- Email: [email protected]
Diagnosing Vincent van Gogh, an expedition from the sources to the present “mer à boire”
Epilepsy & Behavior 28 (2013) 177–180
Contents lists available at SciVerse ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Perspective
Diagnosing Vincent van Gogh, an expedition from the sources to the present “mer à boire” Piet Voskuil Torendreef 14, 4851 BH Ulvenhout, Netherlands
a r t i c l e
i n f o
Article history: Received 13 April 2013 Accepted 15 April 2013 Available online 12 June 2013 Keywords: Vincent van Gogh Epilepsy Psychosis Genetics History
a b s t r a c t The paintings and writings of Vincent van Gogh are widely admired for their great artistic value. This makes it interesting for doctors and patient groups to mold van Gogh's disease into a figurehead of their own specialty or illness. The recent article of ter Borg and Kasteleijn (2012) [1] in this Journal had a welcome approach by placing the diagnoses given in his lifetime in a historical and cultural context. In this article, the author will explore the diagnosis of epilepsy, adding more details without jumping quickly to conclusions. Apart from the information of eyewitnesses, special efforts are made to look critically at the medical sources as well as to investigate the original family chronicles. There is no easy access to that information. The Dutch vocabulary in the family notes made it tempting, for earlier scholars in this field, to easily link all kinds of attacks in family members to the original diagnosis of epilepsy. A part of the archives of the Willem Arntszhuis Utrecht describing the last days of Vincent's brother Theo, so far published only in Dutch (Voskuil, 2009 [16]), is included here. To integrate all this information, interdisciplinary research in a nonmutually excluding, but complementary, synthesis of today's knowledge is the most fruitful way to understand Vincent's behavior and its disturbances while continuing to admire his beautiful art. © 2013 Elsevier Inc. All rights reserved.
1. Background and sources It was a relief to read, in Epilepsy & Behavior, the article by Marlies ter Borg and Dorothée Kasteleijn on the cultural context of the diagnoses given to Vincent van Gogh during his lifetime [1]. As an epilepsy expert, I have, for the past 25 years, been gathering facts concerning the epilepsy diagnosis given to Vincent at the time of the Arles crisis and gauging the reliability of the sources from which it came. On September 7th, 1988, I gave a combined presentation with the art historian professor Evert van Uitert at the fourth British–Danish–Dutch Epilepsy conference entitled “Creativity and madness, Vincent van Gogh for example?” [2]. Our message was that van Gogh produced so many beautiful masterpieces, not thanks to, but in spite of, his illness. The label ‘epilepsy’ has led to confusion rather than clarity. The speculations on the link between van Gogh's madness and his genius – often based on a psychoanalytical framework – generally ignored biographical facts. As ter Borg and Kasteleijn showed, medical terms were often pulled out of their cultural context. It proved too tempting to mold van Gogh into a figurehead for one's own area of expertise. Thus, the term ‘vertigo’, interpreted in the context of the illness of Menière, acted to pull the famous artist into the domain of the otorhinolaryngologist [3]. The authors, Kaufman et al., were misled by the fact that this term was used since medieval times, especially since the time of Esquirol [4], in the combination “vertige épileptique E-mail address: [email protected]. 1525-5050/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.yebeh.2013.04.012
(epileptic vertigo)” for what is today seen as a form of partial epileptic seizure. Interpreting van Gogh's paintings led nonexperts to absurd conclusions concerning diagnosis. Thus, the sprig of foxglove on the portrait of Gachet (F753/JH2007, 1890) (Fig. 1) led Thomas [5] to the ‘diagnosis’ xanthopsia caused by digitalis poisoning as an explanation of the ‘high yellow tone’ Vincent wrote about in letter 752 [6]. He suggested that the artist used such intense yellow in his paintings because by digitalis intoxication he saw all objects in a too intense yellow tone. However, this is a sophism because, if this was the case, he also should have prepared the paint on his palette in a for him more but for healthy people without xanthopsia a less intense yellow. The passage from this letter quoted by ter Borg and Kasteleijn on page 433 is more fitting, taking the term yellow in a figurative rather than a literal meaning. Art historians such as Arnold [7] prefer to interpret van Gogh's paintings, such as the overdiagnosed ‘Starry Night’, in terms of heightened creativity in general and in terms of influences from artistic predecessors in particular, such as the Hague school, the Barbizon group Japanese art, Delacroix, Millet, Dupré, Daubigny, Rousseau, and Jacob Van Ruysdael. My own expedition was not aimed to produce yet another diagnosis but to hold existing diagnoses against the light of the present day state of art [8,9]. A professional diagnosis must be based on anamnesis and research. The extensive letters from and to Vincent make anamneses of sorts possible [10]. Research should be based on statements by eyewitnesses and information of van Gogh's physicians in attendance. Relevant eyewitnesses include Delon, police doctor at Arles; Reverend Salles, hospital pastor in Arles; the postman Roulin; his ward attendants
178
P. Voskuil / Epilepsy & Behavior 28 (2013) 177–180
Fig. 2. Van Gogh, Charles-Elzéard Trabuc, 1889 (F629/JH1774). Kunstmuseum Solothurn. Fig. 1. Van Gogh, Doctor Gachet, 1890 (F753/JH2007). Private collection.
