Re-evaluating the porphyria diagnosis of King George III’s madness

Letter in reply to the two articles re-evaluating George III,  the porphyria diagnosis, and the King’s madness.

Published in History of Psychiatry Journal; March 2010; Vol 21; Issue 1; No 81

Letter-to-Ed

To Professor German E. Berrios, Editor

2nd March 2010.

Dear Editor,
The re-examination of the ‘Royal malady’ of George III and specifically the porphyria diagnosis given by Ida Macalpine and Richard Hunter was long overdue. Timothy J. Peters is to be commended for such a painstaking and thorough investigation using all the available primary archives. This Editorial outlines just how unlikely it was, based on symptomatology and pattern of illness that George III suffered from porphyria.[1] One can only hope that Timothy Peters’ diligence gets as much attention as Macalpine and Hunter did in the late 1960’s. However one is left slightly puzzled, given the Discussion in this Editorial, in which Macalpine and Hunter are questioned for not appearing ‘to have had any clinical experience in porphyria,’ why Timothy Peters’ makes no reference to his lifetime career in clinical biochemistry?

As a doctor and practising NHS psychiatrist who is interested in the history of our profession I took great interest in Timothy Peters’ re-evaluation. The rigour of his investigation is fully persuasive. However, it is certainly clear that episodes of physical illness accompanied the King’s severely disturbed mental state. Accepting that the King did not actually suffer from porphyria, it is the psychiatric re-examination by Dr Allan Beveridge that inevitably raises rather more questions: thus the following comments apply only to the second Editorial.[2]

Just as George III was never a ‘text book case’ of porphyria – surely the same can be said for the King’s mental symptoms that displayed such a strange evolution; with late-onset and a final and protracted period of mania that lasted ten years till his death. I shall not make the mistake of attempting to compare cases I see today as an old-age psychiatrist to those of centuries past, however the King’s presentation could hardly be described as being in ‘broad agreement’ with the general pattern of major mood disorders – even those of late-onset. To compare thus the King’s malady in light of modern-day Bipolar disorder, as offered by Beveridge, must carry considerable caveat. It is certainly a curious omission that no old-age psychiatrist was consulted given such a presentation. Furthermore, the arguments on cognition and ‘mild dementia,’ seem rather poorly developed.

George23b

The King suffered from protracted mental illness (of that we should be satisfied) but the conundrum of symptoms here revisited serves primarily to remind us that one cannot so easily separate the body from the mind. Consider the stresses of a Kingdom, multiple bodily afflictions, cohorts of doctors, and multiple remedies (quinine, antimony and purgatives, to name but a few) then you can see the absurdity of reducing a diagnosis to a singular cause. Whilst we all enjoy the intellectual discourse of reconsidering illness past, we must surely be wary of retrospective diagnosis (for this can often be difficult enough in life.) Equally we must not look to explain every presentation as purely socio-cultural in origin.

Beveridge’s paper is rightfully careful, but is surely not critical enough of Macalpine and Hunter.[3] Perhaps a follow-up paper will appear looking specifically at the mother and son psychiatrists and their monumental placing of porphyria? Having followed their lives, from cradle to grave, a story has emerged almost as fascinating as the malady that they so ‘royally’ served. Macalpine and Hunter believed that this work on porphyria heralded a new understanding of mental distress as a manifestation of physical illness. By bringing on Ida Macalpine at the end of his play (of course clutching her book ‘The Mad Business’) Alan Bennett surely asks a question: were the doctors of the late 1960’s as obsessed with porphyria as Sir Lucas Pepys, one of the King’s many attending physicians, was with the King’s excrement?

Yours sincerely,

George-the-King-(George-III


[1] Peters, Timothy J. and Wilkinson, D. (March 2010) King George III and porphyria: a clinical re-examination of the historical evidence; History of Psychiatry Journal; Vol 21; Issue 1; No 81.

[2] Peters, Timothy J. and Beveridge, A. (March 2010) The madness of King George III: a psychiatric re-assessment; History of Psychiatry Journal; Vol 21; Issue 1; No 81.

[3] Crawford, J. M. (BMJ 1968) “Undoubtedly it has always been, and still is, more respectable to suffer from a physical rather than a mental illness;Ware, Martin (Editor BMJ: 13th January 1968) “Porphyria is the correct diagnosis.” Note: Martin Ware was great-great-great grandson of Sir George Baker, who was “convinced that the key to the royal malady lied in the vagaries of the pulse.” Dent, C.E. (BMJ 1968) I was most distressed to note that one historian seemed to have swallowed the story hook, line, and sinker. I wanted and still want to warn the others. I have my suspicions, too, about you, Mr. Editor, as the result of your putting out a special supplement on the royal malady complete with vivid purple-coloured cover!

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