Mental health issues of Maria I of Portugal and her sisters: the contributions of the Willis family to the development of psychiatry

Abstract

Contemporary accounts credit Dr Francis Willis (1718–1807) with facilitating the recovery of King George III from his major episode of acute mania in 1788–9. Subsequently Willis was summoned to Lisbon to advise on the mental health problems of Queen Maria I. This article reports the nature of the illnesses of Maria and her two similarly affected sisters, and uses the program OPCRIT to propose diagnoses of major depressive disorders. The high prevalence of consanguinity and insanity among the Portuguese monarchy and their antecedents probably contributed to their mental health problems. The successive contributions of the Willis family from Thomas Willis (1621–75) to his grand-nephew, Francis Willis (1792–1859), are reviewed; the popular image is somewhat inaccurate and does not highlight their part in the development of psychiatry.

Keywords

Consanguinity history King George III Maria I Portugal psychiatry Willis family

Introduction

Although much has been discussed about the contribution of the Willis medical family¹ to the management of George III’s mental ill health, the general perception is that their contribution was negligible. The emphasis, particularly in lay circles, is that they were responsible for the ‘brutal techniques’ employed and that the King recovered in spite of rather than because of their care. This interpretation has been presented in the play and film by Alan Bennett describing the King’s major episode of mental ill health in 1788–9. These views have largely been the result of claims by psychiatrists and amateur historians Ida Macalpine and her son Richard Hunter that the King was not mentally ill but suffered from an undiagnosed metabolic disorder, variegate porphyria (Macalpine and Hunter, 1969). The recent detailed re-investigation of their claims showed that their conclusions were flawed (Hift, Peters and Meissner, 2012; Peters, 2009; Peters and Wilkinson, 2010) and that he suffered from recurrent episodes of mania, probably as part of bipolar disorder (Peters, 2011; Peters and Beveridge, 2011a, 2011b). This has stimulated the present review of the contribution of the Willis family to our knowledge and treatment of psychiatric disorders.

After the King’s recovery in March 1789, Francis Willis was in 1792 invited to Lisbon, where Queen Maria I (‘Maria a Louca’, i.e. Maria the Mad) was likewise mentally ill. He was asked to advise on her treatment and future management. In the event, although she improved for a time, she did not recover and, as in the case of George III, her heir was appointed Regent. The main comments about Willis’s care of Maria concern his failure and the large fee of £16,000 paid him (Domingues, 1972: 257). The details, possible causes and nature of her illness and that of her similarly affected sisters, and the approach of Willis have not been hitherto researched in detail.

This article reports from the extensive but unfortunately non-medical sources: the nature of the mental illness of Maria and her two similarly affected younger sisters; details of the management advocated by Francis Willis; and possible reasons for his relative failure. A novel approach has been the use of the computer-based diagnostic program OPCRIT in the evaluation of their illnesses.

The results of this research will be used as a basis for the assessment of the overall contributions of five generations of the Willis family to the development of mental health services.

Sources and methods

In the absence of available medical reports on Maria and her sisters and their antecedents and descendants, it has been necessary to rely mainly on the contemporary confidential reports by British envoys in Lisbon to the Foreign Office in Britain. These papers are preserved at the National Archives, Kew, under SP 89/64-92 and FO 63/1-55, but some reports are wanting.

A brief account of the relevant envoys follows. Between 1766 and 1770 William Lyttelton (1724–1808) was the envoy to Portugal, and his letters between January 1768 and April 1770 are available. A career diplomat, he had previously served as Governor of South Carolina (1756–60) and of Jamaica (1762–6). He was succeeded in Lisbon by the Honourable Robert Walpole. In the interim after Lyttleton’s departure ‘for personal reasons’, the Consul-General Sir John Hort (1735–1807) contributed letters between March and November 1771. There is, however, a gap in the available papers between November 1771 and Walpole’s earliest report in March 1779.

The Honourable Robert Walpole (1736–1810), nephew of Prime Minister Robert Walpole, was envoy to Portugal 1771–1800. This period coincided with the major illnesses of Maria and her relatives. Walpole’s detailed accounts of her symptoms, progress and consequences and of Francis Willis’s time in Portugal are vital to our understanding of these events. The details of Walpole’s insights into the background and causes of Willis’s failure are particularly valuable. Walpole returned to England in July 1799 for health reasons and was followed as envoy by John Hookham Frere, Robert Fitzgerald and Viscount Strangford. Following the arrival of the Royal Family and Court in Brazil in 1808, the correspondence was continued by Francis Hill under Consul-General Sir James Gambier.

In parallel with these reports, there is correspondence between the Portuguese Foreign Minister Luís Pinto de Sousa Coutinho and the Portuguese envoy in London, Cipriano Ribeiro Freire, and extracts are included in Maria’s case history. There are also reports by foreign visitors, most notably William Beckford (1759–1844), to Portugal during these events, and these are included when considered reliable.