at St. Remy, Charles-Ezéard Trabuc and Jean François Poulet; and the artists Gaugain and Signac [11–13]. It is not quite correct in the article of ter Borg and Kasteleijn to state that from Dr. Rey, who was the attendant doctor in the Hospital of Arles, “no notes remain” (p 431). He described, in letters to Vincent's brother Theo on December 29th and 30th, 1888 and February 12th, 1889, symptoms that he observed. Finally, in the hospital archives, there is a no signed letter dated December 29th, 1888 sent to the mayor of Arles. In this letter, some symptoms are described. The author asks to take the necessary steps to have Vincent admitted in a special asylum. Ward attendant Trabuc observed an attack, which could have been epileptic, on July 16th, 1889 (Fig. 2). Later, Gastaut described this incident as follows: “It began with a cramp in the hand, a haggard look, and then the patient fell down”. 1 The notes remaining from van Gogh's attendant doctors are limited and colored by contemporary neuropsychiatric concepts. It is to the credit of ter Borg and Kasteleijn that they shed light on the cultural context of medical terms used by van Gogh's physicians, especially the diagnosis “epilepsie larvée mentale” or masked mental epilepsy. They also show how the patient reacted to this diagnostic label (p. 434). Urpar, the chief physician of the Arles hospital, referring van Gogh to St. Remy, reported that the patient had suffered from “manie aiguë avec délire généralisé”. He followed the terminology of Jules Falret [14] for nonconvulsive phenomenology in epilepsy (état mental des épileptiques). It is of interest that Falret himself also referred patients to St. Remy. For further information on these 19th century concepts, I refer to Temkin [14]. I must conclude that, from the different cultural and medical historical backgrounds of relevant terms, there is no conclusive evidence nor can it be excluded that Vincent van Gogh or close family members
1 Asked in 1988 for his source, Gastaut stated that nearly all his archives were destroyed when he left his clinic in 1984 (personal communication).
suffered from epilepsy in the present day meaning of the term. My research, as will be discussed later on in this article, does show that there were serious neurological problems in the van Gogh and Carbentus (Vincent's mother) family, without attaching to them any definite label. This makes the task of nonexperts to summarize van Gogh's illness for their own goals much more difficult. In the circle of art historians for instance, there is an obvious interest in the expert debate on the illness of Vincent van Gogh. Sometimes, an attempt is made to provide in exhibitions labels and short notes which will ‘explain’ certain biographical incidents to the public (ter Borg, p. 438). A fitting explanation would have to fit into a small space, thus sparing the public's eyesight, which is needed to enjoy the beautiful works. As far as I am concerned, art historians faced with such a task can and should take into account the following facts, framed in short but professionally correct terminology, while leaving the more extensive, scientific explanations to the catalog. Below are the elements which in my view are relevant to art historians desiring to understand the medical problems facing Vincent van Gogh. 2. Characteristics of the main elements in the pathobiography of Vincent van Gogh 2.1. Episodic psychotic phenomena with paranoid delusions, visual and auditory hallucinations, anxiety, agitation, disturbances of cognitive functioning and consciousness, and, sometimes, stupor. From the vantage point of today's knowledge, these can be seen as caused by periodic malfunctioning and remitting of complex, mainly frontal temporal and limbic cerebral, networks. 2.2. Periodic behavioral and mood disorder, possibly caused by the instability of these same cerebral networks. 2.3. Genetic and external factors (emotional stress, use of alcohol, thujone/absinth, underfeeding, and bodily fatigue) interacting with varying neurobiological factors to produce changing symptoms.
