ON LEAD-PALSY IN CHILDREN; WITH A 
REPORT OF THREE CASES. 
BY 
WHARTON SINKLER, M.D., 
OF PHILADELPHIA, 
PHYSICIAN TO THE ORTHOPEDIC HOSPITAL AND INFIRMARY FOR NERVOUS 
DISEASES, AND NEUROLOGIST TO THE PHILADELPHIA HOSPITAL. 
FROM 
THE MEDICAL NEWS, 
July 28, 1894. [Reprinted from The Medical News, July 28, 1894. | 
ON LEAD-PALSY IN CHILDREN, WITH A 
REPORT OF THREE CASES} 
By WHARTON SINKLER, M.D., 
OF PHILADELPHIA \ 
PHYSICIAN TO THE ORTHOPEDIC HOSPITAL AND INFIRMARY FOR NERVOUS 
DISEASES, AND NEUROLOGIST TO THE PHILADELPHIA HOSPITAL. 
A careful search through current literature and 
the text-books shows great paucity of material in re- 
gard to plumbism in young children. In an admir- 
able and thorough article on lead-poisoning, James 
J. Putnam2 remarks that the justification for his 
article “is found not in the abundance but in the 
meagerness of the present accumulation of facts re- 
lating to children, and the importance of taking 
steps toward increasing it.” I have been able to 
find no other cases besides those which Dr. Putnam 
has quoted in the complete table which he has 
added to his paper. 
Wilson, in Pepper's System of Medicine,3 says: 
“Lead-poisoning is an affection of adult life. Of 
X02 cases, two only occurred in individuals below 
twenty years of age.” 
D. D. Stewart, of Philadelphia, whose article on 
1 Read before the Association of American Physicians at Wash- 
ington, D. C., May 31, 1894. 
2 Encyclopedia of the Diseases of Children, vol. iv, p. 615. 
3 “Chronic Lead-poisoning,” System of Medicine, vol. v, p. 
686. 2 
poisoning by buns colored with chrome-yellow 
attracted so much attention a few years ago, writes 
me that he made a thorough search through the 
literature of lead-poisoning when investigating these 
cases, and made notes of all nervous cases, especi- 
ally those with brain-symptoms. He found many 
cases of cerebral disorders, like convulsions, which 
occurred in children, but none of paralysis. He 
also remarks that in German literature there are a 
number of accounts of whole families being poisoned 
by lead, through working and living in the potteries; 
but there are no records of palsies in children 
among these cases, though paralyses in the adults 
are common ; and it was related that the children 
had headache and convulsions. 
Among Stewart’s cases of chronic lead-poisoning 
from eating the chrome-yellow buns, seventy-nine 
in number, there were many children. These were 
especially affected with convulsions, but there were 
no cases of wrist-drop or other palsies among them. 
There is apparently no reason why children should 
not be as susceptible to lead-poisoning as adults. 
Children are as much exposed to the dangers of 
lead-poisoning, except in those cases which occur 
among workers in lead—as, for instance, painters, 
manufacturers of white lead, and those employed in 
potteries. 
There are many cases on record in which children 
of various ages have been seriously poisoned by the 
absorption of lead into the system. On the other 
hand, in epidemics of lead-poisoning from drinking- 
water, the proportion of cases in children is small. 
In the epidemic which occurred at Tredegar, Eng- 3 
land, reported by Dr. Brown, and quoted by 
Putnam, there were no serious symptoms in any 
person under eighteen years of age among fifty-two 
cases of well-marked lead-poisoning. 
Putnam refers to another epidemic, in which 
thirty-eight persons were exposed to poisoning 
through drinking-water. Thirteen were affected; 
but no children were attacked, although there were 
eight among those who had been drinking the in- 
fected water. It is probable, therefore, that children 
are not so liable to lead-poisoning as adults; and 
this is no doubt due to the fact of their possessing 
more active powers of elimination; their greater 
bodily activity, and the greater energy of all of 
their secretions, causing the ready elimination of 
the lead from the system. 
The sources of lead-poisoning are so numerous 
that it is remarkable that more cases do not occur. 
Drinking-water in cities, from passing through lead 
pipes, frequently becomes charged with lead. Lead 
is to be found in cooking utensils, in red rubber, 
which is sometimes used for making nipples for 
nursing-bottles, in the solder used in cans, cover- 
ings of sweetmeats, and in lead chromate, which is 
used in coloring toys, cloths, and other articles. 
