References

1 De Medicina by Cornelius Celsus (c AD 14-37) 2 Historia naturalis by Pliny (Book xxvii, ch 47) and (Book xx, ch 23)3 Galen. De Coposit Med Secund Gerera (quoted by Daniel Turner)4 Massaria, A. (1622) Liber responsorum et consultationum medicinalium5 Turner D. (1723) A Treatise of Diseases Incident to the Skin 2nd edition

London (page 217)6 A practical synopsis of cutaneous diseases, according to the

arrangement of Dr Willan. By Thomas Bateman. Published 1814 by Longman, Hurst, Rees, Orme and Brown.

7 Skin Diseases: their description, pathology, diagnosis and treatment. Tilbury Fox MD Lond. 1873.

8 Alfred Eddowes. A case of ringworm contracted from a hedgehog. 1898. in Transactions of the Dermatological Society of Great Britain and Ireland. Volume IV. Published by HK Lewis, London.

9 Wilson, E: On Ringworm. London, Churchill, 1847.10 Tilbury-Fox. The Lancet 1872 Jan. 11 The Family Physician A manual of Domestic Medicine Cassell and

Company LTD 12 Br. J. Derm. Syph. 61 : 7-8, 1949.

Animals and mycoses of the skin

Animal mycoses have received less attention than thosein man and often have been recognised following theinvestigation of human disease. In 1748, Henry Bakercommunicated to the Royal Society of London a letterfrom the Norwich naturalist William Arderon describingfungal mycosis in a roach: “the finny part of its tail beginsto drop off piece by piece”. In 1835 Agostino Bassi, anItalian lawyer and farmer discovered silkworm muscardinedisease was a mycosis. William Tilbury Fox recorded sevencases of ringworm in man contracted from a white horse.He described tinea circinata in the pony with discolouredpatches and distorted hairs and alopecia and likened it tofeatures of tinea tonsurans in man.7 In 1898 AlfredEddowes reported human ringworm from nursing a pethedgehog on the chin and wrist of a 15 year old girl.8

(figure 6)

Ancient Recognition of Mycoses

Fungal skin infection has been confirmed in Egyptianmummies by DNA analysis. According to the EbersPapyrus (circa.1550BC), skin, hair or nail mycoses mayhave been treated by henna (known as Kupros orCyperus). (figure 1)

The Hippocratic writings (5th century BC) and Celsus1(25BC-50AD) both discuss aphthae, believed to be oralthrush. Celsus, a Roman encyclopedist and physician,referred to cutaneous fungal infections as porrigo (Latin“to spread”). Porrigo was also known as achores andtinea (after Tineidae, the clothes moth, whose depreda-tions allegedly resemble affected skin). (figure 2)According to the Oxford English Dictionary, tinea was firstused in English in 1495.

“Less Work and Good Beer!” - an Historical Review of Fungus and the Skin

Anne-Marie Skellett and Nick Levell, Norfolk and Norwich University Hospital, Colney lane, Norwich, NR4 7UY

design and layout by Medical Illustration Dept • NNUH

Later Treatments

With the ease of microscopic diagnosis it now seemsincredible that some nineteenth century dermatologistsrefused to accept that Tinea was due to a fungalinfection. Erasmus Wilson (1809 - 1884), the leading UKdermatologist of his era, considered the disease wasentirely constitutional. He advocated isolating affectedchildren and giving them a sound animal diet and goodBritish beer (such as “Brewer's porter”).9

However most accepted the fungal aetiology. An Englishringworm school was set up in 1910 in Witham, Essex,with Tilbury Fox's brother, Tommy Colcott Fox, as thevisiting dermatologist. Here, afflicted children weretreated and instructed. Prevention of spread throughthe air was minimised by burning sulphur and dailysponging of healthy heads with diluted sulphurous acidor acetic acid.10 They recommended: “children (withringworm) should do little if any work and have plentyof out-door exercise”11.

