I the undersigned, Doctor of Medicine, Director of the Saint-Rémy mental home, certify that the man named Vincent van Gogh, aged 36, a native of Holland and at present domiciled in Arles (Bouches-du-Rhône), under treatment at this city’s infirmary, suffered an attack of acute mania with visual and auditory hallucinations that led him to mutilate himself by cutting off his ear. Today he appears to have regained his reason, but he does not feel that he has the strength or the courage to live independently and has himself asked to be admitted to the home. Based on all the above, I consider that M. Van Gogh is subject to attacks of epilepsy, separated by long intervals, and that it is advisable to place him under long-term observation in the institution.1
Dr Théophile Peyron, patient notes, 9 May 1889
Since no hospital records exist from his time in Arles, this is the only medical diagnosis we have of Van Gogh’s illness. Dr Peyron gave further information, in particular mentioning that although Vincent had indeed cut off his left ear, ‘he is not aware of it’, noting that ‘he has no more than a vague memory’ of the incident. He reiterated that Vincent was ‘terrified’ by his visual and auditory hallucinations. In his first letters after his breakdown, Van Gogh had written several times about things he saw – in particular visions of the Horla, Maupassant’s haunting spectre, and the sea – imagery also mentioned by Gauguin in his notes and description of Vincent in the midst of his crisis.
There was little that could be done to help people suffering from mental distress in the late 1880s. Van Gogh’s situation was not new; his family had been well aware of his problems since he was a teenager, trying to get him sectioned as early as 1870, when he was only seventeen years old. Throughout the correspondence from the wider family there are remarks that indicate everyone knew Vincent was unwell. Speaking after his death, one of his cousins wrote to Theo’s wife, Jo: ‘I and many in the family regarded it as a relief rather than a misfortune.’2
In France in the late nineteenth century all psychiatric disorders were gathered under the general term of ‘epilepsy’. During his lifetime this was the only diagnosis ever given to Vincent. For many years, suspicious of the seeming inaccuracy of nineteenth-century doctors in their diagnosis of mental-health problems, biographers and historians rejected epilepsy as a cause for Van Gogh’s ills. But Vincent wasn’t the only member of his family to have some form of psychiatric illness, as his conversations with the doctors at Saint-Rémy indicate:
He tells us that his mother’s sister was Epileptic, and that there are several cases in his family. What has happened to this patient may be no more than a continuation of what has happened to several members of his family. He tried to resume his normal life when he left the infirmary in Arles, but he was forced to return there after two days because he was again experiencing bizarre sensations and bad dreams during the night.3
There are numerous examples of Vincent seeing psychiatric problems in the people around him – Gauguin and Mourier-Petersen, for example – but this quote from his medical file was the first acknowledgement from Van Gogh himself that mental illness occurred in his family.
The problem appears to have come through the maternal line. Van Gogh’s mother, Anna, had all her children quite late in life – she was thirty-three years old when she gave birth to Vincent and almost forty-eight when her youngest child, Cornelius (‘Cor’), was born. Anna’s sister, Clara Adriana Carbentus, who died when Vincent was thirteen, was the epileptic aunt whom Vincent mentioned to Dr Peyron.4 There is strong evidence of hereditary psychiatric problems in the Van Gogh family: of the six children to reach adulthood, four suffered from problems with their mental health. The two other sisters showed no signs of troubled mental health. This high proportion of psychiatric issues in a relatively small family seems to have been largely overlooked in academic papers on Vincent’s illness. In addition to Vincent’s breakdowns and subsequent suicide, Willemien entered an asylum in December 1902 and died there in 1941. And Cornelius is believed to have committed suicide in South Africa in 1900. Theo’s illness is, however, a case apart. Although he had a complete mental breakdown within a month of Vincent’s death and died in an asylum in Holland six months later, he was diagnosed as suffering from cerebral syphilis, for which there was no treatment in the nineteenth century.