It is evident from the cases that have been re- 
corded, in which a large number of persons have 
been equally exposed to the danger of lead-poison- 
ing, that the degree of susceptibility varies, as but 
a small proportion of the persons exposed are 
attacked. 
The symptoms of lead-poisoning in children 
which have been most frequently noted are disturb- 4 
ances of digestion, such as colic and vomiting; and 
the cerebral symptoms, indicated by headache, con- 
vulsions, and stupor. Chronic lead-poisoning is most 
likely to be manifested by a general loss of flesh, 
failure of appetite, and the earthen hue of the skin, 
with a jaundiced condition of the conjunctiva. In 
chronic lead-poisoning disorders of digestion are 
most common; constipation, attacks of colic and 
vomiting frequently occur, and there is other evi- 
dence of derangement of the stomach in the defec- 
tive assimilation that exists. In other cases symptoms 
of kidney-disease are present; and it is well known 
that there is a form of nephritis due to accumulation 
of lead in the kidneys. 
The symptoms dependent upon disease of the 
nervous system due to lead-poisoning are motor and 
sensory. The most common of these, of course, is 
paralysis of the extensor muscles of the forearms. In 
children, however, it is a noteworthy fact that the 
paralysis is as liable to affect the lower extremities 
as the upper. There are but few cases reported in 
which sensory disturbances have been met with in 
children. Cerebral symptoms are not uncommon 
in children. The lead encephalopathies in children 
have been frequently met with, especially, as already 
remarked, among the cases reported by Stewart, 
and Putnam refers to other cases. 
The cases of lead-palsy in children which are 
quoted by Putnam are, first, that of a girl of eight 
years, reported in the Lancet, who suffered from 
paralysis of all four extremities, from the use of 
Sheffield drinking-water ; and a similar case which 5 
was related by Seligmiiller, who credits it to 
Duchenne. 
H. D. Chapin1 gives the history of two cases of 
lead-palsy in children. I will detail these at some 
length because of their curious similarity to the 
cases which I shall report later. 
The father was a painter, and kept paint in the 
house, so that the children were constantly exposed 
to its influence. They enjoyed good health until 
December 25, 1882, when the room in which the 
children lived was painted. On January 1, 1883, 
one week later, F. W., aged seven years, was seized 
with abdominal cramps; on the next day R. W., 
aged five, complained of the same symptoms. The 
pain lasted for four weeks, and there was intense 
thirst. There was then pain and soreness in the 
legs, and the children were averse to walking. By 
the last of January they could not stand. They 
then improved somewhat, but during February 
another similar attack occurred. There was pain, 
followed by paralysis, and the loss of power lasted 
much longer than in the first attack. On May 3d, 
a third attack occurred in one boy, in which the 
hand was affected. The children now came under 
Dr. Chapin’s care. They could walk with difficulty, 
and a blue line was observed upon the gums. They 
were lost sight of for a year, when they were ex- 
amined again by Dr. Chapin. They were then worse 
than they had been before; they were utterly unable 
to walk, and pains throughout the body were com- 
plained of. The teeth were loose, the gums were 
spongy, and there was headache. The muscles did 
not respond to faradism or galvanism, but sensation 
1 Medical Record, New York, 1884, p. 546. 6 
was normal. The house in which they lived had 
been cleared of paint a year previous, and there was 
nothing to account for the repeated attacks. 
The children were admitted to the hospital, and 
after treatment they improved greatly and were 
able to walk somewhat. An examination of the 
urine showed the presence of lead. There was 
partial paralysis of the anterior leg-muscles, and 
these showed the reaction of degeneration. 
Dr. Chapin called attention to the striking re- 
semblance of these cases to spinal paralysis of 
infancy. This writer also related the case of a 
child, two and a half years of age, in which a solu- 
tion of lead acetate was applied to a splinter-wound. 
In four days both legs were paralyzed, but the 
child soon got quite well. This is, I think, rather a 
doubtful case of lead-paralysis. 