The diagnoses of Maria and her sisters have hitherto not been considered or have been based on arbitrary unsubstantiated opinion. Thus in her recent book Jenifer Roberts (2009) does not offer a diagnosis for them, but in a personal communication (18 May 2010) she considers Maria to have suffered from bipolar disorder and attributes a diagnosis of ‘an atypical form of manic-depression’ to anonymous medical contacts. In the present study, in order to achieve a more objective diagnosis, the computer-based program OPCRIT has been used.

As this is the first such use of the program in historical medical research, some background and justification are necessary. OPCRIT (Operational Criteria in the studies of psychotic illness) was developed by Peter McGuffin and colleagues in Cardiff for the standardization of patient case records as a basis for their genetic studies (McGuffin, Farmer and Harvey, 1991). The program has been upgraded to include additional clinical features and to respond to subsequent editions of the DSM. The system has been extended and validated by a group of some 30 US and European clinicians (Williams et al., 1996). The version used in the current study is OPCRIT 4 WINDOWS (October 2009).

Results

Figure 1 shows the genealogy of Maria I and indicates her origin from the Houses of Braganza, Habsburg and Bourbon, all of which had a high prevalence of mental illness. Notable is the widespread consanguinity among Portuguese and European royalty, with cousin and uncle/niece and aunt/nephew marriages. Those of her antecedents who had strong evidence of mental ill health are noted. This was mainly validated by the appointment of a Regent and consistent contemporary reports of ‘madness’.

Figure 1.

Maria I’s genealogy showing her Habsburg-Bourbon-Braganza ancestors (compiled by the authors with the help of Liz Jack); ***** indicates evidence of major mental and/or physical abnormalities.

The problems began with the marriage of the Austrian Philip of Habsburg to Joanna of Castile. He became Philip I of Castile but reigned only briefly before his death in 1506. Owing to her severe mental disorder, his wife, Joanna the Mad (‘Juana la Loca’), had already been declared unfit to rule and was succeeded by her son, Charles, who became both Charles I of Spain and Charles V, the Habsburg Holy Roman Emperor. Joanna was the last monarch of the medieval House of Trastámara, but in her case there is no specific evidence of antecedent mental disorder. The Habsburgs, however, now became notorious for three centuries of persistent inbreeding, not only between their Spanish and Austrian branches, but also with the Franco-Spanish House of Bourbon and latterly with the Portuguese House of Braganza. Arguable casualties of this process were Charles II of Spain (severely mentally and physically disabled), Philip V of Spain (a victim, especially in his last decade, of melancholia and mental disorder, with lassitude alternating with frenzy), and Philip, Duke of Calabria (severely mentally and physically disabled), who was the disinherited elder brother of Charles IV of Spain.

Among the Braganzas, Afonso VI of Portugal was severely mentally and physically disabled, though, as with Joanna of Castile, there is no specific evidence of antecedent disabilities. He was eventually deposed in favour of his brother, Pedro II, who appears to have experienced bipolar disorder (Barata, 2011: 18). King Pedro sired John [João] V, who suffered greatly from periods of depression and lethargy and from epilepsy (Barata, 2011: 26; Boléo, 2009: 265). His son, José I, married a Bourbon-Habsburg and sired Queen Maria I of Portugal. It should be noted that Maria married her uncle, Pedro III (José’s brother), and that, among subsequent Braganzas, Pedro IV, suffered from epilepsy throughout his life (Barata, 2011: 50).

Illness of Maria I

Maria of Braganza (1734–1816) was the eldest of the four daughters of Mariana de Bourbon and José of Braganza (José I of Portugal). She was known as Maria the Pious (‘Maria a Piedosa’) in Portugal but as Maria the Mad (‘Maria a Louca’) in Brazil. Her father, a rather ineffective monarch who reigned from 1750 to 1777, left the governance of his realm to the dictatorial First Minister, Sebastião de Carvalho e Melo, the future Marquis of Pombal (1699–1782). Although effective in the aftermath of the catastrophic Lisbon earthquake of 1755, Pombal attempted to turn Portugal into a secular state and progressively removed the Court Jesuits by execution or imprisonment, including the dismissal of Maria’s confessor on whom she was particularly dependent. As she had been brought up in a strongly religious climate she found this a deeply distressing event. Maria’s new confessor was Brother Inácio de São Caetano (who had begun his career as a clown at country fairs); he was planted by Pombal on the grounds that he was ‘sufficiently shrewd, jovial and ignorant to make a very harmless and comfortable confessor’ (Beckford 1834, II: 73). Pombal’s reign of terror included in 1759 the gruesome public execution of the Duke of Aveiro and of members of the noble family of the Távoras for their alleged complicity in an attempt on the life of King José. These events, in conjunction with the confiscation of the property of the Távoras and the imprisonment of other members of their extended family, were a constant source of anguished dilemmas for Maria.

