HERPES ZOSTER FRONTALIS. 
\ BY 
JAMES I. TUCKER, A. M., M. D., 
CHICAGO. 
[ Reprinted from, the Journal of Nervous and Mental Disease, October, 1876.] 
A. 3. KISSELL & CO.. Printers, 196 A 198Clark St.. Chicago. Art. II. CASE OF HERPES ZOSTER FRONTALIS. 
James I. Tucker, A. M., M. I)., Chicago 
(Read before the Chicago Society of Physicians and Surgeons., Sept. 11,1876.) 
F)ECENT advances in neurological science are compelling 
us to pluck diseases, so to speak, one by one, from the 
positions they formerly occupied in this or that classification, 
and, on account of a more intimate acquaintance with their 
real character, to transplant them to a new and more appropri- 
ate field. In this new field, they have doubtless always be- 
longed, and here they have been placed heretofore by shrewd, 
practical conjecture, though it has hitherto been impossible to 
determine their true position and relations, till the broader sig- 
nificance of neurotic influence was fully and truly recognized 
and understood. This is particularly true of many forms of 
cutaneous eruptions, especially the phlyctenoides, the most 
prominent of which is herpes zoster, whose peripheral mani- 
festation has led it to be classified, until quite recently, as 
purely a disease of the skin. Neuro-pathologically considered, 
this disease is, however, as reihote from a purely peripheral 
affection as epilepsy or tetanus, etc., the trophic changes which 
it presents being no less symptoms of internal disease than an 
epileptic or tetanic convulsion—the phenomena peculiar to the 
diseases named being determined by the nervous centre, which 
is the seat of the lesion, or irritation. To look upon this dis- 
ease from an eccentric standpoint alone, and ignore or under- 
estimate the fact that there is an irritation, or lesion, back of 
the external phenomena which produces the trophic changes 
of zoster, is to lose sight of the only rational guide to its 
therapeutics. It is of comparatively little importance to make 
a colored map of this disease, though it may furnish a very 
correct representation of its superficial appearances, presenting 
the character of its vesicles, with their gradual transformation 2 
Tucker—Case of Herpes Zoster Frontalis. 
in the periods of development, maturation, decline and termi- 
nation, for doubtless the identical kind of irritation or lesion, 
located elsewhere, would produce very different peripheral 
phenomena, and it is the internal disease, and not the super- 
ficial affection, which is the subject for treatment. Moreover, 
by referring this class of neuroses to the place where they 
belong, we dispose in a measure of the vexed subject of 
classification, for dermatology is not delineation and nomen- 
clature, however much some writers on skin disease may like 
to make it so. 
But without further preliminary remarks, I will proceed at 
once to report- case of Zoster Frontalis, which has recently 
occurred in my own private practice. 
Case. Dr. X., aged 67, a retired dentist. Followed his 
profession unremittingly nineteen years, after which having 
secured a competency, he retired from active life and removed 
to a quiet suburban residence. In childhood and early man- 
hood, he was “nervous” and delicate, but upon coming to the 
west his health improved, and he had no serious illness till 
1854, when he was attacked with the “cholera,” of that year, 
and came near falling a victim to it. lie was one of those 
who suffered great losses by the Great Fire of 1871, and by 
the lesser one of 1874, and his old business activities were 
again called into play in the restoration of his buildings. 
This implied a severe draught on his muscular and nervous 
systems, he, working every day with hand and head, and 
being unusually exposed to wind and cold and wet, was 
for a time much exercised over his losses. I have noticed for 
years a slight movement of his head forward and to one side, 
not altogether normal; especially when he was in conversation, 
he always carried it a little toward the right side. lie was 
the subject of a partial sun-stroke while he was living in the 
suburbs, and states that his head has never felt quite right 
since that time. There was a sensation of heaviness, a press- 
ure, over his right eye, and he suffered more frequently from 
headache. On the evening of Jan. 12,1876,1 was called to see 
him. He had just returned from the city, having walked 
home, as was his custom, to his residence, now a distance of Tucker—Case of Herpes Zoster Frontalis. 
