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Adult BMI ready reckoner*
Height (m)
1.36
1.40
1.44
1.48
1.52
1.56
1.60
1.64
1.68
1.72
1.76
1.80
1.84
1.88
1.92
1.96
2.00
125 68 64 60 57 54 51 49 46 44 42 40 39 37 35 34 33 31
123 67 63 59 56 53 51 48 46 44 42 40 38 36 35 33 32 31
121 65 62 58 55 52 50 47 45 43 41 39 37 36 34 33 31 30
119 64 61 57 54 52 49 46 44 42 40 38 37 35 34 32 31 30
117 63 60 56 53 51 48 46 44 41 40 38 36 35 33 32 30 29
115 62 59 55 53 50 47 45 43 41 39 37 35 34 33 31 30 29
113 61 58 54 52 49 46 44 42 40 38 36 35 33 32 31 29 28
111 60 57 54 51 48 46 43 41 39 38 36 34 33 31 30 29 28
109 59 56 53 50 47 45 43 41 39 37 35 34 32 31 30 28 27
107 58 55 52 49 46 44 42 40 38 36 35 33 32 30 29 28 27
105 57 54 51 48 45 43 41 39 37 35 34 32 31 30 28 27 26
103 56 53 50 47 45 42 40 38 36 35 33 32 30 29 28 27 26
101 55 52 49 46 44 42 39 38 36 34 33 31 30 29 27 26 25
99 54 51 48 45 43 41 39 37 35 33 32 31 29 28 27 26 25
97 52 49 47 44 42 40 38 36 34 33 31 30 28 27 26 25 24
95 51 48 46 43 41 39 37 35 34 32 31 29 28 27 26 25 24
93 50 47 45 42 40 38 36 35 33 31 30 29 27 26 25 24 23
91 49 46 44 42 39 37 36 34 32 31 29 28 27 26 25 24 23
89 48 45 43 41 39 37 35 33 32 30 29 27 26 25 24 23 22
87 47 44 42 40 38 36 34 32 31 29 28 27 26 25 24 23 22
Weight (kg)

85 46 43 41 39 37 35 33 32 30 29 27 26 25 24 23 22 21
83 45 42 40 38 36 34 32 31 29 28 27 26 25 23 23 22 21
81 44 41 39 37 35 33 32 30 29 27 26 25 24 23 22 21 20
79 43 40 38 36 34 32 31 29 28 27 26 24 23 22 21 21 20
77 42 39 37 35 33 32 30 29 27 26 25 24 23 22 21 20 19
75 41 38 36 34 32 31 29 28 27 25 24 23 22 21 20 20 19
73 39 37 35 33 32 30 29 27 26 25 24 23 22 21 20 19 18
71 38 36 34 32 31 29 28 26 25 24 23 22 21 20 19 18 18
69 37 35 33 32 30 28 27 26 24 23 22 21 20 20 19 18 17
67 36 34 32 31 29 28 26 25 24 23 22 21 20 19 18 17 17
65 35 33 31 30 28 27 25 24 23 22 21 20 19 18 18 17 16
63 34 32 30 29 27 26 25 23 22 21 20 19 19 18 17 16 16
61 33 31 29 28 26 25 24 23 22 21 20 19 18 17 17 16 15
59 32 30 28 27 26 24 23 22 21 20 19 18 17 17 16 15 15
57 31 29 27 26 25 23 22 21 20 19 18 18 17 16 15 15 14
55 30 28 27 25 24 23 21 20 19 19 18 17 16 16 15 14 14
53 29 27 26 24 23 22 21 20 19 18 17 16 16 15 14 14 13
51 28 26 25 23 22 21 20 19 18 17 16 16 15 14 14 13 13
49 26 25 24 22 21 20 19 18 17 17 16 15 14 14 13 13 12
47 25 24 23 21 20 19 18 17 17 16 15 15 14 13 13 12 12
45 24 23 22 21 19 18 18 17 16 15 15 14 13 13 12 12 11
43 23 22 21 20 19 18 17 16 15 15 14 13 13 12 12 11 11

BMI <18.5 – underweight BMI 30–39.9 – obese

BMI 18.5–24.9 – acceptable weight BMI >= 40 – morbid obesity
BMI 25–29.9 – overweight

*
Reproduced from Simon et al, Oxford Handbook of General Practice 2e. By permission of Oxford
University Press.
 i

OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of
Nutrition
and
Dietetics
ii 1

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 1 iii

Oxford Handbook of
Nutrition and
Dietetics

Joan Webster-Gandy

Angela Madden

Michelle Holdsworth
iv 1

Great Clarendon Street, Oxford OX2 6DP

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 1 v

Preface

When we were approached to write this handbook the original idea was
to write a book for general practice. However, we all remember being
student dietitians and all created our own handbook of useful information
that we carried around with us and were totally lost without. On reflection
of what text books are now available in nutrition or dietetics, it became
clear that although there are now concise pocket books written for
dietitians working predominantly in a clinical setting, there was a need for
a user friendly handbook of nutrition and dietetics for a wider audience
that included doctors, nurses, nutritionists and other health care profes-
sionals. The available textbooks are, by necessity, large tomes or series
that are unlikely to adorn the shelves of many doctors or nurses whether
in primary or secondary care.

As a result, we have tried to present nutritional science, therapeutics and

community public health nutrition in a concise and integrated manner.
While writing the text we have tried to identify what information would
be useful to different professionals in a variety of settings. For example a
doctor or nurse may want information on obesity and will find a ready
reckoner for the calculation of BMI, information on associated problems
and treatment options. Dietitians working in the community or public
health will have this information but will find the sections on the meas-
urements of obesity or nutrition interventions more informative. How
well we have achieved this is for the reader to decide.

Nutrition is fascinating for many reasons, one of which is the fact that it is
a very dynamic discipline. We have tried very hard to be contemporary
but there will inevitably be changes in basic science, practice and policy as
the discipline continues to evolve. Major developments and changes will
be posted on the relevant page of the OUP web site. For us it has been a
very enjoyable, if at times rather demanding, process and we hope that
this book is useful to all health care professionals.

