Was It Depression or Disease?

WASHINGTON POST

Wilfred Niels Arnold, a biochemist at the University of Missouri Medical School, knows what ailed Vincent van Gogh. After examining every medical reference from constipation to melancholy in the artist's hundreds of letters, sorting and charting them, and doing chemical experiments on the livers of chicken embryos, Arnold is sure that he has the answer: a liver condition called acute intermittent porphyria, complicated by absinthe abuse.

Kay Redfield Jamison, a writer and professor of psychiatry, is equally sure that Arnold is full of hogwash, or perhaps chicken livers. She, too, has analyzed Van Gogh's letters and life story, and her conclusion is also firm: manic depression. Possibly complicated by absinthe abuse.

Some 108 years after his suicide, Van Gogh remains a source of fascination for doctors of all kinds. Ophthalmologists, physicians, chemists, bio-behaviorists, cultural historians and, of course, psychiatrists have for at least 70 years churned out thousands of pages of post-mortem analysis. Tossing around phrases like "demythologising hermeneutic" and "hyperacusis," they debate with all the passion allowed in medical journals--as though the wretched Dutchman could be helped by their conclusions.

In the end, the diagnosticians split predictably between those who, like Arnold, see his root problem in a biological condition and those who subscribe to a psychological cause. Both acknowledge genetic and environmental influences, including malnutrition and paint chemicals.

The abundance of detailed, fairly well-written letters from the patient fuels much of the diagnosis parlor game. The three volumes of Van Gogh's letters were inherited by Theo van Gogh's wife, Johanna van Gogh Bonger. The letters have been available for seven decades. But there is more to his appeal than the availability of data.

"Van Gogh is someone who is approachable, I think," said Jamison, author of "Touched With Fire: Manic Depressive Illness and the Artistic Temperament" and a manic-depressive herself. "There is always a fascination with a life, with the human story."

A sad human story, in this case, in which the hero repeatedly falls in love with women who can't stand him, drives his relatives crazy, obsesses on religion and self-denial, proves himself incapable of managing the money given him or of supporting himself, can't settle down, drinks too much and eats too little, has several nervous breakdowns--and paints brilliant canvases loved by millions only after his death.

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The letters offer a unique window onto both his suffering and the humdrum details of his life, but--like the Bible--can mean different things to different people. There are about a dozen seriously considered diagnoses, including epilepsy, alcoholism, sunstroke, syphilis and schizophrenia.

"Review of 796 personal letters to family and friends written between 1884 and his suicide in 1890 reveals a man constantly in control of his reason and suffering from severe repeated attacks of disabling vertigo, not a seizure disorder," claimed a group writing in the Journal of the American Medical Assn. in 1990. Van Gogh's "bizarre behavior suggests that his tinnitus had become intolerable and that he felt he might alleviate the 'auditory hallucinations' by eliminating their source. Some patients with Meniere's disease experience such overwhelming tinnitus that they would 'cut off their ear' or 'poke a hole in it with an ice pick' to try to relieve it."

This diagnosis of Meniere's disease was roundly dismissed in a subsequent issue of JAMA, and the authors were said to have misinterpreted and misquoted the letters.

The facts are sometimes left in the dust. Van Gogh cut off part of his ear, not the whole ear.

Van Gogh himself said he had no memory of why he mutilated himself, suggesting an "artist's fit." Nor did he know why he took the piece of ear to a prostitute named Rachel, a teenager he had seen regularly. After he recovered from his ear slashing, she was kind to him, he wrote later.

The rest of the town was not so nice. Eighty people signed a petition demanding that Van Gogh be institutionalized again, so he ended up back in the late 19th century version of a padded cell, "under lock and key and with keepers, without any guilt being proved or even open to proof," he wrote. That sort of thing could make you paranoid.

But let's get back to Arnold's diagnosis of acute intermittent porphyria (AIP) versus Jamison's support of manic depression.

Arnold, author of "Vincent van Gogh: Chemicals, Crises and Creativity," said AIP is essentially an inherited liver enzyme deficiency. It is known to the public as the ailment of King George III (who was thought to be mad) and because it turns urine the color of red wine after exposure to air.

The symptoms include abdominal pain, bladder dysfunction, gastrointestinal problems, irritability, delirium, seizures and paralysis. It can be controlled with diet or exacerbated by certain drugs and chemicals--and Van Gogh's diet was terrible, Arnold says, and his ingestion of noxious chemicals (paint, turpentine, tobacco, absinthe) well documented. An attack can be mistaken for a nervous breakdown.

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Adding to Arnold's conviction is what he believes to be evidence that other members of the Van Gogh family had the disease, especially brother Theo. He died six months after Vincent in the Medical Institute for the Insane in Utrecht, diagnosed with "dementia paralytica." A sister, Wilhelmina, lived most of her life in an asylum, and their youngest brother, Cor, died in South Africa during the Boer War; one contemporary record says he committed suicide. Vincent's suicide was the result of his years of pain and despair at the prospect of more attacks, and his ear mutilation came during some kind of AIP-induced seizure or hallucination, Arnold suggests.

"There isn't anything that can't be explained by AIP," Arnold said. "We have won the day--or at least urged serious scholars to consider it."

Fiddlesticks, Jamison says.

AIP is a very rare disease, while manic depression is very common--why settle on the obscure when the symptoms of bipolar disease are so obvious?

Among these she counts his irritability even as a child, the cyclic pattern of his crises, his insomnia, religious obsession, volatile temper, bursts of productivity, and "very specific attacks of rage and perturbation" combined with periods of great lucidity. She attributes his stomach problems and convulsions to drinking ("self-medicating") and bad diet, and possibly a seizure disorder. Also, she says, AIP is not usually associated with suicide.

Furthermore, there is no record of Van Gogh's urine turning red or any other color.

"In 10 years we'll be able to know something from the DNA," Jamison said. "Although I have a problem with digging up people's graves." She thinks a diagnosis of manic depression still carries a stigma, and that's why some people are reluctant to settle on it. Arnold, on the other hand, thinks the art world does not want to abandon the romantic notion of madness that has become attached to Van Gogh, and accept instead that he was simply a hard-working guy with an enzyme deficiency.

There is one point on which Arnold and Jamison agree: Van Gogh was not schizophrenic, as some early analysts maintained.

"People who say they can see schizophrenia in the paintings are just crazy," Arnold said.

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