W. W. DANGELEISEN, M.D., CINCINNATI, O.
Herpes zoster, sometimes known as zoster, zona, and more commonly as shingles, is an acute inflammatory disease of the skin, appearing over definite areas, accompanied by more or less severe, pain, with usually a unilateral eruption, characterized by the occurrence of groups of firm, tense, glaboid vesicles rising from an edematous base, sometimes followed by ulceration and scarring. The favorite location is on the head or face and about the trunk.
As to the etiology, the exact nature of the infection in herpes zoster has not been fully determined. To this infection, or the toxin arising, the posterior root ganglia show a decided susceptibility, but commonly only one is affected in a given case. The Gasserian and those from the third dorsal to the second lumbar spinal roots are more prone to attack than other ganglia. If the ganglia be secondarily involved in any inflammatory or destructive process, a similar eruption appears. An injury to a nerve trunk may cause an hepatic eruption limited to its cutaneous distribution. Herpes zoster sometimes occurs in connection with malaria, meningitis, typhoid, pneumonia and chicken-pox, and is frequent in tabes and paretic dementia. Arsenical, carbonic oxide gas and intestinal poisonings also give rise to this condition.
Pathological changes occur in the ganglia of the posterior roots of the spinal nerves. The most frequent finding is an interstitial inflammation of the ganglionic centers, less often a descending neuritis.
Symptoms.—Pain, neuralgic in character, often precedes the outbreak of the eruption by a few hours or days, attends the eruption in its course, and may, especially in old people, persist after the eruption has disappeared. The eruption comes out very rapidly or more slowly in two to six days, lasts for eight to ten days or longer, and invariably subsides in three or four weeks. Redness remains for a time after the eruption has subsided, and a few scars are often left, with sometimes pigmentation around. Exceptionally, gangrene occurs, and, if so, such cases are grave.
Wallace Beatty notes the following facts as to the sensory phenomena:
1. Children may have no pain. This is not invariable.
2. Young adults almost always have severe pain, which may need sedatives, but the pain usually subsides with the eruption.
3. Old people suffer severely, and the pain commonly persists after the eruption has disappeared. Pain may persist for weeks or months, or indefinitely.
4. Numbness, which lasts, may be present later at the site of the eruption, The lymphatic glands may be affected early. The distribution of herpes zoster is peculiar and significant. It may occur in the course of any sensory nerve. Its most frequent location is one side of the thorax, due to a lesion of one or two dorsal posterior root ganglia.
Herpes zoster in connection with the trigeminal nerve, due to implication of the Gasserian ganglion, requires special mention. It follows the distribution of the three main branches of the fifth nerve very closely in some instances, and rarely invades the fields of two of them in one patient. This I find to be a favorite location of this disease in cases of general paralysis of the insane, the upper division of the fifth nerve frequently being involved.
Occasionally, when the function of neighboring motor nerves has been interfered with there may be ptosis or facial paralysis, according to the localization of the herpes. About one year ago a patient, aged sixty-five, coming under my care with an involvement of the fifth nerve, developed a marked facial paralysis, which cleared up in about six months' time.
The diagnosis is very readily made; only vesicular eczema and simple herpes are likely to be confounded with it. The course of the malady will clear the problem, as well as the anatomical relations of zoster, which are not presented by eczema. Herpes simplex, affecting the lips and nose in coryza and gastro-intestinal intoxications, and herpes genitalis are still unclassified as to participation of the root ganglia.
Treatment.—Careful consideration should be given to the treatment of herpes zoster. Rest in bed is necessary if the eruption is severe, with proper attention to the action of the bowels. It is often necessary to protect the surface from fiction of the clothes, as in thoracic herpes zoster. Protective and soothing local applications are useful, as a 1 per cent. cocaine ointment, or Lassar's paste. Collodion painted on sometimes hastens the absorption of the fluid and drying up of the vesicles, as does the use of alcohol. However, the local applications which have served me best in cases where the pain is severe are libradol, alternating with an ethyl chloride spray. Aconite and gelsemium are usually indicated as internal treatment. Arsenic has often been used, but we must remember that it is capable of producing the affection, and is likely to aggravate instead of benefiting the disorder. Sometimes the synthetic analgesics, as pyramidon, cibalgine and peralgia, are useful in alleviating pain.
Morphine may be found necessary to relieve pain, but should be used with the greatest care. Tonics may be administered to improve the patient's general condition.
- Beatty, Wallace: Lectures on Diseases of the Skin.
- Ormsby: Diseases of the Skin.
- Sajous: Analytic Cyclopedia of Practical Medicine.
- Church-Peterson: Nervous and Mental Diseases.
National Eclectic Medical Association Quarterly, Vol. 19, 1927-28, was edited by Theodore Davis Adlerman, M.D.