Whatever Vincent was suffering from, he was profoundly lucid about his own problems: ‘As it’s still winter, listen. Let me quietly continue my work, if it’s that of a madman, well, too bad. Then I can’t do anything about it.’ And he continued, referring directly to the symptoms that plagued him so terribly: ‘the unbearable hallucinations have stopped for now, reducing themselves to a simple nightmare on account of taking potassium bromide, I think’.5 This letter, from January 1889, is the first time that medical treatment for Vincent’s illness was mentioned. Potassium bromide was prescribed as a sedative for patients who suffered from seizures. However, if repeatedly ingested, it could provoke ‘depression with loss of muscle control, hallucinations, eye disturbances, irritability, psychoses and memory loss’.6
For researchers into his mental-health problems, details of Vincent’s illness must be gleaned from his letters or the few medical notes that remain, all of which date from his time in Saint-Rémy. Putting together a list of symptoms is a frustrating task. From Vincent’s letters and patient notes, we know he was suffering from hallucinations that were both visual and auditory. The Reverend Salles provided a description of these, telling Theo in his letter of 7 February 1889 that Vincent suffered from paranoid delusions that he was being poisoned.7 Vincent is also recorded as being incoherent, with jumbled speech and confused thoughts.There were also incidents of mania and confusion: in Saint-Rémy he was seen trying to eat tubes of paint and Signac recalled that Van Gogh had tried to drink turpentine while showing him his paintings in the Yellow House.8 Some of his symptoms – hearing voices and seeing visions – are confirmed by the jottings in Gauguin’s sketchbook in the lead-up to his first breakdown. In particular, Gauguin’s use of the word ‘Ictus’ twice in the sketchbook, and again as a doodle on a letter from Vincent that he received soon after the drama. This would seem to confirm that Gauguin had witnessed Van Gogh having some kind of fit and explains the treatment to control seizures adminstered to Vincent.9
Despite the paucity of knowledge, his madness never ceases to fascinate. Since the 1920s several hundred academic papers have been published on the subject. Reading them is an exasperating exercise, as his recorded symptoms could fit a wide variety of psychiatric conditions. In 1991 an American doctor, Russell R. Monroe, analysed 152 academic papers written between 1922 and 1981 about Van Gogh’s illness.10 The most frequent conclusions were that Vincent was suffering from epilepsy (fifty-five times), psychosis (forty-one), schizophrenia (thirteen), character/personality disorder (ten) and bipolar disorder (nine). Amongst the many other pathologies that fit Vincent’s symptoms is acute intermittent porphyria, the hereditary disease that made King George III go mad. The only real point that can be established with any accuracy is the genetic factor behind his mental health, as Vincent told his doctor in Saint-Rémy. In addition to the examples from Vincent’s nuclear family, there seem to be cases much further down the family line.
Modern interpretations of Vincent van Gogh’s problems are subject to changing fashions in diagnoses as well as the geographical location of the writer. When psychiatric analysis took off, there were various different schools of thought about Vincent’s health issues. Many academic articles refer to a key paper on Van Gogh and his illness written by French neurologist Henri Gastaut in 1956. One of the leading specialists in epilepsy at the time, Gastaut described Van Gogh having a seizure, apparently witnessed by a hospital orderly in Saint-Rémy.11 Unfortunately, Gastaut lost the text of this interview, so there is no corroboration of the incident.12 The neurologist diagnosed Van Gogh with temporal lobe epilepsy, exacerbated by the use of absinthe. This form of epilepsy embodies his principal recorded symptoms – auditory and visual hallucinations – and can be genetically transmitted.
