POISONING BY CHROME YELLOW ' 
USED AS A CAKE DYE. 
The Subsequent Clinical History of the Cases, Including a 
Case of Paralysis Agitans and of Chronic Endocarditis. 
BY 
DAVID DENISON STEWART, M.D., 
CHIEF OF THE MEDICAL CLINIC OF THE JEFFERSON MEDICAE COLLEGE; 
PHYSICIAN TO ST. CHRISTOPHER’S HOSPITAL FOR CHILDREN. 
FROM 
THE MEDICAL NEWS 
January 26, 1889. [Reprinted from The Medical News, January 26, 1889.J 
POISONING BY CHROME YELLOW USED AS A 
CAKE DYE. 
The Subsequent Clinical History of the Cases, Including a 
Case of Paralysis Agitans and of Chronic Endocarditis.' 
By DAVID DENISON STEWART, M.D., 
CHIEF OF THE MEDICAL CLINIC OF THE JEFFERSON MEDICAL COLLEGE; 
PHYSICIAN TO ST. CHRISTOPHER’S HOSPITAL FOR CHILDREN. 
I reported, in September, 1887, a clinical anal- 
ysis2 of 64 cases3 of poisoning by chrome yellow 
1 Read before the Philadelphia. County Medical Society, De- 
cember 12, 1888. 
3 This paper was published in The Medical News, Decem- 
ber 31, 1887. 
3 In addition to these, I have notes of 15 others, making a total 
of 79 undoubted cases traced to 2 bakers. The 15 include 4 
cases of lead convulsions, which in 3 ended fatally. It is unfor- 
tunate that I was unable to obtain the histories of very few of the 
large number of early patrons of Palmer, the baker, who used the 
dye freely for years in another section of the city than that in 
which he was apprehended. No doubt there were many inter- 
esting cases of plumbism among these. 
It is to the point, in this connection, to state that I believe I can 
trace to lead-poisoning from dyed cakes many cases of disease of 
seemingly obscure or supposed idiopathic origin, seen in the past 
year and a half of my service in the out-patient medical depart- 
ment of the Jefferson College Hospital. Among these are cases 
of pronounced anaemia, renal fibrosis, peripheral neuritis, spastic 
paralysis, neurasthenia, obstinate headache, and, at least, one case 
of long-standing delusional mania. 2 
STEWART, 
used as a cake dye. The present paper is a further 
history of such of these as I have had under obser- 
vation to the present, a period of fifteen months. 
8 of the 64 died in convulsions. The later his- 
tory of 12 of the 56 survivors I have been unable to 
ascertain. Absolutely nothing could be learned of 
6 of the x 2; they are, however, believed to be 
living. I regret I am unable to report their condi- 
tion. They were severely poisoned, after prolonged 
exposure. Nor could sufficient be learned of the 
second 6 to justify their consideration here. Several 
of these were personally questioned but with un- 
satisfactory results. 
At the time the data for the analysis of the 64 
cases were being collected, all of the 44 now recon- 
sidered exhibited some unmistakable and pro- 
nounced symptoms of plumbism, such as cachexia, 
colic, arthralgia, or encephalopathy, and the blue 
line was present in the gums of all save 1. A 
minority only of the 44 received any continuous 
treatment, and many of these were in the hands of 
homceopathists, who, it is believed, did not give 
eliminants. The health of 31 of the 44 is yet de- 
cidedly impaired, and several of the remaining 13 
ail slightly. 
The lead cachexia is still present markedly in 12. 
In these the skin has been of a decided earthy-yellow 
hue, continuously since the poisoning. The gums 
of 8 of the 12 show a fading though distinct blue 
line, and are retracted from the teeth. In 3 of the 
12 there is a purplish line, and in 1 no trace of a POISONING BY CHROME YELLOW. 
3 
line exists. Considerable anaemia1 is present in 
those in which cachexia is yet marked, and in i in 
which cachexia is absent. The mucous membranes 
and conjunctivae are pale. In several a venous hum 
can be heard in the neck; and, in i, a basic (pul- 
monary) murmur.2 Most of the 12 have breathless- 
ness and palpitation on slight exertion. Several 
speak of praecordial pain. 8 of the 12 are very 
dyspeptic;-5 have yet occasional attacks of severe 
colic which occur unprovoked by food or other 
known cause. All of the 12 have headache, which 
in several is severe and constant. 
Evidences of functional derangement and of or- 
ganic disease of the heart have appeared in 7 of the 
44 since the poisoning. In 6 of the 7 there are 
present symptoms of cardiac irritability, such as 
praecordial pain, increased by exertion and then 
accompanied by palpitation and shortness of breath. 
In 2 of these the palpitation and shortness of breath 
occur often when at rest and in recumbency, as at 
night. All of the 6 have increased frequency of 
pulse, and the heart of each is overacting, with ac- 
centuation of the second sound at the apex and 
some increase in the area and force of the impulse. 
In 3 of the 6 this increase is greater than can be 
accounted for by mere functional overaction, and 
other accompanying physical signs and symptoms 
indicate slight but unmistakable hypertrophy. The 
1 Through an utter lack of cooperation and interest on the part 
of these cases, none of which were my patients, I was unable to 
obtain a blood examination. 