J.W-G.
A.M.M.
M.H.
This page intentionally left blank
 1 vii

Oxford University Press makes no representation, express or implied,

that the drug dosages in this book are correct. Readers must therefore
always check the product information and clinical procedures with the
most up-to-date published product information and data sheets provided
by the manufacturers and the most recent codes of conduct and safety
regulations. The authors and the publishers do not accept responsibility
or legal liability for any errors in the text or for the misuse or misapplica-
tion of material in this work.
viii 1

Foreword

Both health professionals and the general public now realize that good
nutrition is essential for good health. Indeed, nutrition is the health topic
on which the lay public receives the most advice from popular books and
magazines, but often this advice is unsound. It is therefore essential that
health-carers have readily available reliable information about all aspects
of nutrition. This includes nutritional science, public health nutrition, and
therapeutic nutrition.
This handbook provides, in concise format, the information about
nutrition needed by those training to be dietitians (RD), nutritionists
(RNutr), public health nutritionists (RPHNutr), or doctors or nurses
either in hospital or primary care. It will continue to be a valuable
resource after graduation, since the scope of modern nutrition is so large
that a specialist in one field (say, public health nutrition) cannot hope to
have instantly accessible all the necessary information about therapeutic
diets, or nutritional sciences, and vice versa.
The three authors of this Handbook are all registered dietitians, each
of whom has a solid research record as well as extensive experience of
the nutritional problems that dietitians, hospital doctors, general practi-
tioners, and specialist nurses will encounter. I am confident that readers
will be thankful to have this book in their pocket to guide them to the
correct immediate response to a nutritional problem, even if later they
have to consult a senior dietitian or textbook for more detailed advice.

John Garrow MD PhD FRCP

Emeritus Professor of Human Nutrition
University of London.
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 1 ix

Acknowledgements

Special thanks go to everyone who has helped and supported us

during the production of this book. We are particularly grateful to:
Julie Beckerson, Alison Culkin, George Grimble, Michelle Harvie, Catherine
Hodgson, Catherine Humphries, Tom Humphries, Jamie Hustler, Cathy
Mooney, Gail Rees, Alan Rio, Ann Van Duzer, and Liz Weekes.
Finally, thanks to the medical division at OUP for all the encourage-
ment and support.
x 1

Dedication

To Beth, Didier, Catherine, Matthew, Milo, Paula, and Will, with much
love.
 1 xi

Contents

Detailed contents xv
Contributors xxvi
Abbreviations xxix

1 Introduction to nutrition 3
2 Dietary reference values (DRVs) and food-based
dietary guidelines 17
3 Current dietary patterns in the UK 29
4 Nutrition assessment 33
5 Nutrients 55
6 Food labelling, functional foods, and
food supplements 167
7 Non-nutrient components of food 183
8 Drug–nutrient interactions and prescription
of nutritional products 199

9 Diet before and during pregnancy 209

10 Infants and preschool children 221
11 School-aged children and adolescents 255
12 Older people 267
13 Nutrition in special groups 281
14 Nutrition intervention with individuals 305
15 Nutrition intervention with populations 321
xii 1 CONTENTS

contents

16 Nutrition support 347

17 Obesity 405
18 Diabetes 423
19 Cardiovascular disease 449
20 Cancer and leukaemia 475
21 Nutrition in gastrointestinal diseases 489
22 Pancreatic disease 539
23 Liver disease 543
24 Renal disease 555
25 Respiratory disease and cystic fibrosis 585
26 Human immunodeficiency virus (HIV) infection 591
27 Nutrition in mental health 599
28 Nutrition in neurological conditions 609
29 Palliative care 615
30 Inherited metabolic disorders 619
31 Epilepsy and ketogenic diets 627
32 Food hypersensitivity 631
33 Rheumatology and bone health 637
34 Hospital catering 649
35 Popular diets 653
Appendices
1 Weights and measures 659
2 Anthropometrics 661
3 Conversion factors 683
4 Energy expenditure prediction equations 685
5 Clinical chemistry reference ranges 687
6 Dietary reference values 689
7 Nutritional composition of common foods 697
 CONTENTS 1 xiii

8 Useful contacts 705

9 The National Statistics Socio-economic
Classification (UK) 711
10 Bibliography and further reading 713

Index 717

Adult BMI ready reckoner Inside front cover

MUST screening tool Inside back cover

Contents
This page intentionally left blank
 1 xv

Detailed contents

Contributors xxvi
Abbreviations xxix

1 Introduction to nutrition 3
Definitions and titles 4
Components of the diet 6
Food composition tables 10
Digestion 14
2 Dietary reference values (DRVs) and 17
food-based dietary guidelines
Dietary reference values (DRVs) 18
Food-based dietary guidelines (FBDG) 22
3 Current dietary patterns in the UK 29

Current dietary patterns 30

4 Nutrition assessment 33
Dietary assessment 34
Individual assessment 38
Body composition 44
Anthropometry 48
5 Nutrients 55
Macronutrients: introduction 56
Protein 58
Fats 66
Carbohydrate 74
xvi 1 DETAILED CONTENTS

Energy balance 82
Vitamins: introduction 90
Vitamin A (retinol) and carotenoids 92
Vitamin E 96
Vitamin D (calciferols) 98
Vitamin K 100
Vitamin C (ascorbic acid) 102
Riboflavin (vitamin B2) 104
Niacin (nicotinamide, nicotinic acid) 106
Thiamin 108
Folate (folic acid) 110
Vitamin B6 112
Cobalamin B12 114
Biotin 116
Pantothenic acid 118
Minerals and trace elements:
introduction 120
Calcium 122
Phosphorus 126
Iron 128
Zinc 134
Copper 136
Iodine 140
Selenium 142
Magnesium 144
Manganese 146
Molybdenum 148
Chromium 150
Fluorine 152
Electrolytes: introduction 154
Sodium 156
Potassium 160
 DETAILED CONTENTS 1 xvii

Chlorine 162
Fluid balance 164
6 Food labelling, functional foods, and 167
food supplements
Food labelling 168
Functional foods and nutraceuticals 176
Food supplements 180
7 Non-nutrient components of food 183
Alcohol 184
Biologically active dietary constituents 190
Food additives 194
8 Drug–nutrient interactions and 199
prescription of nutritional products
Drug–nutrient interactions 200
Prescription of nutritional products 206
9 Diet before and during pregnancy 209
Pre- and periconceptional nutrition
in women 210
DRVs and dietary guidelines during
pregnancy 212
Food safety in pregnancy and maternal
weight gain 214
Dietary problems in pregnancy 216
Vulnerable groups in pregnancy 218
Useful websites 220
10 Infants and preschool children 221
Infant growth and development 222
Breast versus bottle feeding 226
Promoting and establishing breastfeeding 230
xviii 1 DETAILED CONTENTS

