INT J TUBERC LUNG DIS 20(6):713–716 FOUNDERS OF OUR KNOWLEDGE Q 2016 The Union http://dx.doi.org/10.5588/ijtld.16.0229

The King’s Evil and the Royal Touch: the medical history of scrofula

John F. Murray,* Hans L. Rieder,†‡§ Annette Finley-Croswhite¶# *University of California San Francisco, San Francisco, California, USA; †Tuberculosis Consultant Services, Kirchlindach, ‡Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland; §Research Center Borstel, Leibniz-Center for Medicine and Biosciences, Borstel, Germany; ¶Old Dominion University, Norfolk, Virginia, #Society for the History of Navy Medicine, USA

SCROFULA, today’s cervical lymphatic tuberculosis, with a sixth-century monk, Saint-Marcoul, the has an unusual history tied to past beliefs in the patron saint of scrofula victims.3 healing powers of European monarchs. Ancient By contrast, David Sturdy claims that English Romans and other Latins surely knew of morbus monarchs, beginning with regius—literally the royal disease—but today it (1042–1066), used the royal touch sporadically and remains unclear what disorders were grouped under for a variety of infirmities;4 furthermore, scrofula did this term. Early definitions focused on jaundice, but not emerge in England ‘as the sole illness thus to be later broadened to include leprosy and other skin treated’ until the reign of (1558–1603). disorders. In contrast to ancient Greek and Egyptian Although its origins may be imprecise, documents medical writings, which according to historian Frank and illustrations show that the practice inaugurated a Barlow ignore royal diseases,1 Romans used the term ceremony of immense popularity and cultural signif- morbus regius ‘as long as medical and theological icance among monarchs and their subjects that literature was written in Latin’. Moreover, around endured for centuries. Even Shakespeare described 5 roughly the thirteenth century, one royal disease had the royal touch in his play, . eclipsed all others by metamorphosing into a some- Some of the historical uncertainties concerning what recognizable entity, scrofula or struma in Latin when and how often formal laying on of royal hands or ecrouelles´ in French, which gained fame by the actually occurred can be explained by the time it took to mature from its early origins into a lavish ceremony. growing expectation that it could be both diagnosed And it is clear that the rituals varied considerably from and cured by royalty itself—uniquely the Kings of one monarch to the next: some declined to participate, France and the Kings and Queens of England. Thus and some took frequently lengthy timeouts for evolved the King’s Evil (in today’s French, la maladie crusades and religious warfare. Centuries later, the du roi) and its inseparable partner, the ‘curative’ original, sacrosanct monarchial dictates became in- Royal Touch (le toucher royal), bestowed by a French creasingly challenged and sometimes modified by or English sovereign endowed with divine right and ecclesiastical and legislative constraints. supernatural power. Special ceremonies, such as Royal Touching, Some, but by no means all, evidence underscores included the distribution of regal largesse—charitable the belief that ‘a regular custom of touching the gifts, small coins, and other alms for the poor, meager scrofulous . . . developed in the French royal court, but always welcome efforts to give a lift to the needy. probably in Louis IX’s reign’ (1226–1270) or before. A novel English feature was introduced to the ritual In England, royal touching was already in vogue by one of its founders, King Henry III, who began the under the rule of Edward I (1272–1307). Barlow1 tradition of rewarding each scrofulous patient with also believes that the practice was started by Edward’s one penny for having received a royal touch. By pious father, Henry III (1216–1272), who began to Edward IV’s reign (1461–1470, 1471–1483), the imitate his cousin and brother-in-law, the French King compensation had risen substantially to a small gold Louis IX, the saintly monarch credited with formal- touch-piece, an ‘’, which was hung around each izing the practice of touching and imbuing it with recipient’s neck. Candidates for touching were Christ-like imagery in the royal power to heal.2 In carefully screened by royal physicians to verify that France, it was traditionally believed that kings each of the aspirants truly had scrofula and to received their healing powers at their coronation at interject a critical medical presence into the ceremo- Reims after journeying to a nearby shrine associated ny.6 At the age of 2½ years, sickly , a