P. Voskuil / Epilepsy & Behavior 28 (2013) 177–180
2.4. Only sporadically did Vincent's eyewitnesses report phenomena which could be explained with near certainty as an obvious description of epileptic phenomena by modern insights in epilepsy and psychosis. This is to say: epilepsy is not a disease but a disorder of recurrent brain dysfunction based on a large variety of pathophysiological mechanisms. There is a complex relationship between epilepsy and psychotic phenomena in which the development of the one vis à vis the other can change over time. 3. Genetic aspects These aspects deserve special elaboration, given the importance of genetic vulnerability in the field of neurobiological disorders. I will start with the artist's close family. Vincent's father, Theodorus van Gogh (1822–1885), collapsed and died on his own doorstep as a result of heart failure, according to his sister Mietje (1831–1911) ([15] p. 77). His son Theodorus van Gogh (1857–1891), the artist's brother, was hospitalized on November 28th, 1890 in the Willem Arntsz Huis, a psychiatric center in Utrecht, The Netherlands. His medical dossier came to light in November 1990 when the center's archives were moved. Because there are many misunderstandings about the cause of Theo's death, I will elaborate upon it, on the basis of my Dutch publication [16] (Fig. 3). According to a note in this dossier dated January 26th, 1891, Theo had an attack (Dutch: toeval) on January 23rd, 1891 which reoccurred on January 24th. He collapsed and remained unconscious. His heart and respiration weakened slowly. He became nauseated, his temperature rose, and there were signs of decubitus. He died on January 25th at 11:30 pm. These attacks were probably epileptic attacks rather than a stroke, but a combination, i.e., symptomatic seizures provoked by a cerebrovascular stroke, is possible. A lues cerebri is, given the earlier diagnosis of dementia paralytica, the most probable etiology. The family refused permission for autopsy. Other close family members, notably van Gogh's sister Willemina (Wil, Willemien, 1862–1941), had neuropsychiatric problems. She suffered from chronic psychosis including, among others, depressive characteristics. She was hospitalized on December 4th, 1902 in the psychiatric hospital Veldwijk in Ermelo, where she remained for the rest of her life, slowly growing demented. There was possibly epilepsy in the artist's wider family circle. Thus, Vincent himself relates to Theophile Peyron, his attendant physician in St. Remy, that a sister of his mother suffered from epilepsy. This was Clara Adriana (1817–1866), as becomes clear from notes by M.J. van Gogh (1831–1911), a sister of the artist's father ([17] p. 16). There are two sources concerning Hendrik Jacob Eerligh van Gogh (1853–1886), son of Jan van Gogh, a brother of Vincent's father (1817–1885). Hendrik Jacob Eerligh supposedly suffered from “erge
Fig. 3. Part of the note in the medical files of Theo van Gogh written on January 26th, 1891.
