j Reprinted from The Tri-State Medical Journal and Practitioner, St. Louis, November, 1897.J 
ZONA. 
By A. H. Ohmann-Dumesnil, of St. Louis. 
MONG the diseases of the skin which are 
easily recognized, even by the laity, may 
be reckoned zona, or, as it is perhaps better 
known by the name of, herpes zoster. 
It is the "shingles" of the old granny,and 
nearly every one has had an opportunity 
of observing one or more cases of the af- 
fection. It is called an acute disease of 
the skin and is included by the majorityof 
writers in the inflammatory class. There 
is certainly some reason to question this,as 
it is primarily due to some organic altera- 
tion in the nerves. This is no doubt the 
reason why zona in adults is invariably 
preceded by premonitory symptoms which manifest themselves in the form 
of a neuralgia which is of an apparently intractable character, as it does 
not yield to any form of medication addressed to the alleviation of the 
pain. This neuralgia is of a peculiar character in this way, that it affects 
the area which subsequently becomes the seat of the affection. After the 
neuralgia has existed for some time, for days in some cases, the eruption 
makes its appearance. This eruption of objective lesions, however, is by 
no means a signal of the departure of the subjective symptoms. The 
neuralgia,malaise, and other untoward symptoms may not only be present, 
but generally persist for some time. In fact, it is this pain which causes 
the greater part of the complaints made by patients. The constant neu- 
ralgia is not only of a very marked character,but is inclined to be persistent. 
It is generally said that the prodromic neuralgia exists about two weeks 
before the appearance of the eruption, but this cannot be regarded as a fixed 
rule, for it may not have been felt for a longer period than a few days be- 
fore the cutaneous symptomsappear. At all events, the period is of a suf- 
ficient length to make quite a marked impression upon the general con- 
dition of the one subject to the trouble. 
The eruption is one which is easily recognized, as a rule. The laity 
are all very quick to know it and have a good idea of its subjective symptoms 
and course. And yet, unless the lesions and their grouping be well under- 
stood, mistakes in diagnosis, even by physicians, are apt to occur. The 
eruption first appears in the form of an erythema or reddening of the skin, 
more or less limited in its outlines. The color is quite a bright red and 
there is tingling and smarting of the skin experienced in addition to the 
neuralgia. The distribution of the erythema should always give rise to 
suspicions of the true nature of the disease, as it occupies the portion of 
skin which will later on be covered by the characteristic lesions and which 
will be described further on. Succeeding the erythema there may be noted 
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the appearance of a crop of vesicles arranged in groups. Each group con- 
sists of from three to twelve or more vesicles which vary in size from a 
millet-seed to a split pea. As the lesions grow older they also grow larger 
and new crops successively appear one after the other. One fact to be 
noted is.the peculiarity of the grouping of the vesicles, which is distinctly 
herpetic in character and partakes a great deal in the nature of herpes. 
In fact, the French have applied a generic name to all of this group of 
vesicular distribution in the herpetides, and even contend that there exists 
a herpetic diathesis. Another peculiar fact in connection with the erup- 
tion of zona is that the groups of vesicles are not totally isolated. They 
are in a manner joined to one another by scattered vesicles occurring here 
and there, as if an effort had been made to produce new patches and had 
proven abortive. A glance at almost any good picture of zona will show 
this in a very plain and marked manner. The vesicles in zona are filled 
with a clear serum, and each lesion is surrounded by a bright-red areola; so 
that, upon a mere superficial examination, the eruption looks as if the trans- 
lucent vesicles had been implanted upon a bright-red field, whilst closer 
examination will reveal a distinct areola around each one, the periphery of 
the areola being not so bright as that portion immediately around the 
vesicle. 
One of the most interesting features in connection with zona is its dis- 
tribution. This is valuable to the observer as well, as it enables him to 
recognize the disease and formulate a diagnosis much more easily than he 
could otherwise, and it will often keep him from falling into the pitfall of 
being an alarmist without any adequate reason for so doing. The distribu- 
tion of the lesions is such that the groups of vesicles lie in the tract of dis- 
tribution of some cutaneous nerve and its branches. Occasionally the 
tracts of two or more nerves are implicated; but, even in such a case, each 
one will be accompanied by its own eruption, which will be entirely dis- 
tinct from the other. It is on this account that the eruption, when occur- 
ring upon the trunk, ceases abruptly at the median line, almost always. 