Correspondence to: John F Murray, International Union Against Tuberculosis and Lung Disease, 68, boulevard Saint Michel, 75006 Paris, France. e-mail: [email protected] 714 The International Journal of Tuberculosis and Lung Disease later literary giant, remembered the strenuous 3-day tuberculosis regularly caused 15 to 30 per cent of all coach journey leading to his being last in line to be deaths among adults in the city of London,11 and touched by Queen Anne in 1712; Johnson was not during the same three-century period, the disease is cured, but he wore his ‘Angel’ for the rest of his life. said to have killed over one billion people.12 Tuberculosis as a distinct disease was identified by Proof of Koch’s discovery included results of the early 1800s, thanks to pathologic findings by cultures of tuberculosis lesions in both humans and Laennec¨ and Schonlein¨ showing multiple sites of a variety of mammals, which seemed to confer characteristic granulomatous lesions with caseous pathogenic unity to the considerable diversity in the necrosis, cavitation, and fibrosis.7 Typical manifesta- disease. Sixteen years later, however, Theobald Smith tions of scrofula—unilateral enlargement of rubbery showed ‘sharp differences’ in staining characteristics, cervical lymph nodes, with and without accompany- morphology, sites of disease location, and predomi- ing ulceration and sinus tract formation, and its nance of manifestations between M. bovis and M. frequency in childhood—overlapped findings such as tuberculosis in infants and children.13 In a later abnormalities anywhere in the neck or of the nearby (1901) address on the fight against tuberculosis, Koch skin and, sometimes, more distant sites. minimized the public health importance and patho- genicity of M. bovis as a cause of human disease; he wrote, ‘if such a susceptibility really exists, . . . [it] is THE CEREMONY but a very rare occurrence.’14 The Royal Touch ritual against the King’s Evil, Koch vacillated over the true kinship among the whether French or English, was full of splendor and mycobacterial cousins of M. tuberculosis, which were majesty. The standing or sitting, richly dressed and debatable at the time. But he triumphed at the end for coiffed monarch touched or stroked the head or neck his discovery of tuberculin, the protein-based marker of a kneeling scrofulous patient in an effort to cast out of the presence of active disease or latent infection of the ‘evil’; timorous royals avoided direct bodily both M. tuberculosis and M. bovis. Use of tuberculin contact by making a suitable hand wave or sign of by veterinarians and public health specialists led to the the cross. Most French and English sovereigns virtual eradication of tuberculosis-ridden cattle and accepted their roles with conviction and commitment, other domesticated animals in industrialized countries, as evidenced by the huge numbers of healing rites they although it remains a cause of disease in wildlife and performed. Some kings appeared bare-headed before domesticated animals in Africa.15 M. bovis currently the crowds, evoking a Christ-like healing presence in remains infrequently isolated from man. their performance that further legitimated their divine Even though Koch had documented the presence of right. On Easter Sunday in 1594, King Henry IV of tubercle bacilli in scrofulous lymph nodes, some France, having recently converted from Protestantism, authorities remained doubtful that the disease was touched up to 960 victims of scrofula, thus reinforcing caused by a transmissible agent. According to the reality of his conversion to Catholicism by offering Grzybowski and Allen, even William Osler remained proof to his audience that God had endowed him with skeptical as late as 1892:16 ‘It is not yet definitely the curative power to heal.8 Henry kept at it during the settled whether the virus which produced the chronic remainder of his reign, touching 1250 subjects on adenitis of scrofula differs from that which produced Easter Sunday in 1608 and performing the magical rite tuberculosis in other parts.’ on other holy days such as Christmas until his death in The usual definition of primary tuberculosis 1610.9 French kings performed le toucher royal more includes the first infection by tubercle bacilli, nearly frequently than their cross-channel equals, but Charles always M. tuberculosis, typically in children but also II of England turned out to be overall champion: in adults, and characterized in the lungs by the during 20 years of his reign (1660–1664 and 1667– formation of a primary complex consisting of one or 1682), he touched more than 92 000 scrofulous more small peripheral pulmonary foci with spread to subjects, almost 4600 each year.4 His record was adjacent—most commonly hilar or paratracheal— marred by tragedy, however, when during one lymph nodes. Another kind of primary tuberculosis ceremony, the huge, stampeding crowd trampled seven includes the first infection by M. bovis, also most expectant candidates to death. frequently in children, in which the primary complex consists of one or more foci in the oropharyngeal tract, often tonsil or adenoid, with spread to MYCOBACTERIUM TUBERCULOSIS