WEBVTT - Shingles: The Mystery of Pain 0:00:02.120 --> 0:00:05.119 Shingles is a disease that has been around for thousands 0:00:05.200 --> 0:00:08.720 of years. It affects millions of people every year, but 0:00:08.920 --> 0:00:12.400 as recently as the middle of the twentieth century, scientists 0:00:12.560 --> 0:00:16.560 didn't really know how the disease worked. It was clear 0:00:16.600 --> 0:00:21.200 that shingles and chicken pox were related. People sometimes got 0:00:21.400 --> 0:00:25.400 chicken pox from people with shingles, but the clarity ended there. 0:00:26.160 --> 0:00:29.320 How were the diseases related. Were they caused by different 0:00:29.400 --> 0:00:32.640 viruses or the same virus. Could you get shingles from 0:00:32.640 --> 0:00:36.319 someone with chicken pox? Nobody knew. But by the mid 0:00:36.400 --> 0:00:39.800 nineteen sixties, scientists had figured out what was going on. 0:00:40.240 --> 0:00:42.320 And one of the people who did the most to 0:00:42.320 --> 0:00:45.239 figure it out was not some high powered researcher at 0:00:45.240 --> 0:00:48.600 a prestigious university. It was a family doctor in a 0:00:48.640 --> 0:00:54.240 small British town. His name was Edgar Hope Simpson. I'm 0:00:54.320 --> 0:00:57.640 Jacob Goldstein and this is Incubation, a show about viruses. 0:01:06.160 --> 0:01:08.160 In the second half of the show, we'll talk about 0:01:08.200 --> 0:01:12.000 the most common symptom of shingles, pain and we'll talk 0:01:12.040 --> 0:01:15.000 about the surprising methods that some doctors are using to 0:01:15.040 --> 0:01:18.360 try and alleviate that pain. In this part of the show. 0:01:18.560 --> 0:01:21.360 We're going to talk about Edgar Hope Simpson, that family 0:01:21.400 --> 0:01:24.800 doctor who helped solve the mystery of shingles. I talked 0:01:24.800 --> 0:01:28.760 about Hope Simpson with Anne Arvin. Anne's retired now, but 0:01:28.880 --> 0:01:32.640 she spent decades as a clinician and a microbiologist at Stanford. 0:01:33.080 --> 0:01:37.240 She studied the Vericella zoster virus, the virus that causes shingles. 0:01:37.720 --> 0:01:40.720 Edgar Hope Simpson, as you just said, was a GP 0:01:41.600 --> 0:01:47.600 who was very interested, as many practitioners are, in trying 0:01:47.640 --> 0:01:52.960 to solve unresolved issues in medicine. And his practice was 0:01:53.320 --> 0:01:56.680 largely older people, and he was seeing a lot of 0:01:57.480 --> 0:02:02.240 shingles relatively speaking, but he was also seeing kids with 0:02:02.360 --> 0:02:07.000 chicken pox. It was really easy to see that one 0:02:07.080 --> 0:02:10.120 kid with chicken pox would give it to fifteen other kids. 0:02:10.320 --> 0:02:13.840 They would get chicken pox. That was easy to observe, 0:02:14.280 --> 0:02:18.000 Uh huh. It was a lot more difficult to nail 0:02:18.120 --> 0:02:23.760 down the question of what about shingles and does exposure 0:02:23.919 --> 0:02:30.000 of a child to shingles really result in chicken pox 0:02:30.320 --> 0:02:33.239 or is that just coincidence proximity? 0:02:34.040 --> 0:02:34.560 Huh? 0:02:34.600 --> 0:02:36.760 And so that was his question. 0:02:37.800 --> 0:02:42.600 There's this moment, I guess in the nineteen forties when 0:02:42.840 --> 0:02:47.600 Edgar Hope Simpson reads in a British medical journal just 0:02:47.639 --> 0:02:50.880 a case report, just a letter from a doctor on 0:02:50.919 --> 0:02:57.600 this remote Shetland island called Yell. Tell me about Edgar 0:02:57.639 --> 0:03:00.679 Hope Simpson and this island of Yell and this sort 0:03:00.760 --> 0:03:06.600 of quest to understand the relationship between chicken pox and shingles. 