[Sidenote: Common errors in diet.]
[Sidenote: Beef tea.]
[Sidenote: Eggs.]
[Sidenote: Meat without vegetables.]
[Sidenote: Arrowroot.]
I will mention one or two of the most common errors among women in
charge of sick respecting sick diet. One is the belief that beef tea is
the most nutritive of all articles. Now, just try and boil down a lb. of
beef into beef tea, evaporate your beef tea, and see what is left of
your beef. You will find that there is barely a teaspoonful of solid
nourishment to half a pint of water in beef tea;--nevertheless there is
a certain reparative quality in it, we do not know what, as there is in
tea;--but it may safely be given in almost any inflammatory disease, and
is as little to be depended upon with the healthy or convalescent where
much nourishment is required. Again, it is an ever ready saw that an egg
is equivalent to a lb. of meat,--whereas it is not at all so. Also, it
is seldom noticed with how many patients, particularly of nervous or
bilious temperament, eggs disagree. All puddings made with eggs, are
distasteful to them in consequence. An egg, whipped up with wine, is
often the only form in which they can take this kind of nourishment.
Again, if the patient has attained to eating meat, it is supposed that
to give him meat is the only thing needful for his recovery; whereas
scorbutic sores have been actually known to appear among sick persons
living in the midst of plenty in England, which could be traced to no
other source than this, viz.: that the nurse, depending on meat alone,
had allowed the patient to be without vegetables for a considerable
time, these latter being so badly cooked that he always left them
untouched. Arrowroot is another grand dependence of the nurse. As a
vehicle for wine, and as a restorative quickly prepared, it is all very
well. But it is nothing but starch and water. Flour is both more
nutritive, and less liable to ferment, and is preferable wherever it can
be used.
[Sidenote: Milk, butter, cream, &c.]
Again, milk and the preparations from milk, are a most important
article of food for the sick. Butter is the lightest kind of animal fat,
and though it wants the sugar and some of the other elements which there
are in milk, yet it is most valuable both in itself and in enabling the
patient to eat more bread. Flour, oats, groats, barley, and their kind,
are as we have already said, preferable in all their preparations to all
the preparations of arrow root, sago, tapioca, and their kind. Cream, in
many long chronic diseases, is quite irreplaceable by any other article
whatever. It seems to act in the same manner as beef tea, and to most it
is much easier of digestion than milk. In fact, it seldom disagrees.
Cheese is not usually digestible by the sick, but it is pure nourishment
for repairing waste; and I have seen sick, and not a few either, whose
craving for cheese shewed how much it was needed by them.[23]
But, if fresh milk is so valuable a food for the sick, the least change
or sourness in it, makes it of all articles, perhaps, the most
injurious; diarrhoea is a common result of fresh milk allowed to become
at all sour. The nurse therefore ought to exercise her utmost care in
this. In large institutions for the sick, even the poorest, the utmost
care is exercised. Wenham Lake ice is used for this express purpose
every summer, while the private patient, perhaps, never tastes a drop of
milk that is not sour, all through the hot weather, so little does the
private nurse understand the necessity of such care. Yet, if you
consider that the only drop of real nourishment in your patient's tea is
the drop of milk, and how much almost all English patients depend upon
their tea, you will see the great importance of not depriving your
patient of this drop of milk. Buttermilk, a totally different thing, is
often very useful, especially in fevers.
[Sidenote: Sweet things.]
In laying down rules of diet, by the amounts of "solid nutriment" in
different kinds of food, it is constantly lost sight of what the patient
requires to repair his waste, what he can take and what he can't. You
cannot diet a patient from a book, you cannot make up the human body as
you would make up a prescription,--so many parts "carboniferous," so
many parts "nitrogenous" will constitute a perfect diet for the patient.
The nurse's observation here will materially assist the doctor--the
patient's "fancies" will materially assist the nurse. For instance,
sugar is one of the most nutritive of all articles, being pure carbon,
and is particularly recommended in some books. But the vast majority of
all patients in England, young and old, male and female, rich and poor,
hospital and private, dislike sweet things,--and while I have never
known a person take to sweets when he was ill who disliked them when he
was well, I have known many fond of them when in health, who in sickness
would leave off anything sweet, even to sugar in tea,--sweet puddings,
sweet drinks, are their aversion; the furred tongue almost always likes
what is sharp or pungent. Scorbutic patients are an exception, they
often crave for sweetmeats and jams.