179
toevallen” [18], resp. “toevallen” (serious attacks, seizures?) leading in August 1884 to a broken arm. Aunt Mietje (mentioned earlier; 1831–1911), from whom this last information sprang, notes on August 6th, 1886 [15] that a message came from East Portland, USA. Hendrik had emigrated to America and had died suddenly by falling out of a boat, after a very difficult last year. In the family chronicles, there are more names of family members associated with the Dutch word “toevallen”. Here again, reinterpretation in terms of modern terminology has to be made. In Dutch, the word “toeval” (attack) in the 19th century was used in many connections associated with paroxysmal occurrences. So, one could say rheumatic “toevallen”, gastric “toevallen”, asthmatic “toevallen”, and just “toevallen” meaning epileptic seizures or cerebrovascular strokes. Naifeh and Smith were too quick in translating, in their biography of van Gogh, the word as “epileptic fits” or “seizures” ([19] p. 751). In some cases in the family members, a cerebrovascular stroke is more probable. Four brothers of Vincent's father can be mentioned. Hendrik Vincent (Hein) van Gogh (1814–1877) had a ‘toeval’ in July 1854 at the age of 40 years ([17] p. 49) and again on October 13th, 1872, resulting in paralysis of one side of the body. Willem Daniel van Gogh from Vaals (1818–1872) had his first attack (toeval) in March 1872 at the age of 54, leaving speech and right arm movement severely limited ([13] p. 65). He died that year on December 4th. Jan van Gogh Sr. (1817–1885) experienced a ‘cerebral outburst’ (Dutch: “uitstorting in de hersenen”) on August 3rd, 1885. He was paralyzed on the left side and died 9 days later ([15] p. 80–81). Vincent (Uncle Cent) van Gogh (1820–1888) had some sort of attack (Dutch: “een soort attaque”) [20]. Finally it is of importance that in one transcription of her notes [21], M.J. van Gogh (Aunt Mietje) writes “…. Mother had a serious “toeval””. Mietje's mother was Elisabeth Huberta Vrijdag (1790–1875). Whatever conclusions are drawn by various experts on the subject of Vincent van Gogh's illness, I feel it to be important that they should not remain at loggerheads but should cooperate to integrate their research results. In the case of an artist such as van Gogh, with his unique characteristics, we should aim to go to the frontiers of empirical knowledge, without transgressing them.
References [1] Ter Borg M, Kasteleijn-Nolst Trenité D. The cultural context of diagnosis: the case of Vincent van Gogh. Epilepsy Behav 2012;25:431–9. [2] Voskuil, P. and Van Uitert, E. “Creativity and madness, Vincent van Gogh for example?” (unpublished) paper presented at the fourth British–Danish–Dutch Epilepsy conference, 1988. [3] Kaufman Arenberg I, Flieger Countryman L, Bernstein L, Shambaugh Jr G, et al. Van Gogh had Meniere's disease and not epilepsy. JAMA 1990;264:491–3. [4] Esquirol E. Des maladies mentales, 2 vols. Paris; 1838. [5] Thomas Courtney Lee. Van Gogh's vision. Digitalis intoxication? JAMA 1981;245:727–9. [6] Jansen L, Luijten H, Bakker N, editors. Vincent van Gogh-De brieven. Van Gogh Museum, Huygens Instituut. Amsterdam: Amsterdam University Press; 2009 [www.vangoghlettes.org]. [7] Arnold Matthias. Van Gogh und seine Vorbilder. Eine künstlerische Selbstfindung. München, New York: Prestel; 1997. [8] Voskuil PHA. Vincent van Gogh's malady: a test case for the relationship between temporal lobe dysfunction and epilepsy? J Hist Neurosc 1992;1:155–62. [9] Voskuil PHA. The illness of Vincent van Gogh: letter to the editor and author's response. J Hist Neurosc 2005;14:169–76. [10] Voskuil PHA. Van Gogh's disease in the light of his correspondence. Literary medicine brain disease and doctors in novels, theater and film. Front Neurol NeurosciBasel: Karger; 2013. p. 116–25. [11] de Beucken J. Un portrait de Vincent van Gogh Les Editions du Balancier, Liège; 1938. [12] Gastaut H. La Maladie de Vincent van Gogh envisagée a la lumière des conceptions nouvelles sur l'épilepsie psychomotrice. Anales medicales psychologique de Paris 1956;2:1–43. [13] Tralbaut ME. Vincent van Gogh.Lausanne: Edita; 1974 . pp. 288–290. [14] Falret J. De l'état mental des épileptiques. Archives générales de médecine,Ve série 16 (1860): 661–79;17 (1861):461–91;18 (1861): 423–43. In: Temkin Owsei, editor. The falling sickness, a history of epilepsy from the Greeks to the beginnings of modern neurology. Sec. ed. Baltimore and London: The Johns Hopkins University Press; 1971. [15] Van Beek NA. De Aantekeningen van Tante Mietje van Gogh. In: Erenstein GJ, editor. Transcriptie. Tienstuks Amstelveen; 2010.