0:03:07.040 --> 0:03:10.520 Yes, so why did he jump on the boat or 0:03:10.560 --> 0:03:14.040 train or boat and train or whatever to go practically 0:03:14.080 --> 0:03:17.120 a day and a half to get from where he 0:03:17.280 --> 0:03:20.560 was in sort of southern England up to this remote 0:03:20.600 --> 0:03:23.640 island in the Shetland Islands in the North Sea. Why 0:03:23.720 --> 0:03:24.600 did you do that? 0:03:24.880 --> 0:03:27.239 It was going to go on summer vacation. And he's like, no, 0:03:27.320 --> 0:03:29.040 I'm not going to go on summer vacation. I'm going 0:03:29.080 --> 0:03:30.359 to go investigate this. 0:03:30.360 --> 0:03:36.520 Outbreak because the letter that he read said there was 0:03:36.560 --> 0:03:40.320 a school teacher who had shingles and there was an 0:03:40.440 --> 0:03:43.840 outbreak of chicken pox in her class. 0:03:45.000 --> 0:03:49.760 In nineteen forty six, Hope Simpson reads this letter in 0:03:49.800 --> 0:03:53.119 the medical journal about the school teacher case in Yell, 0:03:53.840 --> 0:03:56.520 and then Hope Simpson reaches out to the local doctor 0:03:56.560 --> 0:03:58.960 who wrote about the case and they stay in touch 0:03:58.960 --> 0:04:03.400 they're corresponding with each other. Eventually, Hope Simpson learns that 0:04:03.440 --> 0:04:06.680 there is another outbreak on the island. There's something like 0:04:06.760 --> 0:04:10.080 one hundred chicken pox cases that seem to have come 0:04:10.120 --> 0:04:12.240 from a single case of shingles. 0:04:13.280 --> 0:04:18.240 When he heard about this crofter who had shingles and 0:04:18.279 --> 0:04:23.320 whose five children then had chicken pox, he thought, this 0:04:23.520 --> 0:04:26.520 is an irresistible opportunity. I will go up there and 0:04:26.600 --> 0:04:30.880 I will actually see this outbreak unfold in real time 0:04:31.520 --> 0:04:37.239 from this shingles case. And so undoubtedly the shingles case 0:04:37.520 --> 0:04:41.960 did lead to chicken pox in that family. The question 0:04:42.279 --> 0:04:46.240 was could he then trace a further outbreak. 0:04:46.920 --> 0:04:50.240 I mean, I guess there's something about a remote island 0:04:50.360 --> 0:04:53.560 that's actually a perfect place to test the hypothesis, right 0:04:53.560 --> 0:04:56.800 because unlike in you know, twentieth century England, people are 0:04:56.839 --> 0:04:58.919 taking trains, people are coming and going, this was like 0:04:59.120 --> 0:05:03.039 truly a remote people are like crofters which I don't 0:05:03.040 --> 0:05:06.279 even know they're farmers or they're raising sheep or something. 0:05:06.400 --> 0:05:09.240 Right Like, it's it's very out there. So he goes 0:05:09.279 --> 0:05:13.599 out there and I mean it's amazing, Like what he's 0:05:13.600 --> 0:05:18.559 doing is contact tracing basically. Right, there's here, he wrote 0:05:18.560 --> 0:05:21.240 this reminiscence that I just want to read because I 0:05:21.240 --> 0:05:24.560 love just a paragraph of it. There's this moment when 0:05:24.720 --> 0:05:27.960 like they're trying to track down one case and he says, 0:05:29.520 --> 0:05:31.200 the team, which is just like him and two other 0:05:31.240 --> 0:05:34.480 people walked from mid Yell to the south shore of 0:05:34.560 --> 0:05:37.200 the vau Vae is apparently a Shetland word for a 0:05:37.240 --> 0:05:42.919 little cove or something road themselves across. He means ourselves 0:05:43.000 --> 0:05:46.000 rode themselves across to north of Vo and walked for 0:05:46.160 --> 0:05:50.040 several miles across the heather to the home of K six. 0:05:51.200 --> 0:05:54.640 And then he was hoping this one particular connection was 0:05:54.720 --> 0:05:58.920 going to answer everything, and he writes, alas no, because 0:05:58.960 --> 0:06:00.920 this girl who was going to tie it all together 0:06:00.960 --> 0:06:03.159 for it was not in fact at this other place. 0:06:03.200 --> 0:06:06.560 So anyways, it's a great story. 0:06:07.839 --> 0:06:10.919 I love that. I love that description too, And I 0:06:11.000 --> 0:06:13.880 had to look up what is a voe? So I'm 0:06:13.920 --> 0:06:17.159 sad that we now know a voe is a bay, 0:06:17.240 --> 0:06:20.320 a small bay. I can tell you that kind of 0:06:20.400 --> 0:06:24.120 vs V Barricela's osterro virus research. That is not how 0:06:24.200 --> 0:06:29.479 we do it now, but it looked kind of interesting 0:06:29.760 --> 0:06:30.800 to be able to do that. 0:06:31.120 --> 0:06:33.600 You never you never wrote, did you? How much rowing 0:06:33.760 --> 0:06:35.160 did you do in your research? 