Dietary recommendations for

lactating mothers 234
Establishing bottle-feeding 236
Weaning 238
Iron deficiency anaemia 242
Faltering growth 244
Constipation, toddler’s diarrhoea, and milk
intolerance 248
Nutritionally vulnerable groups 250
Fussy eaters 252
Websites and literature for parents 254
11 School-aged children and adolescents 255
Why diet is important in childhood and
adolescence 256
What children and adolescents are
eating 258
Dietary recommendations for children and
adolescents 260
Nutritional problems of children and
adolescents 262
Influences on children’s food choice 266
12 Older people 267
Older people: introduction 268
Dietary recommendations for older people
270
Undernutrition in older people 272
Other nutritional problems 276
Community support strategies for promoting
a healthy diet for older people 278
Further information 280
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Exploring the Variety of Random
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batteries, transmitting every movement and thought by means of a thread,
as if the idea and way of thinking were so many strokes on the part of the
manipulator of the telegraphic instrument. The system, as may be
understood, is infinitesimal, for thought, transmitted from one side, forms
on the other as many infinitesimal points as there are atoms forming the
idea.’ ”
MM. Riva and Tanzi observe that many of the ancient alchemists
expressed themselves in precisely the same way.
“So,” they continue, “nothing could be easier than to recognize a born
paranoiac in the King of Bavaria,[306] misanthropic, vain, ambitious,
mystical, romantic, voluble, subject to hallucinations, eccentric in his acts,
his habits, his judgment and his conduct, perverted in his æsthetic tastes, in
love, in the ethical sentiments, exaggerated and unbalanced in everything.
He was so profoundly impressed with the stamp of mediæval atavism that
political journalism—hitting the mark with unconsciously scientific
correctness—designated him as a Sir Percival come to life again.”
The pathologic and atavistic origin of many of the literary productions of
the insane explains the frequent inequalities of the style, which is as feeble
and slovenly when the excitement ceases, as it was at first splendid and
vigorous, and the abrupt transition from stanzas worthy of a classic author
to the scribbling of an idiot. This origin also accounts for the extreme
contradictions to be found in the writings of one and the same author—as is
seen in Farina and Lazzaretti—their fondness for aphorisms and detached
periods, the abrupt and disconnected character of their style—which is both
primitive and childish—and the monotonous repetition of certain words or
phrases, recalling the verses of the Bible or the suras of the Koran. It also
explains their propensity for continually dwelling on the same subject,
nearly always connected with matters out of the line of their own studies,
and (what is more important) of no advantage to themselves or others. Their
works are nearly always autobiographical.
Conclusion.—Summing up what has been said, there is a special
organization in all the writings of madmen, even the absurdest—a true
finality, as Paulhan calls it.
“I understand by this,” he says, “that, as soon as one psychic element
exists, it tends to call forth others. It is not the totality of the mind—if it is
not itself co-ordinated—which determines the appearance of phenomena,
but the elements. That is to say, what is already systematized in the mind
tends to acquire a more complete systematization. If it is a sensation, it will
tend to awaken particular, precise, and appropriate ideas or acts; if it is a
general tendency—a pre-established mental organization—it will tend to
make the mind interpret in such or such a manner the sensations which
reach it.
“As every psychic element is systematic, and as, when finality is not to
be found in the totality of a psychic organism, or of a series of actions, or a
theory, or an argument, or a passion (and in this case all these facts are not
really psychic elements), it exists in the elements. This tendency on the part
of the elements to systematic association, exercising itself without higher
control, without general direction, ends in producing numerous discords in
the totality of psychic operations. The result is somewhat as though all the
musicians in an orchestra were to play different tunes in as many different
keys.
“When, in the constitution of society, an association is dissolved, a law
of finality is broken and the elements (the human beings who formed the
association) are restored to individual life. They then enter upon new forms
of social activity. If, for example, a factory is closed, the men and women
who worked there and were united by a systematic association, go to work
again, each on his or her own account, either separately, or in new
associations, in which some of them may chance to meet again. The same
thing takes place with the psychic elements, wherever, from one cause or
another, the bond which united them is broken; they enter into new
associations where they work, each on its own account, at the risk of
producing nothing but incoherence. This isolated activity of the elements is
met with in a striking manner in mental disease.
“The pun is a form of this disorder. On analyzing it, we find that it
consists essentially in this: A sound employed in a particular complexus
(consisting of the sound, the ideas, and the systematized images constituting
the signification of the sound), itself forming part of a more complex
system, separates itself at least partially from these two systems, and
becomes associated with other systems of ideas and images. The association
through a resemblance between certain parts of the words—for example, by
means of rhyme—is an essentially analogous fact. Here it is a sound which,
systematically associated with other sounds, allies itself at the same time
with different sounds, in order to form simultaneously, or at short intervals,
systems which do not harmonise together. Among the latter class may be
reckoned the greater number of lapsus linguæ and lapsus calami.
“Examples of this abound. M. Regnard has cited several pieces of verse
written by madmen, which show in a high degree the mode of elementary
systematic association. Sometimes one observes a remnant of intellectual
co-ordination, as in the following lines, in which, however, incoherence is
also abundantly manifested:—

“ ‘J’aime le feu de la fougère

Ne durant pas, mais pétillant;
La fumée est âcre de goût.
Mais des cendres de: là Fou j’erre
On peut tirer en s’amusant
Deux sous d’un sel qui lave tout,
De soude, un sel qui lave tout.’[307]

At other times sense disappears altogether, as in these lines, also quoted

by M. Regnard, and composed by a patient whose mania was that of self-
conceit, and who had been insane for twenty-five years:—

“ ‘Magnan! à mon souhait, médecin Magnan ime,

Adore de mon sort la force qui ... t’anime.
..........
Admirant son beau crâne ... autre remord de Phèdre,
Nargue Legrand du Saulle et sois un Grand du Cèdre.’[308]