3 
nearly five miles. I learned that lie had been suffering from 
frontal headaches for several days, and this evening upon 
arriving home, his pain was so intense that he concluded 
to summon his family physician. I found the pain to be 
mostly in the frontal region, but especially over and through 
the right eye, and of a violent neuralgic character. Mor- 
phine gave him temporary relief. On the next day the pain 
persisted in the same regions, and was of an aggravated 
character. On the third day pain was not so severe, and a 
dose of medicine given morning and evening, insured him 
a tolerably comfortable day and night. On the morning of 
the fourth day, on arriving at the house, his wife met me at 
the door and said: “Doctor, you will see a clear case of 
erysipelas up stairs.” My patient was free from pain, but 
upon the right side of his forehead, extending from his temple 
to the median line exactly, and following this line along the 
hairy scalp to the occipital region, was a vivid erythematous 
redness, upon which were phlycteme arranged in clusters 
distributed at different points upon the forehead, in the supra- 
orbital region, upon the right eyelid and right side of the nose. 
There were several isolated vesicles larger than the rest, situa- 
ted immediately to the right of the median line of the scalp. 
The ear was uninvolved. The eye was highly injected. Upon 
the opposite side of the median line of the forehead and scalp, 
the skin presented a perfectly normal appearance. Temp. 96, 
pulse 68. Tongue thickly coated and breath very foul. In 
time, some of the larger vesicles coalesced. The vesicles were 
first filled with a clear fluid; this fluid became milky, then 
purulent. The epidermis covering them broke with re- 
markable ease, and upon discharging its contents, left a 
highly vascular, inflamed base, which bled easily. Soon this 
base was covered with a thick brownish-black crust, which 
covered immense patches over the seat of the phylyctenous 
eruption, and over the eyelid to the extent of sealing the eye 
completely. As these crusts began to detach themselves at 
the edges, there was seen underneath a thick, stinking pus. 
If the slightest violence were exerted to detatch them, the 
surfaces bled freely. The crusts, gradually, but very slowly, 4 
Tucker—Case of TTerpes Zoster Frontalis. 
desiccated and fell off, but were followed by others, thinner 
and lighter in color, which in turn detached themselves. Up 
to this time there was no pain, and the whole surface involved 
in the disease was insensible to touch or pressure. 
On January 26, peculiar neurotic symptoms began to mani- 
fest themselves. At first, flashes of heat, alternating with 
sensations of cold, and when touched, sensations as if needles 
were pricking him. On Feb. 2, the sensations of heat had 
become extremely intense. They were at times almost in- 
sufferable, and caused the patient to cry out in agony: “Oh! 
oh! oh! oh! Fire! fire!! fire!!!” These paroxysms recurred 
at short intervals, but in the brief time between them there 
was comparative freedom from all suffering. On Feb. 7,1 was 
called early in the morning. He had had a bad night. Had 
not slept. It seemed to him as if the right side of his head 
had been immersed constantly in boiling water. Bathing 
with tepid water to some extent mitigated this suffering. 
During the day, and succeeding days, the intervals between 
the paroxysms became longer and longer, and during these 
intervals he would even joke about the fiery furnaces, and the 
cauldrons of hot water into which his forehead was thrust or 
immersed. He said, it seemed as if there were a man and a 
woman engaged, away back in or behind his right eye, building 
fires; the former built a fire suddenly, with petroleum, the latter, 
more slowly, of light kindling wood, and he knew the instant 
they applied the match. The crust has for the most part 
disappeared, the site of the vesicular eruption is well marked 
by raised patches of lighter color than the surrounding skin, 
and now, after the sloughing of the epidermis, has become a 
large, ugly-looking, bleeding ulcer, co-extensive with the 
original boundaries of the eruption. 
Feb. 8. The paroxysms of heat and cold sensations come 
less frequently, and have considerably lessened in intensity. 