regional—especially cervical—lymph nodes. Both On 24 March 1882, in Berlin, Germany, Robert Koch types of primary lesions may heal or progress. announced one of the most important discoveries in the history of human health and disease: the CAUSES OF SCROFULA identification of the cause of tuberculosis, the bacterium later termed Mycobacterium tuberculo- Airborne transmission from the respiratory tract is a sis.10 During the years between 1500 and 1800, far more potent mode for dissemination of tubercle The King’s Evil and the Royal Touch 715 bacilli in a population than transmission through A house was bought for scrofula victims in Reims ingestion. Airborne transmission was and remains in 1645, which was later modified (1683) and named today, for all practical purposes, at the center stage of l’Hopitalˆ Saint-Marcoul.3 However, there is no public health considerations. While there is some possible way of ever knowing the full extent of uncertainty, the global contribution of M. bovis sufferers and which among the thousands of candi- among patients with pulmonary tuberculosis is dates seeking a cure for the King’s Evil in England and currently unlikely to exceed 5 per cent.17 Several France had tuberculosis, whether M. tuberculosis or reasons account for the overwhelming dominance of M. bovis, and which had some other diagnosis. M. tuberculosis in human disease. First, the principal method of transmission of M. tuberculosis is air- THE POWER OF TOUCH borne, whereas that route is distinctly uncommon for M. bovis, which is chiefly spread through the ’s seminal monograph on the ritual of the ingestion of contaminated milk. Second, a large King’s Evil explores the collective medieval mindset proportion of the human population, once weaned, that accepted the thaumaturgic power of the royal culturally avoids ingestion of milk and becomes touch as undisputed reality even if it did not work naturally lactase-deficient on growing up (be it every time.8 To understand the longevity of the rite it adaptive or genetic, e.g., in east Asia). Third, another is thus important to appreciate the diagnoses of the important proportion of people (e.g., on the Indian time, the nature of scrofula itself, and the psychol- sub-continent) boil milk systematically before con- ogy of the crowds who sought sovereign relief. First, sumption, or use souring (mycobacteriocidal) tech- even though royal physicians examined potential niques to preserve milk (e.g., South Africa). Finally, as victims before introducing them to their monarch, Magnus demonstrated, M. bovis is substantially less diagnoses were made only by inspection, and could virulent than M. tuberculosis.18 easily have been confused with various kinds of neck Nevertheless, among populations that customarily lesions and skin disorders. The fact that sores or used raw milk in their diets (some Americans, African fistulas disappeared in the days, weeks, or even years tribes, and Europeans) before pasteurization had after a victim experienced the royal touch gave become more established, certain forms of extra- credence to the , whether the victims actually pulmonary tuberculosis, notably peripheral lymphat- had scrofula or not. Second, while scrofula is a ic and gastrointestinal, occurred in varying propor- chronic disease, it may give the appearance of having tions of from perhaps 5 to 30 per cent or even been cured when the swollen glands associated with substantially higher in some regions among the it resolve spontaneously—perhaps to reappear later, youngest population segments.19 in the same or distant location. Finally, the general Although the reasons for these variations remain psychology during the Middle Ages and afterward inconclusive, pooling of milk must have been an was such that people expected . The King important contributor and became a prerequisite if M. (or Queen, in England) was divinely appointed, and bovis was to affect larger population groups. Tubercu- people believed the curative powers were God-given. losis of the udder is rare. For the same reason, it is quite Monarchs, their royal doctors, chroniclers, religious possible that M. bovis as a cause of human tuberculosis leaders, and courtiers also promoted the idea that may have increased with industrialization and the miraculous healing was possible, reinforcing and accompanying increase in larger milk-distributing exploiting premodern expectations in the magic of conglomerates serving the growing urban population; the royal touch.9 fortunately, it appears that acceptance of milk pasteur- This emphasis on psychology is the most interesting ization in the twentieth century was swifter in urban part of scrofula’s history because it helps to explain London than in the rural United Kingdom.20 the effectiveness of the curative rite. It is quite The King’s Evil may have been caused by M. bovis, M. possible that some people experienced psychological