2 This was not examined for in all. 4 
STEWART, 
seventh case illustrates one of the insidious effects of 
chronic lead poisoning, a tendency toward slow 
degenerative changes in the vascular system. There 
was at first irritable heart, which was succeeded by 
hypertrophy, and that by a chronic mitral valvulitis 
with insufficiency. Dilated hypertrophy of the left 
ventricle then followed.1 
The case is that of Mrs. H. H., aged forty-seven' 
There is absolutely no history of rheumatism, gout’ 
syphilis, or alcoholism. Her health had always been 
good until the spring or summer of 1886. Attacks 
of typical lead colic then developed with the usual 
attending phenomena. These continued, at inter- 
vals, until the summer of 1887. There were also 
present during this period severe headache and con- 
stant mental and physical exhaustion. Slight pains 
in the ankles, unaccompanied by any inflammatory 
condition, but with sensations of numbness and 
burning in the soles of the feet, were occasionally 
felt. When first seen in June, 1887, she had been a 
patron of Palmer for fifteen months, and had eaten 
almost daily of the dyed cakes. Her condition 
then was much as has been stated. In addition, it 
was noted that she was emaciated and dyspeptic, had 
palpitation and shortness of breath on exertion, and 
prsecordial pain. There was heightened arterial ten- 
sion, a much overacting, irritable heart, but no 
murmur. Lead was found in her urine by Dr. Leff- 
mann at this time, and an examination of the eye- 
ground by Dr. Hansell showed “oedema of both 
1 Professor Da Costa, to whom I showed this case somewhat 
more than a year ago, when the valve changes were not percep- 
tible, and, later, when they were markedly present, fully agrees 
with me as to the pathological condition, and as to its plumbic 
origin. POISONING BY CHROME YELLOW. 
5 
retinas, with effusion into the right retina below the 
fovea; pulsation of larger and tortuosity of both 
large and small veins.” 
Because of her absence from the city during the 
summer of 1887 I saw her but seldom. Ailing 
severely in September following, she presented her- 
self for regular treatment, and has been under con- 
stant observation to the present. The mental and 
physical prostration had persisted, and, in August, 
coarse tremor, involving the head and limbs, had 
appeared. The shakingbegan each morning on rising, 
and continued constantly through the day. It was 
especially aggravated by physical exertion. Decided 
weakness of grasp accompanied it, but no paralysis. 
She had continuous headache, and palpitation was 
so troublesome at night that she was unable to rest 
in recumbency. Early in September there was found 
extreme overaction of the heart, with undoubted 
hypertrophy of the left ventricle. No murmur, 
however, could be detected until about the 14th of 
October following. There had then developed a 
faint systolic mitral bruit, which was accompanied 
by distinct accentuation of the pulmonary second 
sound. Palpitation was now more distressing than 
formerly, and was associated with attacks of short- 
ness of breath and of dyspnoea by day, but oftener 
by night. Prior to this, believing renal fibrosis was 
in progress, the urine, which had been of a low 
gravity and profuse in amount, had been frequently 
examined for albumin and casts, but always with 
negative results. Shortly subsequent to the develop- 
ment of the murmuralbumin appeared, detectable 
at first only with picric acid, but soon with nitric. 
The amount never exceeded a gramme to the litre, 
and was usually less. Coincident with the appear- 
ance of the albumin the urine diminished in quan- 6 
STEWART, 
tity, and hyaline and granular casts were very often 
found, sometimes in large amount. 
The remaining facts in the case are concisely as 
follows : The mitral murmur became louder, and the 
area over which it could be heard greater. Evidences 
of stretching of the left ventricle soon appeared, and, 
with these, signs of overloading of the pulmonary and 
general venous circulation assumed prominence. 
The attacks of dyspnoea at night deepened into 
orthopnoea. There were cough and frequent blood- 
spitting. The ankles and feet were at first puffy, 
and then swollen. Purpuric spots appeared on the 
legs. The portal circle was constantly congested, 
causing an icteroid hue of skin and pronounced 
gastro-intestinal catarrh. 
This condition of things continued pretty con- 
stantly until the spring of 1888. She then improved 
very steadily, and the more pronounced signs of 
“back-working” were only occasionally present. 
Since April last the daily quantity of urine passed 
has been normal or above, and albumin and casts 
have been absent. All the usual symptoms of plumb- 
ism had disappeared at this time, The tremor per- 
sisted intermittently for months, but grew less and 
less frequent as her condition ameliorated. 
The physical signs referable to the heart are now 
those of mitral regurgitation and dilated hypertrophy 
of the left ventricle, with hypertrophy in excess of 
the dilatation. The murmur is very distinct, and 
has the usual characteristics of that of mitral insuffi- 
ciency. Though there are yet almost constantly 
present some indications of mechanical derange- 
ment of the circulation, such as oedema of the ankles 
and legs, congestion of the portal viscera, and, at 
times, of the lungs with blood-streaked sputum 
or actual bloodspitting, and attacks of bronchial POISONING BY CHROME YELLOW. 
7 
catarrh, freedom from excessive palpitation in the 
past few months could be obtained only by the per- 
sistent use of aconite. Digitalis and strophanthus, 
which, in moderate doses, were of service a year ago, 
now aggravate the palpitation, and do not materially 
lessen the tendency toward venous congestion. The 
attacks of dyspnoea, which occur once or twice 
weekly, are relieved, as before, by free dry cupping of 
the chest. Restorative agents, such as arsenic, iron, 
and the vegetable tonics, are employed to improve 
nutrition. Frequent resort to purgatives is necessary 
to relieve the portal stasis. 
I have no doubt that some cases of chronic endo- 
carditis, the origin of which we are at a loss to 
account satisfactorily, a history of acute articular 
rheumatism or of strain not being obtainable, are of 
lead origin.1 Lead is, I believe, a more frequent 
1 Chronic valvulitis, as a result of lead poisoning, is not uncom- 
mon, Duroziez reported (L’Union Medicale, December 15,1885) 
eleven cases of mitral stenosis and one of aortic regurgitation, 
occurring in plumbic subjects in whom there was absolutely no 
other assignable cause for the valve affection. 
A typical case of lead endocarditis, originating aortic stenosis 
and mitral regurgitation, is that of B. F. K., a painter for twenty- 
eight years, who has been under constant observation in the out- 
patient medical department of the Jefferson College Hospital 
since 1881. He first presented himself for treatmerit because 
of obstinate colic and an ileocolitis which had arisen in conse- 
quence of lead poisoning. There was a well-marked blue line, 
typical lead cachexia, constant headache and vertigo, and dis- 
tressing arthro- and generalized neuralgia with cramps in the 
muscles of the extremities, and jerking of the limbs. The urine 
was free from albumin. His heart was examined on several occa- 
sions by Prof. Da Costa between 1881 and 1885. On the first 
exploration there were found considerable overaction, and a soft 
systolic murmur limited to the apex. In the autumn of 1884 the 8 
STEWART, 
cause of chronic endocardial inflammation than 
gout, syphilis, or alcoholism. Even where a doubt- 
ful history of rheumatism exists, we should not be 
deterred from an inspection of the gums and an 
inquiry as to the possibility of lead poisoning in 
the past. In all cases of valvulitis of seemingly 
obscure source this should be done as a matter of 
routine. A caution is necessary that a mere his- 
tory of pains in and about the joints must not be 
accepted as undoubted evidence of rheumatism, 
without a careful investigation as to signs of accom- 
panying arthritic inflammation; for it is undoubt- 
edly a fact, of which I have seen striking examples, 
and the non-recognition of which by practitioners 
has caused many lead cases to be overlooked, that 
arthralgic pains are among the most common of 
the protean manifestations of plumbism; and that 
they may persist for lengthy periods entirely without 
other noticeable symptoms, save, perhaps, cachexia ; 
and that even the latter may be absent in undoubted 
cases. 
An abnormally forcible cardiac impulse, with ac- 
centuation of the aortic second sound and increased 
tension in the peripheral arteries, is constantly 
area of cardiac dulness was found to have considerably increased. 
The apical murmur was very distinct, rather harsh in quality, and 
was well transmitted toward the inferior angle of the left scapula. 
There was now present a systolic right basic murmur, distinct in 
quality, and pitch from the apical bruit, and heard in the carotid 
artery. There had been frequent cardiac pain, attacks of palpita- 
tion, and signs of arterial ischaemia. At the present writing the 
mitral and aortic murmurs are very distinct. Compensation is 
good. POISONING BY CHROME YELLOW. 
9 
present in many cases of lead cachexia. In these a 
tendency toward insidious valvular changes must be 
great, and this is no doubt favored by the state of 
faulty nutrition and anaemia always existing in such 
cases. Simple anaemia is supposed sometimes to 
originate chronic valvulitis, through the augmented 
arterial tension present in its earlier stages caus- 
ing increased backward stress on the valve cur- 
tains, and especially on the mitral leaflets, which, 
with each ventricular systole, are subject to a force 
equalling the resistance of the whole arterial circuit. 
Since the conditions favorable for the production of 
chronic valvulitis are more constant and decided in 
plumbism than in ordinary anaemia, it is not unlikely 
that chronic lead poisoning is oftener a cause of 
slow valve changes than mere poverty of blood. 
Having in mind the wide prevalence of lead poison- 
ing and the frequency in the past year and a half 
with which I have encountered cases of somewhat 
obscure type, which no doubt I would have pre- 
viously overlooked, because not on the watch for 
them, and seeing repeatedly in my service in the 
out-patient medical department of the Jefferson 
College Hospital cases which have passed through 
the hands of other practitioners unrecognized, I 
believe it probable that mitral stenosis, often met 
with as an insidious affection in young anaemic 
women free from rheumatic history, not infrequently 
owes its origin to unsuspected lead poisoning. 
Disorders of digestion are prominent in a number 
of the 44, independent of colic or colicky pains. 
