The madness of King George III: a psychiatric re-assessment

Where we came from: continuing professional development for the 18th century physician and surgeon, the genesis of British medical societies

Keeping professionally up to date in 18th-century Britain was not an easy undertaking. Learning on the job was insufficient for the further development of individual medical knowledge. The century witnessed the gradual growth of medical societies to provide a better education than that offered by university institutions. The Worshipful Society of Apothecaries of London in 1815 was empowered to licence and regulate medical practitioners, today's general practitioners. Societies were established in Edinburgh but not so many as around London, where a particularly successful education body was established in 1773, the prestigious Medical Society of London. In 1805 a breakaway group from the society formed an equally highly respected learned body, the Medical and Chirurgical Society of London, that became the nidus for the amalgamation of numerous specialist societies to form, in June 1907, the extant Royal Society of Medicine. By the end of the 18th century, the medical society had fostered professionalism, education and unification within diverse medical and scientific disciplines.

Gene expression imputation across multiple brain regions provides insights into schizophrenia risk

Transcriptomic imputation approaches combine eQTL reference panels with large-scale genotype data in order to test associations between disease and gene expression. These genic associations could elucidate signals in complex genome-wide association study (GWAS) loci and may disentangle the role of different tissues in disease development. We used the largest eQTL reference panel for the dorso-lateral prefrontal cortex (DLPFC) to create a set of gene expression predictors and demonstrate their utility. We applied DLPFC and 12 GTEx-brain predictors to 40,299 schizophrenia cases and 65,264 matched controls for a large transcriptomic imputation study of schizophrenia. We identified 413 genic associations across 13 brain regions. Stepwise conditioning identified 67 non-MHC genes, of which 14 did not fall within previous GWAS loci. We identified 36 significantly enriched pathways, including hexosaminidase-A deficiency, and multiple porphyric disorder pathways. We investigated developmental expression patterns among the 67 non-MHC genes and identified specific groups of pre- and postnatal expression.

Mood disorder in the personal correspondence of Robert Burns: testing a novel interdisciplinary approach

Robert Burns has long been recognised as someone who experienced episodes of melancholia, but no detailed, systematic and objective assessment of his mental health has been undertaken. We tested a novel methodology, combining psychiatric and literary approaches, to assess the feasibility of using Burns's extensive personal correspondence as a source of evidence for assessing the presence of symptoms of a clinically significant mood disorder. We confirmed the potential of this approach and identified putative evidence of episodes of depression and hypomania within the correspondence. While not conclusive of a formal diagnosis of bipolar disorder, this work highlights a need for further systematic examination of Burns's mental health and how this may have influenced his work.

'Details on the Establishment of Doctor Willis, for the Cure of Lunatics' (1796)

The 'mad-doctor' Dr Francis Willis achieved national and international celebrity following his successful treatment of King George III's first major episode of insanity in 1788-9. At the time of his summons to attend the King, Willis was a well-established provincial practitioner and madhouse proprietor. An anonymous French visitor published a description of Willis's Lincolnshire madhouse and his therapeutic practices in 1796. The translated text of the full article provides a unique insight into the work of a key figure in the historical development of psychological medicine. The accompanying Introduction summarizes Francis Willis's career as a mad-doctor and uses salient information from the original text to place him and his madhouse practice within a contemporary context.

The acute mania of King George III: A computational linguistic analysis

We used a computational linguistic approach, exploiting machine learning techniques, to examine the letters written by King George III during mentally healthy and apparently mentally ill periods of his life. The aims of the study were: first, to establish the existence of alterations in the King's written language at the onset of his first manic episode; and secondly to identify salient sources of variation contributing to the changes. Effects on language were sought in two control conditions (politically stressful vs. politically tranquil periods and seasonal variation). We found clear differences in the letter corpus, across a range of different features, in association with the onset of mental derangement, which were driven by a combination of linguistic and information theory features that appeared to be specific to the contrast between acute mania and mental stability. The paucity of existing data relevant to changes in written language in the presence of acute mania suggests that lexical, syntactic and stylometric descriptions of written discourse produced by a cohort of patients with a diagnosis of acute mania will be necessary to support the diagnosis independently and to look for other periods of mental illness of the course of the King's life, and in other historically significant figures with similarly large archives of handwritten documents.