Maria dismissed Pombal on her accession in February 1777, but the two decades of his influence were clearly disturbing and had taken a toll. She was placed under particularly severe stress on the occasions when, as Queen, she was urged, as the result of lawsuits, to sign documents rehabilitating the Távoras and restoring their property (Beirão, 1944: 167; Boléo, 2009: 267; Honrado, 2007: 123; Livermore, 1969: 240–1; Roberts, 2009: 67; Santos, 1974: 559). These incidents provoked delirium, and she became convinced that, for refusing to sign, she was damned to Hell, along with her father.

Maria’s father, like his father in turn, suffered from recurrent strokes and peripheral vascular disease and he died soon after a major stroke in November 1777. Maria’s mother, who suffered from repeated chest pains, died on 3 January 1781 following ‘a violent oppression at her breast’, probably a myocardial infarction.² Thus Maria and her sisters had a strong family history of cardiovascular disease. Maria’s husband Pedro III (her paternal uncle) was similarly affected, dying following ‘repeated paralytic attacks’ on 25 May 1786. The year 1788 was a distressing one for Maria with the death from smallpox of her eldest son and heir, Crown Prince José. In 1777 he had married his maternal aunt, Maria’s sister Benedita. In addition, her daughter Mariana, together with her husband and newborn son, died of smallpox. Maria’s second son João had married the Spanish Princess Carlota in 1785, and there were (unwarranted) concerns about her fertility. Brother Inácio, Maria’s confessor, died in December 1788.

The first account of mental disturbance in Maria was an episode of delirium in 1781 (Beirão, 1944: 167; Willis, 2009). However, on 27 September 1788 Walpole reported; ‘Her Most Faithful Majesty … bears very strong Expressions of affliction in her countenance’.³ This may well relate to the sudden death of her son and heir from smallpox. This loss would have undoubtedly troubled Maria as she had previously been advised to have her family inoculated against smallpox but had refused, largely on the basis of her religious beliefs. It is also noteworthy that from September 1787 the Prince of Brazil, who became Maria’s new heir, and her confessor, Brother Inácio, to whom had been granted the empty title of Archbishop of Thessalonica, were members of the Governing Council, probably reflecting concerns over her disability. News of George III’s serious mental health illness reached Portugal on 24 November 1788.⁴ News, too, of the French Revolution of 1789 may have added to the Queen’s troubles, as was the case with other monarchs throughout Europe; however, the much more sombre and potentially devastating news concerning the execution of Louis XVI and then Marie Antoinette in the early months of 1793 came well after Queen Maria’s mental disorder had been recognized and action taken.

On 29 November 1791 there were concerns over the disposition of Her Most Faithful Majesty, with ‘want of sleep’ and ‘pains in her stomach’.⁵ There is a reference in January 1792 to Maria’s ‘Melancholy Reflections’ and ‘uneasiness and apprehensions’, but generally the reports reflect medical (dropsy, stomach pains and inflated stomach) rather than any psychiatric symptomatology. However, on 1 February 1792 Walpole’s letter stated ‘Her Mind it is said is very afflicted’,⁶ and by that date and subsequently her son João signed her official papers. Walpole refers on 24 February to a proposal ‘to invite Doctor Willis over to give his attendance’. Maria’s symptoms increased without any amendment, and Willis arrived by the Hannover packet on 15 March 1792. Initial reports were favourable, but Willis’s attempts to impose his usual regime of isolation on the patient were unsuccessful. Meanwhile, Maria continued to have major mood swings requiring constraint, blistering and unspecified medication. Her son, the Prince of Brazil, became de facto Regent from February 1792, which was only officially confirmed in 1799.

In parallel with these reports of the British envoys there is similar correspondence between the Portuguese Foreign Minister, Luís Pinto de Sousa Coutinho, and the Portuguese envoy in London, Cipriano de Ribeiro Freire. Thus on 4 February 1792 Coutinho wrote to Freire:

From the beginning of October [1791] she began to present a great melancholia, nocturnal distress, interrupted sleep and deep depression … at the beginning of January Her Majesty was bled on the advice of her doctors; after this juncture her illness has progressively increased and nine days ago it became exacerbated to the point where there are fears of her passing into a total frenzy.⁷

On 11 February, 17 court physicians signed the only medical bulletin known to have survived, a text which records no symptoms but which merely confirms that, on health grounds, Her Majesty should play no part in government affairs until such time as her health recovered (Ramos, 2010: 323–4).