0:06:35.279 --> 0:06:40.680 Absolutely not so. Anyway, he was trying to see whether 0:06:40.720 --> 0:06:45.359 he could get a second, a reproducible finding, so to speak, 0:06:45.480 --> 0:06:50.800 because he heard that the person in the other location 0:06:51.360 --> 0:06:55.279 had shingles, and then he thought, well, there's going to 0:06:55.279 --> 0:07:00.359 be maybe another traceable cluster of cases. So back to 0:07:00.440 --> 0:07:04.760 your question about why islands, islands are really important in 0:07:04.839 --> 0:07:09.640 epidemiology of infectious diseases, and so the reason is because 0:07:09.680 --> 0:07:16.360 the populations are tiny and in that particular geography, as 0:07:16.400 --> 0:07:19.320 you just said, you row your boat, you walk three 0:07:19.400 --> 0:07:22.760 miles or ten miles or whatever, there's a lot less 0:07:22.960 --> 0:07:27.880 contact in a very rural situation. So you can have 0:07:28.040 --> 0:07:32.840 the situation in epidemiologic terms where there's a fair number 0:07:32.880 --> 0:07:37.920 of susceptibles and you can actually then take the so 0:07:38.040 --> 0:07:42.560 called index case and you can map literally house to 0:07:42.680 --> 0:07:44.680 house the cases. 0:07:45.240 --> 0:07:48.679 Yeah, but then I think he sort of dug further 0:07:48.760 --> 0:07:52.480 and figured out more connections, right, and it did suggest, 0:07:52.520 --> 0:07:56.160 although it wasn't conclusive, well, that it's the same virus 0:07:56.240 --> 0:07:59.880 and that you can catch chicken pox from someone with ching. 0:08:00.280 --> 0:08:05.840 Right, he went a great distance, so to speak, towards 0:08:06.080 --> 0:08:08.200 actually proving that hypothesis. 0:08:08.360 --> 0:08:10.559 I picture him with like a wall, like a map, 0:08:10.600 --> 0:08:14.120 but with like pushpins that maybe like red yarn, you know, 0:08:14.240 --> 0:08:16.400 like a like in a detective show or something. 0:08:16.480 --> 0:08:23.440 Sure, well, epidemiology is basically a detective story most of 0:08:23.480 --> 0:08:26.960 the time. So yes, I think that's exactly what he did. 0:08:27.000 --> 0:08:31.040 They went around house to house, took records and ask people. 0:08:31.640 --> 0:08:36.679 Yeah, so this is like a very colorful and you know, 0:08:37.760 --> 0:08:40.800 kind of low key heroic thing he's doing to try 0:08:40.800 --> 0:08:44.400 and learn something for the benefit of humanity. But he 0:08:44.600 --> 0:08:50.120 is doing this longer term study based on his practice 0:08:50.360 --> 0:08:55.199 right where he's closely tracking all of the chicken pox 0:08:55.280 --> 0:08:59.199 cases and all of the shingles cases over many, many years, 0:08:59.800 --> 0:09:03.520 and he winds up giving a lecture, publishing a paper 0:09:03.559 --> 0:09:06.120 that is the summation of that work, and he does 0:09:06.200 --> 0:09:09.320 wind up solving this mystery. Tell me about that paper. 0:09:10.000 --> 0:09:13.960 That paper is about his long term study. And he 0:09:14.040 --> 0:09:18.640 apparently studied everyone in his practice who got shingles. So 0:09:18.760 --> 0:09:21.679 not only did he make the diagnosis, he made a 0:09:21.840 --> 0:09:25.439 chart of each person and marked on this chart here's 0:09:25.480 --> 0:09:28.920 where this person lesions were, this is where the other 0:09:29.000 --> 0:09:33.160 person's lesions were. And so he had an enormous set 0:09:33.280 --> 0:09:39.120 of data on where the shingles rash appears on people's bodies, 0:09:39.559 --> 0:09:42.240 and he also had all of the chicken pox data. 0:09:42.760 --> 0:09:46.080 And what he was able to conclude is it's a 0:09:46.200 --> 0:09:53.080 one way traffic. Shingles causes vericella. Vericella does not cause jingles, right, 0:09:54.440 --> 0:09:59.880 chicken pox. Yeah, So that was his finding, his fundamental observation. 