The sixth case is reported by Putnam, from the 
records of the Children’s Hospital, Boston, in which 
a girl of six years, after having been exposed to a 
freshly-painted house, had attacks of vomiting, 
which affected her at intervals for two weeks, fol- 
lowed by weakness of the legs, toe-drop, and wad- 
dling gait. A month later there was weakness ot 
the fingers and the wrist; the extensor muscles 
were affected in both arms and legs, and the knee- 
jerks were absent. Two months later the paralysis 
had disappeared, but the legs were easily fatigued. 
A seventh case has been reported by Miller,1 
in which a child of four years was poisoned by 
drinking-water; but it is merely observed that 
there was a paralytic state. 
1 New Orleans Medical and Surgical Journal, 1873, vol. i, p. 198 7 
A case is reported by Letheby, in which a child 
of six years took lead acetate in doses of one- 
fifteenth of a grain two or three times a day for nine 
weeks. There was loss of flesh, colic, paralysis of 
the limbs, convulsions and coma, followed by death, 
which occurred two days after withdrawal of the 
medicine. 
These constitute all the cases of lead-palsy in 
children that I have been able to find, except one 
reported by Suckling,1 in a boy of fourteen years, 
who worked in zinc and lead for eighteen months, 
and who presented evidences of multiple neuritis, 
without other symptoms of lead-poisoning. 
The following three cases came under my observa- 
tion at the Philadelphia Orthopedic Hospital and 
Infirmary for Nervous Diseases. The parents were 
healthy and had nine children. One child died 
of spinal meningitis at five years of age. It had 
from birth a large head. Another child died of 
convulsions at three years of age. Four other 
children are perfectly healthy, and the remaining 
three are the cases of which I shall relate the 
histories. 
The father is a house-painter by occupation, and 
had his shop in the house in which he lived. The 
children frequently played about the room in which 
he kept his paints, and often got the paint on their 
hands and faces, and sometimes were seen to put it 
in their mouths. 
Case I.—Sarah McD., aged ten years and six 
months. 
1 British Medical Journal, 1888, vol. i, p. 649. 8 
Previous history. Her health had always been 
good previous to the onset of the present trouble. 
She cut her teeth and walked at an early age, and 
never had any intestinal disorders. 
She was brought for treatment to the Philadel- 
phia Orthopedic Hospital and Infirmary for Ner- 
vous Diseases, in July, 1889. About one month 
previously, she awoke in the morning with partial 
loss of power in the legs. She had fever of short 
duration, and there was constipation and some 
vomiting, but no colic. The weakness of the legs 
steadily increased, and pain in the legs was com- 
plained of. Four weeks later the arms became 
weak, and there was gradual wasting of all the limbs. 
The weakness and atrophy were most marked on 
the right side. 
The child was treated as an out-patient by means 
of electricity, and in October, 1889, she had almost 
completely recovered the use of her legs. In June, 
1890, she grew gradually weak for about a week. 
She then lost the power of standing, and could not 
use her arms. In this attack there was fever, vomit- 
ing, and constipation, but no colic. There were no 
convulsions, no coma, and no headache. On July 
14, 1890, she was admitted to the hospital. Her 
condition was then as follows : 
There was loss of power in all of the muscles of 
the legs, more or less complete ; and there was com- 
plete wrist-drop and ankle-drop. The patient was 
unable to use the hands or arms, except that she 
could slightly move the arms at the shoulders. 
There was great muscular wasting, but no changes 
in sensibility. The patient’s mind was clear, and 
her general health was good. 
The electric examination showed absence of 
response to the faradic current in the extensors of 
the legs, thighs, and forearms, and diminished 
reaction in the flexors to galvanism. 9 
The reactions to the galvanic current were as 
follows: 
Right tibialis anticus and common extensors R D 
Right peronei K cl > A cl. 
Left tibialis anticus and common extensors . K cl — A cl. 
Left peronei K cl > A cl. 
Left forearm-extensors . . . . R D 
Right forearm-extensors . . . . K cl > A cl. 
The patient was treated with daily faradization 
and massage, and in about four months she was able 
to walk about and to use the arms freely. She was 
discharged greatly improved, November 8, 1890. 
