Van Gogh’s Medical Issues

A common misunderstanding about Vincent van Gogh revolves around his well-known “attacks” and hallucinations. Because of these intermittent but acute violent medical problems that resolved spontaneously, he was famously diagnosed with epilepsy at the time he entered the Asylum for Epileptics and Lunatics at Saint-Rémy in 1889. To better understand the impact of his debilitating attacks and hallucinations on his life and his art, and the impact of applying a modern inner-ear disease diagnosis, I have reviewed these medical issues in greater detail. This is an in-depth review of Vincent’s self-described and named symptoms of his “attacks,” namely his use of the word vertige, which could only translate to “vertigo.” Vertigo is the critical clinical diagnostic element required to make the unique diagnosis of Meniere’s disease. Meniere’s disease—which I have long suggested, since 1990, that Vincent suffered from—is a somewhat common condition of the inner ear primarily manifested in acute, violent attacks of vertigo and hallucinations of rotary motion, which often resolve on their own until the next attack occurs unexpectedly. It is noteworthy to accept that the well-known and frequently heard-about attacks that plagued Vincent were from his inner ear and Meniere’s disease, and were not any form of epilepsy. The same applies to the often noted, and directly connected, hallucinations associated with these attacks. If we understand this updated diagnosis, a newfound understanding of van Gogh’s health, mental state, and inner motivations may now be possible. Did this characteristically episodic disease play any role in his death as well? Did an unrequited fear of another, more violent attack of vertigo that would leave him incapable of painting drive him to suicide? More likely, this intense fear that he expressed was a major factor in his compulsive, obsessive need to paint a canvas a day.

Vincent van Gogh was known in the art world and among his many biographers to have suffered from violent attacks of some malady about which there has been no agreement.These were attacks of vertigo as he wrote, not “crises” or seizures. After he recovered from the ear self-mutilation in Arles, Vincent admitted himself to the Asylum for Lunatics and Epileptics in Saint-Rémy, about twenty miles from Arles. Dr. Peyron, the admitting doctor, concluded in his intake history that Vincent’s episodic attacks were epilepsy. A plethora of other diagnoses have flooded both the art history and medical literature over the ensuing years. Still no consensus has emerged. This diagnosis of epilepsy stuck with Vincent until 1990, when I published a “Special Communication” in the Journal of the American Medical Association (JAMA) and concluded that these violent attacks were attacks of inner-ear vertigo. Vertigo is a key element that distinguishes between a diagnosis of Meniere’s disease and epilepsy. This was the cover story for the issue of JAMA, which was published one hundred years to the week after Vincent’s death. ( Arenberg, JAMA,1990)

It is not the purpose of this book to refocus on the various additional medical diagnoses of Vincent van Gogh; anyone, including Vincent, could have had more than one medical problem, which he did. The purpose of discussing his clinical diagnosis of Meniere’s disease and not epilepsy in the context of Killing Vincent is primarily to look at this inner-ear disease and try to determine what impact it may have had on Vincent’s life and his art, and to determine if it may have led to any propensity for suicide or had any impact on his death. Given how much impact they had on his life, it is important to establish whether these attacks of vertigo drove him to suicide, or in some way contributed to the circumstances of his untimely demise.

So what is this vertigo, and why is it so important to distinguish between it and dizziness? Vertigo is best defined as a subjective manifestation of an inner-ear disorder in which the patient experiences violent, unexpected attacks of a hallucination of motion, most often rotary, in which the room is spinning or the patient is spinning inside himself. With a Meniere’s disease attack of inner-ear vertigo, an observer may only see eye movements, known as nystagmus, but cannot see any body movement. A vertigo attack is characterized by an unexpected violent onset of a spinning sensation with hallucinations of rotary motion, often associated with nausea and vomiting, followed by intermittent periods of calm.

A neurologist who has special interest and expertise with patients who have epilepsy is called an epileptologist. One of my co-authors in the 1990 JAMA article (Bernstein, 1990 ) has confirmed that Vincent’s self-described violent attacks of le vertige were not epilepsy but vertigo of inner-ear origin, and not any other disorder from Vincent’s brain. Vincent described his attacks as vertige in his letters:

Parent alternative meaning in English for the French word vertige than vertigo. Here you have Vincent van Gogh stating in his own hand that vertigo was the critical aspect of his recurrent attacks. (Van Gogh,#605) Vincent was very articulate and well-read, with the ability to speak and read several languages, and I must assume that he knew what vertige meant and how to use the word correctly to describe what he felt.

Vincent tells us in his letter about his recurrent vertigo attacks and uses the French word vertige to describe his symptom. The translators of the two comprehensive works of his letters translated vertige as “dizziness,” which is clinically incorrect. Vertigo is a much stronger symptom complex than the generic term “dizziness” would imply. While “dizziness” may seem similar and correct to most people, it is an oversimplification that does not reflect the true depth of the clinical meaning of vertigo to a doctor. Therefore, these distinctions seem minor but may actually distract one from assessing the real significance and impact—or lack thereof—of these vertigo episodes on Vincent’s art and his day-to-day life.

