Ringworm and Irradiation The Historical, Medical, and Legal
Implications of the Forgotten Epidemic
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CONTENTS
Acknowledgement vii
Contributors ix
Introduction xi
1. Ringworm of the scalp: the history of an ancient disease 1
Ciro Bursztein
2. Radiation epilation for tinea capitis: scientific and historical aspects 11
M. Raphael Pfeffer
3. The ringworm children at the Hôpital Saint-Louis, Paris: from
medical neglect to biosocial obsession 31
Gérard Tilles
4. Ringworm: a disease of schools and mass schooling in the United
Kingdom 77
Aya Homei and Michael Worboys
5. The JDC-Joint and OSE campaign for eradication of ringworm in the
Jewish communities in Eastern Europe and North Africa 115
Shifra Shvarts, Pnina Romem, Itzhak Romem, and Mordechai Shani
6. The ringworm campaign in Serbia (former Yugoslavia)
in the 1950s 163
Shifra Shvarts, Goran Sevo, Marija Tasic, Mordechai Shani, and
Siegal Sadetzki-Jackobson
vi C ontents
7. The ringworm campaign in Portugal, 1940–1970: historical review
and present evaluation of x-ray–epilated individuals 181
Paula Boaventura, Dina Pereira, Paula Soares, and José Teixeira-Gomes
8. “Deadly Medicine”: Michael Reese Hospital’s Pandora’s box and the
campaign to warn the public of the late health effects of ionizing
radiation in the United States 215
Itai Bavli and Shifra Shvarts
9. Healing the children and the nation: the campaign to eradicate
ringworm in Israel, 1925–1960 245
Shifra Shvarts, Aya Bar Oz, Eli Shachar, Sari Levi,
Sigal Samchi, and Itai Bavli
10. “Think before you act”: ringworm research in Israel, 1965–1995 293
Siegal Sadetzki-Jackobson
11. The muted voices of the ringworm patients and their families
worldwide 331
Liat Hoffer
Index 353
ACKNOWLEDGEMENT
We would like to thank the Gertner Institute—the Sheba Medical Center
and the Ben Gurion University, Israel for supporting the publication of
this book.
CONTRIBUTORS
Itai Bavli, PhD José Teixeira-Gomes, MD-PhD
Department of the History of IPATIMUP-Institute of Molecular
Science Pathology and Immunology of
Harvard University the University of Porto
Cambridge, Massachusetts, USA i3S—Instituto de Investigação e
and Inovação em Saúde
The University of British Columbia Porto, Portugal
Vancouver, BC, Canada
Liat Hoffer, PhD
Paula Boaventura, PhD Faculty of Health Sciences,
IPATIMUP-Institute of Molecular Ben-Gurion University of
Pathology and Immunology of the Negev
the University of Porto, Porto, Beer-Sheva, Israel
Portugal
Aya Homei, PhD
i3S—Instituto de Investigação e
Japanese Studies, Modern
Inovação em Saúde
Languages and Cultures
Porto, Portugal
University of Manchester
Ciro Bursztein, MSc, MA Manchester, GB, UK
Biovac Pharmacueticals LTD
Sari Levi, MA
Or-Akiva, Israel
Ministry of Health, Sheba
Medical Center
Ramat Gan, Israel
x C ontributors
Aya Bar-Oz, MA Eli Shachar
University of Toronto Ministry of Health
Toronto, ON, Canada Ramat Gan, Israel
Dina Pereira, PhD Mordechai Shani, MD
Center for Neuroscience and Cell The Sheba Medical Center and the
Biology Sackler Faculty of Medicine, Tel
Coimbra, Portugal Aviv University
Tel Aviv, Israel
Raphael Pfeffer, MBBS
Assuta Medical Center Shifra Shvarts, PhD
Tel Aviv, Israel Moshe Prywes Center for Medical
Education, Faculty of Health
Itzhak Romem, MD
Sciences, Ben Gurion University
Soroka Medical Center
of the Negev
Beer Sheva, Israel
Beer Sheva, Israel
Pnina Romem, PhD
Paula Soares, PhD
Faculty of Health Sciences, Ben
IPATIMUP-Institute of Molecular
Gurion University
Pathology and Immunology of
Beer Sheva, Israel
the University of Porto
Siegal Sadetzki-Jackobson, i3S—Instituto de Investigação e
MD-MPH Inovação em Saúde
Ministry of Health; The Gertner Porto, Portugal
Institute for Epidemiology &
Marija Tasic, Prim. Mr Sc, MD
Health Policy Research; Sackler
Institute for Geriatrics and
Faculty of Medicine, Tel Aviv
Palliative Care
University
Belgrade, Serbia
Tel Aviv, Israel
Gérard Tilles, MD, PhD
Sigal Samchi, MA
Hôpital Saint Louis
Ministry of Health
Paris, France
Ramat Gan, Israel
Michael Worboys, DPhil
Goran Sevo, MD, PhD,
Centre for the History of Science,
