LEAD-PALSY IN CHILDREN 
BY 
LEO NEWMARK, M.D., 
OF SAN FRANCISCO, CAL.*, 
PHYSICIAN TO THE SAN FRANCISCO POLYCLINIC. 
FROM 
THE MEDICAL NEWS, 
May ii, 1895. [Reprinted from The Medical News, May 11, 1895.) 
LEAD-PALSY IN CHILDREN. 
By LEO NEWMAKK, M.D., 
OF SAN FRXNCISCO, CAL.; 
PHYSICIAN TO THE SAN FRANCISCO POLYCLINIC. 
Since Dr. J. J. Putnam, in his contribution to Keat- 
ing’s Cyclopedia of the Diseases of Children, about 
four years ago, commented on the apparent rarity of 
lead-palsy in children ana the desirableness of more 
material with which to test certain conclusions sug- 
gested by the facts already published, there have 
been but scanty additions to the literature of the 
subject. Stieglitz,1 writing in 1892, was hampered 
in an important argument by the lack of records 
concerning saturnine paralysis in children. Dr. 
Wharton Sinkler reported three new cases in The 
Medical News of last year, but was unable to add 
any published cases to those comprised in Putnam’s 
table. Putnam himself, however (in a note in the 
Boston Medical and Surgical Journal of February 
23, 1893), mentioned another case that had been 
reported by Sinclair White.2 The patient in this 
instance was a girl, aged eight years, who was 
poisoned by drinking-water. Besides a faint blue 
line she presented “ paresis of the extensor muscles 
of the hands and of the flexors of the feet. The 
1 Archiv fur Psychiatrie, Bd. xxii. 
2 British Medical Journal, 1890, i, p. 18. latter, owing to pointing of the toes, compelled the 
patient to lift the feet high off the ground.” 
The following briefly reported cases are all I have 
been able to glean from the records : Brown,1 of 
Bacup, observed a child, aged four years, with a 
dark-blue line on the gums, severe colic, obstinate 
constipation, painful micturition, and marked 
anemia. It had tremor of the legs, and this was 
followed by paresis, and ultimately paralysis. Recov- 
ery was slow. 
Oliver’s book'2 contains the account of a girl, 
over three years old, who had received daily from 
early infancy a small quantity of botanic beer which 
was carried through forty feet of lead pipe. She 
was very anemic, had a blue line on the upper gum, 
could not talk or even walk well, and there was 
“a good deal of staggering as in locomotor ataxia.” 
The knee-jerks were absent. This child died in a 
few months of convulsions. 
Despite the meagerness of the descriptions, the 
implication of the nervous system in these cases is 
evident, and they may at least serve to illustrate 
that proneness of the lower extremities to suffer 
which has been observed in other instances. 
A case of Oppenheim’s, reported by Anker1 may 
not be relevant, as the paralysis could not be attri- 
buted to direct lead-poisoning, but was considered 
to be probably hereditary saturnine palsy, the father 
of the patient being a compositor and having suf- 
fered repeatedly from lead-colic, but not from par- 
1 Unsuspected Lead-poisoning in Children. British Medical 
Journal, 1890, i, p. 177. 
2 On Lead-poisoning, p. 177. 
3 Berliner klinische Wochenschrift, 1894, p. 577. 3 
alysis. The daughter became mentally weak after 
sustaining an injury to the head in her third year. 
At about the age of seven years progressive weakness 
of both lower extremities set in ; when examined a 
year later there was paralysis of the extensors of the 
feet and toes, except the anterior tibial muscles; in 
the course of the next six months this exception 
disappeared, and there was also degenerative par- 
alysis of the muscles supplied by the radial nerve, 
the supinator longus and triceps escaping, and of 
some of the intrinsic muscles of the hand. Subse- 
quently considerable improvement took place in 
the condition of the upper limbs, but none in the 
lower, and the calf-muscles were also slightly im- 
plicated. In his commentary on this case Anker 
observes that lead-palsy of the lower extremities is 
rare, and that the order in which the lower and upper 
limbs were affected differs from the usual sequence. 