One (Mrs. G. A.), who was so prostrated by 10 
STEWART, 
long-continued colic and arthralgia, that she was 
confined to bed for two months’, and lost thirty 
pounds in flesh, has, in addition to attacks of severe 
generalized headache, constant gastric irritability. 
A trifling dietetic error which in health would not 
affect her, now readily provokes vomiting. 
Obstinate constipation is yet present in 7. In 
these the bowels do not move without purgatives. 
A chronic catarrhal enteritis has existed in 1 
since his first attack of colic fifteen months ago. 
There are five or six loose passages for three or four 
days, succeeded by two or three days of constipation. 
Abdominal tenderness and pain are felt, in addition 
to colic which is yet frequently present though in 
a milder form. He had arthralgia affecting the 
knees and ankles for months, so severe that he was 
compelled constantly to maintain the recumbent 
posture. He also had wrist-drop. 
Apart from slight colicky pains, which have been 
frequent in many since the abatement of pronounced 
symptoms of plumbism, and which, in a few, may 
be traced to dietetic errors, paroxysms of abdominal 
cramp having all the intensity and character of true 
lead colic, yet occur in 5. The seizures appear at 
longer intervals, as time passes, and are lessening 
in intensity. At first the interlapse averaged from 
ten to fourteen days, and the duration of the attack 
was three to seven days, but the former gradually 
lengthened and the latter diminished, until recently, 
in each of the 5, a severe seizure occurred about 
every four to eight weeks, and lasted from one to 
three days. None of these cases received regular POISONING BY CHROME YELLOW. 
11 
treatment. In all there is reason to believe lead is 
yet present in the system. 
Pains about the joints and in the muscles in their 
vicinity yet occur in 15.1 In some the pains have 
been constant, with exacerbations and remissions ; 
in others they have occurred intermittently every 
five to thirty days, in attacks lasting three to ten 
days. The ankles and knees, and the neighboring 
muscles are most frequently affected in 9; 3 of 
these have in addition sharp stabbing pains in 
the wrists, and 1 of the latter, pain in the hip. 
In 2 others the ankles, knees, and hips are equally 
affected; in 1 solely the ankles and wrists, and in 
another the lumbar and sacral regions. Dull and 
aching, burning or darting pains in the muscles 
adjacent to the affected joints accompany the ar- 
thralgia in all, and these muscles are yet the seat 
of frequent painful cramps. 2 have, beside the 
joint pain, very sharp darting pains in the forearms 
and wrists, in the course of the nerve trunks, asso- 
ciated with some loss of power and weakness of 
grasp. In 2 others2 severe burning in the soles of 
the feet, alternating with numbness and tingling in 
the feet and hands, is sometimes felt simultane- 
ously with the arthralgia. 
Very painful and persistent inframaxillary neu- 
ralgia is present in 2 of the 15. Neither has carious 
1 13 of these received no treatment, save from homoeopathists ; 
the remaining 2 were under a regular physician’s care for two or 
three weeks when first affected. 
2 The plantar surfaces in these cases were somewhat anaes- 
thetic. 12 
STEWART, 
teeth, and each has had several sound teeth extracted 
without the pain ameliorating. Aching in the right 
clavicle frequently accompanies the arthralgia in i. 
General muscular aching and loin pains persist in 
3. It is believed that inflammatory conditions 
of the joints, such as redness, heat, or swelling, at 
no time occurred in these cases. They were fre- 
quently searched for. The pains in nearly all are 
aggravated by night. Damp and cold weather 
increase them in 5. 
I was recently able to ascertain the state of 
cutaneous sensibility in 8. Some anaesthesia was 
present in the area supplied by the peroneal nerve 
and its terminal branches in 2 ; there was plantar 
anaesthesia in 2 others; in 4, sensation was normal 
or hyperaesthetic in the painful extremities. No 
tendinous swellings about the wrists, or elsewhere, 
were noticed in any. 
It is difficult to decide as to the exact influence of 
lead in the production of the arthralgic pains in 
these cases. Their character and seat, and their 
continuance in those that received no eliminative 
treatment, and that yet show evidence of plumbism, 
suggest they are in most of the 15 a mild form of 
the articular and muscle pains which were present 
in 47 of the 64 when these cases were thoroughly 
investigated over a year ago. Our knowledge of 
the peculiar morbid state underlying so-called lead 
arthralgia is too slight to permit us to assert that the 
same pathological conditions always exist. In most 
of the 47 the symptoms were originally those of 
aggravated neuralgia of the joints, bones, and intra- POISONING BY CHROME YELLOW. 
13 
muscular nerves. In not a few who were under 
observation for a considerable period and received 
no regular treatment, while the arthralgic pains were 
prominent, there were present symptoms suggestive 
of neuritis, such as sharp pains in the muscles and 
in the limbs in the course of the nerve trunks, often 
with decided tenderness on deep pressure; alterations 
in sensibility such as paraesthesia, hyperaesthesia, and 
anaesthesia; weakness in the limbs ; rigidity, and 
frequent cramps in the muscles. 
The electrical reactions were taken in several of 
these cases, but no quantitative or qualitative changes 
were found. The examinations, however, were made 
at too early a period for the negative result to be of 
much value in the diagnosis of the condition. 
