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 Edward the Confessor 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 Elizabeth I (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, Macbeth. 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 ‘Angel’, 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 Samuel Johnson, 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.