A good example of this phenomenon is afforded by the patient, observed by

Trousseau, who wrote down more than five hundred pages of words
connected with one another by assonance or sense: Chat, chapeau, peau,
manchon, main, manches, robe, rose, jupon, pompon, bouquet, bouquetière,
cimetière, bière, &c.[309]
“One need not be either insane or imbecile to make puns and associate
words together on account of superficial resemblances. In this case, instead
of being a permanent dissociation of the more complex systems, it is a
momentary dissociation which gives rise to the phenomenon. Nothing is
more natural—when one feels the need of unbending one’s mind—than to
restore to themselves the psychic elements retained in complex systems not
necessary to life, and to allow them a liberty which they sometimes abuse.
To continue the above comparison—which may be carried a long way—the
workmen in the factory are not always at work; they have their moments of
rest and recreation, and then usually occupy themselves with less complex
systems.”[310]
Those most prone to these rhythmic manifestations are, in my opinion
(which is borne out by Adriani and Toselli), chronic maniacs, alcoholic
maniacs, and paralytics in the early stage—in whom, however, there is apt
to be more rhyme than verse, and more verse than sense. Melancholy
patients would take the next place, owing to the small number of these
found in asylums; they seem to find in versification a relief from their
habitual silence, or a defence against imaginary persecutions. This is a
much more important fact than would appear at first sight, when connected
with another, already well known, viz., that all great thinkers and poets are
constitutionally inclined to melancholy.

CHAPTER II.

Art in the Insane.

Geographical distribution—Profession—Influence of the special form of alienation—
Originality—Eccentricity—Symbolism—Obscenity—Criminality and moral insanity—
Uselessness—Insanity as a subject—Absurdity—Uniformity—Summary—Music among
the insane.