Prior to the introduction ofGriseofulvin and Chlormidazolein 1958, topical agents such asWhitfield's Ointment (1912) andCastellani's paint (1928) werethe probably the most effectiveantifungals. Sabaroud andKeinböck (1910) introduced thenewly discovered X-rays forscalp ringworm. (figure 7)12

Many of the patients treatedtoday still pay the malignantprice for the overenthusiasticadoption of this new therapy.

Griseofulvin has remained the mainstay of treatment forchildren with Tinea Capitis for nearly 50 years. In the UKit remains the only licensed effective treatment althoughterbinafine is used off-license by many dermatologists.

We suspect that many young people, given the choice,might still wish to supplement this with the historicalapproaches of “less work and a good beer.”

Figure 1 - Henna on the hair and nails of an Egyptianmummy (British museum)

Early Treatments

Celsus anointed ulcers due to thrush with honey, to whichwas added shumach.1 Pliny's remedy for ringworminvolved the application of “goat's gall, in combinationwith Cimolian chalk and vinegar” or ashes of deer's hornin wine. He also described injecting into the ears acombination of goose grease and garlic juice for porrigo.2

Galen (129 - c200 AD) reported curing “Achor capitis”by treating it with the ashes of burnt paper mixed wthvinegar3. Alexander Massaria in 1622 described purgingchildren with achores with rhubarb and calomel, putleeches behind their ears and then put sulphur on thehead.4 Daniel Turner in London in 1723 treated childrenwith tinea or “scall'd head” by "bleeding and generalpurgation" then describes hair removal by either "pullingthem up by the roots with fine nippers, or drawing themup all at once (tho painful) by a Pitch or other plaster"or by clipping then using caustic depilatories followed bya wide range of topical treatments5. Bateman recognisedthat this treatment “...often inflicted great injury to thescalp, and retarded, rather than expedited the progressto recovery.”6

Classification

Robert Willan (1757-1812) and Thomas Bateman (1778-1821) in London described fungal infections as porrigoin their defining classification. Bateman clearly highlightsthe features of tinea capitis, “(it) appearsin…patches…upon the scalp…with clusters of small light-yellow pustules…which become thick and hard…As thepatches extend, the hair covering them becomes lighterin its colour and sometimes breaks off short.”6 WilliamTilbury-Fox (1836-79) modified the Willan-Batemanclassification and illustrations - see figure 4 and 5.

Sabouraud (1864-1938), a French dermatologist, thenpublished “Les Teignes” in 1910 in which he clarifiedclinical descriptions and culture features which providedthe basis for classifications used today.

Figure 2 - Tineola biselliella - clothes moth and larva withdepredations

Establishing causality between fungi andcutaneous eruptions

The association between mycoses and human skinwas first made by Schoenlein, who in 1839 describedTrichophyton favus (subsequently named Trichophytonschoenleinii).

David Gruby, a Hungarian, published accounts ofTrichophyton favus, Microsporum audouini andTrichophyton tonsurans in the skin from 1841-4. Heisolated the fungus “favus” grown on slices of potatoes(prior to agar). He established the contagious nature ofmycoses by inoculating the arms of Professor Rinneker ofWurzburg and himself with favus. Gruby also suggesteddiagnostic criteria for “la vrai teigne” (ringworm) whichincluded microscopic features of round corpuscules(microconidia) and small septate filaments (hyphae).

Figure 3 - painting in the Hermandad de la Santa Carida,Seville, of St Elizabeth of Hungary washing the head ofa child possibly suffering from tinea capitis by Murillo(1617-82)

Figure 4 - i) Tinea tonsurans. Chromo-lithography ofwatercolour paintingii)Tinea favosa. Copy of a model from the College ofSurgeons' museum, thanks to Mr Erasmus Wilson.(Tilbury Fox's “Atlas of skin diseases”. London J&A Churchill 1877).

Figure 5 - Detailed description of parasitic fungal diseasesaccording to Tilbury-Fox. (Skin Diseases: their description,pathology, diagnosis and treatment. Published by Renshaw 1873).

Figure 6 - Girl with tinea infection of her chin caughtfrom her pet hedgehog.

Figure 7 - J.E.M.Macleod (1920)commissioned anx-ray apparatus forepilation havingvisited Sabouraud'sclinic in 1904.