[Sidenote: Preparation of Food]
If the purchase of a good quality of food for the patients in a
hospital is important, the preparation and serving of it is of still
greater importance. The most expensive food may be spoiled in cooking,
or be served in such a manner that the patient has no desire for it. On
the other hand, the cheaper article may be so tastily prepared that it
will be readily partaken of.
In dealing with the sick, the method of preparation and the manner of
serving food assume an importance that is not sufficiently appreciated
by the untrained. It is hardly possible for every hospital to have a
trained chef or a diet cook. Much of the cooking must needs be done
by the ordinary servants, but the hospital housekeeper should have an
intelligent appreciation of the needs of her family, her influence
should pervade the domestic region constantly, and her standards and
methods be understood by every one who handles food for the patients.
The difference between the kind of cooking needed for the sick and the
well needs also to be thoroughly understood, and while in reality the
housekeeper must cater to both classes, yet the sick are her especial
care. The fact must be borne in mind, too, that in a hospital we are
dealing with people in whom frequently the functions of the organs of
digestion and assimilation are seriously disturbed and weakened. These
changes are accompanied by a loss of appetite and often a disgust
for food. Yet the waste of the body, because of the sickness, is
increased, and special effort is needed to supply the most nutritious
food with the minimum tax on digestive powers.
[Sidenote: Objects of Cooking]
The method of cooking, which is in reality preparing the food for
digestion, thus becomes a powerful factor in dealing with diseased
conditions. In most foods, and in animal foods especially, cooking
develops the agreeable flavors and makes them more palatable. It also
enables them to become more readily masticated and therefore more
easily digested. The nutritive elements of food are extracted for
assimilation by the action of the various digestive fluids of the
body. In many diseases the glands that secrete these digestive fluids
are weak or inert, and need stimulating, and here attractive cookery
and artistic serving play an important part. When food is pleasing to
the eye the nerves of sight and taste are excited. These nerves act
reflexly on the nerves of the stomach, stimulating the gastric glands.
Eating is, therefore, made more enjoyable, a greater flow of digestive
juices is produced, and the result is better digestion, better
assimilation and increased strength.
[Sidenote: Classes of Diets]
Four grades of diet for patients are ordinarily recognized in a
hospital. Besides these we have the different grades of food, served
to the different classes of employes on the working staff, making as a
rule seven different classes of dietaries for the hospital housekeeper
to provide each day. Usually there are dishes on the regular diet
that may be used for the semi-solid or the light diets, and also for
the officers’ and employees’ tables. And as a general rule there are
special forms of liquid diet prepared each day, that may be added to
the other dietaries, thus making it possible to cook many of the dishes
in bulk, which is always the more economical way.
For patients on fluid or liquid diet, such articles must be provided
as beef tea, beef juice, chicken broth, mutton broth, gelatine, barley
water, cocoa, certain forms of strained gruel, albumen water, koumyss,
buttermilk, whey and sweet milk served in its natural state or in its
almost numberless combinations that vary the flavor.
For those on semi-solid diet such foods as oatmeal gruel, custard,
ice cream, rice, tapioca, sago, and sometimes milk toast are used in
addition to the foods included in fluid diet.
For patients on light diet such additions are made as bread, toast,
some fruits, certain kinds of fish, such as oysters, clams and the
white-fleshed fishes, poultry and game.
Regular diet in a hospital may include all the above articles with
beef, mutton and other meats added, certain vegetables and all fruits.
For patients in the transition stage with weakened digestive functions,
the shorter fibred meats are usually served in small quantities, before
beef, mutton and other meats more difficult of digestion. But even in
the regular diets, much discretion needs to be used. Many articles
that are permitted in health have no place on the hospital dietary.
Boiled cabbage, or cucumber pickles, or boiled dumplings, might be
relished by the heartier of the patients on regular diet, but would be
entirely unsuitable for the majority, and therefore not an economical
food to serve. Even though digestion is not seriously impaired, the
functions because of lack of exercise are sluggish, and it is unwise
to put unnecessary tax on the excretory organs. So that though doctors
may give full permission for the patient to “eat anything,” the
housekeeper’s common sense will prevent her from incorporating in the
hospital dietary many articles of food allowed in health.
The foods included in each class of diets and the limitations should be
thoroughly understood by the whole working staff of the hospital. It
is well to have printed lists conspicuously posted in different parts
of the hospital. On no account should milk be allowed to be given to
hearty patients on full diet, or to any patient on that class of diet
unless specially ordered by the physician in charge. This rule needs
special emphasis or milk bills may be greatly increased with no special
benefit to any one.