While these statements are true as far as adults are 
concerned, the study of lead-palsy as it occurs in 
children has hitherto resulted in the conclusion that 
what Anker deems exceptional would seem to be 
the rule in these cases. This conclusion is, at least 
partly, confirmed by the following case which has 
been under observation at the San Francisco Poly- 
clinic since the 27th of January, 1894. 
The patient is a girl, now eight years of age. 
During a considerable period preceding her first 
visit she suffered repeatedly from disorders of the 
stomach and bowels, which were treated as attacks 
of ordinary “indigestion.” In November, 1893, 
she was again seized with vomiting, constipation, and 
pain in the abdomen ; her breath was very foul, and 
she could retain nothing in her stomach but milk 4 
and lime-water. On the first of December she took 
to her bed, and two weeks later her mouth became 
very sore; her medical attendant states that “ she 
was suffering with the worst case of aphtha he ever 
saw.” The girl left her bed on the 23d of December, 
1893, but on first attempting to walk she fell; soon, 
however, she regained more control over her legs, 
so that she was able to walk. While still confined 
to bed the position of her hands and her manner of 
grasping objects attracted attention. 
It was at first declared that the girl had had no 
opportunity of coming in contact with lead ; but 
inquiry easily elicited the information that the crib 
in which the child slept had been painted in the 
summer or fall of 1892 with a mixture of paints 
containing white lead; it had not been varnished. 
This covering of paint was very slow in drying, 
requiring, indeed, many months to do so, and the 
patient used to scratch it off with her finger nails. 
In January, 1894, the patient was found to be 
anemic, but not emaciated. On the upper and 
lower gums there was a well-marked blue line. 
The second dentition was in progress, and a small 
quantity of tartar had formed on the teeth. There 
was bilateral wrist-drop. On the right side all the 
muscles supplied by the radial nerve were paralyzed, 
except the triceps and supinator longus ; on the left 
side the triceps, supinator longus, and abductor 
pollicis longus were preserved. Fibrillary twitchings 
were absent, but a jerky tremor was observed. The 
triceps-reflex was present in either arm. Sensibility 
was intact. The affected muscles gave the complete 
reaction of degeneration. 
The patient was able to walk, but she occasionally 
stumbled, owing to her failure to clear the ground 
completely, for there was bilateral ankle drop. She 
could, however, extend the proximal phalanges of the 
toes quite well. This extension of the toes was the 5 
only movement she could execute with the muscles 
supplied by the external popliteal nerve. The an- 
terior tibial muscle was affected like the others. 
The knee-jerks and ankle-jerks were normal. The 
plantar reflex was faint in either foot. In response 
to faradic and galvanic excitation of the external 
popliteal nerve only extension of the toes occurred. 
This effect was produced also with either current by 
applying the electrode at the ankle midway between 
the malleoli, or (less readily) on the dorsum of the 
foot; but the contraction thus produced was rather 
sluggish. Direct faradization of the muscles of the 
lower leg gave a negative result—the constant cur- 
rent elicited the reaction of degeneration. Various 
muscles of the upper arm, shoulder, and thigh re- 
acted to the tests in a normal manner. 
Improvement soon began in the upper extremities, 
and by the middle of April, 1894, the patient had 
regained the use of her hands. It was not until the 
end of June that a tendency to improvement was 
observed in the legs; since then progress has been 
steady but slow, and recovery is not yet complete. 
At present (over a year after the onset of the palsy), 
while all the muscles of the forearms contract per- 
fectly to voluntary impulses, the electric reaction 
of those which have been affected is still abnormal. 
Their responses to indirect and especially to direct 
stimulation are more or less feeble, the diminution 
of irritability being a little greater in the right fore- 
arm than in the left, but they show no modal changes. 
Dorsal flexion of the feet is still defective, and 
the tendency to assume the equinovarus position is 
noticeable, although there has been a great amelior- 
ation in their condition. The toes can be strongly 
extended. The muscles of the lower leg respond to 
excitation of the external popliteal nerve with mod- 
erate faradic and galvanic currents, but an increase 
in the strength of the current is not followed by 6 
a corresponding increase in muscular contraction. 
