LEUKONYCHIA*

T HE white spots that so frequently occur on the nails, especially in young women, have a number of names, many of them frivolous, such as "kisses," "wishes," or "gift spots." Like most strange happenings they have their folklore also, and in Bavaria, according to Heller,2-3 it is believed that the person having them shall live as many years as there are spots on the nails, while on the Rhine the person having them is held to be a liar. That the names should be frivolous is often quite fitting, as frequently the spots are of trifling importance. This, however, is far from saying that they are of no account whatever, as .nothing pertaining to the human being is that, and, furthermore, this symptom, under certain circumstances, may have a grave significance. Jonathan Hutchinson once aptly said: "It is convenient to think of a nail as a gigantic flattened hair." The nail plate corresponds to the hair, the slot out of which it springs to the hair follicle, and the matrix from which the nail grows is analogous to the hair papilla. The matrix, as being an organ of growth, is composed of very soft cells, and in these cells there are scattered minute particles of air, ordinarily invisible. When, however, the root of the nail is rudely pressed upon, as is often the case in pressing back the posterior nail-fold in manicuring, the injury causes the cells to imbibe an unusual quantity of air, so forming the white spots and stripes. That these spots are air can be demonstrated by darkfield illumination of sections of the nail in which the air-filled spaces show white against the darker, normally dense nail substance.' Also, if the surfate of the nail, which in leukonychia is smooth, is cleared off with a file one finds that the white spot is composed of cells which are crumbly, soft and infiltrated with minute air bubbles which, by refraction, give the white cloudy appearance. This cloudiness is often marked, and Sabouraud compares it to the stratified clouds seen in the sky on a summer evening. Heidingsfeld of Cincinnati, therefore, was perfectly correct in stressing this kind of injury in the production of this symptom, and it accounts for its frequent occurrence in young girls who are so interested in nails as ornaments. Leukonychia of the nails of the toes is not nearly so frequently observed as of the fingers. They, of course, are not so exposed to view, and they are also not so exposed to the peculiar kind of injury incident to manicuring. The injury of manicuring is directly over the lunula, and therefore directly over the matrix where, as was said before, leukonychia arises. There are other, more important causes than local injury for the production of both transverse fturrows

venient to think of a nail as a gigantic flattened hair." The nail plate corresponds to the hair, the slot out of which it springs to the hair follicle, and the matrix from which the nail grows is analogous to the hair papilla. The matrix, as being an organ of growth, is composed of very soft cells, and in these cells there are scattered minute particles of air, ordinarily invisible. When, however, the root of the nail is rudely pressed upon, as is often the case in pressing back the posterior nail-fold in manicuring, the injury causes the cells to imbibe an unusual quantity of air, so forming the white spots and stripes. That these spots are air can be demonstrated by darkfield illumination of sections of the nail in which the air-filled spaces show white against the darker, normally dense nail substance.' Also, if the surfate of the nail, which in leukonychia is smooth, is cleared off with a file one finds that the white spot is composed of cells which are crumbly, soft and infiltrated with minute air bubbles which, by refraction, give the white cloudy appearance. This cloudiness is often marked, and Sabouraud compares it to the stratified clouds seen in the sky on a summer evening. Heidingsfeld of Cincinnati, therefore, was perfectly correct in stressing this kind of injury in the production of this symptom, and it accounts for its frequent occurrence in young girls who are so interested in nails as ornaments.
Leukonychia of the nails of the toes is not nearly so frequently observed as of the fingers. They, of course, are not so exposed to view, and they are also not so exposed to the peculiar kind of injury incident to manicuring. The injury of manicuring is directly over the lunula, and therefore directly over the matrix where, as was said before, leukonychia arises.
There are other, more important causes than local injury for the production of both transverse fturrows *Editor's Note: This delightful little classic was found in the editor's files. Dr. Montgomery died December 20. 1941. For many of his old friehds, the reading of this article will bring pleasant memories of a witty, thoughtful man. and white streaks and dots across the nails. They may occur as one of the results of severe fevers, the constitutional turmoil evidently so affecting the matrix as to give rise to this expression of abnormal growth. This may be of great importance forensically as fixing the date of a previous severe illness. It is known that the nail grows at the rate of about 0.1 millimeter a day, and that it takes approximately four months for it to progress from its base at the posterior nail-fold to the white lines of its free terminal border. Of course some allowance may be made for retarded growth during the weakness of convalescence, and also there is a difference in the rate of growth in the young and in the aged, but nevertheless this is the average. White stripes or cross ridges have been observed corresponding to severe attacks of typhoid or typhus or other severe fevers, and one case has been reported in which each attack of relapsing fever was followed by a leukonychia stripe, definitely showing the connection between the attack and the occurrence of the lesion on the nails.2 At one time I had under my care a man, aged 30, who had just recovered from an attack of acute articular rheumatism, with a cardiac residue. When he came to me he was still suffering from excessive sweating, and the nail of each finger and thumb had a band of leukonychia across its middle, corresponding in time with his previous illness. Posterior to each band there was a transverse ridge indicating a profounder affection of the nail matrix at the height of his illness. Either stripes or ridges are of the same nature, the ridges of course indicating a profounder disturbance of the matrix.