As a rule the patient who is on an exclusive liquid diet must be dealt
with individually and with great discrimination. The amount and kind of
diet will be prescribed by the physician. But in these cases special
preparation becomes very important. Milk frequently forms a large part
of the fluid diet, as it is one of the very few complete foods.
Various forms of pre-digested and concentrated foods are in use that
are of great value in such cases, but they belong to the drug room,
rather than the kitchen, and need not be mentioned here.
[Sidenote: Broths]
Next in value to milk and its preparations, on the liquid diet sheet,
come broths. When broths are required for patients suffering from
acute or febrile diseases, the housekeeper should see that a rich and
nutritious article is provided—not water flavored. In the preparation
of these broths, the object should be to extract as much as possible of
the soluble elements of the meat into the water. The meat should be cut
in small pieces and put in cold water, the temperature being gradually
raised to about 160° F. The remainder of the cooking should be a gentle
simmering process. For these broths the cheaper part of meat may be
utilized, and it is hardly necessary to add that when a cheaper grade
article can be used with equal satisfaction it should always be done.
In the preparation of soups, care must be exercised regarding the
flavor. All strong and decided odors, such as onion, should be avoided.
In fact it is usually better to have a carefully combined flavor than
one special flavor that may be disagreeable to some tastes.
[Sidenote: Soups]
As a general rule it is well to have soup of some kind on all the
dietaries of the hospital once a day, except in the very hot weather.
The body, even in health, requires a large proportion of water, and
in most diseases water has a real therapeutic value. It is needed as
a solvent agent during digestion and assists in the various processes
of absorption, secretion and excretion. When, therefore, it can be
combined with certain food substances to form an acceptable article
of diet, it should be done. The value of broths and soups is not
sufficiently appreciated by the poorer classes, and the hospital
dietary should form a practical lesson on sensible diet. The bones
of meat can be utilized in the making of soups, a nutritious extract
consisting chiefly of gelatin being obtained by boiling them. It is
said that three pounds of bone contains as much carbon as one pound of
meat, and as much nitrogen as seven pounds of meat. In serving broths
to patients care must be taken to remove all floating grease. When
there is time, it is always better to allow the soup or broth to become
thoroughly cold, and then have it carefully skimmed. A few drops of
oil or grease on the broth may be sufficient to destroy the appetite
for food that is such an important factor in tiding a patient over the
critical period.
[Sidenote: Cooking Meats]
When the object of boiling meat is simply to cook it, retaining as
much as possible of its soluble constituents, the meat should be in
one large piece and plunged into water already boiling. Brisk boiling
should be continued for ten minutes till the albuminous matter on the
exterior is coagulated. This forms a protective layer which helps in
preventing the escape of the nutritious juices into the water. The
cooking should be completed more slowly. Too great heat causes the meat
to be hard and shrunken. Roasting meat retains the nutritious juices
better than boiling. But, as in the boiling, the meat should be first
exposed to a strong heat, the cooking being completed more slowly.
[Sidenote: Cooking Vegetables]
Green vegetables are valuable as food, not so much because of their
nutritious elements, but because of the salts they supply which
are demanded by the system. Their digestibility depends greatly on
their being well and carefully cooked. In most of them there is a
large proportion of indigestible residue, which acts as a stimulant
to peristalsis. It must not be forgotten that a relish for certain
vegetables is an acquired taste, and unless an article has real
nutritive value it is unwise to try to cultivate the taste while in the
hospital, even for variety. Celery, for instance, is rarely relished by
poor people, and for this reason it is a needless expense to serve it
in the free wards. Other exceptions will readily suggest themselves.
Potatoes are rich in starch and when cooked in quantity are best served
mashed. This method of serving prevents them reaching the stomach in
hard, indigestible masses, as is often the case when served whole.
The profusion of books, giving definite culinary rules for the
preparation of all the various articles of diet, both for the sick and
healthy family, makes unnecessary more than a passing mention of these
few general principles to be observed in preparing a hospital dietary.
One general aim should be kept in view in preparing food in general;
the method of preparation should conserve the nutritive elements of the
food and cause it to make as little tax on the digestive functions as
possible.
[Sidenote: Time of Meals]
As a general rule the heaviest meal of the day—the dinner—should be
served in a hospital at mid-day. This plan will be more satisfactory
to those on whom the preparation of the meal devolves, and it is
distinctly better for the patients. The time needed for the digestion
of meats and vegetables is estimated at from three to five hours. If
the heavy meal is served late in the day the work of the stomach cannot
be completed in time for the patient to get to sleep early, and if
the stomach is actively engaged in digestion the rest is likely to be
retarded or disturbed. This rule of course does not apply to patients
in a weak condition who must be fed at frequent intervals and in
smaller quantities. And it needs also to be remembered that a perfectly
empty stomach does not contribute to repose, and indeed is a frequent
cause of wakefulness.
