The diagnosis of art: Van Gogh and male pattern baldness

It is our impression that male pattern baldness is represented less often in works of art than it occurs in real life. Of course, before Pitt introduced a guinea tax on hair powder in 1795, which discouraged their use, wigs often disguised baldness. And even when wigs were not used, various types of headgear served the same purpose. Many of Holbein's sitters, for example, wore hats, and in Jean Huber's contemporary portrayal of Voltaire getting dressed in the morning, ‘Le Lever de Voltaire’, he is depicted standing on one foot, struggling to pull on his trousers, still wearing his nightgown and nightcap. Huber was fond of caricaturing Voltaire, and in 1772 Voltaire complained bitterly about it: ‘Il m'a rendu ridicule d'un bout de l'Europe a l'autre’. 1 Many of the exceptions are in depictions of saints, in whom baldness may be thought to convey an element of holiness, in line with the monk's tonsured pate and the shaven heads of some Eastern religious devotees. But a major exception is to be seen in Rembrandt's painting of the ‘Anatomy Lesson of Dr Nicolaes Tulp’ (c. 1632). The anatomist himself wears a hat, but his seven companions do not, and most if not all of them have combed their hair forwards to disguise their incipient baldness. Antonio Verrio's self-portrait (c. 1700) is even more striking. The artist is entirely bald, but there is a suggestion of a fine fuzz on his pate and his eyebrows are preserved, so he probably does not have alopecia totalis. There is no evidence of scarring, nor of any of the possible causes of diffuse alopecia, such as thyroid, parathyroid or pituitary disease. He could, however, have had telogen effluvium following an acute febrile illness. You cannot tell from the painting that Verrio was also going blind, because of bilateral cataracts; the full title of the painting is ‘Cieco Antonio, il povero Verrio’. Another example is to be seen in Cranach's portrait of Luther's father (c. 1527) but there the baldness is minor. Even in the 19th and 20th centuries baldness seems to be under-represented, although instances can be found. A very good example is to be seen in Toulouse-Lautrec's portrait of two seedy looking characters, ‘Monsieur, madame, and the dog’ (1893), monsieur's baldness being inadequately concealed by a few thin wisps of hair brushed forwards. And in Pierre-August Renoir's ‘Portrait of Ambroise Vollard’ (1908) the sitter does not have enough hair even to disguise his baldness in this way. But then we come to what is perhaps the most striking example of all – van Gogh's portrait of deep depression, ‘On the Threshold of Eternity’, also known as ‘Old Man in Sorrow’ ( Figure 1), painted at Saint Remy in May 1890, not long before he committed suicide. Figure 1 On the threshold of eternity (1890) by Vincent van Gogh (oil on canvas, 80 x 64 cm; Kroller-Muller Rijksmuseum, Otterlo, The Netherlands). In colour online A man sits in a chair, his face buried in his clenched fists. Our inability to see his face draws our attention to his extreme baldness, emphasized by his side locks. The room is equally bare – no carpet on the floor, no decorations on the walls. The melancholy of the scene is exacerbated by the unremitting blueness of the man's clothes. He is, we can see, on the threshold of eternity, as the title tells us, about to commit suicide. The cheerless fire may be symbolic of the hell to which he feels he is condemned. Hair loss is associated with depression. In a study of 1717 men with varying degrees of male pattern baldness, loss of hair caused significant distress – those with alopecia felt more worried and helpless than those without.2 Such feelings may be exacerbated by the perceptions of others. In a Korean study, balding men were perceived as being older and less attractive by over 90% of non-bald men and women, more commonly by the latter.3 The effects are related to the degree of hair loss and are greater in younger men.4 The feelings are generally mild, but some patients have intense emotional concerns about hair loss, and may spend hours each day compulsively checking their scalp in the mirror, combing and re-combing their hair, and suffering considerable social anxiety and depression.5 Conversely, some have thought that alopecia areata can be triggered by emotional stress.6 Though not himself severely bald, van Gogh seems to have felt instinctively that severe baldness was an important feature of the depressive condition that he sought to depict.