I say the latter advisedly, as will appear later on. It does occur sometimes, 
however, that the corresponding cutaneous nerves of the trunk on either 
side will be simultaneously affected, and then we have true "cingulum," or 
"girdle-rash," which superstitious in former years regarded as inevitably 
fatal. Old crones to-day will assert that when shingles goes around the 
body the patient dies. There is no doubt whatever that the attack is more 
severe, but it is not a fact that it is fatal. The reason ascribed for the 
eruption abruptl>ceasing at the median line is that the nerves do not cross 
it, and yet there seems to exist exceptions to the rule. An example of such 
a condition is shown in Figure 1. The patient, a woman, was affected by 
a zona extending over the left hip and lower part of the abdomen. In the 
dorsal region, at about the lumbo-sacral juncture, a patch of vesicles ex- 
tended horizontally across the median line. This certainly goes to show 
that cutaneous nerves occasionally develop aberrant branches after com- 
plete fusion of the embryonic clefts has occurred. It is also of value as a 
warning to the physician not to reject a diagnosis of zona from the mere fact 
that a patch slightly overlaps the median line. Such cases are by no 
means as rare as text-books might lead us to suppose, and a little more 
attention to this point will reveal a greater number of these apparent ex- 
ceptions. 3 
As has been stated above, the vesicles in zona are filled with a serous, 
translucent fluid which, later on, becomes opaque and undergoes purulent 
transformation. It is not an infrequent occurrence for a number of vesicles 
which are in close proximity to coalesce. If the lesions are not subjected 
to friction, or to some similar external influence, crusts will form and 
develop in the course of eight or ten days and then drop off. As a sequel 
to these crusts there are very thin scars which are stained a rather light- 
brownish color and, in the course of time, become white, so that the former 
site of the lesions may be easily discovered years after they first appeared. 
Should the vesicles be bursted it is not unusual, but rather the rule, for ulcers 
to form. These ulcers are peculiar in their course as well as in their nat- 
ure. They are rather deep and the destruction of tissue is well marked. 
Not only this, but they have a tendency to be chronic and do not heal 
readily, even under the best of treatment. Rather thin and unhealthy 
FIG. i. Zona Crossing Median Line. 
crusts form which are not closely adherent, but fall off at' the slightest 
provocation. The secretion is purulent and somewhat sanious, and there is 
a considerable amount of pain present. The cases which are affected in 
this manner naturally last longer than those which are properly treated. 
The disease, as a rule, will continue for two or three weeks if untreated, 
and the ordinary methods employed for combating the disease curtail this 
but little. On the other hand, an abortive treatment which is efficient 
and which will be outlined further on will succeed in reducing the length 
of an attack from fourto six days. At least such has been my experience in a 
number of cases, and I have called attention to it in a former paper pub- 
lished by me. ' The method was found to be efficient in both children and 
adults. 
When zona attacks young children the process differs somewhat in its 
evolution from the same disease occurring in adults. As a rule, it is not 
preceded by neuralgia, and the younger the child the less complaint there 
* St. Louis Medical and Surgical Journal, August, 1896. 4 
is on that score. This cannot be explained in any other way but that 
which has been adopted to account for the fact that infants suffer less pain 
and its after-effects are shorter, in an operation, than in the case of adults. 
The only rational explanation which has been given for this fact is that 
Fig. 2. Zona of Back. 
the nerves and nerve centers are not as well developed; in other words, 
they are still in the stage of development, and the higher nerve and brain 
centers are not in that receptive state which they assume later on in life. 
The functions of the being are purely vegetative, and all evidences of emo- 
tion are referable to interference with those functions, with the possible 5 
exception of pain due to trauma, and this is of comparatively short dura- 
tion. O11 the other hand, when zona occurs in young children there is 
apt to be quite a marked elevation of temperature. This is known as 
zosterian fever, and is directly due to the disease, which is, no doubt, an 
irritation of the nerve centers. It occasionally becomes alarming, and 
should be combated with antipyretics such as are not heart-depressant, 
for the heart is also apt to suffer from some transitory functional disturb- 
ance more alarming from an apparent standpoint than from a real one. 
The localities attacked by the eruption may be said to embrace the 
entire integument. The lumbar region and the thorax are most frequently 
attacked. Thus, we have zona pectoralis, zona dorsalis, as shown in 
Figure 2, in which it can be plainly seen that two spinal nerves are impli- 
EiG. 3. Zona of I,eg. 
cated. Zoster lumbalis is also a favorite site, and the case shown in 
Figure 1. was of this variety. The sides of the chest, about the eighth or 
ninth intercostal nerves, is the most frequently implicated region. I have 
had occasion to note the eruption over those portions corresponding to the 
inusculo-spiral nerve, the distribution not only mapping out very distinctly 
the nerve, but its branches. Zona brachialis is not seen very often. 
When it does occur, it is very apt to implicate the entire arm from the 
axilla to the flexure of the wrist. Zona cruralis is more often seen, and it 
is not unusual to see it distributed from the points of origin of the crural 
plexus down over the thigh and leg, the lesions being very disseminate. 6 
An example of this form is shown in Figure 3, the lesions below the knee 
being younger in point of appearance than those above. The most severe 
form of zona is, beyond all doubt, that which is localized over the area 
supplied by the first branch of the fifth cranial nerve. This constitutes 
zoster ophthalmicus, and it is not only the most severe in its subjective 
symptoms, but is also very apt to be of a severely destructive character. 
