A health librarian at the theatre: The Madness of George III

It's been several weeks since I "went" to the theatre, but I have just watched the Nottingham Playhouse's production of this Alan Bennett play, on the National Theatre Live YouTube channel.

I saw the film (called The Madness of King George) some years back and I was aware of the idea that the King was not mad, but had porphyria.   The clue was the blue urine, which none of the doctors (in the play) thought was important.

But I had not realised that view has been questioned.   There are several articles in the medical literature, many by Timothy Peters of the University of Birmingham (UK).   It is argued in those that the authors who advanced the porphyria theory were rather selective when it came to symptoms, and misinterpreted the ones they did choose, and did not consider the King's mental health.

There were several things that caught my health librarian eye while watching.

All of this is, of course, Alan Bennett's portrayal of the characters involved.

There were three doctors involved in the King's care, before Dr Francis Willis.    All seemed glued to their view of diagnosis and treatment.   One was sure that blistering was the treatment needed to draw out the bad humour that was the cause.  Another based all their diagnosis on the King's stools.    The third was set on prescribing a particular thing.    They, and the King's servants, noticed the blue urine, but it seems as it did not fit anyone's scheme of treatment, it was not thought relevant. 

It seems physical examination was the last resort, and not the first.   Perhaps that was a reflection of the class divide, in the context where no one addressed the King directly, and all conversations were carried out through someone else.

Then there was Dr Willis.   Dr Willis, who maintained an asylum in Lincolnshire, did address the King directly, and not only that, told him off for his random conversations and inappropriate talk.   Contact with others, including the Queen, was restricted, and if he misbehaved, he was put into a straitjacket.

The manoeuvring of politicians of the time was shown too, and obviously (in Bennett's view, anyway) had a role to play - who was Prime Minister, and whether the Prince of Wales should be Regent.

And the King got well.   The random talk and inappropriate talk subsided, and the urine went back to a more usual colour.

So, did Francis Willis cure him?   And what was it?

Searching PubMed for George III or King George III requires a specific search for George III porphyria, or George III[ps].     An earlier diagnosis, before the one of porphryia, was bipolar disorder (1,2). 

And searching PubMed for willis f[ps] finds a few including this one (3).  

This Patient article for professionals discusses symptoms and treatment of porphyrias.

1.           Peters T. King George III, bipolar disorder, porphyria and lessons for historians. Clin Med. 2011 Jun 1;11(3):261-4.

2.           Peters T. FitzPatrick Lecture: King George III and the porphyria myth – causes, consequences and re-evaluation of his mental illness with computer diagnostics. Clin Med. 2015 Apr 1;15(2):168-72. 

3.           Pearce JMS. The Role of Dr. Francis Willis in the Madness of George III. Eur Neurol. 2017;78(3–4):196–9.

 

de Clérambault, and Enduring Love again

Some more thoughts about the "appendix" to Ian McEwan's Enduring Love, discussed in an earlier post.  The appendix is, or, as it turns out, purports to be, a reprint from the "British Review of Psychiatry", by Wenn and Camia, about de Clérambault's syndrome.  An early review of the book,as you may remember from that earlier post, thought it was the article on which the novel was based.  But others were suspicious, noting that the journal was not one they had heard of, and also that the authors' names were an anagram of Ian McEwan.

I was interested to know what would happen if you critically appraised the paper.   Could you tell that it was (as McEwan admitted in Psychiatric Bulletin) fictional?

Of course, the psychiatric science in the article might well not be fictional at all.  According to Oliver Burkeman's Guardian article (cited in my earlier post), this paper was submitted for publication to the British Journal of Psychiatry, but did not make it into print - it would be fascinating to know why!  An appraisal of the content, though, would be a critical appraisal exercise for psychiatrists or mental health nurses.  But I wondered - what about the references?

The last one is also by Wenn and Camia, so once you know that these are fictional authors, this one is suspect.  It turns out the volume number and year don't match, and those pages in that volume are something else entirely.

One of the British Journal of Psychiatry references has an author name and title belonging to different page numbers and volume, but the page numbers and volume cited actually belong to another article about the same syndrome.

The other British Journal of Psychiatry references are correct, as is the one from Social Science and Medicine (which is, however, missing a section title, being made up of many sections at the time).