His eyelids are still sealed closely, and the eye itself is ex- 
tremely sensitive to light and pressure. New cuticle forming, 
highly congested, pulse 80. Paroxysms of heat sensations alter- 
nate with those of extreme cold, most intense between 4 and 9 
a. m., and at the decline of day. Feb. 9. Slept poorly, usual Tucker—Case of Herjpes Zoster Frontalis. 
5 
morning paroxysms did not recur. In good spirits; appetite 
good; eyelid can be slightly raised; orbit intensely congested; 
extremely sensitive to light. Sensations to touch over the for- 
head becoming normal. Some prickly feeling at times. Line 
of demarcation between sound and unsound side, as from the 
first, absolutely defined and impassable. Feb. 10. Slept 
poorly, occasional paroxysms of sensations of heat and cold. 
Feb. 11. Considerably improved. Slept well last night, 
though he persists in saying, that he does not sleep at all. 
Tongue coated, disinclined to talk. Seems much prostrated. 
Feb. 13-14. Patient still considerably exhausted. Sleeps 
during the day. “Fires” kindled from time to time, but do 
not blaze, pulse 100. Feb. 15-16. More comfortable. 
February 23. Improving rapidly. Sits up two or three hours 
during the day. Appetite good, pulse 80. Cuticle reformed, 
but forehead within original boundaries continuously red. 
Cannot now feel my finger when it is placed upon the forehead 
over seat of eruption. Opposite side normal in every particu- 
lar, and with the exception of a slight oedema of the left eye- 
lid, has been so from the beginning. Knows whether cold 
water or hot is applied to forehead. 
March 9. Doing well. Forehead paler, but still markedly 
red. Eyelids inflamed. Sensations of burning within the 
eye occasion much suffering. 
March 18. Tendons of pyramidales contracted; conjunctiva 
nearly clear. Experiences difficulty in raising the right eye- 
lid. p. 68. Sits up three hours a day. 
April 1. The seat of the eruption becomes livid with con- 
gestion by the effect of light, noise, mental excitement, fullness 
of the bowels, etc.; the circulation in this part being remarkably 
easily influenced by these causes, p. 68. Temperature normal, 
sleeps well. Sits up and walks about the room. Occasional sen- 
sations as if electric shocks passed through his head, sometimes 
starting in the eye and passing to the occipital region and 
anon, taking the opposite direction. Now and then there is a 
slight feeling of construction and suffocation about the upper 
thoracic region. Face slightly bloated on left side of nose and 
cheek. 6 
Tucker—Case of Herpes Zoster Frontalis. 
June 1. Patient goes about the city. Is free from all ab- 
normal sensations, except those of heat-flashes when he stoops, 
or when the circulation in the head is otherwise affected. The 
forehead within the circumscribed region, is still red, and a 
serrated line of demarcation still forms the dividing line be- 
tween the sound and the affected side. There has been no 
delirium or other pscyhic disturbance from the beginning of 
the disease. 
I made the last formal visit upon my patient, August 26th, 
1876, and found him slowly but steadily improving, though 
like a thundercloud which has been scattered and driven away 
by the winds, and now and then exhibits angry flashes, and 
threatens once more to darken the blue sky, so some of the old 
sensations of heat, cold and tingling in mild degree are still a 
cause for complaint; even astray vesicle nowand then appears, 
and did we not know from the natural history of the disease, 
that it seldom recurs, we might apprehend a return of the 
original conditions and phenomena. The abnormal sensations 
are reproduced upon slight pressure over the skin on the side 
of the head which was the peat of the disease. Even if the 
tongue is placed upon the inner side of the cheek, a shock like 
an electric current passes through the side of the head. All 
the functions of the body seem otherwise to be normally per- 
formed. Pulse 72, temperature normal. Appetite good. 
Bowels regular. Urine normal. 
The line of demarcation between the sound and affected side, 
is still distinctly visible, and the affected side is still redder 
than the other side. The eye-sight is weak, but probably not 
more so than before he was taken sick. There is no unusual 
sensitiveness to light. 
In the history of a disease, like herpes zoster, which is of 
such frequent occurrence, it is seldom that we observe sensi- 
tive and trophic disturbances of such an aggravated character 
as appeared in the case I have just recorded, unless it be in 
zoster opthalmicus, a form with which I was previously little 
acquainted. Zoster of the trunk and of the extremities, I had 
frequently seen, but an aggravated variety of zoster of the 
trigeminus, never before. So little notice of it is taken in the Tucker—Case of Ilerjpes Zoster Frontalis. 
7 
English text-books, and so few cases are recorded in the foreign 
journals, that I believe it to be of comparatively infrequent 
occurrence. The sufferings of my patient were very great, and 
the ignis sacra of the ancients reminded him more, he said, of 
the veritable orthodox hell. I doubt whether the bare record of 
the case, as T have given it, can convey to the mind of the 
reader an adequate idea of the degree and amount of suffering 
which was experienced by my patient, when not under the in- 
fluence of medicine. 
Formerly, and even as late as the early part of the present 
century, zoster was supposed to be a form of erysipelas, hut it 
was necessarily withdrawn from this category, when its definite 
limitation was contrasted with the erratic character of erysip- 
elas. This constant feature of zoster is the most important in 
the differential diagnosis of the two diseases, though other 
features would be sufficient to distinguish it, even from those 
forms which most resemble herpes—erysipelas pldyctenoides, 
for example. In the latter disease, the vesicles are superincum- 
bent upon an advanced degree of serous infiltration, while in 
zoster, the vesicles appear in the earliest stage of the eruption. 
But the most important characteristic of the disease under 
consideration, is the neurotic. It is, doubtless, the most prom- 
inent of the neuroses which are attended with trophic disturb- 
ance in the skin. Its exact limitation to the region of cutane- 
ous surface, corresponding to the terminal distribution of a 
particular cranial or spinal nerve, has drawn the attention of 
the medical world to this fact. Its localization and mechanism 
became more and more definite from information derived 
from isolated necroscopic examinations, till it passed beyond 
question, that the disease was referable aetiologically and path- 
ologically to some form of destructive irritation involving, in 
different degrees in zoster of the trunk, etc., the inter-vert- 
ebral ganglion, and in zoster in the region of the distribution 
of the nervus trigeminus—of the first branch, more especially, 
the gasserian ganglion. 
The conclusions of Bserensprung, which appear in Strieker’s 
Medizinische Jahrbuecher, for 1876, in an article “Zur Aetio- 
logie des Herpes Zoster, by” Prof. Dr. Kaposi, are as follows; 8 
Tucker—Case of Herpes Zoster Frontalis. . 
That the brain cannot be the part involved, otherwise the 
eruption would extend over the entire body. 
That the spinal cord cannot be the seat of the disease, other- 
wise the disease would be symmetrical, that is to say, on both 
sides of the body. 
That we cannot attribute the disease to an affection of the 
peripheral nerves because the posterior, as well as the anterior, 
roots are found to be involved. 
Consequently the disease must be referred to some deep- 
lying extra-cranial centre, namely, the ganglion. 
Concerning the intimate nature of zoster, Jul. Parrot 
(IS Union, 27, 29, 30, 1856. Schmidt, 90-310) considers the 
disease as the result of a neuralgia—the eruption being only 
secondary. The frequency of intercostal zoster, he explains 
by the frequency of intercostal neuralgia. 
Boeck (On Diseases of the Skin, 1855,) considers it due to 
a collection of blood-cells in the capillaries of the papillary 
bodies, causing stagnation of blood, and exudative processes. 
He found a neuritis, and considers pain due to trouble in the 
nerves. 