On the death of Brother Inácio, late in 1788, under mysterious circumstances suggestive of foul play (Calmon, 1935: 40), the Queen’s next confessor (appointed within days) was José Maria de Melo, the young Bishop of the Algarve, who was known for his strict Jansenist approach. According to the Papal nuncio, in a letter of 10 May 1792 from Lisbon to the Vatican, the bishop replaced Brother Inácio’s ‘tranquillizing’ effect on the Queen concerning the reinstatement of the Távoras and their relatives with a disquieting approach which ‘aggravated her morbid state’ and her sense of guilt. The nuncio’s view was that the severity of the bishop’s approach and threats of eternal damnation intensified her mental disorder and caused her breakdown (Santos, 1974: 557–9). This opinion was shared by the Italian Cardinal Bartolomeo Pacca, who got to know the Queen during his stay in Lisbon at this time and who reports in his memoirs that the Prince of Brazil was of the same mind (Edmundo, 1957, I: 111).

There are brief contemporaneous sources covering Maria’s behaviour up to 1807, when the Portuguese court moved to Brazil. William Beckford, after a visit to Portugal in 1793–94 (when he frequented Court circles), blamed Bishop Melo ‘for preaching eternal punishment with such energy that his poor penitent has gone mad’ (Pires, 1987: 173–4). Hugues Ranque in a series of letters, written from Portugal in 1801 but published in 1837, attributes her illness to the threats of ‘Hellfire open beneath her feet’ made by her (unspecified) confessor or confessors. He mentions that during this period she had only ‘very brief and very rare moments of reason.’ (Ranque, 1837: 21). Laure Junot, wife of the French ambassador to Portugal, in her Mémoires relating to 1805–06 also attributes the Queen’s illness to Bishop Melo’s influence and describes an episode of violence towards her ladies-in-waiting and ‘a stare that was not just mad, but demoniacal.’ (Junot, 1893, V: 478).

On 29 November 1807 envoy Lord Strangford reported to Foreign Secretary George Canning in London that, owing to the approach of Napoleonic forces and following British encouragement, the entire Royal family, including the two stricken sisters, left Lisbon for Brazil.⁸ Maria was apparently loath to leave Lisbon and during the voyage occupied ‘a barred cabin’ (Norton, 1979: 30). Reflecting Willis’s earlier advice, the two-month sea voyage to Brazil was accompanied by a temporary improvement (Wilcken, 2004: 90). Maria had ‘moments of relief but, once over, the symptoms return stronger than ever’ (Marrocos, 1934: 583; Wilcken, 2004: 166), and ‘moments of lucidity’ (Junot, 1837, II: 235) continued until her death with cardiovascular symptoms in Brazil in 1816 aged 82 (Boléo, 2009: 345; Wilcken, 2004: 166).

Consultation of Dr Francis Willis by Maria I

On 20 December 1788 Walpole received from Maria her best wishes for the recovery of King George’s health⁹ and on 1 April 1789 he sent, in his report, the congratulations from British merchants in Lisbon on the King’s recovery.¹⁰ Reports on, and concern at, the increasing ill health of Maria are found in Walpole’s letters to the British Foreign Office of 1790–2, and on 24 February 1792 he notes, ‘It is rumoured that a Messenger had been sent by Land to invite Doctor Willis over to give his attendance’ and ‘Her Majesty’s State of Health for several days continued without any amendment’.¹¹

Correspondence between Coutinho and Freire continued, with increasing concern over Maria’s health. Freire contacted Willis, persuading him to go to Lisbon; initially reluctant, Willis agreed to go after generous financial terms were agreed on the advice of King George. Willis arrived at Falmouth on 3 March 1792, sailed on the Hannover packet-boat on 8 March and, after the usual sea-tossed crossing, docked on the 15th at Lisbon, where he was luxuriously installed in the Palácio das Necessidades. Interestingly, unlike his arrival at Kew to treat King George, he was not accompanied by either of his medically qualified sons or any assistants, which suggests that his role was as adviser to the Portuguese medical staff and attendants and not as the primary carer. It is this difference and the major cultural differences towards royalty in Portugal as compared to England that may have contributed to his lack of success.

Willis’s initial reports were encouraging; Coutinho reported on 17 March 1792 that Willis did not find her Majesty ‘beyond all hope of cure’ and he ‘happily put into practice his method of cure’.¹² Similarly, Walpole reported on 18 March that Willis’s ‘remedies have had an immediate and surprising effect in restoring Her Majesty to her presence of mind’ and was of the view that he would ‘in a short time restore her health’.¹³

The nature of his treatments are not specified but presumably were similar to those successfully employed on George III, i.e. stopping regular administration of powerful emetics, purgatives and other medications, reducing venesection, blistering and scarification, and adopting his regime of so-called directive psychotherapy and, as necessary, restraint but with adequate nutrition. According to Walpole’s report of 18 March 1792, Willis seems to have claimed that this corrected the ‘erroneous proceedings of the Faculty’. Apparently plans were made for the provision of force feeding of the anorexic Queen. However, the other essential components of his therapeutic regime (removal of the patient from external pressures and stress and complete medical control) proved impossible. Although Willis persuaded the Prince of Brazil to move Maria to the country palace at Queluz to provide a more restricted environment, the myriad of courtiers insisted on accompanying her there. Similarly, there were reports of indiscretion by her female attendants, and attempts by the lady abbess to visit the Queen were forbidden by the Prince. In addition, attempts by Willis, himself a trained and experienced clergyman, to encourage some religious support were also opposed.