In none did the character of the symptoms suggest 
that the pains were of a gouty nature, nor do they 
now in the 15 under consideration. The smaller 
joints were unaffected, and no inflammatory appear- 
ances accompany the pain in the large joints. It is 
not unlikely that slight deposits of urates may occur 
in a joint, and no appreciable objective phenomena 
at once arise. Yet this condition could scarcely 
continue long without an inflammatory outbreak. 
There is no doubt that a special predisposition to 
gout exists in subjects of chronic plumbism, and it 
is not improbable that slight joint pains, with ach- 
ing in the limbs, and muscular cramps, ephemeral 
neuralgias, headache, vertigo, and mental depression, 
occurring in such subjects, are sometimes symptoms 
rather of the gouty or lithgemic state induced by 
lead than of the direct action of that metal. Where 14 
STEWART, 
doubt is felt, it is of diagnostic importance to ex- 
amine the urine and blood-serum, quantitatively, 
for uric acid. I have, as yet, been unable to do 
this in any of the 15 arthralgic cases. It was prob- 
ably excreted in deficient amount in at least 2. 
The urine of these has been more or less scanty, 
since pronounced symptoms of plumbism were pres- 
ent; it often deposits urates, and fits of the gravel 
occur. An unsuccessful effort was made to get 
specimens. 
At the date of the preparation of the clinical 
analysis of the 64 cases, complete paralysis of the 
extensor muscles of the forearms (typical wrist-drop) 
had occurred in but 2 ; bilateral weakness of the 
extensors of the fingers existed in 1 other, and in 2 
others there was slight loss of power in all of the 
extensors of the fingers and of the wrists, without 
actual paralysis. In the third-mentioned of these 
cases (1 of the 44) complete forearm extensor par- 
alysis afterward occurred. In the 2 last mentioned 
the ataxia disappeared without paralysis ensuing. 
So that complete wrist-drop was met with in but 3 
of the 64 cases, and it was not encountered in any 
of the other (15) cases of the chrome yellow poison- 
ing traced to the same source, of which I have notes. 
This exemption among so many cases of pronounced 
plumbism in which the rarer condition—encephal- 
opathy—occurred so frequently, is quite remarkable. 
In none of the 3 cases did the paralysis extend to 
the upper arm or involve the supinator longus. 
Complete recovery has taken place in 1. In 2 of 
the cases power has been partially regained in the POISONING BY CHROME YELLOW. 
15 
extensors of the wrist, so that the hand can be in- 
completely extended if the fingers are flexed into 
the palm, but the extensors of the fingers and thumb 
in both cases are yet too ataxic more than very 
slightly to extend these members or the hand itself 
if the fingers are first passively straightened at the 
metacarpo-phalangeal joint. The paresis is greater 
on the left in i; in the other, it is equally marked 
on both sides. Sensation is unaffected. Consider- 
able atrophy exists in the situation of the paretic 
muscles in each case. Neither would come for elec- 
trical examination. It is presumed reactions of 
degeneration are present, i case is known to have 
taken for some weeks potassium iodide; the other 
received no treatment. 
In i of the 44 in which typical paralysis agitans 
has developed, presumably as a result of lead poison- 
ing, there exists, in consequence of weakness and 
stiffness of the forearm muscles, lack of complete 
extension of the hands and fingers on the wrist, 
more marked on the right. This case is of especial 
interest and worthy of detailed report, because it is 
generally supposed that although lead may occa- 
sionally originate tremor resembling somewhat that 
of paralysis agitans, the typical “shaking palsy,” of 
Parkinson does not arise in consequence of poison- 
ing by that or other metals. 
Mrs. Mary McF. / aged sixty-one years, occupa- 
i This case recently visited me several times in the medical clinic 
of the Jefferson College, and was shown by Prof. Da Costa to the 
class. I may state he is fully in accord with me both as to the 
diagnosis and as to the probable origin of the disease from lead 
poisoning. 16 
STEWART, 
tion general housework. One of a family1 of seven 
all of whom were severely poisoned from the same 
source. She had eaten the chrome yellow buns for 
nearly a year before symptoms other than cachexia, 
constipation, arthralgia, and slight colic, appeared. 
In June, 1886, she was seized with recurrent attacks 
of lead colic, lasting four to ten days, with intervals 
of about one week, during which slighter abdominal 
cramps, with nausea, vomiting, and constipation 
persisted. I visited her frequently in June and July, 
while investigating other cases of poisoning. All 
were studied with great care and it is absolutely 
certain that she was free from tremor then and before. 
In addition to colic, which persisted through the 
summer and autumn, attacks of generalized headache 
were now present with neuralgic pains in the joints 
and limbs. She lost flesh and strength, was de- 
pressed mentally, and sleepless. Tremor of the 
right hand and fingers was first noticed early in 
October, while plumbic symptoms were yet prom- 
inent. It was then slight and inconstant and 
appeared usually after mental or physical fatigue, 
but ceased on voluntary effort, by exercise of the 
will and during sleep. 
I now lost sight of her until September, 1888. 