She was examined on May 17, 1894, and her 
condition was as follows : 
Both feet are flat, and foot-drop is marked on 
both sides, when sitting. The left great toe is 
abducted, and all of the toes of the right foot are 
abducted, the great toe especially. This toe is also 
rotated to an angle of about 90°, so that its dorsal 
surface points laterally. The patient is unable to 
flex the feet. The left leg is a little smaller than 
the right. There is no wasting in the arms, and the 
muscular power in both is good. In walking, there 
is a tendency to walk on the toes, on account of a 
slight contraction of the tendo Achillis. The 
patient’s general health is good, and the gums are 
free from discoloration or disease. 
The eyes were examined by Dr. A. G. Thomson, 
who made the following report: 
The pupils are equal, and react normally to light; 
the discs are a trifle red; the outlines of the discs 
are well marked ; there is no lesion of the fundus; 
the muscular balance is good; the form and color 
fields are normal. V.= 20/20 with both eyes. 
Case II.—-Harry McD., a brother of the preced- 
ing patient, was admitted to the hospital July n, 
1892. He was six years of age, was born normally, 
and was breast-fed. He began to cut teeth at the 10 
age of three months. He was healthy until the 
sixth month, when he had convulsions, which lasted 
three days. The spasms were general, but there was 
no subsequent paralysis. When sixteen months old 
he had entero-colitis. He began to walk at fifteen 
months of age. This child also had access to the 
room in which his father’s paints were kept, and 
was frequently besmeared with paint. In Novem- 
ber, 1891, he had an attack of fever accompanied 
by vomiting, loss of appetite, colic, and constipa- 
tion. This attack lasted for about three weeks, 
when it was noticed that the legs and arms were 
weak. The arms could not be raised above the 
head, and the hands dropped at the wrists. There 
was loss of power in the legs, so that the child was 
unable to walk. Complaint of pain in the knees was 
frequently made. The legs and arms grew steadily 
thinner, and the muscular weakness increased. 
On admission the child was pallid and thin. He 
possessed normal intelligence; his digestion, appe- 
tite, and bowels were in good condition. He was 
unable to stand, or to walk, and there was but little 
power in the muscles of the legs. The feet were in 
a position of ankle-drop, and attempts to flex the 
feet were futile. The arms could be moved slightly 
at the shoulders, but the power in the muscles of 
the arms and forearms was almost absent. There 
was complete wrist-drop. There was no facial 
paralysis. 
Atrophy. There was marked wasting in the 
muscles of both arms and legs. There was no 
response to the faradic current; and there was great 
quantitative change in the extensors of the thighs, 
arms and forearms, to galvanism. R. D. was present 
in the extensors of the left leg, and in the extensors 
of the right leg. The knee-jerks were absent, and 
the arm-jerks were decreased. 11 
The patient was treated with massage and elec- 
tricity, and steady improvement took place; so 
that in five months he was able to walk about 
unassisted, but the toes were dragged and the feet 
flapped in walking. The patient had gained flesh, 
and the color was good. 
March 27, 1894. The condition of the boy was 
noted as follows : He walks with the feet far apart 
and the toes inverted. The left leg is much weaker 
than the right. The circumference of the right thigh 
is eight inches, of the left thigh eight and a quarter 
inches; that of the right calf is six and a quarter 
inches, of the left seven inches. The knee-jerk is 
absent on both sides, and there is no reinforcement. 
There is left foot-drop, and the muscles of the leg 
of this side are markedly wasted. The left hand is 
weak, and there is atrophy of the thenar and hypo- 
thenar muscles. The elbow-jerks can be elicited. 
The electric examination shows good response in 
the peroneal and calf muscles. The flexors of the 
thighs respond readily. R. D. is found in the 
tibialis anticus and extensor communis of both legs. 
The eyes show nothing abnormal. 
Case III.—Eddie McD., aged three years, a brother 
of the two previous patients, was admitted to the 
hospital July n, 1892. He had always been healthy 
up to the present trouble. He began to walk at 
about the age of two years, but only with assistance. 
It was then noticed for the first time that the right 
leg was weak and that the foot was dragged in walk- 
ing. He complained of some pain in the right knee 
at the same time. The leg continued to grow 
smaller until his admission to the hospital. 
On admission, it was found that both legs were 
weak and that there was complete wrist-drop. The 
extensors of the hands seemed to be the only muscles 
which were affected, as the arms could be moved in 12 
all directions. The electric examination showed 
reaction of degeneration in the muscles of both 
legs. The knee-jerks were absent on both sides. 