0:10:00.080 --> 0:10:03.960 And it's a one way traffic. So that means where 0:10:04.000 --> 0:10:07.880 does the virus come from when you've got shingles? 0:10:08.240 --> 0:10:10.720 Uh huh. It doesn't come from someone with chicken pox, 0:10:10.840 --> 0:10:13.240 and it doesn't come from someone with shingles, right. 0:10:13.760 --> 0:10:16.480 That's also what he observed. And so he had all 0:10:16.520 --> 0:10:20.440 this massive data sets of people who had shingles and 0:10:20.480 --> 0:10:24.080 were in close contact with somebody or several other somebodies 0:10:24.360 --> 0:10:27.680 and they didn't get shingles, but if there were kids around, 0:10:27.880 --> 0:10:31.000 they got chicken pox, but not vice versa. 0:10:32.000 --> 0:10:36.480 So from that beautiful data set he can show clinically 0:10:36.520 --> 0:10:40.760 what's happening. And from this clinical finding, he presents in 0:10:40.800 --> 0:10:44.720 this paper a hypothesis of what's going on at the 0:10:44.760 --> 0:10:46.920 micro level, at the cellular scale. 0:10:46.960 --> 0:10:50.920 What does he hypothesize the hypothesis is what we now 0:10:51.240 --> 0:10:55.880 know to call latency. That is, when you have chicken pox. 0:10:56.040 --> 0:11:00.880 In the course of your chicken pox episode, the virus 0:11:00.920 --> 0:11:04.320 you can imagine, is in those little boxes all over. 0:11:05.080 --> 0:11:09.600 And what is also in the skin Right next to 0:11:09.679 --> 0:11:13.000 where those boxes are, which are full of virus, there 0:11:13.000 --> 0:11:19.040 are nerve endings. And so the virus has created a 0:11:20.320 --> 0:11:26.920 great scheme for persisting by taking not just the opportunity 0:11:26.920 --> 0:11:30.760 to form skin lesions, but to go backwards up the 0:11:30.800 --> 0:11:35.400 nerve axons to the nerve cell body, which is in 0:11:35.600 --> 0:11:39.040 what's called sensory ganglia, all up and down the spinal 0:11:39.120 --> 0:11:45.359 cord and cervical spine and face. But developing the hypothesis 0:11:45.400 --> 0:11:49.320 of how the virus got to the sensory ganglia, he 0:11:49.600 --> 0:11:56.160 outlined what he called suppositions. I like the phrase suppositions. 0:11:56.559 --> 0:11:59.800 There's a nice humility to it, right, I don't know, 0:12:00.080 --> 0:12:01.120 but let's suppose. 0:12:01.880 --> 0:12:07.679 Yeah. So he created a set of suppositions that have 0:12:08.720 --> 0:12:14.080 subsequently been found right. But also because they were suppositions, 0:12:14.320 --> 0:12:16.000 a number of them were not right. 0:12:16.640 --> 0:12:17.680 What did he get wrong? 0:12:18.440 --> 0:12:21.880 Well, for starters, he thought chicken pox was a pox virus, 0:12:22.400 --> 0:12:26.720 which it isn't. It's a herpes virus related to herpes 0:12:26.720 --> 0:12:28.360 simplex type one and type two. 0:12:29.240 --> 0:12:33.160 Let's talk for a minute about just herpes viruses, and 0:12:33.200 --> 0:12:37.120 in particular the persistence, right the fact that they have 0:12:37.320 --> 0:12:40.680 this from the point of view of virus clever, from 0:12:40.679 --> 0:12:44.079 the point of view of a human host, insidious quality 0:12:44.640 --> 0:12:48.040 of hanging around forever. Tell me more about that. 0:12:49.120 --> 0:12:53.120 First of all, these viruses are ancient, and they sort 0:12:53.120 --> 0:12:58.080 of evolved into different subgroups over millions of years. And 0:12:58.120 --> 0:13:01.959 if you look at every specie, they all have their 0:13:02.000 --> 0:13:05.280 herpes viruses too. It's not just us. You have a 0:13:05.320 --> 0:13:08.360 guinea pig, that guinea pig has guinea pig herpyes virus. 