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The therapeutic approaches used against scrofula in the 19th Century in Ferrara are discussed. In the manuscripts and treatises of the time treasured in the town's libraries, hygienic and dietetic rules and treatment of this illness were described. In particular, baths and mineral water spas (sulphurous, ferruginous and other mineral waters, such as a bromo-iodine-salt water) and the sea-bathing establishment were recommended. The remedies reported in Campana's Pharmacopoeia ferrarese and the efficacious treatments employed in St Anna Hospital are discussed. The Committee and its President, Marquis Giovanni Manfredini, decided to cure the scrofulous in bathing establishments.

The effects of musk-moxa-string therapy on the immune system in man were investigated in 39 patients with scrofula. Before treatment, the numbers of peripheral blood (PB) CD3+ and DC4+ cells and the ratio CD4+/CD8+ were found to be lower in patients with scrofula than in normal subjects, while those of B cells and DR+ cells were higher. Response of peripheral blood mononuclear cells (PBMC) to phytohemagglutinin (PHA) diminished in patients with scrofula. At month 2-6 of musk-moxa-string therapy the number of PB CD8+ cells showed slight diminution along with significant increases in CD3+ and CD4+ cells and CD4+/CD8+ ratio in total lymphocytes (P less than 0.001). In vitro a marked increased blastogenic response to mitogen stimulation with PHA was observed in PBMC of patients with scrofula after treatment (P less than 0.001). In contrast, B lymphocytes, monocytes, DR+ cells and blastogenic response to concanavalin A and pokeweed mitogen were not influenced by musk-moxa-string therapy.

Purpose: This study was designed to review the diagnostic procedure for tuberculous cervical adenitis and propose a simple protocol for the work-up of patients with suspected tuberculous cervical adenitis. Moreover, it served to increase physician awareness of tuberculosis as possible cause of cervical mass. Patients and Methods: We performed a retrospective study of 57 patients with tuberculous cervical adenitis who were treated at North West Armed Forces Hospital, Tabuk, Saudi Arabia between March 1989 and April 1993. The results of diagnostic procedures, chest x-ray, tuberculin test, fine-needle aspiration, microbiology culture, and histopathology were reviewed. Results: Forteen percent showed changes in chest x-ray, 92% had positive tuberculin test, and 50% of the culture material grew Mycobacterium tuberculosis. All specimens for histopathology were suggestive of tuberculosis. Conclusion: A thorough history and physical examination, tuberculin test, and fine-needle aspiration will help arrive at an early diagnosis of tuberculous cervical adenitis and allow early commencement of treatment before final diagnosis can be made by incisional biopsy and culture. Tuberculosis should be included in the differential diagnosis of neck mass.

The King's evil, or scrofula, were the terms used in the past to designate what we now call tuberculous adenitis of the neck. Royalty, including the kings of France, possessed the gift of curing this malady by "Royal Touch". What was the attitude of the physicians towards this miraculous power? There was at least official collusion between the physician and the magical powers of the sovereign. Both sides were well advised to show consideration for one another (Figure 1).

Les rois de France et d'Angleterre passaient autrefois pour avoir le pouvoir de guerir des scrofules aussi nommees ecrouelles grâce au toucher et apres avoir prononce une formule. L'article decrit une oeuvre retracant cette ceremonie et s'interesse aux origines de cette curieuse tradition qui s'eteignit definitivement peu de temps apres.

Summary Two cases of scrofula are presented. These cases were very different in terms of age of the patient, duration of the lesion, and the clinical course. The final diagnosis was based on the histologic findings and tuberculin tests.

