18th Century England, 18th Century Europe, Alan Bennett, George III, Helen Mirren, Ian Holm, Kings and Queens, Macalpine and Hunter, Medical Stuff, Nigel Hawthorne, Porphyria, The Madness of King George
Viewing Dragon Knight while I was sick left me a little mentally imbalanced, and I needed something to help me recover. So I turned to a film about another man seeking help with mental illness, The Madness of King George (1994, dir. Nicholas Hytner, based on Alan Bennett’s play The Madness of George III, adapted by Bennett for the film). Fortunately, the film proved to be the right treatment, because by the end of it, I felt my wits returning just like King George’s.
What Was the Madness of King George?
The film examines an important incident in English history generally known as the Regency Crisis. The Crisis happened in 1788, when King George III experienced a bout of insanity. George’s symptoms were varied: a brief stomach ache at the start, obstructive jaundice, hypomania (euphoric or irritable moods, physically energetic behavior, extreme talkativeness, and bursts of creative ideas), howling like a dog, hearing voices, and, most unusually, blue urine. His speech bordered on totally incoherent, he became violent toward members of his family, including his wife Queen Charlotte and his oldest son Prince George, and it was necessary to physically restrain him on numerous occasions.
Exactly what was wrong with George has been a subject of debate among both historians and medical specialists. At the time, the consensus was manic depression, although one physician diagnosed it as “flying gout”, suggesting I think that George’s gout had gone from his leg to his brain. Historians for the next 150 years followed the consensus and suggested that his mental illness stemmed from his dissatisfaction with his marriage. He had never particularly wanted to marry Queen Charlotte (a German princess he met for the first time on his wedding day) and while the marriage was a happy one, it was clear that George was a much more highly-sexed man than his wife was. His religious nature meant that he was unwilling to take a mistress, so historians suggest that his sexual frustrations eventually led to his mental breakdown.
But in the later 1960s, a mother/son pair of psychiatrists, Ida Macalpine and Richard Hunter, put forward a very different diagnosis, porphyria. Porphyria is a very rare metabolic disorder that produces various neurological symptoms including abdominal pain, vomiting, hypertension, tachycardia (elevated heart rate), and muscle weakness; it can also produce psychiatric symptoms including anxiety, confusion, and hallucinations. It also often causes the feces and urine to turn purple (hence the name, which is Greek for “purple”). Macalpine and Hunter suggested that the key to understanding George’s symptoms lay in his blue urine, and that his madness was not psychological at all but rather metabolic.
Macalpine and Hunter’s claims provoked considerable debate in the medical community, which seems to have focused entirely on whether the symptoms they had focused on would constitute porphyria rather than on whether the historical record supported such a diagnosis in all details. Over the course of the 1970s and 80s, the Porphyria Theory pushed out the earlier diagnosis of manic depression to the point that many historical organizations, such as the National Gallery and Kew Palace (where George was treated), asserted the veracity of the diagnosis. As a result, it’s come to be accepted as a ‘fact’. By the 1980s, professional historians had generally accepted the diagnosis. Alan Bennett, who studied and taught history before turning to writing plays, assumed the diagnosis of porphyria when he wrote the play.
However, the Porphyria Theory has never actually been proven, and in fact it has some significant problems. First, not all in the medical community had agreed with Macalpine and Hunter in the first place. Second, porphyria is hereditary, and since George III was the grandfather of Queen Victoria, there are numerous generations of the royal family (not to mention other descendants of his 15 children—I told you he was highly-sexed) who might have shown signs of porphyria; but no solid evidence of the disease has shown up among them.
More seriously, Macalpine and Hunter have been accused of cherry-picking their evidence from across George’s lifetime. The claim that he suffered from muscle weakness is contradicted by the reports of his energetic physical exertions and by the violence with which he assaulted his attendants on some occasions. Macalpine and Hunter exaggerated the extent of his abdominal pain, and failed to mention that his vomiting had been induced with a medication.
Most importantly, George’s urine was not consistently reddish-purple (more properly blue, in George’s case) at all. There are only four times when blue color was reported in his urine; on one occasion Macalpine and Hunter point to a report of blue urine, but fail to mention that on six occasions in the previous weeks, his urine was reported to be clear or yellow. Even more importantly, three days before the blue urine was reported, his doctor gave him a medication containing gentian extract, which is known to cause blue urine. So in the opinion of one scholar, Macalpine and Hunter did not just get the diagnosis wrong, they intentionally misrepresented the facts to make their case.