Epidemiologist
Technology and Medicine
Institute for Geriatrics and
(CHSTM)
Palliative Care
University of Manchester
Belgrade, Serbia
Manchester, GB, UK
INTRODUCTION
In July 1973, a study at the University of Chicago linked radiation treat-
ment in childhood to a variety of diseases, including thyroid cancer. A few
months later, a worker at Michael Reese Hospital in Chicago found a reg-
istry of 5,266 former patients treated with radiation during the 1950s and
1960s. Hospital officials decided to contact these patients and arrange for
follow-up medical examinations. Media coverage of Reese’s campaign had
a snowball effect, prompting more medical institutions to follow suit and
the National Cancer Institute (NCI) to launch a nationwide campaign
warning the medical community and public about the late effects of ion-
izing radiation.
The practice of using x-rays for the medical treatment of benign
diseases began in the 1920s and peaked in the 1940s and 1950s. Radiation
therapy was considered good medical practice and was very effective at
eliminating ringworm, often with immediate results. X-ray treatment
gradually came to an end in the 1960s when other effective treatments
were developed (e.g., griseofulvin for ringworm) and studies started to
suggest that benign and malignant tumors of the thyroid gland, as well as
leukemia, were detected in individuals who had been exposed to radiation
treatment during childhood.
In the United States, tens of thousands of children were treated with
radiation therapy for ringworm of the scalp. In Yugoslavia, a UNICEF-
assisted campaign to eliminate ringworm resulted in the treatment of ap-
proximately 50,000 children with radiation. In Portugal, health authorities
xii I ntroduction
treated approximately 30,000 children with scalp ringworm using radi-
ation, and tens of thousands in France, the United Kingdom, Canada,
Australia, North Africa (mainly Morocco), and the Middle East under-
went similar treatments. In Israel, approximately 31,000 children with
ringworm were treated with radiation.
This volume on ringworm, the use of irradiation in its treatment, and
the latent health risks discovered decades later is not simply a medical
history. Rather, it offers a learning experience still relevant to the practice
of medicine today concerning the introduction of any new medical tech-
nology that provides immediate relief but carries potential long-term risks
to the patient and the public. From a public policy standpoint, irradiation
of ringworm constitutes a case study yielding insights into both the pos-
sible consequences of a well-intended practice that was hastily adopted
and poorly executed, and how these consequences have been addressed—
country by country—after discovery of the latent health risks patients face.
1
Ringworm of the scalp
The history of an ancient disease
CIRO BURSZTEIN
INTRODUCTION
This chapter will describe different aspects of the classification, categori-
zation, and treatment of ringworm of the scalp from ancient times until
the beginning of the use of x-rays for the cure of the disease in 1897. In
addition, some of the key figures in different scientific fields who played
an important role in the research of the disease over the centuries will be
presented, along with some of their most important publications on the
subject.
The history of tinea capitis can be divided into three eras:
1. From ancient times until the introduction of modern medical
science in the 17th century (which in my opinion is characterized
by the invention of the microscope)
2. From the 17th century until 1897 with the introduction of Roentgen
rays (x-rays) for the cure of the disease
3. From 1897 until today.
2 R ingworm and I rradiation
The second era may also be divided into various sub-eras, according to
the key figures who played a very important role in the research of the di-
sease (e.g., David Gruby, Raymond Sabouraud). This chapter will describe
the first and second eras, focusing on the second one, since most of the
scientific progress in the research of tinea capitis was achieved during it.
