Porphyria—a Royal Malady*

FARMFR GEORGE was a mad king, and so we lost the American colonies: such in brief is the recollection of what the man-in-the-street garnered at school. It is remarkable that so little attention has been paid to the nature of George III's malady, and it is a sad reflection on British medical historians that during the 200 years that have elapsed since his first overt attack of illness, there have been only two serious studies on this subject, both of them by Americans. Ray (1855) believed that the disorder was recurrent mania although he found no account of earlier symptoms suggestive of an ill-balanced mind in either the illustrious but notably abstemious patient or in members of his family. Guttmacher (1941) accepted the diagnosis of manic-depressive psychosis put forward by Jelliffe (1931) invoking, on the then fashionable basis of psychopathology, self-blame, indecision and frustration on the part of the king as the underlying reasons for the symptoms. Yet, as is clear from the concise and welldocumented account by Doctors Macalpine and Hunter, the contemporary opinion of courtier-physicians, and 'mad-doctors' alike with few exceptions, the disorder of the mind was of the 'consequential' rather than the 'original' type, that is to say, it was presumed to be the result of bodily disease and was not just plain lunacy. For instance Rowley (1790), a commentator of the time, postulated the existence of 'some prevailing irritating acrimony' as a cause of the mental symptoms in the illness which occurred in the winter of 1788-9 while Pargeter (1790) seems to have been of the opinion that the royal patient was suffering from a form of delirium: Addington (1788) wondered how a diagnosis of mania could be justified in the absence of any preceding phase of melancholia. Doctors R. D. Willis and William Heberden junior, who were in attendance in the last prolonged phase of the illness, commented respectively upon his 'bodily indisposition' and 'his peculiarity of constitution'. Sir Henry Halford was surely right when he said that there was no exact precedent for the king's disease: this is possibly still true today. The evidence of the astute Fanny Burney can be invoked by those who believe that the king suffered from a confusional state. In the early phases of the illness in 1788 she reported that he had 'broken forth into positive delirium' when at dinner (19 October). He spoke to her in a hoarse voice and 'in a manner so uncommon that a high fever alone could account for it' (25 October). On 3 November she was anxious because 'he is better and worse so frequently'. She observed that he had had an attack of gout 'on the road' and that 'there is something unmistakably alarming in his smallest indisposition'. But when, on 2 February 1789, shortly before his recovery,