0:13:09.880 --> 0:13:14.440 So it is. It is a story that encompasses the 0:13:14.600 --> 0:13:19.800 entire family of viruses. And what we know is that 0:13:20.240 --> 0:13:23.880 for the most part. The other thing the virus as 0:13:23.960 --> 0:13:27.400 agent has to keep in mind is don't make the 0:13:27.440 --> 0:13:33.319 person too sick, right, accommodate if you can, just don't 0:13:33.360 --> 0:13:37.520 even cause any symptoms at all. Just arrange to be 0:13:38.559 --> 0:13:42.959 periodically showing up at a mucosal surface. In fact, a 0:13:43.080 --> 0:13:47.360 few cells, dump a few virus particles into the saliva 0:13:47.600 --> 0:13:50.360 or whatever, and so be it. 0:13:50.800 --> 0:13:55.359 Everybody's happy. Everybody's happy, right, problem. 0:13:55.120 --> 0:13:58.640 No problem, so in fact, you know, chicken pox is 0:13:58.640 --> 0:14:02.239 a bit unusual in the It does typically cause symptoms, 0:14:02.520 --> 0:14:06.640 but very very mild. When it's not mild, it is 0:14:07.000 --> 0:14:11.120 potentially lethal. And so that's why all of us in 0:14:11.160 --> 0:14:14.880 the field work so hard to develop vaccines, vaccine for 0:14:15.000 --> 0:14:17.120 chicken pox and vaccine for shingles. 0:14:17.559 --> 0:14:21.880 So when you look back at Hope Simpson's work, what 0:14:22.400 --> 0:14:23.080 do you make of it? 0:14:24.120 --> 0:14:27.520 Well, I think it's pretty straightforward for me to say 0:14:27.560 --> 0:14:32.320 why I and my colleagues so much admired the work 0:14:32.360 --> 0:14:35.680 that he did and the suppositions that he came up 0:14:35.720 --> 0:14:42.600 with because he was looking from an evolutionary perspective. He 0:14:42.880 --> 0:14:50.200 was asking why does this happen? And what he proposed, 0:14:50.440 --> 0:14:55.680 which is definitely true, is that the virus gives itself 0:14:55.720 --> 0:14:59.560 a kind of second chance to spread. So, if you 0:14:59.640 --> 0:15:02.760 look at it from an evolutionary perspective, and you're thinking 0:15:02.840 --> 0:15:05.920 from the point of view of the virus, how to 0:15:05.960 --> 0:15:11.640 sustain your life if you will, your life cycle in 0:15:11.760 --> 0:15:16.320 a community is as important as how to sustain it 0:15:16.800 --> 0:15:22.000 in one person. And so you have to imagine a 0:15:22.080 --> 0:15:27.200 rural community if chicken pox isn't reintroduced as a kid 0:15:27.240 --> 0:15:31.000 with chicken pox showing up from somewhere. That is it 0:15:31.160 --> 0:15:36.720 for the virus unless unless there's another way for it 0:15:36.840 --> 0:15:40.640 to introduce itself again, so to speak. And that is 0:15:40.680 --> 0:15:44.720 where the Shingles think. So that is why his work 0:15:45.200 --> 0:15:49.760 in Yale was really important. He was actually showing that 0:15:50.200 --> 0:15:54.280 life cycle as it rolls out in a community. 0:15:54.840 --> 0:15:57.920 Yeah, like the virus as agent. Right, it's giving the 0:15:58.040 --> 0:16:01.720 virus agency. 0:16:00.640 --> 0:16:02.960 Which we know not to do. But it's so. 0:16:03.000 --> 0:16:05.640 Tempting, I mean, whatever that's a word. I mean, I 0:16:05.640 --> 0:16:08.760 think there's a non anthropomorphic way, Like, I don't care 0:16:08.800 --> 0:16:11.680 what anybody says, it's clever that the virus is doing that. 0:16:11.840 --> 0:16:13.240 It's very clever. 0:16:13.520 --> 0:16:18.240 Certainly my point of view. Yeah, So it's an evolutionary 0:16:18.320 --> 0:16:22.240 strategy of the virus. That's one reason why this work 0:16:22.960 --> 0:16:27.200 is important. And the other reason, I think is back 0:16:27.200 --> 0:16:31.880 to the suppositions. He did not assume that the story 0:16:32.120 --> 0:16:36.760 was fully understood, and that was that he knew and 0:16:36.880 --> 0:16:39.920 identified the gaps. So there's a way in which you 0:16:39.920 --> 0:16:42.400 can say we've been filling in the gaps that he 0:16:42.520 --> 0:16:45.320 placed out there as suppositions. 