King George III
King George III; drawing by David Levine

The vulgarities of election campaigns, the bogus bonhomie of international tours, the airport genialities, the carefully planned informality of press conferences, all the stage management and flummery create such an implausible façade for political leaders that the educated may be tempted to give them no more importance than other figures of the entertainment world and to assume that the real business of politics is handled with computerlike impersonality in anonymous offices. Against this view there is only too much evidence from historical studies and political memoirs that national and international events really are affected, especially at crises, by men of flesh and blood—and not only flesh and blood but excessive cholesterol, failing pancreas, gallstones, spirochetes, enlarged prostates, “slight” strokes…in addition to the uncertain side effects of surgical procedures and pharmaceutical supports abundantly available to keep top people functioning long after lesser men would have been retired on grounds of health.

Dr. L’Etang, combing memoirs, newspaper reports, bulletins, and occasional frank statements by physicians, has assembled a dismal array of medical facts (together with a good many suppositions) about political and military leaders from Sir Edward Grey and others involved in the 1914-18 war up to Nasser, whose disabilities when the book was written were still a matter of rumor and surmise.

If body and mind could be neatly separated the upshot of a study like this could only be admiration for the fortitude of these men, most of them elderly, who stuck to their public duties in face of pain, discomfort, and extreme fatigue: Eden with a temperature of 106 as the Suez crisis approached its climax, Woodrow Wilson struggling on after several strokes to get his international policies endorsed by the Senate, Roosevelt at Yalta. But who can believe that their judgment was unaffected by their physical condition? Baldwin in July, 1936, the year that Hitler invaded the Rhineland, was saying, “I am too tired for any fresh effort…. How long do you want me to go on?” And in October a friend was noting hopefully in his diary:

The P.M. is back at No. 10 very much rested…. There is nothing organically wrong with him. He lost his nerve and every burden became a nightmare. He will last till the Coronation we all hope, but if the foreign situation becomes very difficult he may break under it.

Inevitably the effect of ill health and exhaustion on the decisions these men made can be no more than speculation—and Dr. L’Etang speculates freely—but no one can be complacent about it. No one would realize without dismay that his accountant or lawyer or doctor was in such a state. In 1935 when the Italian attack on Abyssinia began, Samuel Hoare

…had been in poor shape since the summer. In August he was crippled by an attack of arthritis in one foot. Worse still he had a number of blackouts; at a cinema, at Glyndebourne, and in the Commons. Early in December his doctor ordered a period of convalescence in Switzerland….

and it was en route for this convalescent holiday that he had his disastrous talks with Laval. He said later, “It may be that I was so pulled down by overwork that my judgment was out of gear.”

Here, as at many points in this story of ill-judged endurance, we see a reflection of the ingrained cultural assumption that fatigue resulting from overwork provides a not discreditable excuse. Fatigue can disturb judgment in much the same way as alcohol and be equally habit forming. No politician is likely to offer drink as an explanation of his blunders, but our long-surviving vestiges of the puritan ethic in which constant labor is meritorious allow overwork and fatigue to constitute a claim for sympathy. Admittedly there are emergencies in which fatigue must be incurred, but the risk of poor judgment rather than the heroism is then the thing to keep in mind. And in any number of cases the overwork is obviously addictive, a way for the obsessional person to hold his anxieties at bay, but of course at the cost of reflection needed for fully considered decisions. Dr. L’Etang quotes in illustration Sir Edward Grey’s own account of his attitude:

Work, incessant, peremptory work, relieves nervous strain; it allows no vacant hours in which anxiety can prey upon an unoccupied mind; it wearies, but by that very weariness helps to ensure sleep sufficient to restore; unless or until it causes exhaustion, it stimulates.

For many of these people life is channeled so exclusively into their public roles that clinging to existence means clinging to office. Attlee commented (with an optimism excusable in a friend) on Ernest Bevin’s last phase after six years of heart trouble:

He clung on. The doctors were often really quite hopeful and he hung on as long as he could but he was suffering intensely. I don’t think it affected his judgment, although some of the newspapers tried to say it did….

When little more than a month before his death, he was displaced, it was a bitter blow because, according to a member of his staff, “he wanted to die in the Foreign Office.” Doctors faced with patients like these may feel profoundly uneasy at seeing national affairs in such hands, but as doctors they put their patient and his hold on life before everything else. When Woodrow Wilson had his almost completely disabling stroke,


His doctors understandably put patient before country and advised against premature resignation for Dr. Dercum was frightened lest loss of office would remove the will to live; a dilemma that would face Moran when Churchill was similarly afflicted.

