OPEN Introduction Fungal infections or mycoses are the great neglected diseases of medical history.1 There are numerous histories of viral, bacterial and protozoan infections, for all times and all places, but very few studies of those caused by fungi. Why? It cannot be because of prevalence. Histori- cal sources and contemporary epidemiological investigations show that fungal infections were and are ubiquitous in human and animal popula- tions. Everyone in Britain and the United States in the last half a century would have heard of, if not suffered from, athlete’s foot or thrush. In the first half of the twentieth century, children feared the school nurse find- ing ringworm on their scalp and having to endure, not only the pains of X-ray depilation or having their shaven head painted with gentian vio- let, but also exclusion from school and the shame of being stigmatised as ‘unclean’.2 It seems that medical historians have followed the agenda of the med- ical profession in showing relatively little interest in conditions, such as the majority of cases of mycoses, that do not lead to ‘illness’ as such, but cause inflammation, irritation and discomfort. Medical history remains dominated by studies of diseases that had, or continue to have, a high profile within medicine, or have attracted government interest and investment because they cause significant morbidity or mortality. Yet, the majority experience of ill health was, and is, of self-limiting and self-treated conditions, where sufferers did not, and do not, consult a doctor and become ‘patients’. In their efforts to recover ‘the patient’s view’, medical historians have ignored the minor illnesses, injuries and infections that were, and remain, outside of the medical gaze.3 But medical historians have also largely ignored the ailments brought on by medical advances, and here too the history of fungal infections 1 A. Homei et al., Fungal Disease in Britain and the United States 1850–2000 © Aya Homei and Michael Worboys 2013 2 Fungal Disease in Britain and the United States 1850–2000 can be instructive. The grand narrative of Western medicine in the twentieth century was one of ‘progress’, evidenced by greater, scientifi- cally based knowledge of the aetiology and pathology of disease, more accurate diagnostics, improved management of symptoms and pain, more effective treatments, innovations in surgery, improved health care, falling mortality rates and greater longevity.4 Those telling this story recognised that progress was not unalloyed, yet amongst doctors such was the step change in their effectiveness and efficiency that problems, like the development of antibiotic resistance, were discounted or seen as something that would be solved by further scientific and technological advances.5 However, medical professionals soon realised that therapeu- tic and technological advances often led to intractable problems; for example, the practice of managing the adverse effects of one drug with another could lead to patients taking more medicines to manage side effects than for their primary illness. Such practices were criticised in the 1960s, but for our narrative of fungal infections Ivan Illich’s book Medical Nemesis, first published in 1975, is most relevant.6 Illich made iatrogenesis – doctor induced disease – central to his critique of mod- ern medicine, claiming that around 10% of all clinical encounters were for such conditions. He argued that the cures of modern medicine were often worse than the disease – if indeed there was a disease in the first place, as Illich also attacked the medicalisation of everyday life, antic- ipating the burgeoning of risk-defined conditions that emerged in the last quarter of the twentieth century.7 Thrush, the most prevalent opportunistic mycosis of the twentieth century, exemplifies these trends. In the 1940s and 1950s, the emer- gence of resistant bacteria was only one side effect of the new drugs. More important then was the development of so-called ‘superinfec- tions’, also caused by antibiotics as they removed not just disease- causing bacteria but many others, and altered the normal microbial flora of the body. These changes opened the body to opportunistic infection by other bacteria, such as Staphylococcus aureus, and by fungi, especially Candida. This fungus had previously only affected the ‘external’ mucus membranes in the mouth and genitalia, but emerged in the 1950s as a rare, but serious, internal and systemic infection, where fungi grew on major organs, such as the heart. It was not just patients on antibiotics who were vulnerable. There were a growing number of patients whose immune systems were weakened or immunocompromised. Initially, this situation developed as a side effect of steroids and other similar treat- ments, but then such states were deliberately produced by doctors to aid the acceptance of transplanted organs, or as a by-product of new Introduction 3 cancer therapies. In 1987, John W. Rippon, a leading American medical mycologist, reflected