‘Struensée’s memoir on the situation of the King’ (1772): Christian VII of Denmark

Introduction

King Christian VII of Denmark (1749–1808) was born into the Oldenburg Royal House through his father, King Frederik V (1723–66), and into the Hanoverian Royal House through his mother, Princess Louise of England (1724–51). Both Royal Houses were descended from a great number of German Ducal Houses, and the Hanoverians also from the Stuarts. Over centuries, many members of these dynasties suffered from mental illnesses. An excellent exposition of ‘ducal insanity’ – ‘princely insanity’ in the German Ducal Houses – was published by Midelfort (1994). The complexities of modern interdisciplinary genealogical, genetic and statistical studies as applied to the European royal and ducal dynasties have been described by Raimar (1997) and Richter (1997), their paradigm being the Bavarian kings, Ludwig II (1815–98) and his brother Otto, both insane, and their numerical relations of ancestry over 13 generations.

Christian ascended the throne in 1766 as Absolute Monarch until his death. Throughout his reign he was insane. In accordance with the ‘Act of Royalty’ (‘Kongeloven’, Lex regia) of 1665, the incumbent Danish king was ‘above all human laws and knows no other superiors and judges in either ecclesiastical or secular matters than God’ (Oakley, 1972). As the Act had no physical or mental incapacity provisions, Christian could not officially be considered insane, as such a view would have constituted lese-majesty. He could, therefore, not be dismissed legally or made to abdicate, nor could a regency be enacted. In comparison, Great Britain with its parliamentary system was not faced with a similar dilemma during the attacks of mental illness of King George III (1738–1820), Christian’s first cousin. Incidentally, in 1766 Christian married Caroline Mathilda (1751–75), George’s sister.

In 1768 the German doctor, Johann Friedrich Struensée (1737–72), city physician at Altona from 1757, was appointed Christian VII’s travelling doctor, to accompany him on his ‘grand continental tour’ to Germany, Holland, England and France. At this time, the King was already manifesting signs of mental illness. Struensée gained his trust and confidence, and on their return to Copenhagen in January 1769 he was appointed the King’s personal physician. Further, in rapid succession Christian elevated Struensée to ‘Reader to their Majesties’ and ‘Honorary Member of the State Council’, ‘Maître des requêtes’ and ‘Cabinet Secretary’. The most controversial step in Struensée’s ascent from royal physician to the office of absolute power came when Christian appointed him ‘Privy Cabinet Minister’ on 14 July 1771. The political drama had gained further momentum as Struensée had had an adulterous relationship with Caroline Mathilda since February 1770. On 7 July 1771 she gave birth to her second child, Louise Augusta, of whom Struensée was assumed to be the father. Only two weeks later, coinciding with the celebration of Caroline Mathilda’s twentieth birthday, and the day of the child’s baptism ceremony, Struensée saw fit to raise himself and his close associate, Enevold Brandt (1738–72), to the rank of count. By the autumn of 1771, public unrest was mounting. In a private letter, dated 28 Sep. 1771, A.P. Bernstorff (Friis, 1904: 381) daringly expressed concern to his uncle, J.H. Bernstorff, who had been dismissed as Prime Minister in 1770, about what should be done if ‘on est obligé d’obéir à un roi imbécile’ who was sharing his authority with Struensée. In the letter, Bernstorff even characterized Struensée as a criminal (‘scélérat avoué’), and the only means he saw for restoring calm in the kingdom was a revolution!

Struensée’s tumultuous but epoch-making reign came to a dramatic end in the so-called Palace Revolution, on 17 Jan. 1772. It was carried out by the Queen-Dowager Juliana Maria, Christian’s stepmother, with her son, Prince Frederik, and other ‘conspirators’. She had been given to believe that Struensée was plotting to usurp the throne, marry Caroline Mathilda and become ‘Protector of the Kingdom’ (Roger, 1858; see also Laursen, 2000). According to the Swiss, E. Reverdil (1732–1808) (Roger, 1858), the King’s former tutor and later adviser, Christian’s abdication was to take place on 28 Jan. 1772, and therefore the haste for Juliana Maria to take action, to which, in his words, ‘la démence du roi’ was a potential obstacle. In a surprise and very risky manoeuvre Juliana and her co-conspirators roused the terrified King from his bed in the early hours of the morning after a masked ball and forced him to sign orders for the arrest of Struensée, Caroline Mathilda, Brandt and others. Struensée and Brandt were incarcerated and shackled in dreadful conditions. Carolina Mathilda was imprisoned at Kronborg Castle at Elsinore, under heavy guard and well out of the King’s reach. News of the coup spread like wildfire all over Europe.