Since then she has been under constant observation. 
The following are the additional facts in her case 
from October, 1887, to the present.2 She at no time 
received continuous treatment directed toward 
eliminating the lead. I had endeavored to persuade 
her to take potassium iodide. After a five days’ trial 
she desisted, believing it aggravated colic and head- 
ache. Her health had always been robust until she 
suffered from plumbism. She had never had tremor 
1 2 of the 3 cases of wrist-drop occurred in this family. 
* November 15, 1888. POISONING BY CHROME YELLOW. 
17 
before, nor had she ever received a physical injury 
or mental shock. No hereditary history of any 
neurosis is obtainable. Her people were sturdy 
Irish, who died rather of old age than of any disease. 
Umbilical colic and severe loin pain yet occur inter- 
mittently. She is dyspeptic and constipated, and 
has a marked blue line, with retracted gums and dis 
colored teeth. Her skin is earthy-yellow and con- 
junctivse are icteroid. There has been quite con- 
stant headache since the autumn of 1887, but it is 
less pronounced now than during the preceding 
winter and spring. Its situation is at times frontal 
and occipital but it is usually severest about the 
vertex. It is sometimes a deep-seated heavy ache, 
at others it is sharp and shooting. Recumbency 
and the approach of night greatly aggravate it. 
Sleeplessness and restlessness continue and she is 
disturbed at night by dreams of so frightful a char- 
acter that she rouses the neighbors by her shrieks. 
Tremor of the right hand and fingers increased 
rapidly in degree, and extended to the forearm and 
arm soon after its appearance. By the third month 
the right foot and leg were noticed to shake while 
she was seated. Seven months later (August, 1888), 
fine tremor appeared in the left lower limb. The 
facial muscles, and those of the tongue, eyeballs, 
neck, and left upper extremity, are entirely free from 
even slight tremor. The right upper extremity, 
especially the fingers and hand, is in a con- 
tinuous state of almost uniform, coarse move- 
ment, which ceases instantly and absolutely— 
though momentarily—when voluntary effort is made 
with it, such as buttoning or unbuttoning the dress. 
If the effort is continued, after a few moments the 
tremor returns slightly, and it starts into redoubled 
violence on cessation of the effort, unless it be car- 18 
ried to complete and lengthy exhaustion of the arm 
muscles. Thus, having found that the constant jerk- 
ing prevents sleep, she has for several months been in 
the habit on retiring of tossing the right arm about 
sometimes for hours, until, from sheer muscular 
weariness, tremor is no longer perceptible and sleep 
comes. It ceases absolutely during sleep. Mental 
excitement greatly augments it. All efforts of the 
will directed to control it are now ineffectual, and, 
indeed, rather increase it. If the tremulous hand is 
forcibly held, the movement becomes more violent 
after a moment, and tremor then appears in the 
opposite arm, and if she is sitting, that present in 
both legs grows coarser. 
Her handwriting is suggestive. Always disliking 
writing, she had not before held a pen for years. 
This renders the zigzag character of the strokes in 
the specimen more interesting. For, were she 
used to the pen, the tremor, which ceases momen- 
tarily on voluntary motion, would perhaps have 
permitted her to complete the few words before it 
reappeared. As she is unaccustomed to writing, the 
will does not readily direct the hand. The move- 
ments are deliberate and the up and down strokes 
slowly and somewhat hesitatingly made. Time is 
therefore afforded the tremor to recommence. 
Muscular weakness, stiffness, and some fixation of 
the limbs are present, but are not yet nearly so char- 
acteristic as the tremor. The grasp as measured by 
the dynamometer at different times recently, varied 
between 15 and 33 with the right hand, and between 
35 and 40 with the left. Incomplete extension of 
the hands and fingers seems to be due largely to 
rigidity of the flexors, as force is required to extend 
passively the fingers at the metacarpo - phalangeal 
joints. The forearms are slightly flexed and stiffened 
STEWART, POISONING BY CHROME YELLOW. 
19 
at the elbow. There is some rigidity of the anterior 
cervical muscles, and muscles of the shoulders, which 
slightly inclines the head forward and causes stoop- 
ing. In the inferior extremities the rigidity is 
greatest at the knee-joints and in the adductors of 
the thigh; more marked on the right. 
Voluntary movement is slow, but the gait is as 
yet not festinating, nor is there propulsion. The 
facial muscles are unaffected. There is no festina- 
tion of speech; articulation is slow rather than 
rapid, but it is monotonous and not syllabic. She 
is said often to “mix” her words. This I have 
not noticed. The knee-jerk is exaggerated on both 
sides. There is no ankle-clonus. Muscular nutri- 
tion is poor. The mechanical irritability of the 
muscles is increased, and there is quantitative dimi- 
nution to both galvanism and faradism, especially 
the latter. This is most pronounced in the exten- 
sors of the forearms and in the right deltoid, but it 
is throughout more marked on the right side. Sen- 
sations of heat are absent. A feeling of constant 
chilliness has been present for nearly a year. It was 
as great during the summer as in cold weather. 