on the situation. The mycology of human infections in the 1980s is the mycology of the soil, rotting vegetables, shower curtains, toilet bowls, leaf piles, wilted flowers and dung heaps. Organisms literally come out of the walls to infect immunosuppressed patients. Technical medical and surgical expertise is such that we can pass around hearts, lungs, and livers only to be thwarted by a Fusarium from a rotting plum.8 Rippon was pointing to a larger truth about human fungal infections, namely, that their prevalence has been linked to specific ecological con- ditions and interactions, not only within the body, but also within the wider social and physical environment. At the time Rippon wrote, the United States, and soon the Western world, was gripped by a popular health panic about fungal disease. Some fringe doctors promoted the view that Candida infection was responsible for all manner of ‘modern’ ailments, including chronic fatigue syndrome (CFS) and inflammatory bowel disease (IBD), in what they styled as ‘the yeast connection’.9 In this book, we discuss the changing medical and public profile of fungal infections in the period 1850–2000. We consider four sets of diseases: ringworm and athlete’s foot (dermatophytosis); thrush or candidiasis (infection with Candida albicans); endemic, geographically specific infections in North America (coccidioidomycosis, blastomycosis and histoplasmosis) and mycotoxins; and aspergillosis (infection with Aspergillus fumigatus). We discuss each disease in relation to developing medical knowledge and practices, and to social changes associated with ‘modernity’. Thus, mass schooling provided ideal conditions for the spread of ringworm of the scalp in children, and the rise of college sports and improvement of personal hygiene led to the spread of athlete’s foot. Antibiotics seemed to open the body to more serious Candida infections, as did new methods to treat cancers and the development of transplan- tation. Regional fungal infections in North America came to the fore due to the economic development of certain regions, where popula- tion movement brought in non-immune groups who were vulnerable to endemic mycoses. Fungal toxins or mycotoxins were discovered as by- products of modern food storage and distribution technologies. Lastly, the rapid development and deployment of new medical technologies, such as intensive care and immunosuppression in the last quarter of the twentieth century, increased the incidence of aspergillosis and other systemic mycoses. 4 Fungal Disease in Britain and the United States 1850–2000 In understanding and managing infectious diseases, scientists and doctors have long argued for thinking about them in terms of the metaphor of ‘seed and soil’, where the ‘seed’ is the infectious organism or pathogen: that is, virus, bacteria, fungi, protozoa (single cell) or meta- zoan (multicellular); and the ‘soil’ is the human body and its environs.10 Thus, for someone with the common cold, the notion of ‘seed and soil’ ensures that we go beyond focusing only on infection by the virus (the seed) and consider the sufferer (the soil). This means looking at the con- ditions in which the person was exposed to the virus, the quantity and quality of the virus reaching the body, the nature of the body’s specific immune response and the overall health of the individual. We all know that we do not ‘catch a cold’ every time we are exposed to the virus and that some people suffer longer and more serious illness than oth- ers do. Some variations are individual, but epidemiological studies have always shown patterns of exposure, susceptibility, sickness and recovery by age, gender, class, occupation, ethnicity and other socio-cultural vari- ables. For example, in their history of pulmonary tuberculosis, René and Jean Dubos systematically use the notion of ‘seed and soil’ to discuss the disease at all levels, from biological factors influencing the susceptibility of cells and tissues, through to the socio-economic and technological variables that have shaped global trends in morbidity and mortality.11 In this book, we frame our history of fungal infections in terms of ‘seed and soil’; hence, our ‘seeds’ are specific fungal pathogens and we interpret ‘soils’ widely to include the human body, social relations and structures, and the medical, material and technological environment. Fungi Fungi and how they cause diseases are not well known, so it will be useful here to give a brief introduction to the nature of the ‘seeds’ of mycoses. Our account is part historical and part current. Mycology is the branch of science that studies fungi and until the 1960s, it was a part of botany, at which time its subject matter was moved to the animal kingdom. Since then, fungi have been placed in their own kingdom, with the other four being plants, animals, proto- zoa and monera (bacteria).12 Current estimates are that there are well over 100,000 species of fungi and many more are still to be classified, let alone discovered.