PARESTHESIA OF THE PHARYNX AND LARYNX 
AS A PREMONITORY SYMPTOM OF 
TUBERCULOSIS OF THE LUNGS. 
BY 
JULIUS WOLFENSTEIN, M.D., 
OF CLEVELAND, OHIO. 
FROM 
THE MEDICAL NEWS, 
September 30,1893. Reprinted from The Medical News, September 30,1893. 
PARESTHESIA OF THE PHARYNX AND LARYNX 
AS A PREMONITORY SYMPTOM OF 
TUBERCULOSIS OF THE 
LUNGS.1 
By JULIUS WOLFENSTEIN, M.D., 
OF CLEVELAND, OHIO. 
Paresthesia of the pharynx and larynx is an 
affection often encountered by the laryngologist, and 
the etiology which suggests itself to his mind is, pri- 
marily, hysteria and hypochondria, and secondarily 
the results of injury to the mucous membrane from 
the swallowing of some hard substance. That these 
are etiologic factors in a large percentage of the 
cases of paresthesia of the pharynx and larynx is 
established beyond doubt; in fact, most of the 
modern text-books mention no other cause. 
To cite but a few instances : Bosworth, in his late 
work on the Diseases of the Nose and Throat, has a 
very unsatisfactory, brief article on this affection, 
and he believes that most cases of paresthesia can 
be traced to some local pathologic condition. This 
same view is also most strongly upheld by Lennox 
Browne in his well-known text-book. 
It is true, Bosworth does mention that the affec- 
tion occurs in anemia and pulmonary tuberculosis, 
1 Read in part before the Ohio State Medical Society, Put-in- 
Bay, Ohio, June 29, 1893. 2 
and in individuals of nervous temperament, but in 
such a cursory manner that the reader perceives 
that he lays very little stress on the subject. 
As another example, take Schrotter's Vorlesungen 
uber die Krankheiten des Kehlkopfes, etc., published 
within a year. This author states that most cases of 
paresthesia of the larynx are due to injuries produced 
by swallowing some hard substance; hypochondria 
and hysteria come next, and anemia is casually men- 
tioned among the causes. Without quoting any 
more authorities, except to say that Mackenzie, 
with his wide experience, merely mentions a nervous 
and traumatic etiology, which would simply be a 
reiteration of what has been said before, allow 
me to call attention to but one more text-book on 
this subject. Gottstein, in his Krankheiten des 
Kehlkopfes, which by the way is certainly the most 
excellent treatise on this subject extant to-day 
in any language, calls attention to the fact that 
paresthesia of the larynx is one of the frequent 
symptoms of the early stages of tuberculosis of the 
lungs. 
The first one to call attention to this fact was, I 
believe, Jurasz in his monograph on the subject of 
"Sensory Neuroses of the Pharynx and Larynx." 
This was published as early as 1881, but it seems 
that the subject has not received the attention 
which its importance demands. 
In his monograph, Jurasz remarks that these 
cases of paresthesia are "relatively not rare com- 
plications of beginning tuberculosis of the lungs." 
As mentioned before, Gottstein's observations co- 
incide with those of Jurasz, and as far as my per- 3 
sonal experience goes, which I admit is not very 
extensive, I have seen at least half a dozen cases of 
paresthesia of the pharynx and larynx in the past 
three years, whose causation could be traced to no 
other source than probable beginning tuberculosis 
of the lungs. The history of several of the cases 
afterward positively proved the correctness of my 
supposition. 
As regards the symptomatology of this affection I 
can be brief. Paresthesia of the pharynx and larynx 
manifests the same indefinite and varied subjective 
sensations that characterize this peculiar symp- 
tom as an accompaniment of so many nervous affec- 
tions, such as tabes dorsalis, cerebro-spinal sclerosis, 
etc. The patients complain of pain, which they now 
locate in the region of the larynx, now in the tonsil, 
now in the tongue, now on one side and now on the 
other. The abnormal sensation is never constantly 
present in a definite locality. Again some patients 
complain of the most peculiar and unheard-of sensa- 
tions of tickling, scratching, burning, pricking, 
numbness, dryness, etc. Schrotter mentions the 
case of a patient who said he had a sensation as 
though " a mouse had run through his throat." As 
is so universally the case in sensory neuroses of the 
body in general, the perverse sensations complained 
of are peculiar and preposterous in direct propor- 
tion to the morbid imagination of the patients. 