On 6 October 1919 Robert Lansing, the Secretary of State, discussed with Tumulty [Wilson’s secretary] the provisions of the Constitution with regard to the removal, death, resignation or disability of a President. Tumulty said that only he or Grayson [Wilson’s private doctor] could provide the evidence and, not only would they never do this, but they would stop any outsider obtaining it….

From October 1919 until March 1921 the Presidency was sustained by a self-elected council of three: Mrs. Wilson, Joseph Tumulty and Dr. Grayson…. Wilson, isolated by his intimates and handicapped by increasing obstinacy, mental deterioration and failure of judgment, destroyed any hope of attaining even some of the objectives for which he had ruined his health.

Dr. L’Etang gives situations like these the most dramatic lighting he can; he may exaggerate, his views about the effects of illness on political action are inevitably speculative—we can never run a controlled experiment—but with all allowances made there remains ample evidence that time after time throughout this century tremendously important affairs have been handled by men who would have been regarded as too ill to run an ordinary business. Eisenhower, who insisted on much more frankness about his heart attack in 1955 and arranged for the delegation of much official business, was lucky in not having vital decisions to make at that time:

He realized later that he could not have resolved the dangerous situation that arose in the Lebanon in 1958 since “the concentration, the weighing of the pros and cons, and the final determination would have represented a burden, during the first week of my illness, which the doctors would likely have found unacceptable for a new cardiac patient to bear.”


“Certainly had there been an emergency such as the detection of incoming bombers, on which I would have had to make a rapid decision regarding the use of United States retaliatory might, there could have been no question, after the first forty-eight hours of my heart attack, of my capacity to act according to my own judgment.”

Dr. L’Etang seems justified in finding some irony in the contrast of these two passages.

He points out that the very advances of medicine and surgery bring dangers. He describes Harold Macmillan at the time of his resignation as prime minister, making decisions and exerting influence of the greatest importance, at least for his party, immediately before and four days after prostatectomy, a major operation requiring “pre-operative sedatives and narcotics, a general anaesthetic, and post-operative sedatives, narcotics and analgesics.” As he remarks, “The ability to sit up in bed and converse gives little idea of the true state of a patient,” and even eight days after the operation Macmillan was not well enough to speak spontaneously in advising the Queen about his successor but read a memorandum he had prepared the night before. “With the benefits of modern surgical and medical treatment, anaesthetics, and resuscitation,” writes Dr. L’Etang, “the statesman can now be shuffled from bed to a summit meeting at unprecedented speed.”

The disturbances of judgment, working capacity, and relations with colleagues to be seen in this long procession of influential invalids are nearly always due to “physical” rather than “mental” causes. Forrestal seems to be the only one whose condition included fairly clear psychotic features. His paranoid delusions were not evident until his last few months of office and there is no reason to think that his disability had more serious effects on his political judgment than the physical illnesses and exhaustion of other men, serious though both may have been. Nevertheless we are likely to feel differently about it, more disturbed at the thought of a “madman” in a position of power.

Reasonable or not, this attitude is central to the study of George III by two British psychiatrists, Ida Macalpine and Richard Hunter (a mother and son team already well-known for authoritative scholarly work in the history of psychological medicine), and still more to the reception of their book. As a background to its main thesis it offers a full study of the eighteenth-century “business” of looking after the mad, filling in the details of what we know already in a general way. For this alone it would have been a valuable study, although one generating respect rather than passion.


The controversial part is the close examination of the clinical records of George III’s spells of madness in support of the theory that his derangements resulted from porphyria, an inherited metabolic disorder. During acute attacks of the illness the excessive production of porphyrin, a pigment distributed throughout the body, causes among other things a purple discoloration of the urine and, much more seriously, can produce psychological disturbances that lead to psychiatric diagnoses. Macalpine and Hunter make a strong case for believing that George III was suffering from porphyria during his periods of derangement, and they think they can identify the condition, though necessarily on weaker grounds, in earlier members of the British royal family, including Mary Queen of Scots; and they report, though without details, having established it by laboratory tests in four living members of the family.

Most of the time porphyria gives no trouble, and among the royal patients whom they discuss George III was the only one to be thought mad. The incompleteness of their case lies in the lack of any compelling reason for the seriousness of his attacks or any explanation of their coming on when they did. Inclined in general to favor physical rather than psychological explanations in psychiatry they can only imply that perhaps some infection or dietary deficiency precipitated the attacks. And in any case no convincing explanation based on psychological stresses seems to be available.