A 73-year-old African American female presented to our clinic with painful lower extremity lesions of 2 weeks duration. She was in her usual state of health until 3 months prior to presentation when she reported symptoms of fatigue and weakness. She also noticed an enlarging mass on the left side of her neck. She denied fevers, chills, night sweats or cough. Her symptoms were unresponsive to a course of oral dicloxacillin. The neck mass enlarged over 8 weeks and she was referred to our institution for evaluation. CT scan of the neck showed an enlarged lymph node. Ten days prior to her presentation in dermatology, a fine needle aspirate of the enlarging lymph node revealed necrotizing granulomas. Tissue was sent for routine mycobacterial and fungal cultures. Routine blood work, chest radiograph, and a tuberculin skin test were also performed. At the time of her dermatology visit she described the development of multiple new painful, non-pruritic lesions, bilaterally on the lower extremities. She also reported a red crusted area that appeared at the site of her tuberculin test that was placed subsequent to the development of her lower extremity lesions. Her past medical history was significant for Parkinson's disease, hypothyroidism and hypertension. Her current medications included l-thyroxine, estrogen and diltiazem. Her travel history was only remarkable for a trip to Jamaica the previous spring. She was born and raised in Haiti. She reported a history of a positive tuberculin skin test 20 years ago, but received no therapy. Physical examination revealed a 2 x 3 centimeter firm, nontender left lateral neck mass (Fig. 1). Her right forearm revealed an erythematous, ulcerated, indurated plaque 1.5 cm in diameter (Fig. 2.). Her lower extremities revealed tender 0.5 to 1 cm erythematous nodules below the knees bilaterally (Fig. 3). A punch biopsy of a lower extremity nodule revealed a mild pervisacular dermal infiltrate. Within the subcutaneous tissue there was septal widening. There was also a lymphohistiocytic infiltrate with a slight admixture of neutrophils within the septa of the fat lobules. There was no evidence of necrotizing vasculitis or collagen necrosis. An acid-fast stain was not performed. The histologic findings were consistent with a diagnosis of erythema nodosum. Her laboratory evaluation including CBC, electrolytes, thyroid studies, angiotensin converting enzyme level and chest radiograph were normal. Approximately 1 week after her dermatological evaluation, the fine-needle aspirate culture grew Mycobacterium tuberculosis. A diagnosis of tuberculous lymphadenitis associated with erythema nodosum was confirmed. The patient was started on quadruple therapy of isoniazid, rifampin, ethambutol and pyrazinamide. Her lower limb skins lesions rapidly resolved over the subsequent month and her neck mass also diminished in size. She completed 6 months of antituberculous therapy with complete resolution of her lymphadenopathy.

We described a diagnostic procedure of two cases of extrapulmonary tuberculosis in elderly people. The paper presents the diagnostic difficulty caused by the lack of obtaining an adequate amount of material and low sensitivity and specificity of the conventional techniques. The probe Tec ET test was used with conventional microbiology and histology helps in diagnosis of extrapulmonary tuberculosis by improving specificity, sensitivity. Probe Tec ET test takes a few hours.

Scrofula, or tuberculous cervical lymphadenitis, though now rare, is more commonly seen in minorities, women and immunosuppressed patients, especially those with HIV. We discuss a patient who presented to the emergency department with an anterior neck abscess and was diagnosed with both advanced HIV and disseminated tuberculosis. A high level of suspicion is necessary to make this diagnosis, but given an increasing degree of global mobility, such patients may present anywhere. Medical management is effective, though difficult. Early diagnosis improves the patient's individual prognosis and may prevent further exposure and transmission to the population.

Background:The commonest form of extrapulmonary tuberculosis is tubercular cervical lymphadenitis, or scrofula.Methods and results:A total of 1827 patients with cervical lymphadenopathy who presented to various out-patients clinics of our institution were studied over a three-year period. Eight hundred and ninety-three (48.87 per cent) of these patients had lesions of tubercular origin. The most common observation was unilateral, matted adenopathy in female patients aged between 11 and 20 years and without constitutional symptoms of tuberculosis. Posterior triangle nodes were affected in 43.8 per cent of cases, followed by upper deep cervical nodes in 33.9 per cent. Fine needle aspiration cytology constituted the main diagnostic tool, with a positive yield in 90 per cent of patients. Polymerase chain reaction analysis was performed in 126 patients, with a sensitivity of 63 per cent. Only 18 per cent of patients had associated pulmonary tuberculosis, the rest having isolated involvement of cervical nodes. Medical treatment with anti-tubercular drugs for a period of six months formed the mainstay of treatment and cure. Surgical management was reserved for selected refractory patients.Conclusion:Tubercular cervical lymphadenitis can readily be diagnosed by fine needle aspiration cytology, a simple and cost-effective test. The disease can be cured completely by a short course of anti-tubercular chemotherapy, without surgical intervention.