Delioux, (Gaz. de Paris, 32, 33, 35, 39, 1855. Schmidt 89, 
57,) recognized three factors in the production of zoster; viz., 
the condition of the blood, that of the digestive organs, and 
the participation of the nervous system. The richness of the 
blood in fibrine has been dwelt upon by Payer. Delioux lays 
great stress on the catarrhal condition of the digestive organs 
in zoster; this is also noticed by Payer. The frequency of 
zoster in summer and spring, when these diseases are common, 
is noticed. These observations must have been made more 
especially in regard to herpes of the trunk—though it is 
probable the aetiology and pathology of one form of zoster is 
true of all forms. A. Ollivier (Gaz. Med. de Paris, Ho. 44, 
1872. V. dc H. Jahrbuch.) found zona opthalmica, with 
herpes in the region of the superior maxillary branch of the 
fifth pair. Kosmunski, (Aerztl. Gesell. K. I. 1874, V. dc H.) 
describes a case in which, besides the skin alterations, there 
were oedema of the upper eyelid, conjunctival catarrh, in- 
flammation of iris, and diminution of intra-ocular pressure. Tucker—Case of Herpes Zoster Frontalis. 
9 
lie thinks, with Hutchinson, that the eye only is implicated 
when the cutaneous alterations involve the region of the naso- 
ciliary nerves. The diminished ocular pressure he explains, 
according to Hippel, as a result of irritation of the superior 
cervical ganglion of the sympathetic. 
Further recent utterances on the subject are a confirmation 
of the fact, that the disease is of neurotic origin. In the July 
number of the American Journal of Medical Sciences, for 
instance, may be found the following by Dr. L. Duncan Bulk- 
ley. His conclusions are too important not to find a place in 
a paper on zoster. 
“ 1. Whatever may be the cause of the nerve irritation,” 
he says, “herpes zoster is always of nerve origin—that is, it is 
“ an inflammatory lesion of the skin, wherein the local cell 
“ action, resulting in the production of vesicles, is but a result 
“ of nerve influence, a perverted cell action caused by per- 
“ verted innervation. 
“ 2. From the almost constant changes found in the gan- 
“ glion developed on the posterior, or sensitive roots of the 
“ spinal nerves of the affected regions, we must infer that the 
“ trophic changes observed in the skin have to do with the 
“ sensitive nerves, which marks a certain advance in the study 
“ of the physiological relations of the trophic nerves, or nerves 
“ of nutrition. 
“ 3. We are not to conclude, however, that zoster is the re- 
“ suit of inflammation of the sensitive ganglia alone, for the 
“ entire nerve on the distal side of the ganglion, has been al- 
“ ways found to be inflamed, and abundant proof exists of 
“ eruptions of zoster due to various nerve lesions, peripheral 
“ and central, injuries and disease of the transmitting nerves. 
“ and of the cord, and the encephalon. 
“ 4. In certain cases, the origin may be shown to he idi- 
“ opathic inflammation of conducting nerves, (as in Kaposi’s 
“ case,) or they may be effected by pressure, or other alteration 
“ caused by the presence of a tumor, or the disease may be tin 
“ result of surgical, or other injury. 
“ 5. The origin, therefore, of herpes zoster is a direct nervt 
“ irritation, and inflammation, and in ordinary, apparently 10 
Tucker—Case of Herpes Zoster Frontalis. 
“ idiopatliic cases, the explanation of this is to he sought for 
“ in the same causes as give rise to neuralgias in general, some 
“ of which are traceable, many are not. The gouty habit, in- 
“ ducing neuralgia, can likewise give occasion to herpes; the 
“ direct exposure to cold of the terminal branches of a nerve, 
“ as in the head and neck, or elsewhere, can cause painful ex- 
“ citation of the nerve itself, or neuralgia, and is equally a 
“cause of zoster; malaria can originate neuralgia, and may not 
“ therefore, some of the cases of zona be due to a malarial in- 
“fluence? Certainly the prompt action of citrate of iron, and 
“ quinia, in some cases, might point to a malarial element. 
