Finally, allow me to e,all attention quite briefly to another akin affec tion, herpes zoster. Barensprung taught us that this eruption always follows the course of a spinal nerve, and that it is dile to disease of the corresponding inter-vertebral ganglion (the ganglion Gasseri). Kaposi affirms that disease in the nerve-centre itself (the spinal cord), or at sorne point in the peripheral portion of the nerve should be regarded as the possible cause, but lie lays special stress upon " hemorrhage and inflam matory irritation of the spinal ganglia." ' This author also mentions as occasional causes neoplasms, cancer, tubercle, suppurating foci, and perios titis, inflammatory exudations and inflammations in general (by which inflammation of adjacent ner.ve trunks is produced), poisoning by carbonic oxide gas (Charcot, Mongeot), and the internal use of arsenic. IVe see that the causes here are quite remote, and that consequently the idea that there is some connection between zoster and the functional changes under consideration is of limited application, even when a case does occasionally occur, in which this theory seems plausible. But let us go a little further. In addition to the c,auses above mentioned, Kaposi him self observes that in most cases of zoster such c,auses cannot be demon strated; he mentions then eruptions of zoster, which he has seen result from traumatic irritation of the nerves (from a shot, cut or blow). but this dermatologist says nothing further. Now I have recently read a paper by Dr. M. Weiss of Prague,' in which he shows on the authority of prominent writers, that there is a central cause for certain forms of zoster, as in symmetrical zona, a case of recurrent zoster (Kaposi), zoster in connection with myelitis, tabes, spinal meningitis, progressive muscu• lar atrophy, epidemic cerebro-spinal meningitis, cerebral hemorrhage, etc., but at the same time he mentions how easily these cases may admit of a different pathogenetic interpretation. In symmetrical zoster there may be simultaneous disease of the symmetrical peripheral nerves, or inter-vertebral ganglia; in cerebral and spinal affections perhaps the process extends from the central organ towards the periphery, the zoster accompanying epidemic cerebro-spinal meningitis may be due to infection, etc. Only after every other cause has been excluded, can we entertain clinically the idea of a zoster of cerebral or spinal origin. However, there are such cases. Bertholle published an account of one, and Weiss himself is able to report one. Clinically, and with reference to the cause, Weiss distinguishes three principal varieties of zoster, the toxic, neurotic, and tropho-nenrotic. The first is caused, like other toxic dermatoses, by an inflammatory irritant circulating in the blood, and is essentially infectious (zoster accompanying cerebro-spinal meningitis). The second results from primary or tmnsmitted neuritis or peri-neuritis due to wounds, cold or adhesive pleurisy; according to him, the inflammatory process may extend from the nerve-endings to the tissue of the skin. Finally, we are to regard as tropho-neurotic zoster that form which, after excluding all these conditions, we can refer to an affection of the central nerrous system, or of the trophic fibres that run in the same. If (as in the case of Mrs. L., described below) I was, as the result of observation, induced to think of a possible connection between an eruption of zoster and climacteric conditions, I should, by this last-quoted definition, find myself limited to the group of zosters with which the cases in question should, in all probability, be classed. It was natumlly important for me to compare the phenomena accompanying the tropho-neurotic zoster in Bertholle's and Weiss's cases with the possible abnormalities during the climacteric. In Berth°lle's case psychical affections formed the constant
cause of the eruption of zoster that appeared on seven oceasions; the eruption was always preceded by severe migraine. In the case recently reported by Weiss, there were at first persistent psychical troubles, a feeling of pressure on the head, depression, photopsia, with loss of appe tite and sleeplessness, followed by local pains, formication, numbness, and finally an eruption of zoster at the affected spot. There appeared also in the same locality, hyperhidrosis, local atrophy and disturbance of motion, and a shining appearance of the skin, which seemed to be as thin as paper. After the eruption had recurred several times, an almost com plete restitutio ad integrum occurred, which was supposed to be due to an improvement in the mental condition.
As regards the attendant phenomena, I cannot dwell upon them here, but must refer to the original. If I consider only the points that seem to stand in direct connection with these cases of zoster, it can hardly be denied that they present a certain similarity to the climacteric phe nomena with which we are already familiar. After what has been stated in these pages, the comparison is self-evident. But if this comparison holds good to some extent, then we are also to a certain degree justified in saying that all cases of zoster, which appear at about the corresponding time of life, and are attended only by some climacteric phenomenon, stand in direct relation with the menopause, i.e., that they constitute in themselves a climacteric phenomenon. This opinion of mine is strength ened by Weiss's own explanation of his case, viz.: " In consequence of mental emotions, there probably occurred, through the medium of the vaso-motor system, a moderate disturbance of nutrition in that section of the spinal cord in which are the centres for the trophic and sweat-fibres which run to the periphery in the median nerves (which were specially affected in this case), whereby the function of these centres is altered, and thus the disturbances were produced." Just such tmnsient, limited trophic disturbances, and resulting functional changes in single centres, it must, in my opinion, be possible to demonstmte in connection with the climacteric, at least it seems to me that this view is justified by many other climacteric changes, which are not less striking in character and concerning the nature of which there is no longer any doubt.
The case, the observation of which led me to the foregoing reffezions, was the following: Mrs. L., aged fifty-five, of a nervous family, matured at sixteen, married at twenty-three, and had six children. She was ir regular between forty-two and fifty; before this time she suffered with severe migraine for fourteen years, which has been relieved since she en tered upon the menopause. Previously the attacks recurred not oftener than once or twice a year, and lasted about a day. &Tice then she has had attacks of congestion, sweating, palpitation, various neuralgim, and especially mental depression. At fifty-one, one year after the complete cessation of menstruation, without any demonstrable cause, there occurred in connection with a marked increase of her general nervousness, an out break of exquisite right-sided zoster of the neck. (partly confluent), which lasted in all something over five weeks. The following year a second, hut less extensive, eruption of vesicles occurred on the same spot, and was attended with the same violent burning sensation. Since then the patient Las remained free from any indication of a recurrence.