In accordance with the Enlightenment, during his short reign Struensée had succeeded in reconstructing the entire central administration of the Twin Kingdoms, Denmark and Norway, with an avalanche of ordinances issued as Cabinet Ordinances of King, in total 1880. They included the famous Ordinance of 4 September 1770 introducing unrestricted freedom of the press – the first in Europe.

A Commission of Inquiry – in fact, two commissions – was appointed (Hansen, 1927–41), made up of high officials who were all known to be enemies of Struensée and his system of government. After a fast-tracked judicial process, he was found guilty of crimen læsæ majestatis. However, his adulterous relationship with Caroline Mathilda was not mentioned explicitly. He was sentenced to death (Hansen, 1927). Brandt was found guilty of the same offence and sentenced accordingly (Hansen, 1927). The sentences were executed in the most barbaric manner in full public view on 28 April 1772.

Christian’s and Caroline Mathilda’s marriage was annulled. Understandably, the relations between Denmark and Great Britain became very strained. George III even considered sending a fleet to blockade Copenhagen. It was finally negotiated to deport Caroline to Celle in Hanover, George’s electorate, where she died three years later.

The sentence of Struensée remains a controversial subject in Danish history (Iuul, 1974). In 1891 N. Lassen, the eminent jurist and later High Court Judge, published the results of his painstaking re-evaluation of the case (Lassen, 1891; Thoresen, 1892). He found that Struensée’s sentence could only be considered defensible if it had been based on the assumptions that the King was insane and therefore was incapable of making rational decisions. As Lassen emphasized, the King’s insanity was not mentioned in the judicial process. On the contrary, the Commission praised him for his ‘merits to and fervour for’ the country. In that case, according to Lassen, how could Struensée be blamed for anything, as it was the King who rescinded the Council of State and issued the Ordinance of 14 July 1771, Struensée’s appointment to Privy Cabinet Minister. Lassen further argued that it was the King who should have been indicted, but that such a step would have been impossible under the provisions of the Act of Royalty. To illustrate his opinion that the King had, in fact, been insane during this critical time in Danish history, Lassen (1891) was the first to present a ‘memoir’ regarding Christian’s ‘situation’; this is an invaluable historical document which Struensée had written in French (Hansen, 1930) during the last two to three weeks of his incarceration.

Struensée’s ‘psychiatric’ knowledge (Winkle, 1980, 1989)

Struensée’s medical duties at Altona included the care of the mentally ill. He recommended autopsies of the insane to obtain rational aetiological explanations of insanity. It was also apparent (‘offenbar’) to him that skull fractures and concussions could give rise to insanity (‘Wahnsinn’). He reiterated that Solanum used in folk medicine for pain, convulsions and infertility, could cause delusions (‘Wahnvorstellungen’) in normal as well as insane persons. He warned that stupefying poisons (‘betäubende Gifte’), e.g. Hyoscyamus niger, Datura stramonium, belladonna and hemp could influence the brain in almost the same way as wine or opium. He referred to the fact that examples of transitory delusions (‘vorübergehende[r] Wahnsinn’) induced by vegetable poisons are found in the medical literature, emphasizing that the ‘ensuing stupefaction [‘Trunkenheit’] could resemble almost any kind of insanity [‘Tollheit’]’. He also suggested that such agents should be used as sedative (‘betäubende’) remedies in the agitated insane (Anon., 1760). Travelling with Christian in 1768 (Winkle, 1989), he had visited the Bedlam, and in Paris Hôtel-Dieu, la Salpétrière and Bicêtre.

Struensée’s memoir on Christian VII

According to this document (Lassen, 1891; Hansen, 1930), Christian harboured much singularity of mind and character, his ideas were bizarre, false and absurd, and he believed them to be true. They would change continuously so that it was difficult to provide a clear picture of these abnormal experiences. Struensée was also struck by Christian’s inconstancy, indifference to or even disgust for all things, which at times was accompanied by significant agitation, and not infrequently a certain insensibility of his nerves. Not only were his imaginings fallacious, without foundation, but they could also develop into ‘le plus grand désordre’ marked by uncontrollable behaviours in the form of ‘paroxisme’, and ‘des grimaces et contorsions’, which at times appeared to be involuntary. He could also break into inappropriate laughter. He used words and expressions, which were not immediately understandable, and he could behave in an oppositional manner. Struensée made the observation that the more it was attempted to dissuade the King from doing certain things, the more he persevered. Importantly though, he reported that Christian also experienced lucid intervals during which his reasoning was correct. Struensée characterized his ‘collections of fictions’ as a novel (‘roman’) and, he added, this was what Christian himself did when he was in good spirits, though without his doubting its ‘veracity’.