“ 6. In considering, then, the true nature of herpes zoster, 
“ we are rather led away from the skin lesion to the antecedent 
“ neuritis, whose manifestations are neuralgia, more or less 
“ marked, and disturbances of sensation in the area of nerve 
“ distribution represented by hyperalgesia, hypersesthesia, and 
“ anaesthesia; while, at the same time, other results of nerve dis- 
turbance may occur, as paralysis of muscle, trophic alter- 
“ ations in the tissues, and even necrosis, and separation of 
“ bone. In other words, the eruption of zoster is an epi- 
“ phenomenon to a primary neuritis, and neuralgia. 
“ 7. The clinical history and therapeutics of herpes zoster 
“ are in themselves almost convincing proofs of the neurotic 
“nature of the disease. In most cases, especially in younger 
“ patients, the treatment is purely expectative; while in severe 
“ cases, and in elderly persons, the neuralgia is the principal 
“ element requiring attention, and this is remedied by meas- 
ures directed to the nervous system. In the majority of in- 
“ stances, the nerve irritation, or inflammation, subsides spon- 
“ taneously, the whole train of morbid phenomena occupying 
“ about the same length of time taken by other self-limited 
“ inflammations, as pneumonia and erysipelas, while under 
“certain circumstances the sequelae require attention, as in 
“ other diseases. The local destruction of tissue is sometimes 
“ a troublesome feature in the way of ulceration, or necrosis 
“ of the skin, or the neuralgia persists to a distressing degree, 
“ even under the most intelligent treatment.” 
A very interesting paper concerning the nature of Herpes Tucker—Case of Herpes Zoster Frontalis. 
11 
Zoster Frontalis, which furnishes a peculiarly fitting supple- 
ment to the case under consideration, was lately read before the 
K. K. Gesellschaft der Aerzte, of Vienna, by Dr. H. Sattler.* 
After calling attention to the fact that in Herpes Zoster, in the 
course of the trigeminus, it is almost always the first branch, 
the opthalmicus which is affected, and to the frequency 
first noticed by Ilebra of the coincidence between Zoster in 
the course of the opthalmicus with affection of the eye, he 
goes on to describe a case which was carefully observed by 
him, and which afterwards he had an opportunity to examine 
anatomically. 
The patient was a man 85 years of age, who 14 days before 
his admission to the hospital, had been found in his room in 
an unconscious condition, in consequence of breathing coal- 
gas. He was restored to consciousness, and on the fourth day 
afterward, had neuralgia of the right side, in the region of the 
frontal nerve; several days after, a swelling on the forehead, 
upon which still later a zoster eruption appeared, and simul- 
taneously disturbance of vision. The eruption appeared on 
the forehead, the side of the nose, the eyelid, and in isolated 
patches upon the temple. He died in another ward, whither 
he had been transferred on account of a cystitis. Upon post- 
mortem examination, tliere was found in the brain, lungs and 
kidney, an atrophic condition of marked degree, chronic 
cystitis, prostatic hypertrophy. The dura mater was thick- 
ened, the vessels of the brain widened. The trigeminus of the 
right side felt softer and more succulent. The ganglion 
gasseri of the affected side was more succulent than normal, 
grayish-red, the normal color being pale-yellow. Neither 
about the ganglion, nor on the trigeminus, was there a trace of 
an extravasation of blood. Upon closer inspection, the 2d and 
3d branches, after their passage out of the ganglion, were 
found to be perfectly normal; the first branch, on the con- 
trary, was round, succulent, grayish-red, its fibres pressed, as 
it were, asunder, and the branches of the opthalmicus present- 
ed a like appearance, as far as they could be traced in the 
*Protokoll der Sitzung von 28 Oct., 1876. Strieker, Am. d. K. K. 