NERVE LESIONS AS CAUSING WHITE STRIPES ON THE NAILS
Besides leukonychia due to direct local injury and that due to the severe infectious fevers, there is that due to nerve lesions. In an organ as richly supplied with nerves as the nail, it is not surprising that its germinative body, the matrix, should be so affected in the multiple neuritis of alcohol or of arsenic as to cause leukonychia. C. T; Aldrich of Cleveland has reported three cases' of leukonychia striata arsenicalis. One of these patients first got drunk and then tried to commit suicide with arsenic, and recovered from both, but with white stripes on his nails to remind him of his adventures.
The finger nails are very sensitive to pain, touch and pressure, and the blood vessels of the finger tips and posterior nail-folds are exceedingly mobile and liable to congestion, showing how sensitive the vasomotor nerves of this region are. A remark of Louis Brocq that many of his leukonychia patients had blue finger tipswindicates how close the association may be between the vasomotor nerves and these white 29 CALIFORNIA MEDICINE Vol. 68, No. 1 spots on the nails.3 Anyone may demonstrate upon himself what delicate organs of touch nails are, and the old Latin idiom, "ad unguem," shows this admirably. It means the minutest exactitude and finish, and derives from the sculptors' practice of running the thumbnail along the marble they were working on to detect any inequalities. As for pain, it was at one time customary to drive a wedge under the nails to elicit information from a recalcitrant witness.
In speaking of affections of the nerves as causing leukonychia one may mention the neurotic. There are patients, principally women, suffering with all sorts of nervous symptoms. They wander from physician to physician, seeking health and finding none. One such was a woman, 30 years of age, the subject of the photograph (Figure 1) . As a girl in the Sacramento Valley she had frequently had malaria. She was a constant sufferer from constipation, acne and, from time to time, severe attacks of herpes simplex of the lips. She frequently had leukonychia. At one time I was able to count seven distinct cross stripes on the left middle and little fingers and seven cross Besides those in the neurotic, there are other instances of striped leukonychia, the origin of which is not so clear, yet most interesting for the dermatologist. There is the constantly recurring history of chronic constipation, indigestion, acne and white stripes on the nails. That in these cases there is often an exacerbation of the acne at each menstrual period is. an old and universally recognized clinical fact. It may well be that each leukonychia stripe may correspond with a menstrual period.
In practice one only occasionally notes such a symptom as white spots on the nails, so that one's histories only represent isolated examples, but a collection of cases throughout the years does give one a realization of the disparity between its occurrence in males and females-21 women and four men.
Furthermore, in the practice of a dermatologist leukonychia would always be noted as occurring with some other disease of the skin, as people only very rarely consult one on account of white marks on the nails alone. Some of the coincidences, however, are interesting. For instance, four out of 25 patients had hyperidrosis, which frequently is a vasomotor symptom, and which shows itself particularly on the palms and soles. One patient with psoriasis had very dry hands, but of course both undue dryness and undue moisture are deviations from the normal of th6 same sets of glands, and therefore closely related.
Of particular interest was the case of a young man who had been an athlete and had changed to a comparatively secondary occupation. He was decidedly overnourished, had a florid face and red congested hands, and suffered from indigestion and spells of constipation. He had a widely extended erythematous eczema, hyperidrosis of the palms, and a vesicular eruption between his fingers and of his feet. No fungus was found, although carefully searched for. He recently had had pain over the site of the appendix. If one could have laid open his alimentary canal to the light of day, it undoubtedly would have presented a wonderful sight.
One of my patients had psoriasis of the palms and volar surfaces of the fingers; another had dry rough hands associated with psoriasis; another had a patch on the back of one hand resembling psoriasis. A woman, severely afflicted with eczema, including the hands, had a constant peeling of the skin below the free border of the nails. A man had a vesicular eczema of the right foot and both palms. No fungus was found, so probably it was a true eczema. A woman had vitiligo of the backs of the Oligits, spreading up the forearms, and another had chronic paronychia and drumstick-fingers. Some of these cases are interesting because of the coincidence of the white stripes and of catarrhal or other inflammation of the hands, as they both involve abnormal blood flow, and therefore abnormal nutrition of the same locality.
Excluding those cases due to traumatism, as in young girls in manicuring their nails, and also excluding those cases that one can say occur accidentally due to acute febrile diseases and to poisons such as arsenic and alcohol, and taking into consideration only those cases in which the white stripes recur persistently, leukonychia is a symptom that has to be regarded seriously and one which indicates a more or less grave, persistent state of ill health. What this condition may be, may not be precisely demonstrable, but it is there and Sabouraud is the only author I have met with who accentuates this view.4