The authors argue effectively against the view that George was mad during his illness of 1765, and show that the worst troubles of his reign were over before the first unquestionable derangement, in 1788. Beyond much doubt they succeed in their determination to show that, with no mental breakdown until the age of fifty, the king was far from the “vulnerable and neurotic personality, liable to break down under strain and stress,” which nineteenth-century historians supposed him to be. He comes out as a person who went through fearful ordeals, stemming from his treatment as much as from his illness, with great courage and, until senility overtook him, with remarkable powers of recovery.

Unfortunately they scarcely safeguard themselves—and possibly had no wish to—against the conclusion that, as one review put it, “George III was not mad, but suffered from…porphyria.” The implied antithesis lies behind the controversial reception of the book in England. A weak, disparaging review, in the manner of Oxbridge common rooms of a generation ago, triggered off an exceptionally lively correspondence in the Times Literary Supplement, with historians, psychiatrists, general physicians, and genealogists hurling themselves into a fierce melee from which the book emerged not quite unscathed but in all essentials intact and far from discredited.

It was evident that great pressure of feeling could still build up around the question whether the king’s mental derangement had an identifiable physical cause. No one doubts that he was deranged. No one doubts that patients with general paresis or Korsakoff’s syndrome are insane, although the physical causes of both conditions are known; and if the determined optimism of some psychiatrists and biochemists in seeking a metabolic causation for schizophrenia were ever justified, schizophrenics would still be mad. Somehow or other the social stain attaching to madness still lingers, and somehow or other an identifiable physical cause, especially a respectable and unavoidable one, serves to bleach it.

And when the psychological disorders are insidious at onset and difficult to assess, taking the form of lowered efficiency, indecisiveness, irritability, clumsiness in personal relations, unsound judgment, failing grasp on complex situations, disorders arising from the physical conditions Dr. L’Etang catalogues among national leaders, then the patient’s colleagues are unlikely to think of his state as a sign of “mental disturbance” at all. Yet the practical effects may be at least as bad, if only because the more florid derangements are not allowed so long a run.

It would be difficult to show that Forrestal’s delusions of persecution had worse consequences than Edward Grey’s overwork. A country that found a solution for the problem of ill health and exhaustion in its major politicians would have made an incalculable but unquestionably important gain. Dr. L’Etang has no solution: he sees mainly the professional conflicts confronting the physicians of these powerful men. Simple Draconian measures are out of the question. Politicians’ errors can be as serious as airline pilots’ but we are not likely to see a fixed and early retirement age and periodic medical checks with reports to someone other than the patient. To whom could reports on the President or the Prime Minister be made?

Public opinion (backed by the self-interest of opposition politicians) can be expected to make it more and more difficult for extreme disablement in the great to be concealed, especially after the example set by Eisenhower. The less obvious handicap of extreme fatigue and emotional strain (Dr. L’Etang notes instances of politicians reduced to tears at the height of crises—British politicians too, not just those volatile races) will never be publicized. Nothing can take the place of self-assessment by the men themselves; but since fatigue, like alcohol, diminishes self-criticism, the difficulty of judging how near you are to the end of your tether increases as you approach it.

Forty years ago the need for a psychological Plimsoll mark was recognized in applied psychology but we still have no such index of the individual’s being overloaded and in danger of foundering. You can only learn your own warning signals: the headaches, indigestion, insomnia, dreams of vertigo, nail biting, increased need of alcohol or tobacco, whatever they may be. But confronted with them the temptation is always to ask a little more of yourself, to believe you have reserves to call on and can stand the strain a little longer. Since people who achieve anything have inevitably had to endure stress resiliently, the able and successful man is especially likely to ignore the warnings and believe that in his circumstances he simply can’t afford to rest or unload responsibility.

More profoundly, though he seldom recognizes it, he can’t afford to relinquish the psychological support of his role. Too often retirement is involved. Politicians exhibit in sharpened form one of our cultural dilemmas about age. They are not likely to reach anything like the power they have hoped for until late middle age and the problems of illness and exhaustion generally face them when they are elderly. We are still to a great extent gerontocratic, but with us (unlike some other cultures) the elderly have genuine respect only while they retain the activity of middle life.

Politicians even more than businessmen are sustained by their roles; the deference, the assistance, the expectations and demands of others constitute cogs that keep the wheel turning. Retirement is a disappearance into the shadows, the writing of memoirs being only one stage in the process of ego-deflation. Men prefer to go on until they are dead, exhausted, or incapacitated beyond concealment rather than face such role deprivation. The ending of the politician’s career only highlights the wider social problem of the transition between “rolesustained” middle age and the old age that people have to live on their own responsibility.

This Issue

January 28, 1971