In an attempt to shield Maria from Court intrigue and give her additional privacy, Willis proposed sea excursions. It has been suggested (Wilcken, 2004: 57–8) that he planned to transfer her to his private treatment house in Lincoln where he had other similarly affected nobility, including some from abroad (Hunter, Macalpine and Payne, 1956). However, Walpole reported on 4 July 1792 that Willis’s proposals for even local excursions were opposed by the Lisbon physicians with support from the local Admiral, and the project to take her to Lincoln was ‘entirely laid aside’.¹⁴ Willis then made plans to return to England and conferred with additional physicians from Coimbra who agreed to take over her future care along the lines Willis used. On being informed of his intended departure (which took place in early August 1792), Maria became more intractable and, although Pinto de Sousa Coutinho said that Willis had done all that was possible for the Queen, her behaviour and the need for restraint were very much as before, and her son the Prince of Brazil acted fully as Regent from then on. Willis received as his fee £10,000, plus £1,000 per month, i.e. £5,000, together with all expenses, thus making £16,000 in all.

Walpole returned on leave to England for six months (23 September 1792 – March 1793) and on his return to Lisbon reported (31 March) that the Queen was ‘in a most melancholy state, her memory seems to have left her and She has but a confused Idea of persons and things’; in addition, she had a serious disorder in one of her eyes which after surgery (not specified) led to a loss of sight.¹⁵

Subsequent reports by Walpole continue in the same vein. Thus on 2 July 1794 he reported: ‘Her Most Faithful Majesty continues in the same unfortunate state of Mind … frequently very fretful: very much disposed to a perfect indifference to everything; and dreading every excitement to exertion.’¹⁶

Mariana [Maria Ana] of Braganza (1736–1813)

Mariana was the second daughter of King José and was Maria’s sister. The first report of illness was on 7 January 1769 when Lyttelton noted, ‘Her Royal Highness the Infanta Donna Marianna [sic] still continued much indisposed.’¹⁷ On 26 October 1782 Walpole reported that the journey of the Royal family from Caldas to Queluz was delayed on account of her illness.¹⁸

A letter from Walpole to Lord Grenville (Foreign Secretary) in London dated 2 July 1794 states: ‘One of Her Most Faithful Majesty’s Sisters, the Princess Dona Marianna, appears to be afflicted with the same Melancholy disorder, as the Queen; and as Her Royal Highness is in a weaker State of Health, it is feared that her existence may be more precarious.’¹⁹ Mariana remained unmarried; she was reported to have an excellent singing voice and was a skilled painter but clearly had chronic psychiatric ill health, although few details are available. She died in Brazil in 1813, when suffering from ‘stomach spasms and vomiting’ (Boléo, 2009: 333).

Dorothea [Doroteia] (1739–71)

The first reports of her chronic illness aged 30 approximates with that for Mariana. Lyttelton wrote (27 January 1769) ‘that Her Royal Highness the Princess Dorothea’s illness is become very dangerous, although there are today some symptoms of amendment; the disorder I am informed is in part Hysteria, and accompanied with almost total loss of appetite, which has reduced Her Royal Highness to a state of extreme weakness.’²⁰ Her situation fluctuated, and Lyttelton reported again on 27 January 1769: ‘HRH The Princess Dorothea is somewhat reliev’d from the disorder She labours under’, but on 12 February: ‘The Princess Dorothea continues still, in a very ill state of health’. It is noteworthy that the entire Royal family with the exception of Dorothea travelled to Salvaterra (the Royal Hunting Lodge outside Lisbon) on 4 April 1769.²¹

There are no further extant reports concerning Dorothea, and she died on 14 January 1771. A report in a recent book suggested that she may have died of a breast tumour (Braga, 2007: 88). Of the three sisters with mental health problems, Dorothea seemed to have the earliest onset, was the most severely affected and died aged 32 years, compared with Maria (82 years) and Mariana (77 years). Neither Dorothea nor Mariana married; they were each proposed as brides for Louis, the Dauphin of France, but their mother refused consent, possibly reflecting her concern over their mental ill health.

