Madness and the monarchy: diagnosing King George III

The recent release of Queen Charlotte: A Bridgerton Story, the Bridgerton spin-off series on Netflix, has reignited interest in the illness of King George III. While the series is described as ‘fiction inspired by fact’, the blossoming romance between Charlotte and George is interwoven with his well-known declining health. The tear-jerking final scenes have led many of us to question the cause of George’s illness and the diagnosis that tinges this love story with sadness. This famous question has been asked many times by medics and historians without an answer. However, the story of King George leads into the wider controversial issue of whether historical figures can, or even should, be diagnosed retrospectively and what potential harm can come from it.

DIAGNOSIS AND RETROSPECTIVE DIAGNOSIS

Contemporary clinicians have long sought to diagnose medical issues of the past, often seen as interesting detective work. From Chopin to Henry VIII, Julius Caesar to Napoleon, there are multitudes of articles attributing a range of conditions (predominantly syphilis) to their behaviours and actions. George III has been subject to many diagnoses and wide-ranging analysis that has covered ‘insanity’, arsenic poisoning, bipolar disorder, and the well-known porphyria hypothesis.

Many have approached re-diagnosing George as a progression of knowledge, with each new diagnosis reflecting a more ‘correct’ and up-to-date understanding. However, this approach is not without its faults and has been a consistent area of tension in the History of Medicine for some time.

Historians of medicine have long been critical of retrospective diagnosis, warning of the dangers of moulding historical experiences of illness into modern diagnostic boxes and anachronism.¹ Some of this criticism is that much so-called evidence is speculation, and the lack of definitive examination or testing means a final diagnosis is likely impossible. For George III, while there are letters and diary entries from himself and his doctors, his symptom list continues to include claims from anonymous witnesses. Quite famously, he was rumoured to have shaken a tree branch thinking it was the King of Prussia but there is no evidence that this truly happened. Further writers have also considered it unethical to propose unsolicited diagnoses without all the relevant information or indeed consent, especially where conditions carry potential risk for descendants.²

Further discourse has centred on how diagnoses are created, understood, and experienced. While many take the view that medical knowledge is progressive and that understanding is based on what we can discover in randomised controlled trials and on scientific underpinnings, there is recognition that illness and diagnosis are inherently linked to the sociocultural context in which they exist. In the case of George III, his differing diagnoses arguably reflect their authors more than his illness, particularly when examining the porphyria hypothesis.

MACALPINE AND HUNTER

In the 1960s, Drs Ida Macalpine and Richard Hunter seemed to lay rest to the previous perception of any sort of mental illness and, instead, diagnosed porphyria based on supposedly neglected physical signs and symptoms.³ However, Macalpine and Hunter wrote openly about psychiatric illnesses being replaced with ones of physical origin given the rise of biomedical scientific knowledge. They were further influenced by the anti-psychiatric movement, born mid-century from concerns around psychotropic medication and involuntary hospitalisation, and seem to have cherry-picked relevant symptoms to fit their hypothesis. Was this new diagnosis a progression of scientific knowledge, or merely a biased reframing of the narrative conforming to personal belief? Certainly, many are inclined to the latter and now look at their work with more prudence than before. Even later work considering bipolar disorder falls into this analytical trap, rewriting and reframing an illness experience both influencing and influenced by a modern understanding.⁴

So where does this leave us with the story of George and Charlotte? For 200 years much of the focus has been on the ‘why’ as opposed to the impact of his illness. While George’s health was a critical storyline, the series presented an alternate narrative — a sympathetic view of a cruel illness and a doomed romance — but never concentrated on a diagnosis. The debate surrounding retrospective diagnosis reminds us to look beyond diagnostic categories to the lives and experiences of our own patients. In Queen Charlotte: A Bridgerton Story, we finally look beyond ‘insanity’, arsenic, porphyria, and bipolar disorder, and, instead, we see ‘Just George’.