The direct irritability of the muscles is greatly di- 
minished—that of the peronei more than that of the 
others. Extension of the toes may be produced in 
the same manner as formerly. Segments of the blue 
line are faintly discernible on the upper and lower 
gums. 
Putnam1 says concerning lead-palsy in children : 
“In every instance that the writer has found de- 
scribed or seen, the legs have been affected as much 
as the arms, or more, as in paralysis from alcohol 
and arsenic, the symptoms generally appearing first 
in them.” The foregoing case again illustrates the 
liability of the lower extremities to suffer. The 
supinator longus escaped in the upper limbs; but 
the tibialis anticus, which usually escapes when the 
legs are involved, was affected. In none of the 
available records of cases relating to children was it 
clearly stated that this muscle had escaped. 
The preservation of the power of extending the 
toes is noteworthy. This function devolved upon 
the short common extensor. No sign of action in 
response to the will or to electricity could be dis- 
tinguished in the long extensor; the point over the 
ankle whence the extension of the toes was provoked 
is the motor point of the branch of the nerve sup- 
plying the short common extensor. This muscle is 
a more powerful extensor of the toes than the long 
one, the latter, according to Oppenheim,2 being 
chiefly a dorsal flexor of the foot, besides raising its 
outer border and abducting it. I have not found 
mention elsewhere of this functional integrity of the 
1 Keating's Cyclopedia, vol. iv, p. 626. 
2 Lehrbuch der Nervenkrankheiten, pp. 24 and 25. 7 
short common extensor of the toes in cases of lead- 
poisoning implicating the external popliteal nerve. 
The sluggish contraction to both currents indicates, 
however, that this muscle did not entirely escape the 
action of the poison. 
As the patient was confined to her bed at the 
onset of the paralysis, the trouble in the legs proba- 
bly remained unnoticed for some time, and it can- 
not, therefore, be determined whether the lower 
extremities were affected before the upper, as seems 
to be the rule in children. Sinkler’s patient, Sarah 
McD., presented in her first attack an example of 
this precedence, and three of the cases in Putnam’s 
table exhibited the same order of progression. It 
is nowhere mentioned that the palsy appeared first 
in the arms. 
It will be observed that, although the arms and 
the legs were equally affected, functional recovery 
took plare much earlier in the former than in the 
latter. This occurred also in two of Chapin’s cases 
and in one of Sinkler’s. It does not appear from 
the literature, as far as it is accessible to me, that in 
any case the disorder has persisted in the muscles 
of the upper extremities after complete recovery of 
the lower. 
Stieglitz, in his experimental researches, succeeded 
in producing saturnine paralysis in animals, but 
failed to obtain the type characteristic of lead- 
poisoning in the human adult. Adopting the sug- 
gestion of Moebius, that excessive use of a group of 
muscles may determine the localization of the palsy, 
Stieglitz concludes that localized paralysis must not 
be expected in animals, as no special group of mus- 
cles in them is subject to a particular strain ; and he 8 
adds that children, being comparable in this respect 
to animals, the localization of their paralysis is just 
as likely to be atypic; and Putnam,1 remarking 
that it is as common to find paralysis of feet and 
legs as of arms in children poisoned by lead, says: 
“The natural conclusion is that in childhood the 
influence of greater and more complex use has not 
made its appearance to increase the susceptibility to 
disease of the neuro-muscular apparatus of the upper 
extremity.” 
Now, the assumption that lead-palsy in children 
follows no type is erroneous; the special tendency 
of the extensors to suffer is about as marked in them 
as in adults, the localizing influence, however, pre- 
dominating in the lower extremity. This predomi- 
nance seems well established ; yet it does not neces- 
sarily follow that the upper limbs in children are 
less susceptible than in adults, but rather that the 
lower are more so. Is this to be ascribed to “greater 
and more complex use ” of the child’s foot? 
The theory of the relation of muscular function 
and the selective action of lead has been employed 
chiefly to explain certain deviations from the ordi- 
nary type of paralysis, such as have been observed 
in file-cutters, for instance; it does not seem to suf- 
fice for typical cases in which the neuro-muscular 
apparatus has not been subjected to excessive exer- 
tion. 
1 Boston Medical and Surgical Journal, February 23, 1893. The Medical News. 
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