FitzPatrick Lecture: King George III and the porphyria myth - causes, consequences and re-evaluation of his mental illness with computer diagnostics

Recent studies have shown that the claim that King George III suffered from acute porphyria is seriously at fault. This article explores some of the causes of this misdiagnosis and the consequences of the misleading claims, also reporting on the nature of the king's recurrent mental illness according to computer diagnostics. In addition, techniques of cognitive archaeology are used to investigate the nature of the king's final decade of mental illness, which resulted in the appointment of the Prince of Wales as Prince Regent. The results of this analysis confirm that the king suffered from bipolar disorder type I, with a final decade of dementia, due, in part, to the neurotoxicity of his recurrent episodes of acute mania.

Mental health issues of Maria I of Portugal and her sisters: the contributions of the Willis family to the development of psychiatry

Contemporary accounts credit Dr Francis Willis (1718-1807) with facilitating the recovery of King George III from his major episode of acute mania in 1788-9. Subsequently Willis was summoned to Lisbon to advise on the mental health problems of Queen Maria I. This article reports the nature of the illnesses of Maria and her two similarly affected sisters, and uses the program OPCRIT to propose diagnoses of major depressive disorders. The high prevalence of consanguinity and insanity among the Portuguese monarchy and their antecedents probably contributed to their mental health problems. The successive contributions of the Willis family from Thomas Willis (1621-75) to his grand-nephew, Francis Willis (1792-1859), are reviewed; the popular image is somewhat inaccurate and does not highlight their part in the development of psychiatry.

Reading about . . . The history of psychiatry

In recent decades ideological battles have raged over how the history of psychiatry should be interpreted. Should the emergence of psychiatry in the late 18th century be seen as the triumph of the Enlightenment, ushering in a rational approach to mental illness and overturning the primitive and often barbaric ideas of previous eras? Or should the rise of psychiatry be seen in a more sinister light? Does it represent the extension of the state into the lives of its citizens, controlling and policing the disaffected and discontented? Are psychiatrists benign humanitarians or agents of oppression? Should the historical narrative be one of progress, as psychiatry steadily extends its knowledge of mental illness and develops more and more effective therapy? Or is the reverse true: has the advent of psychiatry been a calamity for the mad?

Multiple sclerosis or neuromyelitis optica? Re-evaluating an 18th-century illness using 21st-century software

In this paper we report the application of an extensive database of symptoms, signs, laboratory findings and illnesses, to the diagnosis of an historical figure. The medical diagnosis of Augustus d'Este (1794–1848) – widely held to be the first documented case of multiple sclerosis – is reviewed, using the detailed symptom diary, which he kept over many years, as clinical data. Some of the reported features prompted the competing claim that d'Este suffered from acute porphyria, which in turn was used in support of the hypothesis that his grandfather, King George III, also suffered from the disease. We find that multiple sclerosis is statistically the most likely diagnosis, with neuromyelitis optica a strong alternative possibility. The database did not support a diagnosis of any of the acute porphyrias.

King George III, bipolar disorder, porphyria and lessons for historians

In the 1960s, Ida Macalpine and Richard Hunter, mother and son psychiatrists, stated that George III's medical records showed that he suffered from acute porphyria. In spite of well-argued criticisms by Geoffrey Dean and Charles Dent based on their extensive clinical experience of the acute porphyrias, Macalpine and Hunter were able to garnish extensive support for their claims from historians, psychiatrists, physicians and the media circus and their view is now surprisingly widely accepted. Recent research of George III's extensive medical records has shown that Macalpine and Hunter were highly selective in their reporting and interpretation of his signs and symptoms and that the diagnosis of the acute porphyria cannot be sustained. The basis for the false claims and the consequences for historians are considered and indicate that there is now an opportunity to reassess George III's contributions to events in his reign.

King George III and porphyria: a clinical re-examination of the historical evidence

The diagnosis that George III suffered from acute porphyria has gained widespread acceptance,but re-examination of the evidence suggests it is unlikely that he had porphyria.The porphyria diagnosis was advanced by Ida Macalpine and Richard Hunter, whose clinical symptomatology and historical methodology were flawed.They highlighted selected symptoms, while ignoring, dismissing or suppressing counter-evidence.Their claims about peripheral neuropathy, cataracts, vocal hoarseness and abdominal pains are re-evaluated; and it is also demonstrated that evidence of discoloured urine is exceedingly weak. Macalpine and Hunter believed that mental illnesses were primarily caused by physical diseases, and their diagnosis of George III formed part of a wider agenda to promote controversial views about past, contemporary and future methods in psychiatry.