0:16:45.720 --> 0:16:50.680 I think there's something also really elegant, maybe even romantic, 0:16:50.720 --> 0:16:56.280 if I'm being honest about the family doctor, the general 0:16:56.320 --> 0:17:01.160 practitioner as epidemiologist. You know, he's he's there every day 0:17:01.200 --> 0:17:04.360 treating patients. And the thing that he did, I mean 0:17:04.400 --> 0:17:06.480 besides going to yell, which is very dramatic, but the 0:17:06.560 --> 0:17:09.320 less dramatic but maybe ultimately more important thing that he 0:17:09.400 --> 0:17:13.520 did is keep this meticulous data as you say, about 0:17:13.840 --> 0:17:16.919 where the where the rashes are and what the household 0:17:16.960 --> 0:17:21.159 connections are. I mean that transforms his work from you know, 0:17:21.240 --> 0:17:25.840 helping individuals to like making this significant breakthrough in human 0:17:25.920 --> 0:17:28.119 knowledge exactly. 0:17:28.400 --> 0:17:32.280 And picking picking a question. I mean, there's always a 0:17:32.400 --> 0:17:36.800 science of great challenge is pick a question where you 0:17:36.920 --> 0:17:40.720 can really gather some data that's going to lead somewhere. 0:17:41.760 --> 0:17:46.520 That's as much of a contribution as a researcher as 0:17:46.600 --> 0:17:49.520 actually finding answers to some of those questions. 0:17:53.760 --> 0:17:55.760 Thank you for your time. It was great to talk 0:17:55.760 --> 0:18:01.760 with you. You too, And Trevin is a retired clinician 0:18:01.800 --> 0:18:05.399 and microbiologist at Stanford. In a minute, I'll talk with 0:18:05.520 --> 0:18:08.320 a physician and researcher who was a friend of the 0:18:08.400 --> 0:18:11.600 late Edgar Hope Simpson and who has spent decades studying 0:18:11.600 --> 0:18:12.840 shingles and pain. 0:18:26.560 --> 0:18:30.760 Anyone who has done any work on shingles. Probably the 0:18:30.840 --> 0:18:34.120 first name they will come across is Edgar Hope Simpson. 0:18:34.840 --> 0:18:36.479 Is it true that you knew him? 0:18:36.640 --> 0:18:40.360 Oh? Yes, I can't tell you precisely when, but I'll 0:18:40.359 --> 0:18:40.880 tell you how. 0:18:41.560 --> 0:18:45.560 Robert Johnson is a physician who spent decades treating shingle's patients. 0:18:45.880 --> 0:18:48.120 He no longer has a clinical practice, but he still 0:18:48.200 --> 0:18:50.480 does research at the University of Bristol. 0:18:50.800 --> 0:18:53.880 It was about nineteen ninety four. There were a group 0:18:53.920 --> 0:18:57.080 of us who were going to be presenting in a 0:18:57.119 --> 0:19:03.040 symposium and somebody said, is Simpson still alive? And I said, 0:19:03.040 --> 0:19:05.400 I have no idea. Let's have a look and telephone directory. 0:19:05.640 --> 0:19:08.640 So we looked up and there was Hope sinstance siahen sister. 0:19:09.040 --> 0:19:11.119 So we phoned him. I think it was about eight 0:19:11.119 --> 0:19:15.000 o'clock one evening, and there was a fairly brusque answer. 0:19:15.000 --> 0:19:19.080 I Hope Simpson here, I said, is that doctor Egger 0:19:19.119 --> 0:19:22.399 Hope Simpson? He said yes, And I said, could I 0:19:22.440 --> 0:19:24.880 ask you? Are you still interested in shingles? 0:19:25.400 --> 0:19:25.800 Oh? 0:19:25.920 --> 0:19:29.280 Yes, he said, And that was the start of it. 0:19:29.760 --> 0:19:33.119 And he was brilliant. He was the most humble man 0:19:33.200 --> 0:19:38.240 you can imagine, an enormous breadth of knowledge. Everyone had 0:19:38.280 --> 0:19:42.720 stories about him, both from the medical point of view, 0:19:43.080 --> 0:19:46.640 as a friend and in particular as a general practitioner. 0:19:46.720 --> 0:19:51.280 He was clearly extremely caring, and they told me that 0:19:51.920 --> 0:19:55.679 he'd be known to ski in the winter out to 0:19:55.760 --> 0:19:59.800 a patient for an emergency call. He was obviously a 0:19:59.840 --> 0:20:01.840 very dedicated a character. 0:20:03.000 --> 0:20:07.320 So I want to talk about shingles as a disease 0:20:07.359 --> 0:20:11.879 and about your work with shingles. What happens in the 0:20:11.920 --> 0:20:13.840 body when you get shingles. 