A vesicle developing on the cornea is very prone to lead to perforation, 
with all which such a condition implies. It is for this reason that most 
energetic measures should be employed, as the loss of sight in one eye 
is always a contingency which should be guarded against. It is also for 
this reason that zona should be recognized quite early, as treatment may 
be inaugurated earlier and a disaster to eyesight much more easily averted. 
The pathology of this disease has been very thoroughly worked up, 
although there are yet some lacunae to be filled. The exact demonstration 
of the anatomo-pathological origin of zona must be credited to Baerens- 
prung, who discovered changes in the cutaneous nerves and spinal gan- 
glia.* But, as Eeloir very justly observes,! cases occur in which neither 
the nerve trunks nor the ganglia are affected, and in which, manifestly, 
the cutaneous terminal filaments suffer. At all events, all writers and 
investigators are of the comfuon opinion that there are organic changes in 
the nerves or spinal ganglia, or both, and that the cutaneous eruption is 
simply a reflex symptom of this condition, just as all herpetic eruptions 
are indications of some deeper neurotic diseased state, whose exact nature 
must be determined and eliminated before any decided and permanent 
relief can be hoped for. 
An interesting question in connection with zona is the consideration 
of what causes it. Upon this problem there exist, in general, two opinions, 
and treatment accordingly varies. One opinion, which is supported by 
very respectable authority, is that the cause is purely parasitic. Micro- 
organisms cause the trouble and the disease originates from'without; or, in 
other words, is purely extrinsic. The theory which I am inclined to favor 
is that of the intrinsic origin. Experimental inoculations have failed, in 
my hands, to reproduce the eruption. On the other hand, I have been 
able to trace the inception of the trouble to a cold, exposure to air, being 
chilled, getting the clothing wet and thus reacting on the cutaneous sur- 
face, a chill being marked; mental emotions, such as anger, a fright, etc. 
In all, some nervous phenomenon could be made out and the relations of 
cause and effect appeared very plain. On the other hand, I have seen a 
zoha;form eruption appear as a result of the intoxication produced by 
Fowler's solution. No neuralgic pains were apparent, but in all other 
respects it was a typical zona in each case. In connection with this part 
of the subject it may not be uninteresting to mention the fact that it has 
been, and still is to some extent, a popular belief, supported by medical 
authority, that one attack of the disease confers immunity against subse- 
quent attacks. Very good evidence has gone to show that this is a fallacy,' 
and quite a large number of individuals have been reported (orally) as 
having suffered successive attacks, one as often as once a month, showing 
that this is far from being an unusual occurrence. 
* Annalen der Charite. Volume XII. Berlin, 1868, 
tRecherches Cliniques et Anatomo-Pathologiques sur les Affections Cutanees d'origine Nerveuse. Paris 
1882, p. 153, et seq. 7 
The treatment of zona should be both general and local. The pro- 
dromic symptoms should be treated by some nerve sedative, bnt cases 
rarely apply at this early stage for treatment, a belladonna or mustard 
plaster or some similar treatment being employed by the patient, who con- 
siders it an unimportant neuralgia. It is when the disease is developed, 
when the cutaneous lesions appear, that the pains are most marked. Here 
it is that energetic employment of remedies must be carried out. Phos- 
phide of zinc, in one-third grain doses, has been recommended, the dose 
indicated being given four times daily, but it does not seem to be adequate 
to the cases. A good pill is the Asiatic, made as follows: 
Acidi arseuiosi gr. i 
Pulv. piperis nigris 5 i 
Ext. gentianae q. s. 
M. Ft. pil. No. 30. Sig.-One pill after each meal. 
This is superior to Fowler's solution, as it produces no untoward 
symptoms. If there be much pain at night, opium acts as the bestsedative. 
Locally, the treatment may be summed up in two words-protection 
and anodynes. A powder composed as follows is good: 
It Pulv. camphorae 3 ss 
Talc, veneti 
Cretae preparat aa 3 j M. 
But pure campho-phenique powder is much better. Whichever is 
used, it should be freely dusted on the affected part, and the whole covered 
with cotton batting. Should the local pain be very intense, it will be 
found advantageous to apply a four per cent, solution of cocaine muriate 
before the use of the dressing. Various anodyne solutions have been 
recommended, such as aqueous solutions of carbolic acid, bichloride of 
mercury and tincture of opium. The calamine and zinc lotion has been 
applied, but powders will be found to act much more satisfactorily. But 
whatever application is determined on, it should never be forgotten that 
the use of a cotton dressing is of the utmost importance. It protects the 
blebs and vesicles from being broken, and thus prevents the formation of 
chronic, ill-conditioned ulcers which will otherwise result and leave marked 
scars to demonstrate their former presence. 
The prognosis of zona should always be a good one. The majority of 
authors give the average duration of the disease as two or three weeks. By 
using the treatment outlined above (arsenic pill and campho-phenique 
powder), this will be shortened to from four to six days, a circumstance 
which will be highly appreciated by patients.