The term ‘zoster’ is nowadays associated with ‘herpes zoster’, the condition resulting from reactivation of the latent varicella-zoster virus which causes shingles. But in antiquity the meaning of ‘zoster’, a Latin word originating from the Greek for a belt or girdle, was variously associated in men with a form of body armour which could enclose just one half of the body; in women with a garment worn around the waist and sometimes called a ‘zona’; and with a place, Zoster, linked mythologically then with the goddess Leto and her zona. Around 48 AD, the Roman physician Scribonius Largus became the first to associate ‘zona’ with ‘herpes’, and to attribute a medical meaning to ‘zona’, here an abbreviation of ‘zona ignea’ (‘fiery girdle’). Although in the past the terms ‘zoster’ and ‘zona’ were sometimes used interchangeably, today only ‘zoster’ remains—even when etymologically illogical in those patients whose zoster rash occurs in body areas other than the trunk.
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Recently a successful phase III trial of a new herpes zoster subunit vaccine was reported,1 increasing the possibility that eventually a vaccine might make zoster, or shingles, a disease of the past. Even if the disease is finally conquered, however, the term ‘zoster’ with its intriguing and convoluted past will surely endure; but how did it originate?
At first glance, today's use of the term to denote the creeping or ‘herpetic’ rash needs no explanation: ‘zoster’ is the Latin term derived from the Greek ζωστήρ—a belt or girdle, thereby acknowledging that the thoracic dermatomes are those most commonly affected by reactivation of latent varicella-zoster virus (VZV) from the dorsal root or cranial nerve ganglia2 (figure 1). But in antiquity ‘zoster’ was a noun with several other meanings, and the present discussion traces the term's history which witnesses the emergence of ‘zoster’ from its various classical roots into the current vocabulary of medicine.
‘Zoster’, and its sister ‘zona’, in antiquity
Probably the oldest meaning of ‘zoster’ related to a form of decorated body armour, for which there is archaeological evidence dating back some three millennia.3 Worn by heroic warriors, these zosteres (zosters) were constructed out of metal, sometimes including silver; they were used for protection during warfare—a ‘heroic warrior's belt’ or a ‘war belt’, and are referred to on several occasions by Homer in both the Iliad and the Odyssey.3 Zosters could also serve as gifts bestowed between those of high rank, when they were often coloured red—particularly ‘blood-red’.3 It is noteworthy that the metal part of a zoster, sometimes called a ‘zooster’,4 could also enclose just one half of the body, and a bronze girdle of this type which was fastened with a leather belt was among many Greek and Roman antiquities brought to England 200 years ago.4
Women, too, wore zoster-like belts, which were more usually called by the Latin term ‘zonae’, and these were a form of belt worn around the waist.3 Again they are referred to by Homer, and it seems that the terms ‘zoster’ and ‘zona’ have sometimes been used interchangeably. For women, however, zonae had quite different functions, and while they were garments worn around the waist, they could also imply chastity or, conversely, be used seductively to reveal the body. Naturally they had to be discarded or loosened at the time of childbirth,3 and such loosening of the girdle gave rise to a Greek myth which curiously gave rise to another meaning of zoster: geographical.
This enchanting myth is of relevance here and concerns the goddess Leto, daughter of the Titans Coeus and Phoebe. Leto (Latona in Latin) was the mother of Apollo and Artemis (figure 2), and there are at least three classical references which concern the birth of Apollo. Leto had sought a place of shelter for her labour, which would eventually be the island of Delos, but on her journey she rested for a while at Zoster. The 4th century BC Greek writer Hyperides, thought to be the originator of the myth, reported in his Delian speech in which he acts for Athens against Delos concerning the control of the temple of Apollo on Delos:
It is said that Leto, who was about to give birth to the children of Zeus, was driven by Hera over land and sea. And when she was already weary and distressed she came to our country and loosened her girdle in the place now called Zoster. (Fragment 67)5
Similarly, according to Pausanias, the renowned Roman geographer and chronicler who was writing in 155–180 AD about the Greece he had explored:
In the town of GIRDLE [Zoster] on the coast there are altars of Athene, of Apollo, of Artemis, and of Leto. They do not claim Leto bore her children here, only that she loosed her girdle here before her labour, and this is how the place got its name. (1.31.1)6
And writing in the 6th century AD, the grammarian Stephanus of Byzantium noted in his Ethnica, also known in its Latin version as De Urbibus, that Zoster was ‘where Latona untied [her] zona’,7 thereby nicely linking the word ‘zoster’ with ‘zona’.