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[16] Voskuil PHA. De doodsoorzaak van Theo van Gogh (1857–1891). Ned Tijdschr Geneeskd 2009;153:B362–. [17] van Gogh Maria Johanna. Handwritten family history. Van Gogh Museum, Vincent van Gogh Foundation; 196216 [Inv. no. b3260V/]. [18] van Gogh Theodorus. Letter to his son Theo, Nuenen 27 October 1884. Van Gogh Museum, Vincent van Gogh Foundation; 1982 [Inv. no. b2258 V/].
[19] Naifeh S, White Smith G. Van Gogh. The life. London: Profile Books Ltd.; 2011. [20] van Gogh Theodorus. Letter to his son Theo, Helvoirt 22 October 1873. Van Gogh Museum, Vincent van Gogh Foundation; 1982 [Inv. no. b2670V/]. [21] van Gogh MJ. To: Family members. Handwritten. Without place and date. Van Gogh Museum, Vincent van Gogh Foundation; 196263 [Inv.nr.b3259V/].
Contents lists available at SciVerse ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Perspective
Diagnosing Vincent van Gogh, an expedition from the sources to the present “mer à boire” Piet Voskuil Torendreef 14, 4851 BH Ulvenhout, Netherlands
a r t i c l e
i n f o
Article history: Received 13 April 2013 Accepted 15 April 2013 Available online 12 June 2013 Keywords: Vincent van Gogh Epilepsy Psychosis Genetics History
a b s t r a c t The paintings and writings of Vincent van Gogh are widely admired for their great artistic value. This makes it interesting for doctors and patient groups to mold van Gogh's disease into a figurehead of their own specialty or illness. The recent article of ter Borg and Kasteleijn (2012) [1] in this Journal had a welcome approach by placing the diagnoses given in his lifetime in a historical and cultural context. In this article, the author will explore the diagnosis of epilepsy, adding more details without jumping quickly to conclusions. Apart from the information of eyewitnesses, special efforts are made to look critically at the medical sources as well as to investigate the original family chronicles. There is no easy access to that information. The Dutch vocabulary in the family notes made it tempting, for earlier scholars in this field, to easily link all kinds of attacks in family members to the original diagnosis of epilepsy. A part of the archives of the Willem Arntszhuis Utrecht describing the last days of Vincent's brother Theo, so far published only in Dutch (Voskuil, 2009 [16]), is included here. To integrate all this information, interdisciplinary research in a nonmutually excluding, but complementary, synthesis of today's knowledge is the most fruitful way to understand Vincent's behavior and its disturbances while continuing to admire his beautiful art. © 2013 Elsevier Inc. All rights reserved.