Struensée’s memoir is corroborated by the memoirs of Reverdil (Roger, 1858), but possibly not recorded until 20 years after the Palace Revolution in 1772 (Bobé, 1916), when he was sent into exile (he had also been exiled from November 1767 to February 1771). Whereas Struensée, for whatever reason, used non-technical language, Reverdil used terminology such as démence, folie, délire, imbécilité and aliénation. Both of them might have been acquainted with eighteenth-century ‘psychiatric’ classification (see also Menninger, 1963), for instance based on articles in the famous Encyclopédie (Diderot and d’Alembert, 1751–72). However, as Garrabé (personal communication, 2006) importantly suggested, given that Reverdil’s memoirs were not published until 1858 by Reverdil’s cousin, A. Roger, a magistrate, the terminology used might have undergone revision in the editing process, either by Reverdil himself or his cousin, in accordance with the teachings of Pinel and Esquirol.

Struensée’s ‘diagnosis’ and treatment of Christian

Struensée considered Christian’s symptoms to be caused by or the effect of an indulgence in ‘a bad habit’, ‘a habit that one can guess without naming it’. He strongly discouraged him from this, but his efforts were to no avail. He prescribed him ‘cold baths’, which he considered the best remedy to stop ‘les mauvaises suites’, but he was concerned that there would be no cure unless a more efficacious remedy could be found. Despite this gloomy outlook, he did, however, see prospects for improvement.

The court physician, Just von Berger, had given evidence to the Commission of Inquiry (Hansen, 1927: 393–4) that Struensée had consulted him ‘every time’ when he thought the King’s health necessitated it. To combat the ‘indisposition’, for which he thought ‘that certain extremely injurious defects of life style could be the cause’, he recommended the King take ‘China [bark] and steel [powder], and the cold bath’ (Hansen, 1927: 391–2). He also referred to his colleague, Christian Johan Berger, who had confirmed to him that the King used ‘China and steel powders’ (Hansen, 1927: 6). According to Reverdil, Berger had also treated the King with ‘le quinquina et les bains froids’ (Roger, 1858: 258, 437–8).

It had been rumoured, for instance by the historiographer-royal, P. F. Suhm (1728–88) (Clausen, 1918: 49–50, 68), that Struensée was poisoning the King with opium and other dangerous medicaments. ¹ The Commission therefore impounded his medicaments and prescriptions: rhubarb powder, China bark, limatura martialis, Elaesacch. cinnam, Radix Jalappae, Laudanum liquidum. However, foul play could not be established (Hansen, 1927: 391–4; Roger, 1858: 247, 258, 356, 437–8; Snorrason, 1968: 76–9).

Based on his memoir on Christian’s condition as he had observed and treated it, Struensée would have considered it to be a case of masturbatic insanity. This was supported by other contemporary sources, e.g. one by Councillor Wasserslebe (Blangstrup, 1890: 217–18) stating that Christian was given to ‘cette debauche solitaire, pollution volontaire’, which had ruined not only his body, but ‘affaibli son esprit’. Without mentioning masturbation explicitly, Reverdil wrote that this disorder ‘dut contribuer aux progrès de sa démence’.

Eighteenth- and nineteenth-century medical views of masturbation

In the eighteenth century, views of masturbation were mainly influenced by two notable works: (1) that of ‘Doctor Bekkers’, 1716 (Hunter and MacAlpine, 1963: 348–50) which had appeared in 22 editions by 1778; and (2) that of S.A. Tissot (1758, 1760) which totalled 131 editions in seven languages by 1766. In accordance with other medical authorities, Tissot mentioned a plethora of disturbances (‘une foule de maux’): apoplexy, lethargy, epilepsy, blindness, tremor, paralyses, spasms, pains in the membranes of the brain, inertia, stupidity and insanity (‘la folie’, ‘la démence’), ‘la plus noire mélancholie’, ‘un relâchement total du système nerveux’. Tissot himself had observed hypochondriacs in whom masturbation could facilitate attacks of ‘délire ou de manie’, developing into states of imbecility which could be interspersed by attacks of ‘frénésie’, and states of ‘légère démence’. Pinel (1809: 68–9) generally expressed a more optimistic view, whereas Esquirol (1838, Vol. 1: 47, 68, 391; Vol. 2: 156, 235) saw masturbation as a frequent cause of folie (aliénation mentale), and in some cases as a prelude to manie and démence. Subsequently, masturbation was even discussed as a possible underlying cause of hebephrenia (later dementia praecox) (Hecker, 1871: 420), until this view was finally dispelled by Kraepelin (1896: 50–2).