Benedita (1746–1829)

In contrast, the youngest of the four sisters, Benedita, had apparently no significant mental health issues and married her nephew José, Prince of Beira. They had no children, although she had two miscarriages. As Dowager Princess of Brazil she devoted herself successfully to various charitable projects (Braga, 2007).

Summary and diagnoses

Three of the four sisters had severe intractable mental illness. There was a family history of similar mental illness with consanguinity but, with the exception of Dorothea, a normal life span. There was a family history of cardiovascular disease, including strokes with paralysis, and this may have contributed to their mental illness, most likely in old age. Major affective psychoses are a most likely diagnosis.

However, in an attempt to inject an objective independent element into the diagnosis of Maria and her affected sisters the diagnostic computer program OPCRIT has been used (see Table 1). The diagnoses are related to the various criteria. All three sisters are reported as having a major depressive disorder of moderate intensity by the criteria of DSM-IIIR and DSM-IV, and depression with psychosis by DSM-III criteria. It is noteworthy that the more severely affected sister, Dorothea, meets the 1975 RDC criteria for major depression rather than the schizoid-affective disorder label attributed to her two elder sisters. Similarly, she is noted to have somatic symptoms associated with her depression by the ICD-10 criteria. Some of these diagnostic variations will reflect developments in diagnostic nomenclature in the different manuals.

Table 1.

OPCRIT (Version 4.0) analysis of Maria I and her sisters Mariana and Dorothea.

Criteria	Maria	Mariana	Dorothea
Dates	1734–1816	1736–1813	1739–71
Age of onset (yrs)	46	33	23
Duration of illness (yrs)	36	44	8
RDC (1975)	Schizo-affective depressive	Schizo-affective disorder	Major depression
DSM-III (1980)	Depression with psychosis	Depression with psychosis	Depression with psychosis
DSM-IIIR (1987)	Major depressive disorder	Major depressive disorder	Major depressive disorder
DSM-IV (1994)	Major depressive disorder	Major depressive disorder	Major depressive disorder
ICD-10 (1993)	Moderate depression disorder	Moderate depression disorder	Moderate depression with somatic syndrome

Note: OPCRIT: Operation Criteria in Studies of Psychotic Illness; RDC: Research Diagnostic Criteria; DSM: Diagnostic and Statistical Manual of Mental Disorders; ICD-10: International Classification of Diseases (10th rev.).

Discussion

Consanguinity

Royal marriages of genetically close relatives were common in Europe during the eighteenth and nineteenth centuries. This was largely for political reasons and, in a relative small country like Portugal, was important to preserve its integrity, particularly after regaining its independence from Spain in 1640. The religious divides in Europe at that time would also have imposed constraints on the selection of possible partners. As a strongly Roman Catholic family, Portuguese Royalty would have had to seek possible mates predominantly in Spain and France. Northern European countries, including Britain, would be excluded sources, although there were close political, industrial and economic ties with Britain.

Consanguineous marriages produce offspring with a higher incidence of genetic abnormalities. Consanguinity is defined as unions contracted between persons biologically related as second cousins or closer. It is noteworthy that Mary Queen of Scots had to seek papal permission to marry her cousin Lord Henry Darnley (Fraser, 1969: 257) and this degree of consanguinity may have contributed to the medical problems of their son the future James VI/I (Peters, Garrard, Ganesan and Stephenson, 2012). Surprisingly, higher fertility rates are reported for consanguineous marriages (Bittles, 1995).

It is important to note that recent studies on the consequences of consanguinity are based on selected populations mainly in the Middle East and the Indo-Asian continent, and the findings may not necessarily be relevant to historical European royalty. However, in a recent review, a long-term follow-up of two rural French studies, there was noted a significant deleterious effect of consanguinity on mortality (Bittles and Neel, 1994).

Lower birth weights and an increased infant mortality have been reported in inbred families in an Arabian community (Jaber, Merlob, Gabriel and Shohat, 1997). A detailed study of the offspring of consanguineous marriages indicate that there was a higher prevalence of congenital abnormalities, malignancies, mental retardation and physical handicap compared with the offspring of non-consanguineous marriages (Abdulrazzaq et al., 1997).

Consanguinity and mental disorder have long been studied in the UK, comparing parental consanguinity in general hospital and mental hospital patients, with generally a higher prevalence in the latter (Munro, 1938). More recent studies have confirmed these findings and shown that consanguinity is a risk factor for cardiovascular disease (Shami, Qaisir and Bittles, 1991), bipolar disorder 1 (Mansour et al., 2009), schizophrenia (Mansour et al., 2010) and Alzheimer disease (Farrer et al., 2002). These results may be relevant to the high prevalence of mental and cardiovascular disorders in the Habsburg-Bourbon-Braganzas of Portugal.