Gesell, der Aerite in Wien. 12 
Tucker—Case of Herpes Zoster Frontalis. 
orbit. The ciliary ganglion was gray, its surroundings thick- 
ened. These were the macroscopic appearances. Upon micro- 
scopical examination, the changes in the ganglion gasseri were 
found to consist in infiltration of the interstitial connective 
tissue, with round cells, in a regressive metamorphosis of the 
ganglionic cells, completely destroying them, transformation 
of the tissues surrounding the ganglion into a homogeneous 
mass, and finally degeneration of the nerve-fibre beyond recog- 
nition. These changes involved only that part of the ganglion 
gasseri which contributed to the formation of the first branch, 
and only those fibres were degenerated which had their origin 
in the ganglion. The cells of the ganglion ciliare were nearly 
intact, but its connective tissue was abundantly infiltrated with 
round cells. The entering nerve-branches were rich in de- 
generated fibres. The out-going ciliary nerves were affected 
to their last ramification; the more intensely, the nearer they 
were to the ganglion. 
There are two theories named in Sattler’s paper explaining 
the proximate causation of the singular phenomena of zoster. 
Snellen’s theory is that a neuritis extends from the ganglion to 
the terminal distribution of the nerve in the skin and eye, an- 
alogous to retrobulbar neuritis following retinitis. The second 
theory is, that it is an affection of specific (trophic) nerves. 
Sattler concludes that trouble in these nerves, originating in 
and passing out of the ganglion, is the real cause of zoster. 
The position resting upon pathological facts, though not as 
yet demonstrated by physiological experiment, is nevertheless 
growing in general recognition and acceptance, that there is a 
separate and distinct set of nerves, whose function it is to 
preside over nutrition, to regulate and control it. These are 
called the trophic nerves, and the question is ably discussed 
by neuro-physiologists, among the most prominent of whom is 
Samuel (Die trophische Nerven). After collecting a great 
number of facts, clinically and experimentally observed, he 
arrives at this broad generalization (Ilaujpt resultat) that the 
principle of nutrition lies in the cell and the measure of it in 
trophic nerves, jp. 352). Dr. Sattler was led to conclude that 
this is the true explanation of the trophic alterations of Tucker—Case of Herpes Zoster Frontalis. 
13 
zoster, among other reasons, because in his case the neuritis 
gradually decreased as it extended from centre to periphery. 
Of course the sensitive fibres are also affected directly or 
indirectly, otherwise we could not account for the neuralgia, 
and other disturbances of sensation. 
Before concluding, I wish to mention another variety of 
zoster, which at the present day is attracting considerable at- 
tention, and shedding light upon the pathology of the disease. 
I refer to zoster traumaticus. 
An illustrative case is reported by Dr. O’Risel, of Ilalle.* 
The patient was a somewhat anaemic, poorly nourished woman 
thirty-six years of age, whose mamma and axillary glands had 
been excised. After the operation, secondary hemorrhage 
set in which rendered it necessary to reopen the wound to tie 
a number of small arteries. This was on the lltli and 12th 
of November. On the 14th there was a burning pain of the 
fore arm, especially in the ulnar region. On the 15th the 
skin over the region of the ulnar, as far as the palm of the 
hand, was covered with an eruption which at first resem- 
bled urticaria. In the evening, clusters of vesicles made their 
appearance upon an inflamed and swollen surface which extend- 
ed three fingers in width from the condylus internus to the 
palmus maims. The inner side of the arm was free from the 
exanthem. On the 16th, the herpetic eruption ceased to ex- 
tend, the contents of the vesicles became purulent and the 
surroundings paler—the pain in the forearm diminishing. 
After two or three days, the exanthem had dessicated and 
healed upon the formation of thin crusts, some painful sen- 
sations remaining. 
As a rule, considerable time elapses between the wound and 
the appearance of the herpetic eruption. Dr. O’Bisel quotes the 
two exceptional cases reported by Bohn, in the Jahrb.f Kin- 
derheilk., N’. F. 11. 1869, p. 22, in which the early local symp- 
toms appeared immediately—the first zoster of the finger,— 
after violent exercise in the gymnasium, the second zost. 
lumbo-abdominalis in a boy, after repeated jumping from a 
* Deutsche med. Wochenschrift, June 10, 1876. 14 
Tucker—Case of TTerjpes Zoster Frontalis. 
high chair. Tims a slight traumatic effect upon the nerves is 
sufficient to elicit an eruption of zoster. 