Tactile sensation was carefully taken on three 
separate occasions, and, contrary to what is the rule 
in this disease, it was twice found very decidedly 
impaired. This was manifest on all surfaces of the 
arms, shoulders, and legs. It was not taken on the 
trunk or thighs. The whole surface of the right 
upper extremity was especially anaesthetic. This 
condition was noted in September, and again in the 
early part of October, 1888. Six weeks later, on 
casually retaking sensation in the finger-tips and 
hands, I was surprised to find the anaesthesia had 
disappeared. The cause for this is not clear. It is, 
however, unlikely that the loss of sensation had any 20 
STEWART, 
direct dependence upon the paralysis agitans. Most 
probably it was of plumbic origin, had existed for 
some time, and was in process of disappearing when 
she came under observation this autumn. Lead was 
found in her urine in August, 1887. Albumin and 
sugar are absent. 
The eye-ground was recently examined by Dr. 
Hansell, who reported: “ R. — ; L. — ; opacities 
XL cc 
in cornea; double optic atrophy with choroidal ring 
and slight cup. The arteries and veins are small. 
Pupils normal.” 
Mental and physical depression is still a constant 
symptom in 10 cases. Headache is present in 8 of 
these, which before plumbic symptoms appeared were 
free from it. In several it is described as a diffused, 
deep-seated ache. In 3 it is severest in the frontal 
and occipital regions. In all of the 8, until quite 
recently, it was constant, with exacerbations and 
remissions. It is now of far less severity than for- 
merly. 
In 5 of the 8 the urine was examined for albumin, 
but with negative results. In one of these cases 
(Mrs. S.) in whose urine considerable lead but no 
albumin was found a year ago, and who had for 
months epileptiform convulsions of undoubted lead 
origin, subacute mania developed with hallucina- 
tions of sight and hearing and delusions of persecu- 
tion. This condition still exists. In another (Mrs. 
G. W. L.), last seen in September, 1888, an eye- 
ground examination disclosed oedema of the tem- 
poral side of each nerve and tortuosity of the veins. 
Headache, worse at night, has been constant with POISONING BY CHROME YELLOW. 
21 
her for more than a year. She now is melancholic, 
and has delusions of conspiracy. There are restless- 
ness and sleeplessness at night and bad dreams. Her 
skin is sallow. The gums and teeth are still dis- 
colored by lead. There are arthralgic pains; dys- 
peptic symptoms ; complete anorexia ; a tense, full 
pulse; overacting heart, with a markedly accen- 
tuated aortic second sound. Her urine, recently 
examined, was of low gravity, but contained no 
albumin. Lead was not sought for, as the quantity 
furnished was small, and she would not take potas- 
sium iodide. 
One other of the 5, a girl, aged seventeen years, 
had an attack of chorea, during January, February, 
and March, 1888, while decided cachexia, colic, 
and the blue line were yet present. She had never 
had rheumatism, and no family history of it or of 
chorea can be elicited. Her heart was functionally 
disturbed, but there was no murmur. None of these 
3 cases received any regular treatment. 
Curious spells of generalized tremor, of brief dura- 
tion, have occurred in 1 of the 44 (Mrs. D., aged 
thirty-eight years), for the past sixteen months. An 
attack consists of a sensation of numbness starting 
in the wrists, and rapidly spreading over the body. 
There is then a feeling of impending danger, and 
immediately coarse, uncontrollable tremor seizes the 
head and limbs and continues for a half-hour or 
longer. Profuse diuresis generally takes place on 
its cessation. There is no loss of consciousness or 
tendency to spasm. The fit is not hysterical, nor 
are there at any time indications of the hysterical 22 
STEWART, 
state. Motility and sensation are unaffected in the 
intervals. They were not tested during or imme- 
diately subsequent to one of the seizures. These 
spells occur about every three to five weeks irregu- 
larly ; not at the menstrual period. Appropriate re- 
medial measures directed to prevent their recurrence 
have the desired effect when pursued with regularity. 
She will not continue treatment sufficiently long to 
be entirely rid of them. This woman had con- 
vulsions in April, 1887.1 Five of her children were 
similarly affected about the same time, and four died.2 
Another was born in May, 1887, while symptoms of 
lead poisoning were yet present. This infant was 
undersized and cachectic at birth, and, though not 
suckled by the mother and every effort was made to 
raise it, it did not thrive. When aged four months, 
rhachitis developed; paroxysms of laryngismus 
stridulus were frequent, and death took place in 
convulsions in the tenth month.3 
The appearance of the gums and teeth in 24 of 
the 44 cases is yet indicative of plumbism. But 
3 of the 24 received eliminative treatment. A 
decided though fading blue line is present in 10, 
a distinctly bluish-purple line in 5, and a purple in 
1 Her urine was slightly albuminous at that time. The albumin 
disappeared very soon after treatment was began to eliminate the 
lead, and has at no time been present since. 
2 Vide “ Notes on Some Obscure Cases of Poisoning by Lead 
Chromate," The Medical News, June 18, 1887. 