Ringworm of the scalp (tinea capitis) is a fungal infectious disease
that attacks the hair and scalp of humans. It produces localized alopecia,
scaling, reddening, and crusting of the scalp. It can also lead to secondary
microbial infections. The disease varies from a benign scaly, noninflamed,
subclinical colonization to an inflammatory disease characterized by the
production of scaly erythematous lesions and by alopecia that may be-
come severely inflamed. It is very contagious and widespread in crowded
and dirty places.1
THE FIRST ERA
The earliest mentions of tinea capitis and other mycoses go back many
centuries and even millennia ago. The biblical disease of leprosy (tzara’at)
may well have been confused with mycotic infection of the scalp and/or
body.2,3 Fungal diseases has been confirmed in Egyptian mummies by
DNA analysis. According to the Ebers Papyrus, one of the most ancient
medical documents (c. 1550 B.C.), skin, hair, and nail mycoses may have
been treated by henna (known as kupros or cyperus).4 Hippocrates first
documented oral pseudomembranous candidosis with the name aphthae
albae, a finding that was corroborated by Clarissimus Galen5 (Galen
[130–200 A.D] lived in the Roman Empire and was a well-known Greek
physician6). Aulus Cornelius Celsus, in his encyclopedic De medicina, was
the first to describe favus, which he did in the first century A.D. (Celsus
[25 B.C.–50 A.D.] lived in Rome and was one of the greatest Roman med-
ical writers7). He referred to cutaneous fungal disease as porrigo (“to
spread” in Latin).8
Cassius Felix is thought to be the first to use the term tinea, which
he did in about the year 400 A.D. in his summary of medicine9 (Felix, a
History of Ringworm 3
fifth-century physician from Cirta, Numidia, wrote a treatise called De
medicina10). The word tinea, which was used to describe the tenacity of
the disease, is found in the writings of Etienne of Antioch, who translated
the work of Haly-Abbas11 (Haly-Abbas [925–994] was a Persian physician
and psychologist most famous for the Kitab al-Maliki [“Complete Book
of the Medical Art”], his textbook on medicine and psychology12). Guy
de Chauliac adopted this term and identified five types of tinea: tinea
favosa, tinea ficosa, tinea amedosa, tinea uberosa, and tinea lupinosa (de
Chauliac [1300–1368] lived in France and was the most eminent surgeon
of the European Middle Ages. His Chirurgia Magna [1363] was a standard
work on surgery until at least the 17th century13). This classification of
the disease remained valid until the beginning of the 19th century and
was even adopted by Jean-Louis Alibert, who represented the old tradi-
tion in French medicine14 (Alibert [1768–1837] was the pioneer of French
dermatology15). Physicians in the Renaissance era, like Hieronymus
Mercurialis, used the term tinea or teigne to describe all diseases of the
scalp16 (Mercurialis [1530–1606] was an Italian philologist and physician,
most famous for his work De arte gymnastica17).
Since Roman times, the literature has presented different kinds of
remedies. Aulus Celsus anointed infected areas of the scalp with honey
and shumach.18 Gaius Plinius Secundus (23–79 A.D), a Roman author,
naturalist, and natural philosopher, described in his publication Historia
naturalis his treatment for tinea capitis, which included the use of goat’s
gall with Cimolian chalk and vinegar.19 During the Middle Ages the
treatment of choice for ringworm of the scalp was the use of a variety
of ointments such as bell grease, celandine leaves, and soft creamy juice
expressed from a houseleek, which were rubbed into the ringworm le-
sion.20 Irritating ointment was also used in order to cause an artificial in-
flammation of the scalp, resulting in the falling out of the diseased hair
in the inflamed area. These ointments were applied for months and even
years with a low rate of success and in some cases led to serious sequelae.
Another method to treat the disease was the epilation of the scalp by
using the calotte (skullcap) or capellus piceus. The calotte was a kind of
helmet applied to the scalp with an adhesive ointment. It was left in place
4 R ingworm and I rradiation
for 2 to 3 days and then forcibly removed. The logic of this treatment was
to pluck out any diseased hair. It was followed by manual epilation of the
remaining hair using tweezers or forceps. Needless to say, healthy hair was
also removed, and this was a very painful and cruel method for treating
the disease.