[Sidenote: Jelly.]
Jelly is another article of diet in great favour with nurses and friends
of the sick; even if it could be eaten solid, it would not nourish, but
it is simply the height of folly to take 1/8 oz. of gelatine and make it
into a certain bulk by dissolving it in water and then to give it to the
sick, as if the mere bulk represented nourishment. It is now known that
jelly does not nourish, that it has a tendency to produce diarrhoea,--and
to trust to it to repair the waste of a diseased constitution is simply
to starve the sick under the guise of feeding them. If 100 spoonfuls of
jelly were given in the course of the day, you would have given one
spoonful of gelatine, which spoonful has no nutritive power whatever.
And, nevertheless, gelatine contains a large quantity of nitrogen, which
is one of the most powerful elements in nutrition; on the other hand,
beef tea may be chosen as an illustration of great nutrient power in
sickness, co-existing with a very small amount of solid nitrogenous
matter.
[Sidenote: Beef tea.]
Dr. Christison says that "every one will be struck with the readiness
with which" certain classes of "patients will often take diluted meat
juice or beef tea repeatedly, when they refuse all other kinds of food."
This is particularly remarkable in "cases of gastric fever, in which,"
he says, "little or nothing else besides beef tea or diluted meat juice"
has been taken for weeks or even months, "and yet a pint of beef tea
contains scarcely 1/4 oz. of anything but water,"--the result is so
striking that he asks what is its mode of action? "Not simply
nutrient--1/4 oz. of the most nutritive material cannot nearly replace
the daily wear and tear of the tissues in any circumstances. Possibly,"
he says, "it belongs to a new denomination of remedies."
It has been observed that a small quantity of beef tea added to other
articles of nutrition augments their power out of all proportion to the
additional amount of solid matter.
The reason why jelly should be innutritious and beef tea nutritious to
the sick, is a secret yet undiscovered, but it clearly shows that
careful observation of the sick is the only clue to the best dietary.
[Sidenote: Observation, not chemistry, must decide sick diet.]
Chemistry has as yet afforded little insight into the dieting of sick.
All that chemistry can tell us is the amount of "carboniferous" or
"nitrogenous" elements discoverable in different dietetic articles. It
has given us lists of dietetic substances, arranged in the order of
their richness in one or other of these principles; but that is all. In
the great majority of cases, the stomach of the patient is guided by
other principles of selection than merely the amount of carbon or
nitrogen in the diet. No doubt, in this as in other things, nature has
very definite rules for her guidance, but these rules can only be
ascertained by the most careful observation at the bed-side. She there
teaches us that living chemistry, the chemistry of reparation, is
something different from the chemistry of the laboratory. Organic
chemistry is useful, as all knowledge is, when we come face to face with
nature; but it by no means follows that we should learn in the
laboratory any one of the reparative processes going on in disease.
Again, the nutritive power of milk and of the preparations from milk, is
very much undervalued; there is nearly as much nourishment in half a
pint of milk as there is in a quarter of a lb. of meat. But this is not
the whole question or nearly the whole. The main question is what the
patient's stomach can assimilate or derive nourishment from, and of this
the patient's stomach is the sole judge. Chemistry cannot tell this. The
patient's stomach must be its own chemist. The diet which will keep the
healthy man healthy, will kill the sick one. The same beef which is the
most nutritive of all meat and which nourishes the healthy man, is the
least nourishing of all food to the sick man, whose half-dead stomach
can _assimilate_ no part of it, that is, make no food out of it. On a
diet of beef tea healthy men on the other hand speedily lose their
strength.
[Sidenote: Home-made bread.]
I have known patients live for many months without touching bread,
because they could not eat baker's bread. These were mostly country
patients, but not all. Home-made bread or brown bread is a most
important article of diet for many patients. The use of aperients may be
entirely superseded by it. Oat cake is another.
[Sidenote: Sound observation has scarcely yet been brought to bear on
sick diet.]