The coefficient of inbreeding (F) is used as a measure of the degree of consanguinity. Thus, for first cousin marriages (F = 0.0625), their progeny are predicted to have inherited identical gene copies from each parent at 6.25 per cent of all gene loci. The medical problems depend on the closeness of the biological relationship. Uncle-niece and aunt-nephew marriages (F = 0.125), not uncommon in the Braganzas, will be associated with a higher prevalence of genetic defects (Bittles and Neel, 1994).

The contribution of the Willises to the understanding and treatment of mental illness

Members of the Willis family for five generations over two hundred years (1650–1850) have contributed to the understanding and management of the mentally ill. It should be noted that Francis Willis senior was the grand-nephew of Thomas Willis MD Oxon., FRS (1621–75), the distinguished Oxford-based physician and father of British neurology (Haslam, 1997). It is noteworthy, although famed for his neuropathology studies, particularly of the cerebral vasculature, that as a physician he had an active practice for patients with mental health problems (Hughes, 2009). His Oxford medical lectures as Sedleian Professor of Natural Philosophy (elected 1660) for 1663–4 have been translated and analysed by the late Peter Dewhurst, a practising psychiatrist (Dewhurst, 1980). Of the topics covered, frenzy, delirium, melancholia, mania and stupidity clearly relate to psychiatric disorders. Willis’s approaches, as expected, have a neuro-pathological rather than a psychological emphasis (Dewhurst, 1980). Reflecting this interest and his contribution to early psychiatry, of the 50 cases described in Willis’s Casebook for 1650–2, nine are clearly psychiatric disorders: anxiety state, anxiety depression, premenstrual tension, manic-depressive psychosis, depression, hysteria, alcohol misuse and self-poisoning. Willis is credited with the first description of manic-depressive psychosis in the English literature which meets the DSM-IV criteria for Bipolar II disorder (Dewhurst, 1981: 126–7). His medical receipts, published after his death, contain remedies for ‘phrensie’, madness, stupidity and especially for melancholia. Of the 180 receipts listed, over one-third of them are for psychiatric disorders (Willis T, 1701). His major contribution, however, was the clear localization of mental illness to brain disorder rather than to various abdominal organs.

Willis’s book De anima brutorum (1672) has been described as a pioneering work, laying the foundations of neuropsychiatry by focussing attention on the brain (and soul) rather than the spleen, uterus and other organs as the site of mental illness (Dewhurst, 1980: 130–2). His recommended treatments were that ‘Furious Mad-men are sooner, and more certainly cured by punishments, and hard usage, in a strait-room than by Physick or Medicines’ (Hunter and Macalpine, 1963: 191), and are reminiscent of those used by the succeeding Willises in the treatment of George III and Maria I.

Dr Francis Willis senior, MA, MD Oxon. (1718–1807)

Willis was invited, against strong opposition from the distinguished London physicians then treating George III, to direct and carry out the successful treatment of the King in his first episode of mania in 1788. He trained and practised as a clergyman, later developing an interest in medicine especially the mentally afflicted, and in 1769 he was appointed physician to Lincoln Hospital. The Church had a long tradition of caring for the mentally ill, reaching a peak in the medieval era, but by the seventeenth century it no longer had this as a major role. Nevertheless, individual clerics acted as ‘general practitioners’, especially in rural areas. Willis had a private facility (‘mad house’) and his apparent methods were considered novel and effective. It is clear from the Daily Memorandum²² of Robert Battiscombe (1782–1833), apothecary to the Royal family (1780–1830), that from early December when the Willises were in charge of the King’s care, Battiscombe no longer carried out lancing, cupping and blistering of the King as he had done in the preceding 3 months. His role was confined to dressing the blisters on the King’s leg which were causing him considerable discomfort (Greville, 1930: 125) and according to Willis were exacerbating the King’s symptoms. The additional assistance of Francis Willis by his medically qualified sons, John and Robert Darling, also experienced in the care of ‘mad’ patients, was clearly important (Porter, 2004).²³

John Willis MD Edin. (1751–1835) assisted his father in the treatment of the King in 1788–9, but the London physicians were very disapproving of his qualifications.²⁴ Although consulted during subsequent relapses of the King, he was largely based at the thriving family licensed houses in Lincolnshire, especially after the death of his aged father in 1807. Dr Robert Darling Willis MD Cantab., FRCP (1780–1821) was based in London and was very much involved in the care of the King during his relapses in 1801 and 1810–20 (Parry-Jones, 1972: 75–6).