The use of forceps and tweezers for the epilation of the diseased hair
was much more effective and much gentler than epilation with the
calotte, and it replaced the latter in the beginning of the 19th century.
This technique had been described by Mercurialis back in 1577.21 The
calotte was used much more commonly in France than in other parts of
Europe.
Tinea capitis was not only described in the medical literature but was
also presented in the arts. It is shown in some artworks by famous painters
from the end of the Middle Ages (Figure 1.1).22
THE SECOND ERA
The greatest advances in the research of tinea capitis took place during
the second era, especially in the 18th century, when we encounter many
key figures who played a very important role in the research of the di-
sease (e.g., David Gruby, Raymond Sabouraud, Johann Lukas Schöenlein,
Samuel Plumbe, the Mahon brothers, Robert Remak, Daniel Turner,
Robert Willan, Thomas Bateman). This section of the chapter will de-
scribe their work, their contributions to the research of the disease, some
of their most important publications, and of course the advances made
until the end of this era.
There is no exact date to the end of the first era and the beginning of
the second one. It is possible to base this division on some processes and
inventions that took place in Europe that greatly contributed to the de-
velopment of science, such as the Renaissance, the Age of Enlightenment,
the invention and subsequent refinement of the microscope, and
many others. All this processes greatly contributed to the transition
from the superstition-based “science” of the Middle Ages to a more
History of Ringworm 5
Figure 1.1 “Santa Isabela Reina de Hungria Curando a los Enfermos” by Bartolome
Esteban Murillo (1617–1682), a Baroque painter from Seville. This 1672 painting
illustrates Saint Elizabeth, daughter of Andrew II of Hungary, curing children infected
with ringworm in the 13th century. The child near the pail has typical manifestations of
ringworm.
Courtesy of the Hospital of Santa Caridad in Seville.
observation-based and rational science of the second era that greatly
benefited the research of all fields of science.
In the second era, the research of tinea capitis, as well as other fields of
cutaneous diseases and mycology, was mainly focused in England, France,
6 R ingworm and I rradiation
and the German-speaking territories. The United States was somewhat of
a latecomer to this field.
Skin diseases were not presented as a dedicated medical area until
Mercurialis’s De morbis cutaneis (“Diseases of the Skin”) was published in
1572. Mercurialis classified skin disorders into two groups: ones involving
the head and ones involving the rest of the body. The ninth chapter, on
cephalic dermatoses, is called “Achores and Favus.” Achores is a term close
to tinea or to head ulcerations and was used to designate oozing cephalic
dermatoses that were common in children.23 The Englishman Daniel
Turner’s (1667–1741) De Morbis Cutaneis: A Treatise of Disease Incident
to the Skin, published in 1714, was the first full book in English dedicated
to the subject of skin diseases.24 Later he described his treatment of the
disease: “bleeding and general purgation . . . Pulling them [the hair] up by
the roots with fine nippers, or drawing them up all at once by a Pitch or
other plaster.”25 In A Treatise of Disease Incident to the Skin, he described
the origin of the term tinea: It derived from Latin and describes the little
holes visible in the scalp. It is also the name of a moth worm, and the
damage the worm causes to fabrics resembles the damage seen on the
scalp of the afflicted. Turner continued to describe the physiologic ap-
pearance of the disease on the scalp. Later on he proposed some remedies
for the disease, including bleeding and repeat purgation. If there were dry
scabs, he suggested, then it was possible to begin with local application
of a different ointment. However, in order to do that, the hair must be
removed (if it interferes with the use of the different remedies) by being
pulled out with “fine nippers” or pitch (see the earlier discussion of the
calotte). Turner warned of possible side effects of the epilation, such as
fever and pain. Some of the ointments suggested by Turner are butter
hog’s lard covered with a cap made of hog’s bladder, beeswax, oleum, cal-
omel, and more.
Turner described an interesting incident in which he was asked to treat
a 10-month-old baby suffering from ulcers upon the hairy scalp secreting
some fluids (probably caused by some kind of tinea). Turner purged
the baby with syrup of chicory twice a week. Between the treatments he