0:20:14.520 --> 0:20:18.920 What happens is that the virus, which has been dormant 0:20:19.280 --> 0:20:22.560 in nerve tissue near to the spinal cord and near 0:20:22.600 --> 0:20:27.240 to the certain areas of the brain, has found itself 0:20:27.280 --> 0:20:32.520 able to reactivate without getting an immune response adequate to 0:20:32.640 --> 0:20:36.800 prevent its spread. And then the virus replicates it, It 0:20:37.000 --> 0:20:41.399 increases its numbers, it multiplies and spreads along the peripheral 0:20:41.440 --> 0:20:44.639 nerve that runs from the area where it was latent 0:20:45.160 --> 0:20:48.440 and eventually reaches the skin, where you get the typical 0:20:48.760 --> 0:20:50.440 rash of shingles. 0:20:51.160 --> 0:20:56.000 So I had chicken pucks decades ago, and right now 0:20:56.800 --> 0:20:59.520 inside my nerve cells inside my body, there is that 0:20:59.600 --> 0:21:05.359 virus still just hanging out weeding more or less and 0:21:05.400 --> 0:21:07.520 if there is some moment when my immune system is 0:21:07.560 --> 0:21:11.480 compromised in some set of factors, a line I will 0:21:11.480 --> 0:21:12.160 get shingles. 0:21:12.520 --> 0:21:16.639 Yes, you're absolutely right. In a lifetime, about thirty percent 0:21:16.640 --> 0:21:19.280 of us will get shingles, and if one lives into 0:21:19.280 --> 0:21:22.320 one's eighties, which these days is very common, it's about 0:21:22.320 --> 0:21:24.520 a fifty percent chance of getting shingles. 0:21:25.240 --> 0:21:27.639 Tell me more about the symptoms of having shingles. What 0:21:27.720 --> 0:21:28.960 is it like to have shingles? 0:21:29.480 --> 0:21:34.119 Very frequently one has several days of pain or tingling sensation, 0:21:34.560 --> 0:21:38.120 maybe feeling a little bit unwell, but then the rash 0:21:38.119 --> 0:21:45.160 appears and the diagnosis becomes clear. Almost always, the acute disease, 0:21:45.320 --> 0:21:49.199 the first three or four weeks is painful, and it 0:21:49.240 --> 0:21:53.840 can be extremely painful. In some people, the lucky ones, 0:21:54.359 --> 0:21:57.359 the rash the pain over a period of ten days 0:21:57.359 --> 0:22:00.320 to three weeks disappear. There's often a little bit of 0:22:00.359 --> 0:22:04.480 scarring and that's the end of it. But in others 0:22:04.680 --> 0:22:09.080 that's not the case. The pain persists. It can be intermittent, 0:22:09.280 --> 0:22:13.560 but it can go on for weeks, months, or even years, 0:22:14.440 --> 0:22:19.359 and when it reaches three months from the rash appearance, 0:22:19.520 --> 0:22:21.760 we call it post Pettit euralgia. 0:22:21.880 --> 0:22:25.480 So post herpetic neuralgia is the technical term, the term 0:22:25.520 --> 0:22:29.960 of art for basically long term pain after you have shingles. 0:22:30.680 --> 0:22:32.800 You can sort of unpack it right, post her petic 0:22:32.880 --> 0:22:37.800 after herpes and neuralgia is a pain from from the nerves, 0:22:37.880 --> 0:22:41.400 right from the nerve, absolutely, and it seems like that 0:22:41.560 --> 0:22:44.000 is I mean, shingles is the thing you don't want. 0:22:44.200 --> 0:22:47.280 Post herpetic neuralgia, long term pain from shingles is the 0:22:47.320 --> 0:22:50.080 thing you really don't want, right, So let's talk some 0:22:50.119 --> 0:22:53.080 more about that. I know you're working on that. What 0:22:53.280 --> 0:22:56.199 is the mechanism of post her petic neuralgia. Why is 0:22:56.240 --> 0:22:58.200 it that some people get it and some people don't. 0:23:00.480 --> 0:23:03.560 I'd say I don't know, but I will try and 0:23:03.600 --> 0:23:08.800 give you a full answer without waffling too much. There 0:23:08.920 --> 0:23:14.919 is definite damage to nerve tissue, nerve fibers right from 0:23:15.119 --> 0:23:19.719 the skin to the spinal cord and indeed within the 0:23:19.720 --> 0:23:24.919 spinal cord. But the problem starts with the clinical side, 0:23:24.960 --> 0:23:28.440 because there is no single pain syndrome