T
HOUGH the artistic tendency is very pronounced, and might almost be
called a general characteristic, in some varieties of insanity, few authors
have paid sufficient attention to it.
The only exceptions are Tardieu, who, in his Études Médico-Légales sur
la folie, remarks that the drawings of the insane are of great importance
from the point of view of forensic medicine; Simon,[311] who, in speaking
of drawing among megalomaniacs, observes that the imagination appears in
them in inverse proportion to the intellect; and Frigerio, who some time
later gave a survey of the subject in an excellent essay, published in the
Diario del Manicomio di Pesaro.[312] Since then I have been able to make a
completer examination of this subject, thanks to the curious documents
supplied to me by MM. Riva, Toselli, Lolli, Frigerio, Tamburini,
Maragliano, and Maxime du Camp.
 By comparing their observations with my own, I find a total of 108
mental patients with artistic tendencies, of which:—46 were towards
painting, 10 sculpture, 11 engraving, 8 music, 5 architecture, 28 poetry.
The prevailing psychopathic forms in these 108 cases were:—In 25,
sensorial monomania and that of persecution; 21 dementia, 16
megalomania, 14 acute or intermittent mania, 8 melancholia, 8 general
paralysis, 5 moral insanity, 2 epilepsy.
It is evident that those which predominate are the congenital and least
readily curable forms (monomania and moral insanity), together with
dementia, and those forms which it accompanies, or in which it is latent
(megalomania and paralysis).
Let us now consider the special characteristics of these insane artists.
Geographical distribution.—In the districts where the artistic tendency
is more marked among the sane, the number of insane artists is also higher.
In fact, I have found very few of the latter at Turin, Pavia, or Reggio, while
at Perugia, Lucca, and Siena they abound.
Profession.—Only in a few cases could the tendency be explained by
profession or habits acquired before the appearance of the disease. We find
among the insane artists mentioned above—8 ex-painters or sculptors, 10
ex-architects, carpenters, or cabinet makers; 10 former schoolmasters or
priests, 1 telegraphist, 2 students, 6 sailors, soldiers, or officers of
engineers.
Among modern painters affected with insanity, we may note Gill, Cham,
Chirico, Mancini, and others.
In some cases, former tendencies were accentuated by insanity. Thus, a
mechanician made drawings of machines, two sailors constructed models of
ships, a major-domo traced, on the floor, pictures of tables prepared for a
banquet, with pyramids of fruit. At Reggio, a cabinet-maker carved some
very fine foliage and ornaments; a naval officer at Genoa at first carved
models of ships, and afterwards was continually occupied in depicting—
though he had never learnt to paint—scenes at sea which, he said, consoled
him for being debarred from his favourite element.
Sometimes these men were inspired by insanity with a strange energy in
their work, “just as if,” as MM. de Paoli and Adriani wrote to me, “they had
been paid for it. They cover the walls, the tables, and even the floor, with
painting.” One of them, a painter, who had formerly only reached
mediocrity, attained such perfection through his malady, that a copy of one
of Raphael’s Madonnas, executed by him during one of his attacks, gained a
prize medal at the Exhibition.
Mignoni, the celebrated painter of Reggio, who became an inmate of the
asylum at that town on account of dementia and megalomania, remained
idle there for fourteen years. At last, at the suggestion of Dr. Zani, he
resumed his brush, and covered the walls of the asylum with excellent
frescoes. One of them represented the story of Count Ugolino so vividly,
that one of the patients began to throw meat at it, so that the father and
children might not die of hunger, and the grease spots are still to be seen.
[313]
Of eight painters, whose history Adriani has related to me, four kept
their former skill while under the influence of acute or intermittent mania;
in two others, it was so far weakened that one of them, after his recovery,
sincerely deplored the work done during his illness.
Influence of the special form of Insanity.—In many cases, the choice of
subject is inspired by the malady. A melancholiac was continually carving a
figure of a man with a skull in his hand. A woman affected with
megalomania was always working the word DIO (God) into her
embroidery. Most monomaniacs habitually allude to their imaginary
misfortunes by means of special emblems.
A monomaniac, who laboured under the delusion that he was being
persecuted, drew his enemies pursuing him on one side of the picture and
Justice defending him on the other.
Alcoholic maniacs often make an excessive use of yellow in their
pictures. One painter, in whom alcohol had completely destroyed the sense
of colour, became very skilful in the rendering of white, and, between his
drunken fits, became the best painter of snow-scenes in France.
An artist of note, C——, when affected with general paralysis, lost his
sense of proportion, e.g., he began to sketch a tree which, if drawn in its
entirety, would have reached beyond the frame of the picture. He collected
the poorest oleographs and admired them, and coloured everything green.
It is more usual, however, for insanity to transform into painters persons
who have never been accustomed to handle a brush, than for it to improve
skilled artists. Sometimes the disease, while suppressing some qualities of
value to art, causes the appearance of others which did not previously exist,
and gives to all a peculiar character.
Insanity changed Luke Clennell from a painter to a poet,[314] while
Melmour, a physician who fell into a state of dementia after the loss of his
wife, who died on their wedding-day, took to literature and lost his previous
aptitudes.
“Exaggeration pushed to its extreme—to the improbable, or even the
impossible,” says Regnard, “is one characteristic of paralytics. One of these
madmen painted a man touching the stars with his head and the earth with
his feet.”[315]
Daudet, in Jack, speaks of insane artists whose pictures seemed to
represent earthquakes or the inside of a ship during a storm.
Individuals, who previously had not the remotest idea of art, are
impelled by disease to paint, especially at the periods of strongest
excitement. B——, a mason, became a painter while in the Pesaro asylum.
His attacks of mania were always announced by an outbreak of his
tendency to draw caricatures of the hospital staff, whom he condemned, in
effigy, to the strangest punishments. For instance, he painted the cook, a
stout and ruddy man, in the attitude of an Ecce Homo, behind a grating
which prevented him from touching the most appetising viands. This was
the penalty for having refused B—— one of his favourite dishes.
The grotesque apotheosis of himself, painted by the pederast and
megalomaniac, R——, in which he excretes and fecundates eggs which
symbolise worlds, is characteristic of the boundless vanity and unbridled
imagination of megalomaniacs and paralytics.
Among the pictures executed by the patients at San Servolo, the most
curious is one by a lunatic who, in his lucid intervals, paints fairly well,
though with excessive minuteness of detail; but during his attacks this
minuteness is so far exaggerated as to become grotesque.
Nothing but an intense religious monomania could have inspired the
singular self-crucifixion of the Venetian shoemaker, Matteo Lovat. I have
been able to procure an authentic picture of this strange performance which
is reproduced below. Shortly afterwards Lovat died in an asylum.[316]
 One patient, G——, was a poor peasant woman, utterly uneducated, in
whose family pellagra and insanity were both hereditary. In the long
isolation required by her state, she developed great skill (quite unknown
before her illness) in embroidering on linen, with coloured threads pulled
from her clothing, an extraordinary number of figures, which were faithful
representations of her delusions. Her autobiography is, so to speak, traced
in this embroidery; in every piece of work she has represented herself,
sometimes struggling with the nurses or the nuns, sometimes herding cows,
or occupied with other rustic work. Elsewhere she would depict tables
spread for meals, with an infinite variety of accessories. But the most
singular thing is that the outlines are drawn with a clearness which would
be the envy of a professional caricaturist; no shading whatever, four
stitches, representing nose, eyes, and mouth, were arranged with so much
artistic judgment as to show clearly the individual expression of each face.
Another artist in the same line, though of less striking gifts, is a certain I
——, suffering from moral insanity, who shows numerous degenerative
symptoms. She, too, embroiders figures of men and women with
considerable skill, but always in harmony with her perverted sexual
tendencies.[317]
 Originality.—Disease often develops (as we have already seen in the
case of insane authors) an originality of invention which may also be
observed in mattoids, because their imagination, freed from all restraint,
allows of creations from which a more calculating mind would shrink, for
fear of absurdity, and because intensity of conviction supports and perfects
the work.
At Pesaro there was a woman who drew, or embroidered, by a method
peculiar to herself, unravelling cloth, and fastening the threads on paper by
means of saliva.
Another embroideress, formerly given to drink, executed butterflies
which seemed to be alive. She had applied to white embroidery the methods
of coloured work, and was able to produce marvellous effects of light and
shade.
At Macerata a patient, with a number of pipe-stems, constructed a model
of the front of the asylum; another had the idea of representing a song in
sculpture. At Genoa, a dementia patient carved pipes out of coal.
One Zanini, at Reggio, constructed a boot which was unique of its kind,
so that, as he said, no one else should be able to put it on. This exceptional
foot-gear was open on one side, and tied up with string, its edges were
ornamental, and worked with hieroglyphics.
M. L—— of Pesaro was constantly making requests to leave the asylum.
When told that there was no means of transporting him to his home, he set
about constructing one for himself. This was a four-wheeled cart, with an
upright pole, at the top of which was a pulley with a rope running through
it. One end of the rope was fastened to the axle of the fore-wheels, the other
to that of the hind-wheels. An elastic cord was attached to the rope for a
distance of four or five centimetres, and by pulling this, first at one end and
then at the other, a person standing on the cart was able to make the wheels
go round.[318]
In many arabesques drawn by a megalomaniac, one can trace, carefully
hidden among the curves, sometimes a ship, sometimes an animal, a human
head, or a railway train, or even landscapes and towns; though the essential
character of arabesques is the absence of the human figure.
The best asylums of Italy have sent to the exhibitions of Siena and
Voghera, models in relief of their respective buildings, admirably executed
by some of the patients. That of the asylum at Reggio could be taken to
pieces, and showed the inside arrangements, staircases, rooms, with their
furniture, &c., all carefully finished. Even the trees, I am told, were copied
accurately from nature.
A canon, who had no technical knowledge of architecture, began, after
an attack of melancholia, to construct with cardboard and papier-mâché,
models of temples and amphitheatres, which excited great admiration.
Dr. Virgilio has made me a present of some portraits of Italian
specialists, nearly all of them exceedingly lifelike, the work of a
melancholia patient. The note of originality only comes out in some
accessory introduced into each picture, such as a fly, or a butterfly, repeated
persistently in every copy, or in the way in which the artist’s name is
worked into the painting, in vertical lines so as to form some sort of
decorative ornament.
A work of extreme though useless skill and originality is the self-
crucifixion of Lovat, already mentioned.
“The monomaniac, King Louis of Bavaria, was the first who entirely
understood Wagner. His prodigality in spending money, and the creation of
the theatre at Bayreuth—one of his most original conceptions—have been
known for years, but the greatest manifestation of his genius is known only
to a few. Three castles, three palaces of splendid and indescribable beauty,
rose from the earth, as if by enchantment. He superintended even the
minutest details himself. King Louis’s madness was a dream with his eyes
open. By himself, in the space of ten years, he accomplished more than any
twenty sovereigns, aided by the artistic genius of the best ages. Certainly no
one, at the present day, could produce another such hall, 75 mètres in length
(without counting the two rooms at either end, which would bring the
length up to 100 mètres), a gallery illuminated by 17 great windows, 33
rock-crystal chandeliers, 44 candelabra, and who knows what else!”[319]
Eccentricity.—But even originality ends by degenerating, in all, or
nearly all, into mere eccentricity, which only seems logical when one enters
into the idea of the delusion.
Simon remarks that, in manias of persecution, and in paralytic
megalomania, the greater the mental disturbance the livelier the
imagination, and the more grotesque the fancies engendered by it. He
mentions the case of a painter, who declared that he could see the interior of
the earth, filled with houses of crystal, illuminated by electric light, and
