Nail sign: white bands (leukonychia striata) traversing the full width of the nail, running parallel to the lunula, with no palpable ridges. As the nail grows they bands move distally and finally disappear when trimmed. The finding was initially related to acute arsenic poisoning.
The finding of leukonychia striata has subsequently been recorded in cases of heavy metal poisoning (arsenic, thallium and selenium); renal dysfunction; chemotherapy; systemic illness and high altitude mountaineering.
1900 – Ernest Septimus Reynolds (1861 – 1926) wrote extensively regarding the effects of arsenic upon the beer drinking population of North England and the Midlands. In 1901 he published his findings and reviews in the Lancet and Medico-Chirurgical Transactions concentrating on the signs and symptoms of polyneuropathy due to acute arsenic poisoning.
Nails: In many cases the nails are affected. After the patients have stopped taking the beer for some weeks the best appearances are seen, for then there is a transverse white ridge across the nail; proximal to this the nail is normal, but distal to it the nail is whiter, cracked, thin, and towards the tip almost papery and much flattened. In some cases there have been a series of parallel transverse ridges of the nails, also suggesting a series of week-end drinking bouts. These deformed nails of course break easily.Reynolds 1901
1901 – Florence R. Sabin (1871 – 1953) described the signs and symptoms of a patient suffering from arsenical neuritis whom she saw in consultation with Dr William Osler:
The patient is a young woman who was brought to the hospital two months ago, November 23, 1900, after having taken about a dram of ‘Rough on Rats’…Her stomach was washed out repeatedly and large doses of the antidote given, together with epsom salts and castor oil. She was dismissed in five days feeling well, but noted that on walking up the steps of her home her feet were numb and the steps felt soft.
The numbness of the feet gradually increased and she became unable to walk. When she came to the hospital again she had double footdrop and wrist-drop, the muscles involved, however, were not entirely paralyzed. Her hands were so weak that she could not feed herself…On both hands there is a white line running transversely across each nail.Sabin 1901
1904 – Charles John Aldrich (1861 – 1908) provided an early published description (1904) of three cases he treated in 1899, fifteen years before RA Mees 1919 description. Aldrich termed the phenomenon ‘Leuconychia striata arsenicalis transversus’
Five years ago at the Cleveland City Hospital, while examining a woman suffering from a very severe arsenical neuritis, I was struck by the observance of a peculiar white transverse line occupying the middle of the outer third of the finger-nails of each hand...she had taken a teaspoonful of “Rough on Rats,” which is well known to contain a large quantity of arsenic.Aldrich 1904: 701
The white streaks were about one-sixteenth of an inch in width, quite regular, with fairly sharp margins, and occupying an identical position on each nail. They were slightly larger on some nails than upon others and a little wider in the centre than near the margins; extended from side to side, forming a crescentic band, with the convexity directed to the free margins of the nail, and presenting a curve identical with that of the lunula. The markings were less plainly seen upon the toe-nails.Aldrich 1904: 703
1919 – Rudolf Adriaan Mees (1873-1964) reviewed the cases of three patients with ‘polyneuritis arsenicosa’ (polyneuropathy due to acute arsenic intoxication) as a result of ingesting a large single dose of arsenic salts. He discusses two cases of attempted suicide and one of attempted murder.
Mees suggested the use of the nail sign in diagnosing polyneuropathy due to acute arsenic intoxication
Mees had described the nail sign; identified the predisposing cause; hypothesised as to the pathological basis; and proposed the signs use in forensic analysis. identified. Now he set about reviewing the international literature for evidence of previous published documentation of the nail sign:
Mees also refers to Reynolds publication in the Review of Neurology and Psychiatry (1905). In this paper Reynolds provided a comparative overview of arsenical neuritis and alcoholic neuritis to complement Buchanan’s paper ‘Some aspects of alcoholism‘ published within the same journal. True, there is no specific mention of nail changes, however this particular article was focused on the differences between alcohol and arsenic poisoning with respect to neuritis, neuropathy and skin pigmentation. No reference is made to the work of Sabin (1901) and Aldrich (1904)
- Jacob Mendez Da Costa (1833 – 1900)
- Ernest Septimus Reynolds (1861 – 1926)
- Florence R. Sabin (1871 – 1953)
- William Osler (1849 – 1919)
- Charles J. Aldrich (1861 – 1908)
- Rudolf Adriaan Mees (1873-1964)
- leukonychia striata; leuconychia striata arsenicalis transversus
- Reynolds lines
- Aldrich – Mees lines;
- Reynolds-Sabin-Aldrich-Mees lines
Leukonychia striata in chronic disease
1877 – Jacob Mendez Da Costa (1833 – 1900) described transverse white bands the full width of the finger nail appearing after a relapse of typhoid fever. Coloured illustration of a hand the nails of which are traversed with several white bands, each corresponding to a relapse of the typhoid from which the patient had suffered. Systemic illness variant of Mees lines
1877 – Morris Longstreth published in the same journal edition as Da Costa his personal account of transverse white bands extending over the surface of the nails. These bands appeared after each exacerbation his own relapsing fever in 1869 with each band relating to a relapse of teh fever.
- Da Costa JM. Relapses in Typhoid Fever. Transactions of the College of Physicians of Philadelphia. 1877; 3: 101-112
- Longstreth M. Changes in the nails in fever, and especially in relapsing fever. Transactions of the College of Physicians of Philadelphia. 1877; 3: 113-125
- Reynolds ES. An Account of the Epidemic Outbreak of Arsenical Poisoning occurring in Beer Drinkers in the North of England and the Midland Counties in 1900. Lancet. 1901; 157(4038): 166-170
- Reynolds ES. An Account of the Epidemic Outbreak of Arsenical Poisoning occurring in Beer Drinkers in the North of England and the Midland Counties in 1900. Medico-Chirurgical Transactions. 1901; 84: 409‐452
- Reynolds ES. A note on alcoholic and arsenical neuritis. Review of neurology and psychiatry, 1905; 3: 264-267
- Sabin FR. A case of arsenical neuritis. 1901; 12(124): 212
- Aldrich CJ. Leuconychia striata arsenicalis transversus, with report of three cases, American journal of the medical sciences. 1904; 127(4): 702–709
- Mees RA. Een Verschijnsel bij Polyneuritis Arsenicosa, Nederlands tijdschrift voor geneeskunde 1919; 63(1a): 391-396 [PDF]
- Hutton JT, Christians BL. Sources, symptoms, and signs of arsenic poisoning. J Fam Pract. 1983;17(3):423‐426.
- Saddique A, Peterson CD. Thallium poisoning: a review. Vet Hum Toxicol. 1983;25(1):16‐22.
- Seavolt MB, Sarro RA, Levin K, Camisa C. Mees’ lines in a patient following acute arsenic intoxication. Int J Dermatol. 2002;41(7):399‐401.
- Chauhan S, D’Cruz S, Singh R, Sachdev A. Mees’ lines. Lancet. 2008;372(9647):1410.
- Rohrig TP. Chapter 6: Anatomical Findings. In: Postmortem Toxicology, 2019: 59–77.
- Aujayeb A. Mees’ lines in high altitude mountaineering. BMJ Case Rep. 2019; 12(3): e229644
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