The only definite thing in the history of this class 
of cases is the indefinite character of the symptoms; 
that is, the uncertainty on the part of the patient 
of localizing and describing the perverse sensations 
and the oftentimes changing character of these 
sensations. 4 
Besides these sensory neurotic symptoms, there 
are also present at times paroxyms of cough, in the 
vain attempts to remove the irritation felt by the 
patients. There are also present at times motor neu- 
rotic symptoms, like contractions of the laryngeal 
and pharyngeal muscles, which are very disagreeable 
to the patients. 
Coming to the most important part of my paper, 
the differential diagnosis of the various kinds of 
paresthesia of the pharynx and larynx from the 
etiologic standpoint, I shall try to be brief and 
give you succinctly the most important symptoms 
that characterize this affection as an accompanying, 
and particularly as a premonitory, symptom of 
pulmonary tuberculosis. 
In every case of paresthesia of the pharynx or 
larynx a most careful local examinaton must be 
made, to exclude any local pathologic condition 
as a cause for the paresthesia. It is hardly necessary 
to add that, particularly in nervous individuals, a 
naso-pharyngeal catarrh, a chronic pharyngitis or 
laryngitis, or even the tiniest of those almost 
universally-present granulations on the posterior 
wall of the pharynx, or hypertrophy of the lingual 
tonsil, may produce paresthesia. All local causes 
must therefore be first excluded. 
The hysterical cases are generally easily excluded 
from the history, and from the fact that there is 
usually present in almost all of these cases the well- 
known globus hystericus. 
The hypochondriac cases are more difficult of 
exclusion. They are generally found in otherwise 
healthy individuals who use their voices profession- 5 
ally, e. g., teachers, singers, clergymen, etc. An- 
other class of these hypochondriac patients are the 
syphilophobes who constantly imagine that syphilis 
is manifesting itself in their throats. I have under 
observation a very striking example of this kind. A 
patient visits me regularly several times a year, 
complaining of a peculiar train of symptoms- 
tickling, pricking, drawing, etc. Still I have never 
been able to find anything abnormal. The man is 
perfectly healthy, but he had a chancre several 
years ago. He is fearful that syphilis will " break 
out " in his throat, and he comes to me several times 
a year for consolation. 
As regards the class of cases due to injury of the 
mucous membrane produced by swallowing some 
hard substance, when the patients complain of 
the sensation of a foreign body in various por- 
tions of the throat, the history of the cases will 
generally give us a clew as to the character of 
the paresthesia. The patient can generally state 
definitely when the peculiar symptoms were first 
noticed, and their beginning can then in most 
cases be traced to an injury produced by swallowing 
some substance which, by its irregularity or hard- 
ness, wounded the mucous membrane of the throat. 
This wound or injury, which may be so slight as to 
escape detection, on even the most careful examina- 
tion, may give rise to the sensation of a foreign body 
in the throat. These painful or disagreeable sensations 
can, as a rule, be perfectly localized by the patient, 
and their locality does not vary. A most careful ex- 
amination of the entire throat and naso-pharynx must 
be made, so as to be positive that there really is no 6 
foreign body present, and after this is done, appro- 
priate measures should be used to remove as speedily 
as possible the inflammation and irritation follow- 
ing the injury. But there are cases of so-called 
imaginary foreign bodies in the throat, in which the 
peculiar sensations complained of by the patient 
cannot be traced to any injury of the mucosa or to 
the presence of a foreign body. These cases 
generally occur in anemic individuals, particularly 
women. They are very refractory to treatment. 
I am inclined to believe that the majority may 
perhaps be included under that category of pares- 
thesia of the throat which is premonitory of tuber- 
culosis of the lungs. 
Allow me to give in brief the history of only two 
cases of this nature. I believe this will best bring out 
the points in the differential diagnosis that I wish 
to make. In the first case the paresthesia was an 
accompanying symptom, in the second case it was 
a premonitory manifestation of pulmonary tuber- 
culosis. 