tuberculosis, pyogenic bacteria, and—to a lesser extent— benefits from the royal touch. Medieval canonical environmental mycobacteria, and, even more rarely, records report that people felt better after seeking other etiologies. Today, an experienced clinician has little healing from a holy person or a saint’s relics.21 A trouble making a clinical diagnosis of characteristic similar state of euphoria could have occurred in the mycobacterial lymphadenitis, but identifying the myco- presence of a King or Queen creating a positive bacterial species is more challenging. Tuberculosis emotional response in scrofulous victims that allowed experts in the ‘old days’ may have concluded that ‘high them to feel cured. This scenario also reveals collar’ (e.g., sub-mandibular) adenopathy was more premodern people to have been actively engaged in likely due to M. bovis than M. tuberculosis,whereasa their own health care. Scrofula sufferers were not just ‘collar’ lower on the neck (e.g., supraclavicular) was mindless victims, but people with agency, often more likely to be tuberculosis. And only since the travelling hundreds of miles to participate in the twentieth century could a modern microbiology labora- curative ceremony. Rather than accepting their fate, tory provide the definitive diagnosis. people sought out their monarch, and being in the 716 The International Journal of Tuberculosis and Lung Disease royal presence may have given them a plausible 4 Sturdy D J. The Royal Touch in England. 171–184. In: mental boost.8 Years later they might even revive that Duchhardt H, Jackson R A, eds. European Monarchy. Its positive feeling by stroking the precious touch-piece evolution and practice from Roman antiquity to modern times. Stuttgart, Germany: Franz Steiner Verlag, 1992. still hanging around their neck. This interpretation is 5 Shakespeare W. Macbeth. Act IV, Scene III, lines 147–159. strengthened by recent psychological studies that link Kenneth Muir, ed. The Arden Edition. Reprinted 2005. survivorship among victims of serious illnesses with London, UK. Thomson Learning, 2005. positive attitudes22 and with the benefits of touch and 6 Perez S. Le toucher des ecrouelles:´ medecine,´ thaumaturgie et prayer in improving patient responses to critical corps du roi au Grand Siecle.` Rev Hist Mod Cont 2006; 53: 92– 111. 23 situations. 7 Murray J F. The white plague: down and out or up and coming? J Burns Amberson Lecture. Am Rev Respir Dis 1989; 140: 1788–1795. CONCLUSION 8 Bloch M. The Royal Touch: sacred monarchy and scrofula in Enthusiasm for and the practice of The King’s Evil England and France. Anderson J E, trans. London, UK: Routledge & Kegan Paul, 1973. ceremony proved remarkably durable, and was 9 Finley-Croswhite A. Henry IV and the diseased body politic. celebrated for more than 500 years. During the 131–146. In: Gosman M, MacDonald A J, MacDonald A A, Reformation, however, Protestants increasingly de- Vanderjagt AJ , eds. Princes and Princely Culture. 1450–1650. veloped a healthy skepticism of anything magical, Boston, MD, USA: Brill, Leiden, 2003. rejecting the miracle in the Eucharist and other rites 10 Koch R. Die Aetiologie der Tuberculose. Berl Klin Wschr 1882; 19: 221–230. deemed pagan. Enlightenment thinkers such as 11 Wilson L G. Commentary: medicine, population, and poked fun at the royal practice, and tuberculosis. Int J Epidemiol 2005; 34: 521–524. monarchs grew increasingly cautious of milling about 12 Murray J F. The Industrial Revolution and the decline in death in crowds. rates from tuberculosis. Int J Tuberc Lung Dis 2015; 19: 502– Queen Anne was the last English monarch to 503. 13 Smith T. Two varieties of the tubercle bacillus from mammals. dispense the royal touch, which was ‘suddenly and Trans Assoc Am Phys 1896; 11: 75–95. irrevocably abandoned [by decree] in 1714’.1 In 14 Koch R. An address on the fight against tuberculosis. In the France, the custom sputtered on for more than light of experience that has been gained in the successful another century until touched over 100 combat against other infectious diseases. BMJ 1901; ii: 189– victims during his coronation in Reims on 29 May 193. 15 Ayele W Y, Neill S D, Zinsstag J, Weiss M G, Pavlik I. Bovine 1825, and then quit as the forces of change brought tuberculosis: an old disease but a new threat to Africa. Int J 8 the reign of the Bourbons to an end. Royal touching Tuberc Lung Dis 2004; 8: 924–937. came to an end with the end of divine right monarchy; 16 Grzybowski S, Allen E A. History and importance of scrofula. without the power of divine right ordained by kings Lancet 1995; 346: 1472–1474. and queens, the syndrome called scrofula began to 17 Kleeberg H H. Human tuberculosis of bovine origin in relation 24 to public health. Rev Sci Tech Off Int Epiz 1984; 3: 11–32. peter out. Meanwhile, the disease cervical lymphat- 18 Magnus K. 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