To watch for the opinions, then, which the patient's stomach gives,
rather than to read "analyses of foods," is the business of all those
who have to settle what the patient is to eat--perhaps the most
important thing to be provided for him after the air he is to breathe.
Now the medical man who sees the patient only once a day or even only
once or twice a week, cannot possibly tell this without the assistance
of the patient himself, or of those who are in constant observation on
the patient. The utmost the medical man can tell is whether the patient
is weaker or stronger at this visit than he was at the last visit. I
should therefore say that incomparably the most important office of the
nurse, after she has taken care of the patient's air, is to take care
to observe the effect of his food, and report it to the medical
attendant.
It is quite incalculable the good that would certainly come from such
_sound_ and close observation in this almost neglected branch of
nursing, or the help it would give to the medical man.
[Sidenote: Tea and coffee.]
A great deal too much against tea[24] is said by wise people, and a
great deal too much of tea is given to the sick by foolish people. When
you see the natural and almost universal craving in English sick for
their "tea," you cannot but feel that nature knows what she is about.
But a little tea or coffee restores them quite as much as a great deal,
and a great deal of tea and especially of coffee impairs the little
power of digestion they have. Yet a nurse because she sees how one or
two cups of tea or coffee restores her patient, thinks that three or
four cups will do twice as much. This is not the case at all; it is
however certain that there is nothing yet discovered which is a
substitute to the English patient for his cup of tea; he can take it
when he can take nothing else, and he often can't take anything else if
he has it not. I should be very glad if any of the abusers of tea would
point out what to give to an English patient after a sleepless night,
instead of tea. If you give it at 5 or 6 o'clock in the morning, he may
even sometimes fall asleep after it, and get perhaps his only two or
three hours' sleep during the twenty-four. At the same time you never
should give tea or coffee to the sick, as a rule, after 5 o'clock in the
afternoon. Sleeplessness in the early night is from excitement generally
and is increased by tea or coffee; sleeplessness which continues to the
early morning is from exhaustion often, and is relieved by tea. The only
English patients I have ever known refuse tea, have been typhus cases,
and the first sign of their getting better was their craving again for
tea. In general, the dry and dirty tongue always prefers tea to coffee,
and will quite decline milk, unless with tea. Coffee is a better
restorative than tea, but a greater impairer of the digestion. Let the
patient's taste decide. You will say that, in cases of great thirst, the
patient's craving decides that it will drink _a great deal_ of tea, and
that you cannot help it. But in these cases be sure that the patient
requires diluents for quite other purposes than quenching the thirst; he
wants a great deal of some drink, not only of tea, and the doctor will
order what he is to have, barley water or lemonade, or soda water and
milk, as the case may be.
Lehmann, quoted by Dr. Christison, says that, among the well and active
"the infusion of 1 oz. of roasted coffee daily will diminish the waste"
going on in the body "by one-fourth," and Dr. Christison adds that tea
has the same property. Now this is actual experiment. Lehmann weighs the
man and finds the fact from his weight. It is not deduced from any
"analysis" of food. All experience among the sick shows the same
thing.[25]
[Sidenote: Cocoa.]
Cocoa is often recommended to the sick in lieu of tea or coffee. But
independently of the fact that English sick very generally dislike
cocoa, it has quite a different effect from tea or coffee. It is an oily
starchy nut having no restorative power at all, but simply increasing
fat. It is pure mockery of the sick, therefore, to call it a substitute
for tea. For any renovating stimulus it has, you might just as well
offer them chesnuts instead of tea.
[Sidenote: Bulk.]
An almost universal error among nurses is in the bulk of the food and
especially the drinks they offer to their patients. Suppose a patient
ordered 4 oz. brandy during the day, how is he to take this if you make
it into four pints with diluting it? The same with tea and beef tea,
with arrowroot, milk, &c. You have not increased the nourishment, you
have not increased the renovating power of these articles, by increasing
their bulk,--you have very likely diminished both by giving the
patient's digestion more to do, and most likely of all, the patient will
leave half of what he has been ordered to take, because he cannot
swallow the bulk with which you have been pleased to invest it. It
requires very nice observation and care (and meets with hardly any) to
determine what will not be too thick or strong for the patient to take,
while giving him no more than the bulk which he is able to swallow.