Case I.-About three years ago a man of twenty- 
five years of age was sent to me for treatment. For 
the preceding few months he had noticed the follow- 
ing symptoms : A peculiar, indefinite sensation of 
pain and burning in the various regions of the throat, 
now in the palate, now far back in the pharynx, 
now on one side of the larynx, now on the other. He 
could not state definitely either the cause or the 
time of the beginning of these symptoms. He also 
coughed occasionally. There was a history of tuber- 
culosis in the family. A careful examination of the 
nose, naso-pharynx, pharynx, and larynx revealed 
nothing abnormal outside of a slight redness of the 7 
true vocal bands; but as the man used his voice con- 
siderably, this was not surprising. An examination of 
the lungs revealed a moderate degree of apical catarrh 
on both sides ; there was also slight rise of tempera- 
ture, 99.50 F., and some acceleration of the pulse- 
84. In view of the family history, the physical 
signs in the lungs, the elevation of temperature and 
acceleration of the pulse, a diagnosis of beginning 
tuberculosis of the lungs was made. The patient 
was given creosote in increasing doses, was ordered 
to take plenty of nourishing food, and was given 
the well-known instructions ordered to patients 
with beginning pulmonary tuberculosis. No treat- 
ment was ordered for the throat. In four weeks 
the paresthesia disappeared, and, except for some 
slight recurrences, has not returned for two years. 
The patient is now practically well. 
Case II. -A woman, aged about twenty-six, came 
to me about four months ago. She was sent for 
an examination of her throat. She complained 
of pain in the throat for about three months past, 
with some cough and occasionally spasmodic con- 
tractions of the muscles of the larynx and neck, so 
that she sometimes had difficulty in breathing. 
This was, however, only momentary. The pain 
and "drawing," as she termed it, were not con- 
stant, nor were they always on the same side. 
Sometimes these symptoms disappeared for a week 
at a time, when the cough also disappeared with 
the pain and contractions. The physician who had 
sent her to me had made an examination of the 
lungs, but had found nothing abnormal. I also 
found no abnormality. The throat was absolutely 
normal; there was not even anemia of the structures. 
After much questioning the patient remembered that 
some distant relative of hers had died of tuberculosis. 
To do something I gave the patient creosote in mod- 
erate doses, four grains per day. So as not to preju- 8 
dice her mind, I told her that her throat-affection was 
a nervous trouble and would probably last a long 
while. Two weeks later the patient informed me, 
without any interrogation on my part, that the pares- 
thesia was considerably improved. I increased the 
dose of creosote to six grains daily, and four weeks 
later the patient informed me that while the pares- 
thesia was still occasionally present, it was much 
improved. The patient has gained in weight, looks 
better, and has a better appetite. 
In brief, then, the cases of paresthesia of the 
throat which are premonitory of tuberculosis of the 
lungs are characterized principally by uncertainty 
on the part of the patients as to the cause and the 
time of beginning of their symptoms. Then in cases 
of anemia of the throat, in combination with the 
paresthetic symptoms, this condition should be 
thought of, although, as I shall mention later, anemia 
of the tissues of the throat is not an absolutely 
necessary condition in this class of cases. 
This condition should also be suspected in all 
cases in which the patient has the well-known hab- 
itus phthisicus, or in which there is a tuberculous 
family history, and finally in all cases which cannot 
be definitely traced to an injury of the mucosa, or 
which are not positive types of the hysterical or 
hypochondriac varieties. 
As regards the pathology of this affection we 
must honestly say " ignoramus." We do not know 
the reason why in the beginning stages of tuber- 
culosis of the lungs there should be these peculiar 
nervous manifestations in the throat. Jurasz has 
attempted an explanation and calls these paresthetic 9 
manifestations " reflexempfindungen " (reflex sen- 
sations). He explains their causation by transfer- 
ence of the irritation produced by the pulmonary 
changes on the sensory fibers of the nerves in the 
lungs to the centripetal fibers (z. e., the sensory 
fibers) of the pharyngeal and laryngeal nerves. He 
says that this theory is rendered plausible by the 
fact that these fibers are branches of the same 
nerve, the pneumogastric, which, it is well-known, 
distributes sensory fibers both to the lungs and to 
the pharynx and larynx, and also motor branches 
to the muscles of the latter. This attempted ex- 
planation is still an unsubstantiated theory, and, 
while very probable, we must confess that we do 
not to-day know the true reason for the presence 
of paresthesia of the throat in the early stages of 
tuberculosis of the lungs. 
