Saturday, January 10, 2009

I don't know what happened to scrofula.

Two different books I've been reading this week mention scrofula, a disease that was endemic in England and France from medieval times well into the 19th century. Known as "the king's evil," scrofula was supposedly curable by the touch of a king, or even the application of a ring or coin the king had touched.

Scrofula is a skin disease caused by the tuberculosis bacterium, in adults. The medical term is cervical tuberculous lymphadenopathy, which means "tuberculosis of the neck that makes your lymph glands swell in an unnatural way." The major symptom of scrofula is a big lump on the neck, which over time can swell, rupture and fester. Pretty, huh?

Removing the lump with surgery is a bad idea. Surgery does not remove the infection, which just makes more lumps over a wider area. Scrofula does respond to antibiotics, just as other forms of tuberculosis do.

As with other forms of tuberculosis, scrofula made a comeback with the rise of AIDS, and when it shows up now, it's often drug-resistant; the CDC says that scrofula affects about 5% of severely immunodeficient AIDS patients.

The virtual disappearance of tuberculosis in the developed world is one of the greatest triumphs of public health. A few years ago a friend came back from China testing positive for exposure to tuberculosis, and I remember feeling an almost superstitious shock of dread at the news -- but nine months of antibiotics later, he was fine.

Still, it's one thing to treat TB; what's more amazing, and what I don't understand as well, is why people stopped getting TB and scrofula -- or for that matter, in the developed world, many visible diseases at all.

Three hundred years ago, a walk through any city in the world was a tour of innumerable visible signs of disease: the rotting noses of syphilis, the flush of erysipelas (a strep infection of the skin), the lumps of scrofula. Now, walking the streets of New York and London, we simply don't see it.

This had started to happen even before the widespread use of antibiotics, so some of the credit must go to basic hygiene practices, things like hand-washing and food safety and indoor plumbing. But I wonder, too, whether certain diseases -- like leprosy -- just burn themselves out over time.

And I'm very glad I've never had scrofula. Though I worry about this skin tag on my neck...


Anonymous said...

At work just about three weeks ago a patient came in through the ER into the ICU with a raging case of tuberculosis that had gone untreated for months. One of the doctors I work with (and God forbid I ever end up in the ICU - I hope he's on service) told me how this person had been living with several other people in an apartment nearby. Dozens of people worked on this person for 6 hours or more and there was no telling how many people were exposed. Just a little tidbit to shore up your paranoid hypochondria. What can I say? I'm a giver.


norby said...

Basic hygiene probably did have a lot to do with it, and better living conditions.

When I was going through the steps to get into nursing school my TB antibody test came back positive. Being exposed and having an active infection are different. Fortunately I had never been sick, but it does give you a creepy, dirty feeling, especially when you can't pinpoint the time or location of your exposure.

I had to take antibiotics and extra vitamins for nine months and from now on I can never have the typical TB test, I have to get a lung x-ray done.

It still makes me feel a little strange knowing that at some point I was exposed to TB and never knew it...

Kevin Wignall said...

My feeling is that hygiene and living conditions are only half the story (as is the later impact of antibiotics). I think the ages of industrialization and mass migration brought about an increase in infectious diseases, but naturally, resistence started to emerge naturally in static and crowded populations.

The irony is, our current living conditions can leave us more exposed to infections as soon as circumstances change. It's no surprise that so many of us pick up minor chest or throat infections after travelling by plane, for example. The test case for this was the first world war - boys from the inner city slums were weak, small for their age and malnourished, but thrived in the army, whereas boys from the country were big and strong but succumbed in huge numbers to infectious diseases. Exposure is a big factor to widespread resistance.

On a related and reassuring note. You often hear about antibiotic-resistant bacteria, but resistance is very costly to bacteria and any given drug only has to be kept out of circulation for a relatively short time for its efficacy to be restored. It's astonishing how many people in the medical and scientific worlds aren't aware of this.

AnswerGirl said...

Susan, Nicholas Kristof wrote a terrifying article about extreme drug-resistant TB in last month's NY Times, and I've been thinking about it ever since -- see

I won't be visiting Armenia any time soon, not that I was planning to.

Deb, when I volunteered at a free clinic in DC, we had to be tested every year. One of the points Kristof makes in his article is that the diagnostic for TB is still a 19th-century procedure, which is a little mind-boggling.

And Kevin, I agree that natural selection has something to do with it. I think I've noted before that almost everyone in Western Europe, and most Americans and Canadians, are descended from people who survived the Black Death, so we must have some immunity... but as we see, the diseases themselves adapt as well.

SteveHL said...

There's a short story by Avram Davidson titled "King's Evil" about (among other things) scrofula. It' on the web here: