical fever occurring in a female 
aged 27. The patient complained of 
many and varied hysterical symptoms, 
with fever lasting several months. The 
fever was irregular and at times very 
high (109° F.), pulse 100, respiration 22. 
No special complaint was made during 
this period of hyperpyrexia beyond a 
slight sense of shivering and thirst. 
During the patient's stay in the hospital 
her nutrition was good and her weight 
was increased. The conclusions adduced 
by the author are : 1. There may exist 
over a lengthened period cases of daily 
rises of bodily temperature, very mis- 
leading from their closely simulating the 
symptoms of organic disease. 2. A care- 
ful observation of such cases, including 
regular weighing and frequent urea esti- 
mation; will probably bring out the fact 
that no excessive tissue waste is in prog- 
ress. 3. There will usually be found, 
after careful observation, other symp- 
toms, or a history pointing to hysteria. 
A somewhat similar case to the above 
is given by Esteves {Nouvelle Iconogra- 
phie de la Salpbtriere}. Two papers by 
Debove {Gazette hebdomadaire, Febru- 
ary, 1885, May, 1886) call attention to 
the irregularity of the fever, its long du- 
ration and intensity, and the fact that 
there is no evening exacerbation. This 
author states that he has been able to 
raise the temperature 1.50 C. (2.70 F.) 
by suggestion in the hypnotic state. 
Barie {Gazette hebdomadaire, June, 1886) 
mentions a case lasting 21 days, pulse 
and respiration remaining normal. 
Bressler {Medical Record, April, 1888) 
calls attention to the irregularity of the 
fever both as regards duration and in- 
tensity, and relates cases. Raffaele {Ga- 
zetta della clinic a) concludes from clini- 
cal observations that hysterical fever is 
definitely understood, and represents 
the thermic equivalent of the status epi- 
lepticus. 2. It causes no changes in the 
tissues of the body. 3. The examina- 
tion of the urine in cases of fever of un- 
known origin is of great importance, 
since in the scarcity of its solid princi- 
ples one has a good criterion in diag- 
nosis. See also paper by M. P. Jacobi, 
Journal of Nervous and Mental Diseases, 
1890. 
Many more authorities might be cited, 
but enough are given to prove conclu- 
sively the existence of hysterical fever. 
The cause of hysterical fever cannot be 
clearly understood until certain ques- 
tions relating to the influence of the 
nervous system upon heat regulation are 
definitely settled. As to type, hysteri- 
cal fever may be either continuous or 
paroxysmal. The continuous fever bears 
out its hysterical origin by mimicking 
many forms of fever of organic nature, 
tuberculosis, typhoid, malarial and the 
like. The fever is characterized by its 
irregular course, its long duration, its 
atypical exacerbations. The paroxys- 
mal fever follows some exciting cause, 
may be very high, disappears suddenly. 
It is possible that the explanation of the 
French school may hold good in cases im- 
mediately following convulsive seizures, 
namely, that the excessive muscular 
action is responsible for their existence. 
It is noteworthy that the modern an- 
tipyretics have been found to have little 
or no effect upon hysterical fever. The 
urine never shows the excess of uric acid 
that so commonly accompanies other 
fevers. Nutrition is not impaired, even 
after a very protracted period of what 
might be called hyperpyrexia. While 
in some instances all the phenomena of 
fever are present, it very often happens 4 
that the pulse and respiration remain 
comparatively normal. 
A point of some practical value which 
has not been dwelt upon is that in cases 
of fever from various causes, hysteria 
may incidentally occur and change the 
form of the fever and greatly increase its 
intensity. It is difficult to speak defi- 
nitely on this point, but the fact above 
mentioned has often come under my ob- 
servation. It has already been men- 
tioned that a rise of temperature has 
been obtained by suggestion in the hyp- 
notic state. In one experiment upon a 
•►hysterical woman I was able to raise the 
temperature i° F. by non-hypnotic sug- 
gestion. It is not to be wondered at that 
in hysterical persons fearing or expect- 
ing some fever, puerperal or malarial, 
for example, auto-suggestion acts upon 
the heat-regulating centers. 
From the various facts above men- 
tioned it would seem reasonable to pre- 
sent the following conclusions : 
1. In hysterical individuals a rise of 
temperature may occur, due probably to 
disturbance of the heat-regulating cen- 
ters in the central nervous system. 
2. The type of this fever is either con- 
tinuous or intermittent. 
3. The fever is characterized by its 
great irregularity and atypical exacerba- 
tions, by the fact that the pulse and res- 
piration frequently remain normal, or 
nearly so ; that the temperature is often 
different on the two sides of the body, 
by the temperature not yielding readily 
to antipyretic measures, by the unal- 
tered urine, by the unchanged nutrition. 
4. Hysteria often complicates exist- 
ing fevers, changing their type. 
5. This hysterical manifestation would 
be more frequently noted if the tempera- 
ture were carefully taken in all cases.