A plain, wholesome early breakfast for the “help” and for the nurses is
a necessity in a hospital where the heaviest work comes in the morning
hours. This should be as substantial as the appetite and digestion
are equal to. With nurses who are constantly exposed to morbid and
depressing influences, the breakfast is of special importance, and
a nurse who does not partake of a hearty breakfast is always more
susceptible to deleterious influences. The rush of work, long hours,
mental anxiety, and almost constant walking or standing, which are
incident to hospital life, make it very necessary for a good quality
and quantity of food to be prepared for those who have the direct
responsibility of the care of the sick. And while extravagance ought to
be guarded against, yet no mistaken idea of economy should prevent the
housekeeper from serving a well-balanced, nutritious and attractive
dietary to these important members of her household.
The housekeeper should not fail to remind herself constantly that
“variety is the spice of life,” and should see that “wholesome variety”
characterizes her meals, for the nurses as well as patients, from week
to week. The element of surprise or unexpectedness figures largely
in the pleasures of every-day life. Anything that leaves out the
possibility of the “unexpected,” especially on a nurses’ table, has
much in it to condemn and little to commend.
On the nurses’ table clean table linen at frequent intervals ought
not to be regarded as a luxury, and certainly it adds greatly to the
enjoyment of a meal. A few of the flowers that are often distributed
lavishly in a ward would as fully fulfil their mission there. A pretty
growing plant purchased occasionally for the same purpose is an
extravagance that could be forgiven. Then, besides refined surroundings
and neat, attractive table service, the character of the food, the
quality, could be greatly improved by a little careful planning without
any great, if indeed any, increase of expense. Dr. Peters, of the Rhode
Island Hospital, in an admirable paper on hospital dietaries, asked the
following pertinent questions:
“Do we realize the satisfaction that a variety of soups, so easily
and cheaply prepared, give to our inmates? Do we remember the many
ways of preparing meats to be served with a great variety of gravies
and sauces? Do we realize that mincing meat is an important method
of preparation? Do we appreciate how much more satisfactory fresh
vegetables are than canned? Don’t we forget the natural craving for
fruit? Couldn’t we, with a little forethought, give our nurses and
employes salads, ices, etc., at practically no greater cost than the
routine dishes? Did you ever realize the variety of ways such common
articles as potatoes, rice, apples, etc., can be cooked and served?
Do we serve fish in as great a variety and often enough? Do we give
attention enough to the possible varieties of dessert? Are all these
questions trite? Yes; but possibly worth repeating to act as reminders.”
It is time that the system of arranging a nurses’ bill of fare for
months ahead were forever abandoned in every institution. The very
monotony of it makes one weary at the thought. To know that on a
certain day of the week one is doomed to a dinner of corned beef and
cabbage is certainly not likely to create enthusiasm for the morning’s
work. To contemplate while dressing that “this is the day for fried
liver for breakfast,” is sufficient to nauseate some of the less hearty
members of the family. To know that of all the list of fruits in the
market only about three or four are likely to appear on the nurses’
table till the authorities see fit to change the bill of fare is, to
say the least, depressing. Monday, apple sauce; Tuesday, stewed prunes;
Wednesday, dried peaches or apricots, etc. And the desserts are often
equally monotonous: Bread pudding, rice pudding, apple pie and again
bread pudding, rice or tapioca pudding; apple pie, with a dish of
cornstarch—sometimes pink, sometimes white—on Sunday. It is little
wonder that after two or three years of this monotony in diet, many
nurses regard these articles of food as things to be avoided for the
remainder of their lives.
As a general rule it is best to avoid, as far as possible, serving
food that has been warmed over, or twice cooked, to sick people,
though perfectly proper for those in health. It is better, however,
to calculate as carefully as possible the amounts required for each
meal, and cook no more than will be used. Meat, fish and vegetables,
especially, are better for the sick when cooked fresh.
While many of the salads—lobster salad for instance—are not suitable
for a hospital dietary, when viewed either from the standpoint of
economy or digestibility, yet delicious salads may be made of very
common articles without any extra expense. A salad composed of apples,
celery, a few nuts and a little French dressing could scarcely be
considered an expensive dish at any season, and yet such a simple
combination would add a relish to an otherwise commonplace meal. A bean
salad is both dainty and nutritious. Many such delightful combinations
will suggest themselves to the housekeeper whose heart is in her work,
and who is really mistress of her art, and these all go to make up the
difference between variety and monotony.