1. Background and sources It was a relief to read, in Epilepsy & Behavior, the article by Marlies ter Borg and Dorothée Kasteleijn on the cultural context of the diagnoses given to Vincent van Gogh during his lifetime [1]. As an epilepsy expert, I have, for the past 25 years, been gathering facts concerning the epilepsy diagnosis given to Vincent at the time of the Arles crisis and gauging the reliability of the sources from which it came. On September 7th, 1988, I gave a combined presentation with the art historian professor Evert van Uitert at the fourth British–Danish–Dutch Epilepsy conference entitled “Creativity and madness, Vincent van Gogh for example?” [2]. Our message was that van Gogh produced so many beautiful masterpieces, not thanks to, but in spite of, his illness. The label ‘epilepsy’ has led to confusion rather than clarity. The speculations on the link between van Gogh's madness and his genius – often based on a psychoanalytical framework – generally ignored biographical facts. As ter Borg and Kasteleijn showed, medical terms were often pulled out of their cultural context. It proved too tempting to mold van Gogh into a figurehead for one's own area of expertise. Thus, the term ‘vertigo’, interpreted in the context of the illness of Menière, acted to pull the famous artist into the domain of the otorhinolaryngologist [3]. The authors, Kaufman et al., were misled by the fact that this term was used since medieval times, especially since the time of Esquirol [4], in the combination “vertige épileptique E-mail address: [email protected]. 1525-5050/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.yebeh.2013.04.012
(epileptic vertigo)” for what is today seen as a form of partial epileptic seizure. Interpreting van Gogh's paintings led nonexperts to absurd conclusions concerning diagnosis. Thus, the sprig of foxglove on the portrait of Gachet (F753/JH2007, 1890) (Fig. 1) led Thomas [5] to the ‘diagnosis’ xanthopsia caused by digitalis poisoning as an explanation of the ‘high yellow tone’ Vincent wrote about in letter 752 [6]. He suggested that the artist used such intense yellow in his paintings because by digitalis intoxication he saw all objects in a too intense yellow tone. However, this is a sophism because, if this was the case, he also should have prepared the paint on his palette in a for him more but for healthy people without xanthopsia a less intense yellow. The passage from this letter quoted by ter Borg and Kasteleijn on page 433 is more fitting, taking the term yellow in a figurative rather than a literal meaning. Art historians such as Arnold [7] prefer to interpret van Gogh's paintings, such as the overdiagnosed ‘Starry Night’, in terms of heightened creativity in general and in terms of influences from artistic predecessors in particular, such as the Hague school, the Barbizon group Japanese art, Delacroix, Millet, Dupré, Daubigny, Rousseau, and Jacob Van Ruysdael. My own expedition was not aimed to produce yet another diagnosis but to hold existing diagnoses against the light of the present day state of art [8,9]. A professional diagnosis must be based on anamnesis and research. The extensive letters from and to Vincent make anamneses of sorts possible [10]. Research should be based on statements by eyewitnesses and information of van Gogh's physicians in attendance. Relevant eyewitnesses include Delon, police doctor at Arles; Reverend Salles, hospital pastor in Arles; the postman Roulin; his ward attendants
178
P. Voskuil / Epilepsy & Behavior 28 (2013) 177–180
Fig. 2. Van Gogh, Charles-Elzéard Trabuc, 1889 (F629/JH1774). Kunstmuseum Solothurn. Fig. 1. Van Gogh, Doctor Gachet, 1890 (F753/JH2007). Private collection.
at St. Remy, Charles-Ezéard Trabuc and Jean François Poulet; and the artists Gaugain and Signac [11–13]. It is not quite correct in the article of ter Borg and Kasteleijn to state that from Dr. Rey, who was the attendant doctor in the Hospital of Arles, “no notes remain” (p 431). He described, in letters to Vincent's brother Theo on December 29th and 30th, 1888 and February 12th, 1889, symptoms that he observed. Finally, in the hospital archives, there is a no signed letter dated December 29th, 1888 sent to the mayor of Arles. In this letter, some symptoms are described. The author asks to take the necessary steps to have Vincent admitted in a special asylum. Ward attendant Trabuc observed an attack, which could have been epileptic, on July 16th, 1889 (Fig. 2). Later, Gastaut described this incident as follows: “It began with a cramp in the hand, a haggard look, and then the patient fell down”. 1 The notes remaining from van Gogh's attendant doctors are limited and colored by contemporary neuropsychiatric concepts. It is to the credit of ter Borg and Kasteleijn that they shed light on the cultural context of medical terms used by van Gogh's physicians, especially the diagnosis “epilepsie larvée mentale” or masked mental epilepsy. They also show how the patient reacted to this diagnostic label (p. 434). Urpar, the chief physician of the Arles hospital, referring van Gogh to St. Remy, reported that the patient had suffered from “manie aiguë avec délire généralisé”. He followed the terminology of Jules Falret [14] for nonconvulsive phenomenology in epilepsy (état mental des épileptiques). It is of interest that Falret himself also referred patients to St. Remy. For further information on these 19th century concepts, I refer to Temkin [14]. I must conclude that, from the different cultural and medical historical backgrounds of relevant terms, there is no conclusive evidence nor can it be excluded that Vincent van Gogh or close family members
1 Asked in 1988 for his source, Gastaut stated that nearly all his archives were destroyed when he left his clinic in 1984 (personal communication).