I will not extend the limits of this paper by reciting Erb’s 
experiments on dogs and rabbits, (Deutsch. Archiv. f. Klin. 
Med. V. jp. 42) in which the nervous and trophic alterations 
peculiar to zoster followed intentional injury to the nerve trunk. 
Returning to our own case, I have now only room left for a 
resume. I have said that although cases of herpes zoster have 
appeared frequently in the course of my practice, the particular 
variety under consideration was comparatively novel. Its 
character was so marked, that I did not feel justified in letting 
it remain unrecorded. I have said that there is a remarkable 
dearth in the English literature on the subject, and I should add 
that the clinical cases which come to necroscopic examination 
are rare the world over. I was particularly delighted to find that 
Dr. Sattler had not failed to faithfully observe and communi- 
cate to the profession his case which presented the most promi- 
nent points of interest exhibited by this remarkable disease. 
I would add a few remarks concerning the therapeutics of 
zoster, were it not so plainly indicated by its pathology. Given 
the pathology, it is of very little importance to add more when 
writing for medical men. Anodynes are clearly indicated to 
mitigate the suffering. Bromide of potassium was of signal 
service to me in the treatment of my case. Quinia met the 
condition of periodicity. Local applications were worse than 
useless, and electricity has not yet been given an adequate trial. 
Beard and Rockwell say that herpes yields rapidly to central 
galvanization. It might be added that in the great majority of 
cases there is an intrinsic tendency to speedy recovery. 
Bulkley says that three therapeutic agents seem to have a 
marked control over herpes zoster, whose cutaneous manifesta- 
tions, as well as painful element, they appear to arrest; viz., 
phosphorus, given early to abort the disease; electricity, the 
galvanic current passed directly through the affected nerves, 
their trunks and peripheral distributions, to abort the eruption 
and dry up the newly formed vesicles much sooner than other- 
wise, besides pretty certainly checking the pain. And quinia, 
which combined with iron, shortens the duration much and Tucker—Case of Ilerpes Zoster Frontalis. 
15 
relieves the unpleasant symptons. All these, it will be 
observed, should be used early in the disease. “ Whether,” 
he continues, “ergot, which has been of great service in 
“ neuralgia in the hands of some, would check this congestive 
“ neurosis, I cannot say, but should hope much from it. The 
“ hypodermic injection of morphia, as we know, relieves the 
“ neuralgia, and, if used early and repeatedly, might abort the 
“disease by checking the nerve-irritation, especially if con- 
joined with atropia. Painting the surface with collodion, or 
“ colloid coating containing morphia would serve the same 
“ purpose. Some assert that it is a very valuable measure. 
“ Ordinarily the only local treatment required is protection of 
“ the inflamed surface, and this is best accomplished by pow- 
“ dering it with starch and keeping a single thickening of mus- 
“ lin firmly applied, and left on until the vesicles are dried.” 
My own experience, limited as I have stated, was decidedly 
against local applications of every kind,—and, I think, I gave 
those which are recommended above a faithful trial with the 
effect only to aggravate the symptoms,—except upon the 
anaesthetic surface, in the very earliest ages of the disease, 
to facilitate the drying of the vesicles. 
It is a problem which I have yet to solve, how to dispose of 
the distressing sequelae which are still persisting. 
I have thus taken occasion to review the subject of zoster 
as far as my limits would permit, and the many other import- 
ant points suggested by my case and recorded in recent 
medical literature, I must reserve for another occasion. 
In my opinion there is sufficient ground to warrant us in 
concluding that— 
1. Zoster is one of the neuroses. 
2. The primary seat of the disease is the ganglion. Of 
zoster frontalis it is the ganglion of Gasser. The trigeminal 
nerve is affected secondarily, and finally, the skin by inflamma- 
tion. The 2d and 3d branches are generally intact. 
3. The peculiar character of the cutaneous affection (nutri- 
tive) would seem to indicate that a special kind of nerve is 
principally, involved namely the trophic. 
50 Douglas Place, Sept. 11, 1876.