pervaded by sweet odours. He described the city of Emma, whose
inhabitants have two noses and two mouths—one for ordinary food, the
other for sweet things—a silver chin, golden hair, three or four arms, and
only one leg resting on a little wheel.[320]
These bizarre creations arise in great part from the strange hallucinations
to which the patients are subject. We may see an example of this in the four-
legged and seven-headed beasts painted by Lazzaretti on his banners. A
melancholiac made himself a cuirass of stones, to defend himself against
his enemies. Another would continue all day drawing the map of the stains
left by damp on the walls of his room. Later on it was discovered that he
believed those lines to represent the topography of the regions which God
had given him to rule over on earth.
This is one of the reasons why, sometimes, greater excellence in art is
found in cases of dementia, than in those of mania or melancholia.
Symbolism.—Another characteristic trait of art in the insane is the
mingling of inscriptions and drawings, and, in the latter, the abundance of
symbols and hieroglyphics. All this closely recalls Japanese and Indian
pictures, and the ancient wall-paintings of Egypt, and is due in part to the
same cause at work in these—the need of helping out speech or picture,
each powerless by itself to express a given idea with the requisite energy.
This cause is very evident in a case communicated to me by Dr. Monti,
in which an architectural design, though well and accurately drawn, was
rendered incomprehensible by the numerous inscriptions, often in rhyme,
which had been crowded into it by its author, an aphasiac, who had suffered
from dementia for fifteen years.
In some megalomaniacs this happens through the fancy they have for
expressing their ideas in a language different from that of ordinary human
beings. Such was the case of the master of the world, fully treated of
elsewhere, by M. Toselli and myself.[321]
The patient in question was a peasant named G—— L——, 63 years of
age, with an easy and confident bearing, prominent cheek-bones, spacious
forehead, and expressive and penetrating look. Cranial capacity 1544, index
82, temperature, 37° 6´.
In the autumn of 1871 he became noted for vagrancy and excessive
loquacity; he stopped the most notable persons of the village in public
places, complaining of injustice which he alleged himself to have suffered;
he destroyed the vines, devastated the fields, and rushed about the streets,
threatening terrible vengeance.
Gradually he began to identify himself with the Deity, and believe
himself ruler of the universe, and preached in the Cathedral of Alba on his
lofty destiny. In the asylum he remained calm as long as he was able to
believe that his power was recognized by every one, but at the first show of
opposition he threatened—in the character of ruler and personification of
the elements, calling himself sometimes the son, sometimes the brother, or
at others the father of the sun—to convulse the world with earthquakes,
overthrow kingdoms and empires, and erect his throne on the ruins. He was
tired, he said, of keeping up so many armies, and providing for so many idle
persons; it would be but just if the authorities and the rich were at least to
send him a large sum of money, to redeem themselves from what he called
“the debts of death.” In return for this payment he would allow them to live
for ever. The poor ought all to die, as useless persons, and it was
preposterous that he had to support so many madmen in his own palace. He
therefore suggested to the doctor that it would be well to cut their heads off;
yet he waited on them with the greatest unselfishness when they were ill, an
inconsistency which is among the characteristics of paranoia.
He usually bestowed his scanty earnings on some rogue whom he
entrusted with letters and commissions for the other world, addressed to the
sun, the stars, the weather, Death, the lightning, and other powers, whose
help he was in the habit of invoking, and with whom he held confidential
conversations at night. He was quite pleased when some calamity had
desolated the country, this being the beginning of the judgments threatened
by him, and a sign that the weather, the sun, or the lightning, had obeyed
him.
He kept in a trunk some roughly-fashioned crowns which, he said, were
the true royal and imperial crowns of Italy, France, and other states. Those
worn by the actual sovereigns of these states were no longer of any value,
having been usurped by wretched men, doomed to speedy destruction,
unless they paid him their debts of death, in letters of exchange to the
amount of several hundred millions.
But his most characteristic eccentricities were the writings in which his
delusion was manifested. Although able to read and write, he scorned the
use of the ordinary kind of writing, and, in a character of his own, scrawled
letters, orders, and cheques, to the Sun, to Death, or to the civil and military
authorities. He always had his pockets full of these documents. His writing
consisted mainly of large capital letters, mixed, at intervals, with signs and
figures indicating objects or persons. The words are usually separated by
one or two large dots, and he only wrote some of the letters of each word
(nearly always the consonants) without any respect for the laws of
syllabation. In some of his writings, the alphabet almost entirely disappears.
For instance, in order to demonstrate his effective power, he sketched a
series of rough figures representing the elements and powers which were
his familiar spirits,—the army ready, at a sign from him, to make war on all
terrestrial powers contending with him for the dominion of the world. These
are—1. The Eternal Father. 2. The Holy Spirit. 3. St. Martin. 4. Death. 5.
Time. 6. Thunder. 7. Lightning. 8. Earthquake. 9. The Sun. 10. The Moon.
11. Fire (his minister of war). 12. A very powerful man who has lived ever
since the beginning of the world, and is G. L.’s brother. 13. The Lion of
Hell. 14. Bread. 15. Wine. The whole is followed of his usual signature—a
two-headed eagle. Each of these powers is also indicated by letters placed
beneath the figures, thus, the 1st=P. D. E.; the 2nd=L. S. P. S., &c.
This mixture of letters, hieroglyphics, and figurative signs, constitutes a
kind of writing recalling the phonetico-ideographic stage through which
primitive peoples (the Mexicans and Chinese certainly) passed, before the
discovery of alphabetic writing.
Among the savages of America and Australia, writing consists in a more
or less rough kind of painting; e.g., to indicate, “would that I had the
swiftness of a bird,” they depict a man with wings instead of arms.[322]
These characters are not so much writing as aids to memory still further
connected together and vivified by traditional songs or stories.
Some tribes, however, have attained to a somewhat less imperfect mode,
which resembles our rebus; for instance, the Maya of America, to signify a
physician, painted a man with a herb in his hand and wings to his feet; an
evident allusion to the rapidity with which he is obliged to hasten to those
who require him. Rain is represented by a bucket.[323]
The ancient Chinese represented malice by means of three women, light
by the sun and moon, and the verb to listen by an ear between two doors.
This primitive writing shows us that the rhetorical tropes and figures of
which our pedants are so proud, are expressions of poverty rather than
wealth on the part of the intellect. In fact, they are frequently found in the
speech of idiots and of educated deaf-mutes.
After having used this system for a considerable time, some more
civilised races, such as the Chinese and Mexicans, took another step
forward. They classified the more or less picturesque figures referred to
above, and succeeded in forming ingenious combinations which, without
directly representing the idea, indirectly suggested a reminiscence of it, as
in our charades. Besides this, to prevent any uncertainty on the reader’s
part, they placed either before or after these signs a sketch of the object to
be expressed—a scanty remnant of the actual picture-writing of a previous
age. This certainly took place at a time when—the language once being
fixed—it was observed how some people, in writing down a given sign,
recalled the sound of the words which it suggested. Thus Itzicoatl, the name
of a Mexican king, was written by drawing a serpent (Coatl, in Mexican)
and a lance (Itzli); thus, too, in Chinese, the character tschen represents
boat, lance, and table.[324]
Our megalomaniac, by reviving this custom, affords one more proof that,
in the visible manifestation of their thoughts, the insane frequently revert
(as also do criminals) to the prehistoric stage of civilization. In the present
case, it is quite easy to understand by what mental process G—— came to
use this mode of writing. Under the megalomaniac delusion, believing
himself lord of the elements, superior to all known or imaginable forces, he
could not make himself properly understood with the common words of
ignorant and incredulous men; neither could ordinary writing suffice to
express ideas so new and marvellous. The lion’s claws, the eagle’s beak, the
serpent’s tongue, the lightning-flash, the sun’s rays, the arms of the savage,
were much worthier of him, and more calculated to inspire men with fear
and respect for his person.
Nor is this an isolated case. One quite analogous to it is described by
Raggi in his excellent study of the writings of the insane. Prof. Morselli has
furnished me with another and still more interesting instance.
“The patient A. T——” he writes, “was a joiner and cabinet-maker; he
had a certain skill in wood-carving, and his furniture was much sought after.
[325] About seven years ago he was attacked with mental disease, apparently
melancholia, and tried to commit suicide by throwing himself from the roof
of the town hall. He is now subject to attacks of excitement with
systematized delusions. His predominant ideas are political—republican
and anarchist—on a certain groundwork of ambition. He fancies himself
changed into some great criminal; sometimes he is Gasperone, sometimes Il
Passatore, at others Passanante. He is always drawing or carving, and his
work generally takes the form of trophies or allegorical figures.
“The most curious of all these is a piece of carving which represents a
man dressed as a soldier, provided with wings, and standing on an inlaid
pedestal covered with allegorical inscriptions. This figure has a trophy on
its head, and other objects are carved on or around it, each of which
expresses emblematically some one of T——’s delusions. For instance, the
wings recall the fact that, when his first attack came on, he was in the
square at Porto Recanati, selling his carvings, among which were several
figures of angels, at a soldo a-piece. The ‘Medal of the order of the Pig’ is a
token of contempt, wherewith he would like to decorate all the rich and
powerful of the earth. The helmet, with a lantern hanging to the vizor (a
reminiscence of Offenbach’s Brigands), symbolises the gendarmes who
escorted him to the asylum. The cigar placed crosswise (note the position)
represents his disdain for kings and tyrants; and the position of the leg
recalls a fracture of that limb sustained by him in his attempt at suicide.
“The inscriptions on the pedestal are scraps of verse or extracts from
newspapers which T—— is always quoting, and to which he attaches some
mysterious significance. They always, however, refer to the state of slavery
to which he is reduced (i.e., his detention in the asylum), and the vengeance
he will one day wreak on his captors.
“The most remarkable thing, however, is the trophy resting on the head
of the figure, which is the graphic expression, so to speak, of a song[326]
either written by him or adapted from other popular poetry. Each phrase of
the song has its symbol in the trophy. Thus the word poison in the first verse
is represented by the cup; the two daggers are likewise present; the end of
life and the tomb are figured by a kind of sarcophagus or closed chest; love
by two sprays of flowers. The bell of the second stanza is easily
recognisable; the funereal music are the two trumpets crossed, lower down.
The cross of the third stanza, and the priest (represented by a clerical hat)
are not forgotten. It is curious that the gallows should be wanting to
complete this trophy. The spoon and fork, by the by, are T——’s favourite
implements. They denote that he eats and drinks in slavery, or, as he says, in
a convict-prison; and for this reason, he always wears a set, carved in wood
by himself, in the button-hole of his coat, or in his cap.”
We may once more remind the reader that savages hand down their
history by associating picture-signs with poetry.
A most interesting example of elaborate symbolic faculty in a
monomaniac, combined with higher artistic power than is usually found
among the insane, has been recorded with very full illustrations by Dr.
William Noyes.[327] This patient studied art at Paris under Gérome and
returned to America to become an illustrator of books and magazines. He
developed systematic religious delusions, and frequently worked them out
in very beautiful and artistic shapes, nine of which, all executed in the
asylum at which he was confined, are here reproduced. The circular design
is one of a series of twelve charts (one for each of the tribes of Israel)
illustrating the progress of the Holy Spirit. They were all delicately
coloured in water colours, the fine shading making it very difficult to give
in black and white an adequate idea of the beauty of the original.