By now a clear link had thus been established between Leto's girdle and a place, although exactly where Zoster was situated remains debated. Certainly it is in the region of today's Vouliagmene, near Athens (figure 3), but different classical sources have variously identified Zoster as being the deme (an Attic township in ancient Greece), the cape, just one of the three promontories of the cape, the isthmus or a nearby lake.8 ,9 What is not in doubt, however, is that in classical times Zoster existed, and it has also been argued—by an anonymous author enigmatically signing himself ‘E.E.G’—that Zoster was a promontory which may have received its name because of its girdle-like shape.10
The pivotal moment: Scribonius Largus introduces ‘zona’ into medicine
If zoster is variously the name for a form of metallic armoured belt, a garment and a place, how did it become associated with an herpetic affliction of the skin? The pivotal moment seems to have occurred around 48 AD, and is attributable to a few very brief references by the little studied Roman physician Scribonius Largus, active during the reign of the Emperor Claudius, and who is chiefly remembered for introducing the use of the electric shocks of the torpedo fish as the earliest form of electrotherapy.11 ,12 In his treatise De Compositione Medicamentorum, which has never been fully translated into English, he uses the term ‘zona’ five times, and on three of these occasions he refers to the link between the terms ‘zona’ and ‘herpes’.13 For instance, on one occasion Scribonius Largus writes:
This medication is efficacious for carbuncles [or tumours], for the sacred fire and the zona which the Greeks called herpes. (lxiii)14
Scribonius thus achieves the distinction of being the first to associate the Latin term ‘zona’ with the Greek term ‘herpes’, and the first to attribute a medical meaning to the word ‘zona’, a meaning not recorded in the Greek literature before or since.13 Perhaps surprisingly ‘zona’ was still to be seen heading letters in the British Medical Journal at the end of the 19th century, and apparently the term is still used by the French.13
Scribonius' use of ‘zona’ probably represents here an abbreviation of ‘zona ignea’ (Latin for ‘fiery girdle’) and is thus similar to his ‘sacred fire’ (‘ignis sacer’), perhaps anticipating the Norwegian expression for herpes zoster as ‘a belt of roses from Hell’.15
What is the ‘sacred fire’ that Scribonius refers to? Inevitably this disorder is obscure today, although Celsus in the 1st century BC considered that:
‘Ignis sacer should be counted also among the bad ulcerations. Of this there are two kinds; one…attacks chiefly the chest or flanks or extremities, particularly the soles of the feet’. Of the other kind, ‘it is the aged who are mostly afflicted…but chiefly in the legs’. (V.28.4)16
Neither kind seems typical of zoster, and in a commentary on Celsus' descriptions, Spencer noted that ‘ignis sacer’ had often been a term the Greeks originally used for any redness of the skin due to ‘an eruption or ulceration’. Celsus, however, seems to denote by it an erysipelatous complication of a chronic creeping ulceration, such as the tuberculous ulceration now called lupus.17 Only a few years later, in his famous Natural History dated around 77–79 AD, Pliny the Elder discusses
…several kinds of erysipelas, among them one called zoster, which goes round the patient's waist, and is fatal if the circle becomes quite complete. (xxvi.lxxiv.121)18
While Pliny appears to have been responsible for the erroneous view that bilateral zoster is fatal, he nevertheless clearly distinguished zoster from other forms of erythematous skin eruptions which fall under the rubrics of erysipelas and ‘ignis sacer’.
And what of the ‘herpes’ to which Scribonius also refers? ‘The origin and use of the word herpes’ have been comprehensively reviewed by Beswick, who noted that the term ‘herpes’ was already well known in Hippocrates' time but likely did not apply to those conditions which are termed herpetic today.19
‘Zoster’, ‘schingles’, and their treatment
Around the 1st century AD, therefore, there seems to have been a convergence in the use of the terms ‘zoster’, ‘zona’, ‘ignis sacer’ and ‘herpes’. A thousand years were to elapse before the postclassical Latin ‘cingulus’, a variant of the Latin ‘cingulum’ (a girdle), evolved in the English language as ‘schingles’, the first recorded mention being that of Bartholomaeus Anglicus in his De Proprietatibus Rerum of 1398:
And helpeth therefore against ycchyng and scabbes wete and drye and against the schingles… (II.xvii.xciii)20
And a further thousand years were to elapse before the nature and cause of zoster as a reactivation of the VZV infection with its dermatological, neurological and occasionally other features were to be established, and the history of the advances made over the past century have been documented on many occasions.21–23
What about treatment and perhaps finally eradication of zoster? Pliny recommended treatment of the ‘creeping forms’ of zoster with root of cotyledon with honey wine, aizoüm (houseleek), and the juice of linozostis (annual mercury) with vinegar.18 Few better remedies were available up to 50 years ago, since when antiviral agents and a moderately effective live-attenuated vaccine for prophylaxis have been developed. But hopefully, perhaps as a result of developments in new vaccines,1 and what appear to be prolonged immune responsiveness and safety of such vaccines,24 herpes zoster—and its often chronic, painful sequel of postherpetic neuralgia—will become diseases of the past.
An etymological conundrum: herpes zoster sine ‘zoster’?
However, notwithstanding these scientific advances, and that herpes zoster can occur without the rash—zoster sine herpete,25 there remains a conundrum. One need only recall the classical reports and illustrations of the 450 patients with herpes zoster studied by Henry Head a century ago to confirm that the rash can also affect the limbs (figure 4), head and face (figure 5)26—distributions which are anything but girdle-like: herpes zoster sine ‘zoster’? Nevertheless, it would be both naïve and churlish to suppose that such illogicality would lead to etymological revision. Rather, justly celebrating its classical origins, the term ‘zoster’ will surely continue to be associated with the VZV rash wherever over the body it appears.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.