This patient also improved under the use of massage 
and electricity, and in five months he began to walk 
unassisted, but dragged the toes on both sides, more 
especially on the right side. The knee-jerks had 
returned and were slightly exaggerated. 
March 27, 1894. The patient looks strong and 
ruddy. He runs about with freedom, but drags the 
right foot, and when lying down there is right foot- 
drop. The leg is wasted and there is inability to flex 
the foot. The thighs are each ten inches in circum- 
ference; the right calf is seven inches, and the left 
seven and a half inches. Sensation is perfect, and 
there are no trophic changes. The left hand is 
somewhat weaker than the right. The right knee- 
jerk is grossly exaggerated, but there is no ankle- 
clonus. The knee-jerk on the left is slightly ex- 
aggerated. The electric examination shows normal 
reactions in all of the muscles of the left leg and of 
the right calf. In the extensors of the right foot 
there is loss to the faradic current and reaction of 
degeneration. 
In neither of these children was any blue line on 
the gums observed, or any diseased condition of the 
teeth or gums. The digestive organs were in fairly 
good condition on admiss’on to the hospital, and 
although the children were thin and pallid, there 
was no distinct saturnine cachexia noticeable. 
When the two boys were first admitted, an 
attempt was made to examine the urine for lead, 
but this was not successful. They were readmitted 
in March, 1894, and after potassium iodid had 
been administered for several days, the urine was 13 
collected, evaporated, and carefully tested for lead 
on three different occasions; but no trace of lead 
could be recovered. The investigation was made 
in a careful and thorough manner by Dr. J. E. 
Talley, the resident physician. 
The significance of the presence of lead in the 
urine in small quantities is not great, when we con- 
sider the statement of Putnam, in the article already 
referred to, that Drs. Comey and Worcester had 
analyzed for him the urine of more than 150 persons 
living mainly in the neighborhood of Boston, and not 
presenting symptoms of lead-poisoning, and found 
traces of lead in about 25 per cent, of them. Dr. 
J. Dickson Mann1 gives as the result of a careful 
study of two cases these conclusions : “ That lead is 
slowly and more or less continuously eliminated by 
the bowels, and, to a very much less extent, by the 
kidneys; that when once deposited in the tissues it 
exists as a stable compound, over which drugs have 
little, if any power.” He also asserts that potassium 
iodid has absolutely no power as an eliminant of 
lead, although he admits that it may be beneficial 
in some other way in cases of chronic lead-poisoning. 
In the cases that I have related, the symptoms 
presented were those of poliomyelitis ; indeed, when 
Sarah McD., the eldest child, first presented herself 
at the Infirmary, I believed the case was one of that 
disease; and when she returned a year later with a 
relapse, I regarded it as a remarkable instance of a 
second attack of infantile spinal paralysis. It was 
not until the second child was brought to me for 
1 British Med. Journ., February 25, 1893. 14 
treatment that I suspected some common cause for 
the disease, and thought that it might be one of 
those instances of epidemic poliomyelitis due to 
microbic infection. 
On inquiring into the history of the children I 
found that their father was a painter, but the mother 
strenuously denied that they had been exposed to 
contact with the paints. When the third case was 
brought to me I asked my friend, Dr. J. H. Rhein, 
to visit the home of the children; and he discovered 
the fact that there was a great deal of white lead 
lying about, and that the children had frequently 
played in the paint-room, and were often daubed 
with paint. 
The resemblance of lead-palsy in children to 
poliomyelitis has been noted by several writers; 
and it seems possible that some of the cases that 
have been recorded as instances of poliomyelitis may 
have been due to chronic lead-poisoning. 
The pathology of lead-poisoning in children is 
generally considered as consisting in changes in the 
peripheral nerves; and these alterations are very 
closely allied to those met with in the ordinary 
forms of multiple neuritis. There is good reason to 
believe, however, that in many cases of typical lead- 
paralysis the symptoms are due primarily to the 
direct action of the lead upon the muscles. It is 
also probable, and this is also suggested by Putnam, 
that chronic lead-poisoning may produce typical 
changes in the anterior horns of the spinal cord, 
and thus give rise to a poliomyelitis, identical in its 
symptoms with the acute, or, so to speak, idiopathic 
form of the disease. The Medical News. 
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