CHAPTER VIII.
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.
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.
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.
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.
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.
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.
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.
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.