suffered from epilepsy in the present day meaning of the term. My research, as will be discussed later on in this article, does show that there were serious neurological problems in the van Gogh and Carbentus (Vincent's mother) family, without attaching to them any definite label. This makes the task of nonexperts to summarize van Gogh's illness for their own goals much more difficult. In the circle of art historians for instance, there is an obvious interest in the expert debate on the illness of Vincent van Gogh. Sometimes, an attempt is made to provide in exhibitions labels and short notes which will ‘explain’ certain biographical incidents to the public (ter Borg, p. 438). A fitting explanation would have to fit into a small space, thus sparing the public's eyesight, which is needed to enjoy the beautiful works. As far as I am concerned, art historians faced with such a task can and should take into account the following facts, framed in short but professionally correct terminology, while leaving the more extensive, scientific explanations to the catalog. Below are the elements which in my view are relevant to art historians desiring to understand the medical problems facing Vincent van Gogh. 2. Characteristics of the main elements in the pathobiography of Vincent van Gogh 2.1. Episodic psychotic phenomena with paranoid delusions, visual and auditory hallucinations, anxiety, agitation, disturbances of cognitive functioning and consciousness, and, sometimes, stupor. From the vantage point of today's knowledge, these can be seen as caused by periodic malfunctioning and remitting of complex, mainly frontal temporal and limbic cerebral, networks. 2.2. Periodic behavioral and mood disorder, possibly caused by the instability of these same cerebral networks. 2.3. Genetic and external factors (emotional stress, use of alcohol, thujone/absinth, underfeeding, and bodily fatigue) interacting with varying neurobiological factors to produce changing symptoms.
P. Voskuil / Epilepsy & Behavior 28 (2013) 177–180
2.4. Only sporadically did Vincent's eyewitnesses report phenomena which could be explained with near certainty as an obvious description of epileptic phenomena by modern insights in epilepsy and psychosis. This is to say: epilepsy is not a disease but a disorder of recurrent brain dysfunction based on a large variety of pathophysiological mechanisms. There is a complex relationship between epilepsy and psychotic phenomena in which the development of the one vis à vis the other can change over time. 3. Genetic aspects These aspects deserve special elaboration, given the importance of genetic vulnerability in the field of neurobiological disorders. I will start with the artist's close family. Vincent's father, Theodorus van Gogh (1822–1885), collapsed and died on his own doorstep as a result of heart failure, according to his sister Mietje (1831–1911) ([15] p. 77). His son Theodorus van Gogh (1857–1891), the artist's brother, was hospitalized on November 28th, 1890 in the Willem Arntsz Huis, a psychiatric center in Utrecht, The Netherlands. His medical dossier came to light in November 1990 when the center's archives were moved. Because there are many misunderstandings about the cause of Theo's death, I will elaborate upon it, on the basis of my Dutch publication [16] (Fig. 3). According to a note in this dossier dated January 26th, 1891, Theo had an attack (Dutch: toeval) on January 23rd, 1891 which reoccurred on January 24th. He collapsed and remained unconscious. His heart and respiration weakened slowly. He became nauseated, his temperature rose, and there were signs of decubitus. He died on January 25th at 11:30 pm. These attacks were probably epileptic attacks rather than a stroke, but a combination, i.e., symptomatic seizures provoked by a cerebrovascular stroke, is possible. A lues cerebri is, given the earlier diagnosis of dementia paralytica, the most probable etiology. The family refused permission for autopsy. Other close family members, notably van Gogh's sister Willemina (Wil, Willemien, 1862–1941), had neuropsychiatric problems. She suffered from chronic psychosis including, among others, depressive characteristics. She was hospitalized on December 4th, 1902 in the psychiatric hospital Veldwijk in Ermelo, where she remained for the rest of her life, slowly growing demented. There was possibly epilepsy in the artist's wider family circle. Thus, Vincent himself relates to Theophile Peyron, his attendant physician in St. Remy, that a sister of his mother suffered from epilepsy. This was Clara Adriana (1817–1866), as becomes clear from notes by M.J. van Gogh (1831–1911), a sister of the artist's father ([17] p. 16). There are two sources concerning Hendrik Jacob Eerligh van Gogh (1853–1886), son of Jan van Gogh, a brother of Vincent's father (1817–1885). Hendrik Jacob Eerligh supposedly suffered from “erge
Fig. 3. Part of the note in the medical files of Theo van Gogh written on January 26th, 1891.