The most likely cause of these debilitating attacks of vertigo is the condition known as Meniere’s disease. This disease was first described in 1861 by Prosper Meniere ( 1861) and now bears his name. Meniere was an ear doctor far ahead of his time. Prior to his brilliant insight, such attacks of vertigo were considered to be coming from the brain and not the inner ear; consequently, they were lumped together as a type of central nervous system problem, placed in the “junk drawer” of everything that had a violent onset but resolved on its own, and considered a form of epilepsy. If the problem did not get better, it was then considered a stroke or a brain tumor. This huge category of “brain problems” remained until Charcot ( 1881) opened up the modern form of neurology, distinguishing so many different brain problems into more meaningful clinical subcategories. Meniere wrote in 1861 about the inner ear problem that would bear his name. This work preceded much of Charcot’s work, and thus clearly put Meniere far ahead of his time for effectively first distinguishing inner-ear disorders as an important entity distinct from brain disorders. A society, the Prosper Meniere Society, was created, and a gold medal was awarded to distinguished ear specialists to address and reward progress made in the field of this challenging disease. The medal depicts the only known image of Prosper Meniere, which was incorporated into the medal design.

Meniere’s disease is characterized clinically by episodes of violent vertigo and hallucinations of rotary motion, fluctuating sensory hearing loss, ringing or noises in the ear or head (tinnitus), and a sense of pressure, pain, or discomfort in the ear or head. True rotary vertigo is the single most critical clinical element in diagnosing Meniere’s disease. As one contemporary patient described:

“You really get low on yourself when this disease attacks you. You’re helpless and you feel like your life is going to be virtually over. Vertigo is everything around you are spinning. You have no sense of up or down or left or right. The only thing you want to do is find the floor.” – Paul McNamee (Meniere’s disease educational video)

True, rotary, hallucinatory vertigo is so much more clinically significant and meaningful than dizziness, disequilibrium, imbalance, and other lesser forms of an inner-ear or brain balance discomforts and maladies. An attack is not accompanied by any of the body movement you may expect in a seizure disorder. Another patient said:

“I became extremely dizzy. Falling over chairs and objects. Tried to regain my composure and it was as if I was drunk. One moment you will be fine. 5-10 minutes later you will be in a full-blown attack. You’ll have difficulty standing up. You’ll be bouncing off of walls. It’s very difficult to describe to the normal person.” Tom Brown, Meniere’s Patient, Interview Channel 2 News Cover Story Segment

To those who witnessed one of Vincent’s attacks, he may have exhibited some very unusual verbal and physical behaviors, leading outsiders to assume he was “mad” or intoxicated, or both. He may have appeared as if he had been drinking and feeling like he was inebriated, with nausea and vomiting that can often be hard to distinguish from drunkenness if the drinking episode went unwitnessed. These unexpected, unprovoked hallucinations and other unpleasant symptoms, which interrupted his intense focus on his painting, may also have provoked extreme frustration and outrageous outbursts of anger. But he was not crazy or mad, as he would have appeared during an attack, when observed by another person watching and listening to him during an acute attack. An observer may only see eye movements known as nystagmus.

“All of the sudden the room would start spinning violently. You start wondering what is happening to you. You feel a little bit crazy because it comes and goes. It’s not something a person can visually look at you and see something is wrong.” – Jan Hurst, Meniere’s Patient (Interview 9 News, with Sherry Sellers)

Meniere’s disease runs along a very diverse spectrum with lots of volatility and can outwardly manifest itself in many different ways to both the viewer and the afflicted one. In a major attack, this hallucination of violent motion is often accompanied by an increase in the patient hearing noises inside his ears or head, called tinnitus. This can be accompanied by a transient loss of hearing in the affected ear. At the same time, an attack can be accompanied by pain or pressure in the ears or head as well as headaches, nausea, vomiting, and profuse sweating. The patient could have difficulty standing, walking, maintaining his balance. They could end up prostrate on the ground, retching as this might be the only safe position of relative stability until the hallucination stops. The patient in the midst of such a dire attack most likely would be nauseated and even vomiting.

“When the attacks came the world was spinning. There was no way to keep your balance. If you weren’t holding yourself against the wall trying to get somewhere, you were crawling.” – Paul McNamee (Interview News 7, Mike Fenwick)

If suffering a severe enough reaction for a protracted time, the victim can fall, lose consciousness, and—in rare cases—lose bowel and bladder function. In a minor or less severe adjunctive spell of vertigo, after a briefer vertiginous episode, any of the other symptoms described above could occur concurrently but be less severe.

Meniere’s disease is not an uncommon disorder; in 1973, the projected incidence and prevalence in the United States was between three and seven million people (Stahle, 1978). This disease is an unfortunate affliction that is not rare and could easily explain Vincent’s attacks as well as his hallucinations. It could further explain the strange noises in his head and the ear pressure he sensed. Additionally, this inner-ear affliction could also explain his volatility and mood swings between his periods of calm and his almost daily, frenetic painting with explosions of color. That never-ending, nightmarish, gnawing fear of another, more violent attack could explain his biggest fear, that he would forever lose his ability to create his art. It could have been what drove him to continue to experiment and paint what he saw better and better. It could also significantly contribute to his exceptional drive to paint a canvas a day, as if each painting were his last.