Tissot’s prescription for masturbation

Tissot (1760) recommended Peruvian bark and cold baths (‘le quinquina et les bain froids’) – ‘les deux plus efficaces’ – and limatura martialis (‘le fer, les eaux ferrugineuses’, ‘les eaux martiales’), and ‘un opiate composé de quinquina’. There can be no doubt that Tissot’s treatment regime is the one applied in Christian’s case, thus confirming that Struensée and the King’s other doctors were fully acquainted with Tissot’s work on masturbation, which was also summarized in the Encyclopédie (Diderot and d’Alembert, 1765, Vol. 10: 47–9).

Viggo Christiansen’s pathography of Christian VII

It is plausible to conclude that a contemporary ‘diagnosis’ of Christian VII’s condition was masturbatic insanity. It was not until 1906, at the request of the eminent Danish historian, Aa. Friis, that his countryman, the neurologist and psychiatrist Viggo Christiansen (1906/1978) subjected the King’s illness to a pathographical study. His main sources were the memoirs of Struensée and Reverdil. Especially Struensée’s, he found ‘paradigmatic, containing as it does quite a number of details and minor traits whose diagnostic significance it has not become possible to evaluate until the advent of later studies on insane people, but for today’s psychiatrist not only lend life and lucidity to his description, but also allow for an accurate diagnosis of the King’s insanity’. Emphasizing features such as early onset, apathy, emotional indifference, neologisms, negativism, inappropriate laughter, grimacing, automatic movements, grandiose and persecutory delusions, impulsive behaviour, fits of agitation, melancholia and hypochondria, with a sinister course and outcome, but with lucid intervals, Christiansen concluded that the King suffered from dementia praecox, i.e. schizophrenia, but importantly, he drew attention to the fact that there was no link between masturbation and dementia praecox. Notwithstanding, both Porter (1987: 240) and Green (1993) wrote that Christiansen had expressed the opposite opinion.

Christian VII’s illness has subsequently been evaluated by many authors, among them Hallager (1907; see also Christiansen, 1907), Koch (1907), Reddaway (1916), Hansen (1917), Lange (1926), Snorrason (1968, 1973), Langberg (1972: 7, 95–9), Schioldann and Juel-Nielsen (in Christiansen 1906/1978), Reisby (1978) Winkle (1980, 1989), Porter (1987: 51–3), Ragsdale (1988: 155–7), Green (1993), Mellergård (2001), Retterstøl (1990: 191–5, 2004: 36–51), Amdisen (2002), and Tillyard (2006).

George III and Christian VII

Refuting Guttmacher’s (1941, 1964) hypothesis of manic-depressive illness in the case of George III, Macalpine and Hunter (1966, 1969) and Macalpine, Hunter and Rimington (1968) espoused the hypothesis that he and several other members of the Hanoverian dynasty suffered from porphyria, which can cause recurrent insanity. This epoch-making hypothesis caused and continues to cause great controversy among doctors and historians alike, epitomized by strong support by With (1983) and Cox et al. (2005), and a disparaging categorical dismissal by Peters and Wilkinson (2010; see also Dean, 1971). Based upon a large amount of literature on the subject, both for and against, I have found the hypothesis to be plausible and credible, a view shared by Berrios (personal communications, 2006, 2012) based partly upon his conversations with Hunter.

In 1968 the medical historian, Snorrason, confirmed Christiansen’s findings and drew attention to Macalpine’s and Hunter’s hypothesis, recommending that this should also be given consideration in the Oldenburg dynasty; he mentioned Christian’s father, Frederik V, and his forebears as possible porphyria sufferers. Intriguingly, Debrett’s Kings and Queens of Europe included Christian, noting that he ‘seems to have inherited the terrible “royal malady”, porphyria, from his Hanoverian mother [Louise] and his mental capacities were greatly impaired thereby’ (Williamson, 1988: 116).

