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 medicinalium 5 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 those in man and often have been recognised following the investigation of human disease. In 1748, Henry Baker communicated to the Royal Society of London a letter from the Norwich naturalist William Arderon describing fungal mycosis in a roach: “the finny part of its tail begins to drop off piece by piece”. In 1835 Agostino Bassi, an Italian lawyer and farmer discovered silkworm muscardine disease was a mycosis. William Tilbury Fox recorded seven cases of ringworm in man contracted from a white horse. He described tinea circinata in the pony with discoloured patches and distorted hairs and alopecia and likened it to features of tinea tonsurans in man. 7 In 1898 Alfred Eddowes reported human ringworm from nursing a pet hedgehog 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 Egyptian mummies by DNA analysis. According to the Ebers Papyrus (circa.1550BC), skin, hair or nail mycoses may have been treated by henna (known as Kupros or Cyperus). (figure 1) The Hippocratic writings (5th century BC) and Celsus1 (25BC-50AD) both discuss aphthae, believed to be oral thrush. Celsus, a Roman encyclopedist and physician, referred to cutaneous fungal infections as porrigo (Latin “to spread”). Porrigo was also known as achores and tinea (after Tineidae, the clothes moth, whose depreda- tions allegedly resemble affected skin). (figure 2) According to the Oxford English Dictionary, tinea was first used 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 seems incredible that some nineteenth century dermatologists refused to accept that Tinea was due to a fungal infection. Erasmus Wilson (1809 - 1884), the leading UK dermatologist of his era, considered the disease was entirely constitutional. He advocated isolating affected children and giving them a sound animal diet and good British beer (such as “Brewer's porter”). 9 However most accepted the fungal aetiology. An English ringworm school was set up in 1910 in Witham, Essex, with Tilbury Fox's brother, Tommy Colcott Fox, as the visiting dermatologist. Here, afflicted children were treated and instructed. Prevention of spread through the air was minimised by burning sulphur and daily sponging of healthy heads with diluted sulphurous acid or acetic acid. 10 They recommended: “children (with ringworm) should do little if any work and have plenty of out-door exercise” 11 . Prior to the introduction of Griseofulvin and Chlormidazole in 1958, topical agents such as Whitfield's Ointment (1912) and Castellani's paint (1928) were the probably the most effective antifungals. Sabaroud and Keinböck (1910) introduced the newly discovered X-rays for scalp ringworm. (figure 7) 12 Many of the patients treated today still pay the malignant price for the overenthusiastic adoption of this new therapy. Griseofulvin has remained the mainstay of treatment for children with Tinea Capitis for nearly 50 years. In the UK it remains the only licensed effective treatment although terbinafine is used off-license by many dermatologists. We suspect that many young people, given the choice, might still wish to supplement this with the historical approaches of “less work and a good beer.” Figure 1 - Henna on the hair and nails of an Egyptian mummy (British museum) Early Treatments Celsus anointed ulcers due to thrush with honey, to which was added shumach. 1 Pliny's remedy for ringworm involved the application of “goat's gall, in combination with Cimolian chalk and vinegar” or ashes of deer's horn in wine. He also described injecting into the ears a combination 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 wth vinegar 3 . Alexander Massaria in 1622 described purging children with achores with rhubarb and calomel, put leeches behind their ears and then put sulphur on the head. 4 Daniel Turner in London in 1723 treated children with tinea or “scall'd head” by "bleeding and general purgation" then describes hair removal by either "pulling them up by the roots with fine nippers, or drawing them up all at once (tho painful) by a Pitch or other plaster" or by clipping then using caustic depilatories followed by a wide range of topical treatments 5 . Bateman recognised that this treatment “...often inflicted great injury to the scalp, and retarded, rather than expedited the progress to recovery.” 6 Classification Robert Willan (1757-1812) and Thomas Bateman (1778- 1821) in London described fungal infections as porrigo in their defining classification. Bateman clearly highlights the features of tinea capitis, “(it) appears in…patches…upon the scalp…with clusters of small light- yellow pustules…which become thick and hard…As the patches extend, the hair covering them becomes lighter in its colour and sometimes breaks off short.” 6 William Tilbury-Fox (1836-79) modified the Willan-Bateman classification and illustrations - see figure 4 and 5. Sabouraud (1864-1938), a French dermatologist, then published “Les Teignes” in 1910 in which he clarified clinical descriptions and culture features which provided the basis for classifications used today. Figure 2 - Tineola biselliella - clothes moth and larva with depredations Establishing causality between fungi and cutaneous eruptions The association between mycoses and human skin was first made by Schoenlein, who in 1839 described Trichophyton favus (subsequently named Trichophyton schoenleinii). David Gruby, a Hungarian, published accounts of Trichophyton favus, Microsporum audouini and Trichophyton tonsurans in the skin from 1841-4. He isolated the fungus “favus” grown on slices of potatoes (prior to agar). He established the contagious nature of mycoses by inoculating the arms of Professor Rinneker of Wurzburg and himself with favus. Gruby also suggested diagnostic criteria for “la vrai teigne” (ringworm) which included 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 of a child possibly suffering from tinea capitis by Murillo (1617-82) Figure 4 - i) Tinea tonsurans. Chromo-lithography of watercolour painting ii)Tinea favosa. Copy of a model from the College of Surgeons' 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 diseases according to Tilbury-Fox. (Skin Diseases: their description, pathology, diagnosis and treatment. Published by Renshaw 1873). Figure 6 - Girl with tinea infection of her chin caught from her pet hedgehog. Figure 7 - J.E.M. Macleod (1920) commissioned an x-ray apparatus for epilation having visited Sabouraud's clinic in 1904.