Finally, recent analysis of George III’s numerous letters by Peter Gerrard and Vassiliki Rentoumi has suggested that his vocabulary and writing style during his attack mirror patterns seen in modern patients suffering from bipolar disorder (as manic depression is termed nowadays). During his attacks, his sentences may contain 400 words and 8 verbs, for example.
There are serious problems with trying to diagnose medical and psychological conditions in historical figures. Historians are rarely qualified physicians and I doubt more than one or two of them have ever been skilled at differential diagnosis (what House does in every episode of his tv show). Conversely, physicians are rarely skilled at historical research or aware of all the relevant documents (which seems to be the reason why Macalpine and Hunter’s argument persuaded some physicians).
Furthermore, historical diagnosis relies very heavily on the observations of people from the historical figure’s own time; George’s physicians may have failed to notice or failed to remark on certain symptoms that modern scholars might spot (such as the shift in his vocabulary that Gerrard and Rentoumi found) or may spot symptoms that they failed to make sense of (such as failing to recognize that George’s blue urine might have been caused by gentian extract).
Unless a historical figure’s body is available for forensic analysis, it is impossible for there to be any sort of examination by a modern medical specialist. In cases where this is possible, medical analysis can help scholars sort out legitimate clues in historical sources from lies and gossip. A good example here is the recent discovery of King Richard III’s body, which enabled scholars to confirm that he was in fact a hunchback, while disproving the not-very-serious gossip that he had a tail.
What this means is that modern historians have to move very carefully when they attempt to answer a question like what George III suffered from. The Porphyria Theory seems very shaky, and Gerrard and Rentoumi’s work would support a diagnosis of bipolar disorder, but it cannot conclusively prove it, especially given the notorious issue of psychologists trying to diagnose patients they have not spoken with. But bipolar disorder was essentially the diagnosis made by George’s own physicians, and since it seems to fit with the available facts more readily than porphyria does, that’s the one I’m going with in my look at the film.
How the Film Deals with the Symptoms
Bennett wrote his play in 1991, when the Porphyria Theory had become dominant. I have no information about how Bennett researched the play, so I don’t know if he looked at genuine historical documents about the king’s illness or if he relied on Macalpine and Hunter’s papers on the subject. Nor do I know how substantially Bennett revised the medical details in his original script for the film. But the film works to establish many of the symptoms of porphyria.
The first medical symptoms George (Nigel Hawthorne, reprising his performance from the debut of the play) has are an inability to fart followed by an intense abdominal pain that causes Queen Charlotte (Helen Mirren) to call for help. The film suggests that he continued to have fits of pain at the height of his illness, but once he begins to recover they are not shown again. This would seem to follow Macalpine and Hunter’s misleading claims that he suffered from abdominal pain almost continuously, when in fact he suffered only one attack right before his more dramatic symptoms appeared.
In the film his mood shifts erratically from enthusiastic to angry to overwhelmed and miserable. His violence toward the queen is not shown, but his infamous physical assault on Prince George is shown, although the film presents it as an assault intentionally triggered by the power-hungry prince in which he chases the prince around a room beating him with his hat; in fact it was a spontaneous outburst in which he choked the prince into near-unconsciousness. Since Prince George is the villain of the play, the facts have to be massaged a little to keep the audience from accidentally sympathizing with him.
The film makes repeated references to his urine and feces. Early on, one attendant points out that the urine is blue, but the king’s physicians insist it is a meaningless symptom. Dr Pepys (Cyril Shaps) is obsessed with the quality of the king’s stools, but Dr. Warren (Geoffrey Palmer), the prince’s physician, ridicules this. At the end of the film, one attendant notices that the king’s urine has turned normal again and comments that the urine was blue throughout the whole episode. This is the film’s way of suggesting that the king’s doctors had all missed the central symptom that should have told them it was porphyria (which was first diagnosed more than 2,000 years earlier). This claim is completely false; as I’ve mentioned, it relies on Macalpine and Hunter’s apparently deliberate misrepresentation of the actual facts.