Porphyria

Porphyria was described as a clinical entity by Günther in 1911 and modified by Waldenström in the 1930s (Goldberg and Rimington, 1962). Acute Intermittent Porphyria, including the variegate type with dermatological manifestations, are the most common forms, inherited as autosomal dominant metabolic diseases with incomplete penetrance. Severe abdominal colic, nausea, vomiting and constipation, and tachycardia occur very frequently. Porphyrin is excreted in excessive amounts in the urine, often resulting in burgundy red or black urine. Motor weakness (pareses or paralyses) is frequent, at times in the form of Landry’s paralysis (Courville and Mason, 1931). The disease process can ascend to the brain stem, leading to dysphagia, dysarthria, dysphonia and, when bulbar paralysis ensues, respiratory failure and asphyxia. Epileptic seizures are frequent. Temporary or protracted blindness can also occur. A variety of neuropsychiatric disorders can be prominent as vague subjective complaints resembling functional conversion symptoms or anxiety attacks, insomnia or erratic, incorrigible behaviour, or metabolic-toxic psychoses with delirium, hallucinations and delusions. Some patients, however, develop psychoses which are indistinguishable from schizophrenia or bipolar disorder (Boon and Ellis, 1989; Waldenström, 1939). These psychoses can occur as the only clinical manifestation of acute porphyria (Ellencweig, Schoenfeld and Zemishlany, 2006). Importantly, certain agents such as lead, arsenic, sulphonal, barbiturates and alcohol can provoke illness attacks.

Louise

Among the many individuals analysed in Macalpine’s and Hunter’s work, there is no mention of Christian’s mother, Louise. According to a medical report from 1751 (Lübbers, 1906), before her marriage she was already suffering from some illness of her chest (‘affectu pectoris’), and also, for some years, from strong substernal pain and breathing problems (‘beschwerlichen starcken Schmertzen unter der Mitte des Sterni und schweres Atemholen’), at times with some vomiting of blood (‘je zuweilen einiges Geblüte ausgeworfen’), and with aggravation during her pregnancies. During her last pregnancy, she had been very sensitive (‘sehr empfindlich’). Moreover, she was operated for an incarcerated umbilical hernia and died (Lübbers, 1906; Petersen, 1892).

Caroline Mathilda

According to a letter, dated 15 May 1775 (Wheatley, 1884), Carolina Mathilda died from a condition marked by tachycardia (‘131 Pulsschläge’[!] and mounting), followed by an attack of ‘fièvre pourprée’. Since October 1774, in her own words, her attending physician, Dr Leyser, had cured her ‘de deux maladies assez sérieuses’. Macalpine and Hunter (1969) credibly suggested, in my opinion, that she suffered and died from porphyria. Among others, they referred to a report by the English envoy, Gunning, September 1770, that she ‘was much indisposed by a fresh attack of cholick’. Prince Carl of Hesse – married to Christian’s younger sister, Louise, confirmed this in a letter, dated 25 Oct. 1770, that she had been ‘très mal’ for almost four weeks due to ‘une collique hémoroïdale’ (Friis, 1907: 115). In November 1767 she had succumbed to a brief episode of ‘fièvre de fluxion assés forte qui nous a allarmé’ (Friis, 1904: 381). Later, before becoming intimate with her in early 1770, Struensée, at Christian’s request, attended to her for what was assumed to be a case of ‘hydropsie’ (Roger, 1858).

Porphyria in the Oldenburg dynasty?

I have studied the medical reports of the Oldenburgs, published by Lübbers (1906), and find the following persons with pathology suggestive of a possible retrospective diagnosis of porphyria.

Christian VII’s health after the Palace Revolution 1772

After 1772 the sources concerning Christian VII’s mental state became scarce (see Friis, 1908). He was now only a symbolic figurehead. At New Year 1807 he was suddenly physically ill. He was first assumed to have sustained an apoplexy or an epileptic fit, but, based on his immediate recovery, the diagnosis was revised to a case of lipothymy (Bobé, 1923). He died suddenly at Rendsburg Castle in Holstein, on 13 March 1808 from a presumed apoplexy (‘Nerveslag’) (Friis, 1958). However, this is not borne out by his autopsy report, which was retrieved by Snorrason (1968). The only remarkable features observed were those of ‘more than usual’ congestion of blood in the Vasa sanguifera Cerebri, especially Vasa Cerebelli, but without any sign of Extravasatum Sanguinis, Lymphæ [sive] Puris.

Did Christian VII suffer from porphyria?

In the opinion of Snorrason (1968), it is possible that Christian VII might have suffered from porphyria. However, he eventually discarded this view because, in his words, it does not transpire from Struensée’s ‘well-written memoir’. I would argue that even if porphyria had been known as a clinical entity in 1906 when Christiansen undertook his study, Struensée’s memoir per se would not have allowed for such a conclusion. In my opinion, it should be given consideration through a comprehensive re-appraisal of the King, including a detailed family history. This must encompass not only his forebears but also his descendants because in acute intermittent porphyria and its variegate form, being Mendelian dominant disorders, approximately half of the offspring would be carriers and therefore detectable by means of biochemical and genetic (DNA) testing.

Struensée’s memoir, a unique primary source for the study of Christian VII’s insanity, deserves a place in the history of psychiatry, and is therefore presented below as a Classic Text, translated from the French version which was published by Hansen (1930).