Gottstein lays stress upon his observations that 
all of these cases occur in anemic conditions of the 
pharynx and larynx, and hence he considers the 
paresthesia as a tropho-neurosis. This certainly 
does not hold good in all cases, for Jurasz declares 
that there are cases of paresthesia of this kind in 
which there is absolutely no anemia, and that it 
occurs in the very earliest stages of tuberculosis of 
the lungs, in cases in which positively no abnormal- 
ity can be detected by the most careful examination 
-and which later by their history proved to be 
cases of pulmonary tuberculosis-and in which 
there had not yet been sufficient time for the anemia 
of the throat to have supervened. 
I can corroborate this statement, for in the second 
case here detailed there was absolutely no anemia 10 
of the throat and no apparent abnormality in the 
lungs. Still I am convinced that this is one of those 
cases of paresthesia accompanying the initiatory 
stage of pulmonary tuberculosis, in which the changes 
in the lung-tissues are so slightly developed as to 
escape detection by our present methods of examina- 
tion. 
If we feel convinced that the paresthesia is due 
to or accompanies the initiatory stage of tuber- 
culosis of the lungs, the prognosis is generally 
favorable. That is to say, if the pulmonary patho- 
logic conditions can still be inhibited or made to 
disappear by appropriate treatment, the paresthesia 
will in time disappear in the great majority of 
cases. Still there are some cases which will persist 
in spite of any and all treatment. As regards the 
treatment, local measures should be entirely dis- 
carded. They are of no avail, and it is simply a 
waste of time and energy to persist in their use. 
It would be ' ' like sending owls to Athens " were 
I to attempt to bring forward any arguments to-day 
in behalf of the employment of creosote in the 
treatment of tuberculous affections of the lungs, 
especially in the early stages. I have seen most 
excellent results in quite a number of cases of tuber- 
culosis of the lungs in their early stage from the 
administration of creosote, and I consider it the 
remedy par excellence in these cases, both uncom- 
plicated and complicated with throat-affections. 
I consider the paresthesia of the throat as one of 
the complications of pulmonary tuberculosis, even 
in those cases in which no physical changes can be dis- 
covered in the lungs by auscultation and percussion, 11 
and I would advise the use of creosote in gradually 
increasing doses as the remedy that to-day gives the 
best results in these cases. 
To recapitulate : Paresthesia of the pharynx and 
larynx is not a rare accompaniment of the early 
stages of tuberculosis of the lungs. In those cases in 
which no physical signs can be found in the lungs, 
it should be considered a premonitory symptom of 
tuberculosis of these organs : (T) if there is tuber- 
culous family history ; (2) if the paresthesia cannot 
be definitely traced to a foreign body, or an injury 
produced by such an agency, or by the swallowing 
of some hard substance; (3) in the cases of imagi- 
nary foreign bodies of indefinite etiology, with the 
presence of anemia; (4) in all those cases which 
cannot be positively placed under the head of hysteria 
or hypochondria. Finally, these cases are best treated 
by the internal administration of creosote, without 
the use of any local treatment. 
Bibliography. 
Bosworth : Diseases of the Nose and Throat, 1892, vol. ii, 
pp. 636, 637. 
Lennox Browne : The Throat and its Diseases, 1887, second 
edition, pp. 208, 209, 464. 
Schrotter: Vorlesungen iiber die Krankheiten des Kehlhopfes, 
1892, Band i, 6. Lieferung, pp. 382-384. 
Mackenzie: Diseases of the Nose and Throat, published by 
William Wood& Co., vol. i, pp. 84, 307, 308. 
Gottstein : Die Krankheiten des Kehlkopfes, 1890, third edi- 
tion, pp. 217-219. 
Jurasz : " Ueber die Sensibilitats-neurosen des Rachens und 
des Kehlkopfes," Sammlung klinischer Vortrage, herausgegeben 
von Richard Volkmann, 1881, No. 195. The Medical News. 
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