There is also some discussion of the king’s pulse, which is extremely high. Dr. Warren comments that it’s irrelevant because his pulse varies too much. This is obviously the tachycardia associated with porphyria. Nothing I’ve read on the king’s illness has mentioned tachycardia at all, so I’m unsure if this was actually one of the king’s symptoms or if it was added by Bennett to strength the case for porphyria.
The two major symptoms mentioned by Macalpine and Hunter that the film omits are the king’s blindness (which only happened many years later and so is irrelevant in this film), and his muscle weakness. Muscle weakness plays a major role in Macalpine and Hunter’s argument, and I suspect that Bennett omitted it for the same reason that I’ve already mentioned; it doesn’t fit with the reports of the king’s physical struggles with his attendants. Those struggles are important moments; they dramatize the king’s problems and often serve to generate sympathy for him as we see him being humiliatingly manhandled by Dr. Willis’ orderlies. So the struggles have to stay, and that would make muscle weakness almost impossible to present in a coherent fashion.
Isn’t Modern Medicine Wonderful?
A central theme of the film is the comparatively primitive medical knowledge of the time. In the first portion of the film three doctors attend George, Drs Warren, Pepys, and Baker (Roger Hammond). They spend much of the film arguing about which of his symptoms are important and which are incidental. Warren, as already noted, insists that neither his pulse nor his urine are important, while Pepys is obsessed with the quality of his stools. This is played for mild humor; the audience is intended to be amused by Warren’s inability to realize that the pulse and urine matter, and Pepys’ interest in George’s stools is almost farcical. But Warren’s disinterest in these symptoms is quite unrealistic. Taking the pulse was an important procedure from before the time of the Greeks, just as it is today. Physicians of the day routinely examined both urine and stools (as is evident from the fact that George’s doctors noted the quality of his urine quite a lot).
At the same time that Warren ‘s skepticism represents modern amusement about 18th century medical practice, he also represents what today would be considered barbaric medical treatment. He insists on blistering the king (applying heated glass cups to the skin to draw fluids to the surface and then lancing the resulting blister to drain the fluid). It was an extremely painful process, as the film shows, and serves to horrify the audience and increase their sympathy for George.
Baker is dithering and ineffectual. At the start of the crisis, rather than examining the king directly, he questions the king’s equerry, because protocol forbids speaking to the king about his symptoms. Again, we’re supposed to be amused and appalled by the poor quality of the medical treatment given to George.
When Dr. Willis (Ian Holm, reprising his role from the debut of the play) arrives, he is presented as being a different kind of doctor. Indeed, Warren sniffs that he isn’t actually a legitimate doctor (although the real Willis had his medical degree from Oxford). He approaches George’s problems from a completely different direction. He takes the position that George’s inability to restrain his speech and actions are caused by the fact that George has never actually had to restrain himself, because the court indulges his whims and cossets him at every turn. In other words, George’s sickness is moral rather than medical. What George needs is to learn restraint through a process of being restrained whenever he misbehaves. George is immediately tied down to what today would be considered a bondage chair and gagged with a leather strap. He is also kept in a straight jacket. As he shows self-control, he is increasingly permitted to live more comfortably, but whenever he acts out, Willis immediately forces him into the chair. Gradually, George learns to go into the chair voluntarily when he misbehaves, and then learns to self-correct whenever Willis says something or even just looks at him. By the end of the film, George has returned to his old demeanor and no longer needs Willis standing in a corner clearing his throat as a reminder.
There is some truth to all this. Willis did employ restraints in alternation with more gentle treatment. But he also employed blistering, which the film associates with Warren instead. He also employed manual labor, which isn’t shown either.
The Problem with the Film
The film sets up Baker, Warren, and Pepys to represent ‘old’ medicine as quackery and ineffective, and Willis as ‘new’ medicine, which is both more effective and more humane. It encourages the audience to be both amused and horrified by how terrible medicine was in the past, and thus implicitly glad that we have come so far from those ‘bad old days’.
In an epilogue text, the film tells us the color of the king’s urine suggests he was suffering from porphyria, thus explaining the significance of the references to the king’s urine. So it asserts that we now know what was wrong with the king, even if they didn’t know it back then, and we are encouraged to assume that if George III were alive today, he would receive much better treatment. The film is flattering us for being so much smarter and more enlightened than our ancestors were in the late 18th century.