Many articles about Van Gogh’s ‘madness’ refer to his suggested alcoholism. In the first academic article ever written on his illness, penned by French doctors Doiteau and Leroy in 1936, the idea that Vincent drank ‘too much absinthe’ was reiterated, as well as the excessive use of stimulants: coffee and tobacco.13 More recently it was suggested to me that Vincent could have been suffering from schizoaffective disorder, which also embodies many of these symptoms.14 In addition, much has been made of the fact that he was born a year to the day after a stillborn child also called Vincent Willem van Gogh, and the heavy psychological implications of being a replacement for another child.15
Non-medical reasons have also been suggested for Van Gogh committing such a unique act of self-harm. These, too, have found a public. Vincent ‘hated’ his mother, father, all women, and so on; or he was suffering from ‘penis envy’ of Gauguin, who was more successful with women. There is also a theory that he was inspired to cut off his ear by Jack the Ripper, whose murders of prostitutes took place in the autumn of 1888, just a few months before Van Gogh’s breakdown – not quite as outlandish as it sounds, since Jack the Ripper cut off the ears of two of his victims, which was widely reported by the press in France.16 It has also been suggested that Van Gogh was influenced by St Peter, who sliced the ear off a Roman soldier at the moment that Jesus was arrested in the Garden of Gethsemane. A fervent admirer of Giotto, Vincent would probably have been familiar with his famous image of the scene from the Scrovegni Chapel in Padua. Van Gogh’s letters immediately after the drama certainly indicate that, like Jesus, he felt betrayed – especially by Gauguin.
Since none of these suggestions can be proved irrefutably, understanding what disorder Van Gogh suffered from quickly becomes a labyrinth of dead ends. As I studied each of these complicated illnesses in depth, I realised I was getting distracted. I’m no doctor; I needed to rely on expert opinion, not conjecture. An expert was recommended to me by the Van Gogh Museum, Dr Piet Voskuil, a Dutch neurologist and expert in epilepsy who has studied Van Gogh’s pathology in depth. He warned me to be circumspect when analysing medical hypotheses and theories about Van Gogh. To a specialist in ear, nose and throat disorders, he pointed out, it will seem that he was suffering from Ménière’s disease (tinnitus), for example.17 A psychiatrist will make a psychiatric diagnosis; a neurologist will find a neurological disorder; and so on. Each expert can find something in Vincent’s symptoms to support their theory.
Epilepsy is one of the earliest-recorded pathologies, with the first-ever recorded seizure around 2000 BC.18 It was believed by the ancient Romans to be a curse from the gods, and the first treatment for epilepsy came in the mid-nineteenth century with the use of bromide to control seizures. Being the most up-to-date treatment available, this compound was naturally administered to Van Gogh. Because epilepsy was considered a general term for all psychiatric illness, for many years it was overlooked as a possible reason for his behaviour. Yet there is good evidence to support the theory that epilepsy was indeed at the root of Vincent’s mental distress. Heredity is now believed to be involved in the majority of cases of epilepsy, either directly due to genetic disposition or indirectly – for example, through childhood trauma. Given that other Van Gogh siblings seem to have suffered from mental illness, there has been speculation that Vincent experienced head-trauma during birth, which can provoke the illness. Similarly, the suicide rate of epileptics is significantly higher than it is among the general population.19 Seizures – so often associated with the illness – can be full-blown, partial or even absent in patients, who are nonetheless still diagnosed as being epileptic.
Each form of epilepsy has its own pathology. ‘Grand mal’ seizures are the ones we recognise – patients have convulsions, shake violently and lose consciousness or fall into a semi-conscious state. Most patients describe partial seizure attacks that are preceded by an aura, a sensation of dizziness and the feeling of déjà vu.20 Partial seizures have a wide variety of symptoms, including sudden and inexplicable feelings of fear or anger, sensory illusions, hallucinations, delusions and laboured speech. The hallucinations are slightly different from those experienced by psychotic patients, in that epileptics are aware that the hallucinations are not real. The so-called ‘absent seizures’ are more subtle, sometimes almost imperceptible – hence the name – and are occasionally characterised by jerking movements or blinking of the eyes. Gauguin, amongst others, spoke about Vincent’s particularly strange, uneven way of walking, and both Adeline Ravoux in Auvers (daughter of the owners of the inn where Van Gogh lodged) and Dr Rey in Arles commented that Vincent blinked rapidly as he worked. In the wider Van Gogh family there is evidence of a disposition for cerebral-vascular strokes, which were similarly interpreted as seizures by those who saw them.21 Without a brain scan or detailed medical notes and history, it is impossible to be totally certain of what was truly the cause of his troubles. But, after looking at all the evidence, I can only concur with the Van Gogh Museum’s theory that it seems most likely that he was suffering from some form of epilepsy, perhaps combined with schizophrenia or bipolar disorder.