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toevallen” [18], resp. “toevallen” (serious attacks, seizures?) leading in August 1884 to a broken arm. Aunt Mietje (mentioned earlier; 1831–1911), from whom this last information sprang, notes on August 6th, 1886 [15] that a message came from East Portland, USA. Hendrik had emigrated to America and had died suddenly by falling out of a boat, after a very difficult last year. In the family chronicles, there are more names of family members associated with the Dutch word “toevallen”. Here again, reinterpretation in terms of modern terminology has to be made. In Dutch, the word “toeval” (attack) in the 19th century was used in many connections associated with paroxysmal occurrences. So, one could say rheumatic “toevallen”, gastric “toevallen”, asthmatic “toevallen”, and just “toevallen” meaning epileptic seizures or cerebrovascular strokes. Naifeh and Smith were too quick in translating, in their biography of van Gogh, the word as “epileptic fits” or “seizures” ([19] p. 751). In some cases in the family members, a cerebrovascular stroke is more probable. Four brothers of Vincent's father can be mentioned. Hendrik Vincent (Hein) van Gogh (1814–1877) had a ‘toeval’ in July 1854 at the age of 40 years ([17] p. 49) and again on October 13th, 1872, resulting in paralysis of one side of the body. Willem Daniel van Gogh from Vaals (1818–1872) had his first attack (toeval) in March 1872 at the age of 54, leaving speech and right arm movement severely limited ([13] p. 65). He died that year on December 4th. Jan van Gogh Sr. (1817–1885) experienced a ‘cerebral outburst’ (Dutch: “uitstorting in de hersenen”) on August 3rd, 1885. He was paralyzed on the left side and died 9 days later ([15] p. 80–81). Vincent (Uncle Cent) van Gogh (1820–1888) had some sort of attack (Dutch: “een soort attaque”) [20]. Finally it is of importance that in one transcription of her notes [21], M.J. van Gogh (Aunt Mietje) writes “…. Mother had a serious “toeval””. Mietje's mother was Elisabeth Huberta Vrijdag (1790–1875). Whatever conclusions are drawn by various experts on the subject of Vincent van Gogh's illness, I feel it to be important that they should not remain at loggerheads but should cooperate to integrate their research results. In the case of an artist such as van Gogh, with his unique characteristics, we should aim to go to the frontiers of empirical knowledge, without transgressing them.
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[16] Voskuil PHA. De doodsoorzaak van Theo van Gogh (1857–1891). Ned Tijdschr Geneeskd 2009;153:B362–. [17] van Gogh Maria Johanna. Handwritten family history. Van Gogh Museum, Vincent van Gogh Foundation; 196216 [Inv. no. b3260V/]. [18] van Gogh Theodorus. Letter to his son Theo, Nuenen 27 October 1884. Van Gogh Museum, Vincent van Gogh Foundation; 1982 [Inv. no. b2258 V/].
[19] Naifeh S, White Smith G. Van Gogh. The life. London: Profile Books Ltd.; 2011. [20] van Gogh Theodorus. Letter to his son Theo, Helvoirt 22 October 1873. Van Gogh Museum, Vincent van Gogh Foundation; 1982 [Inv. no. b2670V/]. [21] van Gogh MJ. To: Family members. Handwritten. Without place and date. Van Gogh Museum, Vincent van Gogh Foundation; 196263 [Inv.nr.b3259V/].