of post de 0:23:28.520 --> 0:23:32.080 pendant euralgia. You can have numbness, or you can have 0:23:32.280 --> 0:23:36.800 a severely increased sensitivities to touch. You can have a 0:23:36.920 --> 0:23:40.720 reduction in sensitivity to heat and cold, or you can 0:23:40.760 --> 0:23:44.359 have an increase. You can have a continuous burning pain, 0:23:45.320 --> 0:23:50.880 you can have severe intermittent lancinating, page shooting, electric shock 0:23:51.080 --> 0:23:54.800 like pains, And if you take that forward to months 0:23:54.920 --> 0:23:57.960 and years, you can see what it can do to 0:23:58.000 --> 0:23:58.479 a patient. 0:23:59.240 --> 0:24:02.920 Let's talk about eatment and prevention, right, Okay, what can 0:24:02.960 --> 0:24:05.480 you do to avoid getting shingles in. 0:24:05.480 --> 0:24:10.560 The first place? Don't have chicken pox, And the only 0:24:10.640 --> 0:24:13.560 way you can be fairly confident in not having chicken 0:24:13.600 --> 0:24:16.760 pox is to be vaccinated against it, which in the 0:24:16.840 --> 0:24:21.200 States you have done pretty routinely since nineteen ninety five. 0:24:21.920 --> 0:24:24.280 But it's going to be some years before we see 0:24:24.320 --> 0:24:28.520 any marked effect on that in shingles because those people 0:24:28.560 --> 0:24:32.200 are still, relatively speaking young as far as the age 0:24:32.200 --> 0:24:36.920 for getting shingles is concerned. So vaccination against chicken pox 0:24:37.000 --> 0:24:41.960 is one, the next one is vaccination against shingles. 0:24:42.720 --> 0:24:47.760 If you are not fortunate enough to prevent shingles, what 0:24:48.000 --> 0:24:53.119 is the treatment both for the initial disease and for 0:24:53.240 --> 0:24:54.800 post herpetic neuroalgia. 0:24:55.240 --> 0:25:01.199 Right, Well, one may have a capacity to actually even 0:25:01.240 --> 0:25:04.760 when shingles has started prevent post to pedant euralgea. It's 0:25:04.800 --> 0:25:09.359 a bit uncertain. Anti virals we hoped would have a 0:25:09.400 --> 0:25:13.320 massive effect on that. And the anti viral drugs are 0:25:13.359 --> 0:25:18.400 remarkable for treating the acute symptoms and any serious disease, 0:25:18.960 --> 0:25:22.119 But how much they influence development of post to pedant 0:25:22.119 --> 0:25:25.600 euralgia's always remained a bit of a gray area. It's 0:25:25.920 --> 0:25:29.520 very hard to see why they wouldn't. But if they do, 0:25:30.119 --> 0:25:33.960 it hasn't reduced the incidence of post pedant euralgia overall 0:25:34.080 --> 0:25:34.560 very much. 0:25:34.760 --> 0:25:36.400 If they work, we can't see it. 0:25:37.080 --> 0:25:41.400 Well, that's sort of how it is. Yes, Having said that, 0:25:41.560 --> 0:25:45.840 I wouldn't want to underplay the value of the antiviral drugs. 0:25:46.040 --> 0:25:49.080 My personal view is that almost everybody who gets shingles 0:25:49.080 --> 0:25:50.200 should receive them. 0:25:50.560 --> 0:25:53.520 I know you're working now on a study looking at 0:25:53.560 --> 0:25:56.960 it at another way of treating shingle's patients with lasting pain. 0:25:57.600 --> 0:25:58.320 Tell me about that. 0:25:58.840 --> 0:26:03.720 We're now looking. In England, we have a study based 0:26:03.760 --> 0:26:09.280 on Bristol looking at amitriptlen that was originally an antidepressant drug, 0:26:09.640 --> 0:26:13.199 but in very low doses it has an effect on 0:26:13.280 --> 0:26:19.680 europathic pain. And another neurologist called David Bouscher from Liverpool 0:26:19.720 --> 0:26:23.320 in England had published a study all three decades ago, 0:26:23.359 --> 0:26:30.000 perhaps basically showing that probably low dose ami triptlen given 0:26:30.800 --> 0:26:34.600 early in the course of jingles reduced the incidents of 0:26:34.880 --> 0:26:40.880 post dependant eualgia dramatically. David Bouscher was a character and 0:26:41.240 --> 0:26:45.920 he did push the case of herpes oster extremely well 0:26:46.320 --> 0:26:50.480