However, it was Francis Willis’s structured ‘directive psychotherapy’ which seems to have been the mainstay of his treatment. As mentioned earlier, his strategy appeared to be reduction of the so-called medical approach, with avoidance of venesection, cupping, application of leeches and scarification. This would indicate that the humoral theory of mental illnesses held little appeal to Willis. Unfortunately, other than two medical case reports, Willis did not record or publish on his therapeutic approach to the care of patients with mental illness. Reports of his care of George III and of visitors to his licensed houses in Gretford and Shillingthorpe have provided some insight into his methods. With King George he adopted an approach of controlling all the King’s activities and dismissing the courtly deference adopted by the King’s other medical attendants, most notably by Sir George Baker. He used a directive quasi-mesmerizing technique of fixing the patient with his eye. He seemed to lay stress on adequate and appropriate nutrition and thus, in dealing with Maria’s refusal to eat and accompanying weight loss, made arrangements to employ nutrition via an oral tube although in practice this proved unnecessary

His approach had been noted by visitors to his Lincolnshire house. Thus Fredrick Reynolds (1826, II: 154) ‘was astonished to find almost all the surrounding ploughmen, gardeners, threshers, thatchers, and other labourers, attired in black coats, white waistcoats, black silk stockings, and the head of each well powdered, curled and arranged. These were the doctor’s patients.’ This suggests that Willis established a therapeutic community with his family for the patients. A more detailed account was published by an anonymous French visitor:

He observes his patients for quite a lengthy period before setting in motion whichever treatment is appropriate for each one of them; though he has no truly general approach, he always begins by seeking to restore a patient’s natural condition in every physical function … The mentally ill enjoy every freedom compatible with their condition; each of them has a guardian who never leaves him or her, and whose vigilance is maintained by a very simple and effective arrangement; that is if the patient escapes, the guardian is held responsible … (Anon., 1796)

Philippe Pinel, the distinguished French professor of medicine in his book A Treatise on Insanity is less salutary and writes:

Of the celebrated Willis it has been said, that the utmost sweetness and affability is the usual expression of his countenance. But, when he looks a maniac in the face for the first time, he appears instantly to change character. His features present a new aspect, such as commands the respect and attention, even of lunatics. His looks appear to penetrate into their hearts, and to read their thoughts as soon as they are formed. … But Dr. Willis’s general principles of treatment, are no where developed, and applied to the character, intensity and varieties of insanity. (Pinel, 1806: 49–50)

Willis’s grandson, Francis Willis junior MD, FRCP (1792–1859), in his three Gulstonian lectures to the Royal College of Physicians of London in 1822, used this as an opportunity to defend his grandfather’s reputation, which had been criticized following his claim ‘that patients placed under his care, within three months after the attack of the disease, nine out of ten recovered’ (original italics). This he attempted by summarizing his grandfather’s career and quoting supporting statements (Willis, 1823). He also noted the contemporary introduction of a non-restraint system which he claimed was carried out successfully by his grandfather. He also emphasized the supportive rather than therapeutic role of religious instruction in convalescent patients, as advocated by his grandfather and practised by his father Rev. Thomas Willis (1754–1827) in the case of George III.

Contributions of mental illness in royalty to the subsequent provision of facilities to the general population

This aspect has been considered in detail by several commentators with respect to British care of psychiatric patients. However, little is known of any such developments in Portugal, certainly in the short term, owing to the French occupation, the flight to Brazil and subsequent civil unrest in both countries. Certainly by the twentieth century, Portuguese neuroscience was active in the development of psychosurgery, most notably by the Nobel laureate Egas Moniz (António Caetano de Abreu Freire, 1874–1955) (Berrios and Freeman, 1991: 194).

It is difficult to separate the developments in the UK mental health services in the nineteenth century following the King’s illness that were a direct consequence of his episodes of acute mania in 1788–9 from those that were in train and would have occurred even in the absence of the King’s illness. ‘Madness’, its nature, causes and treatment were widely discussed during the period 1780–1820, and King George himself after his remission in 1789 certainly took a personal interest in such initiatives. In the case of the attempted Royal assassination by the mentally deranged Margaret Nicholson in 1786, her confinement in Bedlam hospital rather than execution was a course of action dictated by the King himself (Macalpine and Hunter, 1969: 310–13). This and other issues stimulated the Select Committee Report of 1807 which led to the subsequent County Asylums Act of 1808 and the Amending Acts of 1811, 1815 and 1819 (Jones, 1993: 33–40). It is likely that King George was actively involved with the initial Act, since a leading member of the Select Committee was his personal friend George Rose, whom he regularly visited during his holidays in Weymouth (Macalpine and Hunter, 1969: 129). It thus highly likely that the King’s episodes of ‘madness’ had both direct and indirect effects on the understanding, provision and treatment, including medications, of mental health disorders (Macalpine and Hunter, 1968).

Footnotes

Acknowledgements

We are grateful to: Jenifer Roberts, Drs Ana Isabel Buescu, Michael Haslam, J. Trevor Hughes and F. Peter Willis for helpful discussions during the course of this research; to Liz Jack for assistance with the family tree; and to the staff of the following archives and libraries: The British Library; Dorset County Record Office; The National Archives, Kew.

Notes

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