“In the centre is the dove representing the Holy Spirit, and surrounding it
are seven different crosses [St. Andrew, St. Colomba, St. George, St.
Michael, The Prophet, St. Evangeli, Royal Priesthood], and a close study
will show the seven crosses, most ingeniously worked together. It is
probable that in looking at the design closely for the first time one will
suddenly see a new cross take shape before his eyes, and this indeed is what
the patient says occurs with him. In describing the crosses he will say, for
example, that in drawing the cross of St. Andrew the lines suddenly took a
new shape and he found he had also made a cross of St. Michael. This to
him is a matter of deep significance, and he feels that, his work is directly
controlled by a higher power, and that the work of his fancy is really
inspired.
“Outside these central crosses are the names of three ancient deities who
were each characterized by some special attribute, and under these the parts
of the body that the artist conceives these deities especially to have
represented, and then comes the name of the Biblical personage in whom
these elements were finally exemplified and embodied. To the left of the
dove is Venus, representing Blood, exemplified in Moses; above is Osiris,
representing Flesh, embodied in Adam; and to the right Psyche,
representing Water, typified in Noah. These three are but the gross and
material parts of Man, representing indeed necessary steps in his progress
through life, but secondary and subordinate to the higher part of his nature
represented by Truth and the Spirit—which receive their ultimate
embodiment in Christ.
“The Lion denotes Might, and the Eagle signifies Emulation; but it is
uncertain just what symbolism is connected with the serpent twining round
the cross, and the open book crossed by a sword and pen, unless indeed this
last may mean the Bible with the emblems of peace and war lying quietly
within it, and it seems not unlikely that the serpent is emblematic of the
Betrayal. For the rest of the design, however, we need make no inferences,
as it corresponds closely with his description.
“Outside of the circle enclosing the crosses are the seals, sealing the
Holy Spirit. In the large light triangles, or rather rays of the sun, are given
the names of the twelve apostles, forming the Seal of the Prophet. Above
these, in the same space, are the signs of the zodiac in the extreme points of
the triangle, with the names of the parts of the body underneath, that these
signs correspond to in the ancient mythology; this forms the Seal of the
Zodiac. Between these large light coloured triangles are the twelve holy
stones, represented as ovals, and with their names plainly distinguished in
the cut, making the Seal of the Holy Stones. In the small triangles directly
above the Holy Stones are given the names of the twelve tribes of Israel, but
the colour of these in the chart (vermilion) is such that the lettering does not
come out in the photographic negative. This gives the Seal of the Twelve
Tribes. Directly beneath the Holy Stones, filling in the space between the
bottom of each large triangle, is the Seal of the Germ, coloured dark green,
and running down on each side of the top of these large triangles are small
triangles, coloured dark red and forming the Seal of the Aceldama or
Bloody Seal. On the circumference are the names of the constellations of
the zodiac, and directly under these the names of the corresponding months
of the year, and under these again are the mythological representations of
the constellations, Leo (July) being at the top, and then in order to the right
come Virgo (August), Libra (September), Scorpio (October), Sagittarius
(November), Capricornus (December), Aquarius (January), Pisces
(February), Aries (March), Taurus (April), Gemini (May), Cancer (June).
This gives the last sealing of the Seed, the Seal of the Sun.
“It will be seen that beginning at the circumference at any point and
going toward the centre there is a complete astronomical representation of
the season of the year, first the name of the constellation, then in succession
the month, the constellation depicted pictorially, the sign of the zodiac and
the part of the human body corresponding in the old astronomy to this sign
of the zodiac.”
Of the four designs reproduced together, the first, the Shechinah, or
Light of Love, represents that miraculous light or visible glory which was to
the Jews a symbol of the Divine presence; the second represents the angel
Sandalphon with the Holy Grail at the side and the letters Alpha and Omega
at top (the design must be inverted to make out the Omega); the third, Sub
Rosa, and the fourth, Imp and Frogs, are graceful fancies which sufficiently
explain themselves, as does the Witch.
While working on these sketches, he made at the same time the design
for a book-plate, representing Cupid learning the alphabet, and the entire
design, he says, is full of symbolism—a favourite word with him. Cupid has
his finger on Alpha, signifying the beginning of his education; above the
book is Cupid’s target, with a heart for
SHECHINAH. SANDALPHON
 SUB ROSA. IMP AND FROGS.