3 All of the five infants born of mothers exhibiting symptoms of 
lead poisoning during gestation had convulsions ; four within two 
months after birth. Three of the five died in them. Another in- 
fant, born in July, 1888, of a mother who had pronounced lead 
poisoning during the early months of pregnancy, died in the 
fourth month in convulsions. POISONING BY CHROME YELLOW. 
23 
9- In 12 of the 24 there is much retraction and 
atrophy of the free margin of the gum, permitting 
considerable exposure of the neck and fang surfaces 
of the teeth, which, together with the crown surfaces, 
in the greater number of the 24, are yet discolored 
by lead sulphide. The free margins of the gum in 
many of the 24 are hemorrhagic. In these, slight 
friction causes venous oozing. The purple line is 
present in the situation previously occupied by the 
blue. In many of the cases I have watched this dis- 
coloration of the free gingival margin through its 
varied phases. It is of diagnostic interest to note 
that at first the so-called “ line ” consists of a num- 
ber of fine black dots irregularly distributed, or an 
aggregation of them, forming a narrow bluish-black 
streak in the interdental portion of the gum, or in 
the extreme edge of the free margin, grasping one 
or more teeth, usually the lower bicuspids and molars, 
the teeth which are apt to be longest in contact with 
particles of food and about which decomposition of 
food elements is likely to be greatest. 
Friction renders the pigmentation more distinct 
and perhaps causes slight hemorrhage. If the poison- 
ing is slight and the absorption of lead ceases, the 
pigmentation slowly fades without destruction of the 
affected edge of the gum and no retraction of the 
gingival margin occurs. In several cases, three 
months after the lead ceased to be ingested, the 
narrow black streak or the fine dotting in the thin 
edge of the gum was distinctly visible, and at the 
end of a year the same thin edge was of a purple 
color. 24 
POISONING BY CHROME YELLOW. 
Continued absorption of lead in considerable 
quantities produces an intense bluish discoloration 
of the buccal gingival margin several lines in breadth 
in the gums about the teeth in the upper and lower 
jaw. The lead sulphide, deposited in the lumen of the 
vessels, in their walls, and in the perivascular tissue, 
interferes with the nutrition of the affected portion 
of the gum and leads to its partial atrophy. The 
gums become exceedingly hemorrhagic so that the 
slightest friction causes venous oozing. Their dental 
margins in some situations become, after a time, 
fringed, and retracted from the neck of the teeth, 
exposing a part of the fang. When the blue line is 
decided, the crown, neck, and the denuded fang sur- 
face of the teeth are apt to contain a black deposit of 
lead sulphide, which persists for months after expo- 
sure to the poisoning has ceased, and then gradually 
fades, giving place to a yellowish-brown stain. 
At a variable period following the cessation of the 
systemic absorption of lead, the extent depending 
largely upon the severity of the poisoning and 
whether efforts have been made to eliminate the 
metal, a bluish-purple discoloration succeeds the 
bluish in the affected portion of the gum, and it, in 
its turn, is succeeded by a purplish, and this by a 
red line entirely without any element of blueness. 
In conclusion, I desire to expre s my indebtedness 
to Dr. Leffmann for examining the urine of a num- 
ber of the cases for lead, and to Dr. Hansell for eye 
examinations. 
2620 North Fifth Street, Philadelphia. THE MEDICAL NEWS. 
A N ational Weekly Medical Periodical, containing 28-32 Double- 
Columed Quarto Pages of Reading Matter in Each 
Issue. $5 00 per annum, post-paid 
Uniting in itself the best characteristics of the magazine and the news- 
paper, The Medical News renders a service of exceptional value to the 
profession. It presents original articles, hospital notes and clinical lectures 
by the ablest writers and teachers of the day, discusses living topics editor- 
ially in a clear and scholarly manner, and employs all the recent and 
approved methods of medical journalism—the telegraph, reporters and a 
corps of special correspondents covering all the medical centres of the 
globe. It thus imparts, without loss of time, all advances of knowledge 
attained in the medical sciences. In short, it is the effort of all concerned 
in the publication of The News that it shall be indispensable to every 
physician in active practice. 
The American Journal of the Medical Sciences. 
Edited by I. Minis Hays, A M , M.D 
Published monthly, beginning with 1888. Each number 
contains 112 octavo pages, amply illustrated. Price 
reduced to $4.00 per annum, post-paid. 
In his contribution to A Century of American Medicine, published in 
1876, Dr. John S. Billings, U. S. A., Librarian of the National Medical 
Library, Washington, thus graphically outlines the character and services 
of The American Journal—" The ninety-seven volumes of this Journal 
need no eulogy. They contain many original papers of the highest value; 
nearly all the real criticisms and reviews which we possess; and such care- 
fully prepared summaries of the progress of medical science, and abstracts 
and notices of foreign works, that from this file alone, were all other pro- 
ductions of the press for the last fifty years destroyed, it would be possible 
to reproduce the great majority of the real contributions of the world to 
medical science'during " 
COM MUTATION It A TE. — Postayr. paid. 
The Medical News, published every Saturday, 
The American Journal ok the" Medical 
Sciences, monthly, 
in advance, $7 50. 
LEA BROTHERS & CO., 706 & 708 Sansom St., Phi/a.