This is a common problem with historical movies, which often operate by establishing an implicit position of moral and intellectual superiority toward the past. Such films often tell us that we are smarter than or morally superior to our ancestors because we no longer do X, with X being whatever the film is about. (See my thoughts on Gladiator and its depiction of gladiatorial combat for another variation of this.)
The problem is, as I frequently tell my students, we are no smarter than our historical ancestors were. We know more and we have better technology, but we’re not actually smarter than they are. What looks to us as stupidity and barbarity is actually just a different culture acting on different assumptions and different bodies of knowledge than we use. In 200 years, I have no doubt that film audiences will be told to marvel at how ignorant and barbaric 21st century Americans were because they still believed something that 23rd century science has disproven. Who knows, maybe 23rd century epigenetics will disprove the ridiculous notion that bacteria cause disease. So someday a film make will show moronic, hidebound 21st century physicians –gasp!—giving syphilis patients antibiotics rather than gene therapy. My point is that we have no way of knowing what facets of current society our descendants will be embarrassed or horrified by. So it would be best to get out of the habit of gawking at our ancestors like they were a freak show before we ourselves get trundled out as the next exhibit by our great-grandchildren.
And, in fact, The Madness of King George demonstrates this problem quite well. Bennett relied on the Porphyria Theory when he wrote the play and revised it for the screen. But as I’ve already noted, the Porphyria Theory is probably wrong. The king’s urine was probably occasionally blue because of a medication he was taking, and his other symptoms have to be aggressively manipulated and misrepresented to fit such a diagnosis. If the actual problem was bipolar disorder, then the modern film is wrong and George’s doctors were actually right. The consensus at the time was that George was suffering from a mental illness, not a physical one, So they probably got it right and Macalpine, Hunter, Bennett, and the film got it wrong.
The Deeper Problem with the Film
Bennett’s story does a wonderful job of dramatizing George’s plight, and the film itself is loaded with great performances, especially Hawthorne and Holm’s. But the film doesn’t realize that there is a major problem with its presentation of the medical issues.
The foundation of the play medically is that George was suffering from a metabolic disorder. Even though that’s probably wrong historically, it’s a valid approach, especially since at the time the play and the film were produced, many scholars had accepted the Porphyria Theory. So we can’t blame Bennett for following the roughly accepting thinking of the day on the issue.
But Bennett doesn’t actually approach George’s cure as a question of treating a metabolic disorder. Willis’ treatment is entirely in the realm of morality. He adopts a moral theory of what is wrong with George, proposes a course of treatment based on moral re-education, and achieves results. This would be as problematic as if George’s underlying medical problem were a brain tumor. No amount of teaching George self-restraint could possibly cure his porphyria, because good manners don’t qualify as an effective treatment for metabolic disorders.
The film hints at this in the epilogue text when it says that porphyria is “periodic, unpredictable—and hereditary”. The film essentially says “oh yeah, the story we just depicted is bullshit because what helped George was actually his disease going dormant, not anything that we just showed you.” So the film is trying eat its cake and have it too. We get a heartwarming story of how modern democratic values (as represented by Willis’ refusal to abide by court protocols) help cure a king whose problem is that no one will tell him anything he doesn’t want to hear, and then the film winks at us and tells us to disregard what it just showed us. The film unfortunately perpetuates the myth that mental illness is mostly a matter of lack of self-control. In doing this, it falls right in line with people who tell someone suffering from depression to “just snap out of it” or who condemn alcoholics for their lack of self-control. Even as it wants us to sympathize with George III’s sufferings, it’s also blaming him for his turmoil because he was too weak to keep himself in line. So in an odd way, the film too is suffering from its own mental disorder, schizophrenically saying mutually contradictory things and expecting us to believe both of them at once.
Want to Know More?
Janice Hadlow’s A Royal Experiment: The Private Life of King George IIIis a well-received study of George’s private life that examines his rather unpleasant childhood, his relationship with his wife and children, and his mental illness. She’s not a professional historian, though, so read it with a bit of caution. It’s only available in hardcover or Kindle editions.