the centre, that he has pierced with an arrow, while the full quiver stands to
the right. The curious fish under the Veritas represents the ΙΧΘΥΣ of the
early Christians, while three crosses, symbolic of the Christian religion, are
in the upper left-hand corner, brought out by heavy shading of the cross
lines. On the book of knowledge is perched the dove, emblematic of purity,
while the olive branch at the left of the book and the palm under the Fool’s
Bauble give still other religious symbols. The lamp of knowledge is burning
brightly in front of Cupid, while at his feet are the square, compass,
triangle, and pencils, symbolizing the designer’s profession.
Minuteness of Detail.—In some insane artists, especially monomaniacs,
we find an opposite characteristic—the exaggeration of particular details—
the general effect being lost in obscurity through their excessive efforts
after verisimilitude. Thus, in a landscape exhibited among those rejected
from the Turin salon, not only was a general view of the country given, but
every separate blade of grass could be distinguished. In another picture,
intended to be very imposing, the strokes of the brush produced the effect of
pencil shading.

Atavism.—Both minuteness and symbolism are themselves atavistic

phenomena; but, in addition to them, there may be noted (in a large number
of cases) a

THE WITCH.
 ARABESQUES BY PARANOIAC ARTIST.

total absence of perspective, while the rest of the execution shows clearly
enough that the author is not wanting in artistic sense. One would take him
to be a true artist, but one brought up in China or ancient Egypt. Here we
have evidently a kind of atavism explicable by arrested development of
some one organ, and a corresponding backwardness in the products of that
organ. A French captain, suffering from paralysis, drew figures stiff as
Egyptian profiles. A megalomaniac of Reggio executed a coloured bas-
relief, in which the disproportionate size of the feet and hands, the extreme
smallness of the faces, and the stiffness of the limbs, completely recall the
work of the thirteenth century. Another patient, at Genoa, carved bas-reliefs
on pipes and on vases, exactly similar to those of the Neolithic Age.
Raggi has sent me some flints carved by a monomaniac entirely ignorant
of archæology, which, in the choice of figures and emblems, recall the style
of Egyptian and Phœnician amulets. In these instances we see the influence
of similar psychical conditions at work.
Arabesques.—In some few patients, M. Toselli has called my attention
to a singular predilection for arabesques and ornaments which tend to
assume a purely geometric form, without loss of elegance. This is the case
with monomaniacs; in cases of dementia and acute mania there prevails a
chaotic confusion, which, however, does not always imply absence of taste.
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