One reference has no article title.   Another has different punctuation. 

But apart from the Wenn and Camia article, and that mixed up British Journal of Psychiatry reference, this is all relatively trivial.   In days gone by I was "bibliographic adviser" for a microbiology journal, and checked the reference lists for accuracy.   There were often errors of this sort, so this "British Review of Psychiatry" paper is, I suspect, no worse!

de Clérambault is cited as C.G., rather than G.G., but that again is minor (although possibly if you were a psychiatrist, you would know - possibly not, though).

Here, in closing, is some reading material about de Clérambault and his work.  He was a French psychiatrist, who trained first in law, who published many articles, and whose "Oeuvres psychiatriques" were collected together after his death.

de Clérambault's syndrome, from Patient.info.

Signer, S. F. (1991). “Les psychoses passionnelles” reconsidered: a review of de Clérambault’s cases and syndrome with respect to mood disorders. Journal of Psychiatry and Neuroscience, 16(2), 81–90. 
(Another of Signer's papers is cited in the appendix, but with the wrong initials, I think).

Clérambault, from Encyclopedia Universalis (in French)

Lerner, V. and Witztum, El. (2010). Gaétan Gatian de Clérambault, 1872–1934 – psychiatry in pictures.

British Journal of Psychiatry, 197 (5) 371.

Mental health on, or in, film

A conversation at home about F.D.C. Willard reminded me of Ian McEwan's novel "Enduring Love", for reasons which will become apparent in a later post.  There is brief mention of this novel in an earlier post about autobiography and biography as health literature, as it is a novel that deals with mental health issues.

Looking for material on the web about the novel, I found the Minds on Film blog from the Royal College of Psychiatrists, which has an entry about the film of the novel.  This blog has been going for five years (there is an index, by health condition, of the first five years) and features structured reviews of films that deal with mental health issues, each review summarises the story and addresses its relevance to the field of mental health.

The latest films reviewed include Still Alice (I have just ordered the novel for work, following my Dementia Friends training) and the television series The Outcast.

If you are looking for film or television that deals with mental health issues, I would recommend a look at Minds on Film.

Karl Bonhoeffer

Many years ago I read a lot about Dietrich Bonhoeffer, the minister and theologian.  His ideas about the church and Christianity I found interesting, and I was also interested in his involvement in plots to kill Hitler.  He was executed in 1945 for that involvement.  

And so I discovered that his father, Karl (1868-1948) was a psychiatrist.  And because at the time I worked at the Royal Society of Medicine Library in London, which was (and is) a research library of historical record which kept all sorts of things, and we had Index Medicus in print and Medline on CD Rom, I could find material about him and then find the actual articles.  

Karl seemed to have been a psychiatrist of some note.   People published Festschriften in his honour when he reached significant ages (and we had them, in German).  But what did he know about what his family were doing?   Two sons and two sons in law were executed by the Nazis.   I seem to remember reading in one biography of Dietrich that Dietrich had used Karl's car to transport material to use in an attempt on Hitler's life.    And what did he think of the Nazis' policy of sterilisation?   Was he involved?  I seem to remember material that indicated he was.  But why?  


I had at the time written an article about Jean-Paul Marat, the French revolutionary, who was a doctor, and meant to write something about Karl Bonhoeffer.  But other things happened instead, and I never did.  Perhaps this is it!   

Anyway, I have just looked again for material about Karl, using the University of Leicester Library search, and found a new thing, and a thing I am not sure I have found before.  

The new thing comes from a symposium about Karl's role in Nazism, and is an article by Hanfried Helmchen published in German this year in Der Nervenarzt, and asking about his position on sterilisation (1).   And a short piece in the American Journal of Psychiatry in 1944 (2), which seems to be a reprint of a Lancet obituary, reporting that Karl had died the previous year at the age of 75.   In fact, he did not die until 1948, which leaves me wondering where that report came from and why.

I hope this is a work in progress!

References

(1) Helmchen H. Bonhoeffers Position zur Sterilisation psychisch Kranker. Nervenarzt 2015;86:77-84.  doi: 10.1007/s00115-013-3999-x
 
(2)  Karl Bonhoeffer. Am J Psychiatr 1944;101:127-8.