HOSPITAL
HOUSEKEEPING

By

CHARLOTTE A. AIKENS

Late Director Sibley Memorial Hospital, Washington, D. C.; Late
Superintendent of Iowa Methodist Hospital, Des Moines;
Superintendent of Columbia Hospital, Pittsburg;
Former Associate Editor The National
Hospital Record

SECOND EDITION

Detroit, Mich.
DEL T. SUTTON
1910

Copyright 1906
by
DEL T. SUTTON

PREFACE

In the preparation of this volume, three classes of readers have been in mind: the trained nurse who, without practical experience in hospital management, finds herself in charge of a hospital, small or large; the practical woman who, having had no opportunity for special training, has upon her the responsibility of the direction of the domestic affairs of an institution; and the lady member of the hospital board of managers who, in the discharge of the duties of her position, becomes responsible to the public for the proper government of institutional affairs. It was thought that the latter, especially, might, through the use of this volume, secure a better grasp of the details of hospital housekeeping as a whole than is possible without some such aid. The ability to see all around a situation, to view the institution as a whole, is essential to good management. As a rule, such ability comes only by experience. Especial pains have been taken to make the volume thoroughly practical, and to present clearly and concisely lessons learned in actual dealing with, and close study of, the questions discussed. The greater portion of the contents of the volume have already seen the light of day in the columns of the National Hospital Record. Since their appearance in that journal, the papers have been carefully revised, and much new and important matter added. For assistance in preparation, the author has been under great obligation to a number of hospital superintendents, who have furnished information as to methods, and to contemporary writers, especially on the subject of dietetics. Special mention should be made of the works of W. Gilman Thompson, M. D., Mrs. Ellen H. Richards, I. Burney Yeo, M. D., Sir Henry Burdett, and of the literature of the United States Department of Agriculture. To Miss Emma Lynch, who, as hospital matron, has been for several years associated with the author in institutional work, special thanks are due for valuable assistance. Many practical suggestions have been gleaned from the papers given at the annual conventions of the Association of Hospital Superintendents. To the writers of these papers the author expresses grateful appreciation. Many of the electrotypes used for illustration have been kindly furnished by courtesy of the business firms whose names accompany them. These have been introduced because they were deemed essential to a clear understanding of the subject on the part of such readers as may not be familiar with the use of such appliances. So far as the author is aware, no attempt has previously been made to discuss the subject of hospital housekeeping as a whole. As a pioneer in the field, the book doubtless has many defects. If it proves of practical value to even a small number of those for whose assistance it was prepared, it will have justified its existence.

Charlotte A. Aikens.

TABLE OF CONTENTS.

Hospital Housekeeping

CHAPTER I.

The Hospital Housekeeper

Hospital housekeeping is intensely practical business. If it is to be successfully and satisfactorily conducted, it demands that the housekeeper be a woman of no inferior or uncertain attainments. All the elements that make for success in home housekeeping, and many more, are needed in a hospital. There must be breadth of vision, the qualities of an organizer, the ability to deal with large problems, a keen sense of justice, and the executive force needed to manage, without fear, fuss or favor, the various classes of people that touch the housekeeper’s realm. Many a man who is a success in managing a village store would utterly fail when placed in charge of even one section of a great department store. And the same may be said of the average woman in hospital housekeeping. Apart from the special knowledge of the business, that comes only by diligent study, accurate observation and experience—never by accident—the housekeeper needs special qualities of mind and heart. Indeed, special qualifications are needed by every one whose life work is to be wrought out in an institution. A hospital or any institution that has to deal with infirm, aged or unfortunate members of society, is no place for a person of strong racial antipathies. It is no place for the tale-bearer or the gossip, nor for the person who has a grudge against fate and feels she has never received justice. It is no place for the person who is discouraged, or who assumes the air of a martyr, and leads a crushed life, bemoaning the fact that her highest motives and best efforts are never appreciated. Those who would live happily in an institution must be prepared to be misunderstood, and fortified against discouragement from that source. Sympathy with the aims of the institution is a primary qualification. No one should enter an institution as a worker, and especially as head of a department, who is not prepared to have her interests centered in the people for whose benefit the institution was brought into existence. Ability to see things from more than one standpoint, to work comfortably with different classes of people, an infinite capacity for detail, and systematic business habits—these are a few of the qualities that should characterize the woman who undertakes to manage the domestic affairs of a hospital. It need hardly be mentioned that she needs a healthy body and a strong constitution.

The hospital housekeeper needs, if anyone needs it, reliability of judgment, and poise of soul. If she is to control others, she must know how to control herself. The ability to reprimand without arousing antagonism must be hers. She should endeavor to cultivate the feeling of personal responsibility in all over whom she has authority, and to make them understand that the success of an institution depends not on perfection of equipment, nor in numbers, but in thorough co-ordination of the work in all the departments, and faithful service on the part of all.

They should know that a lack of punctuality or carelessness in one department disturbs the working of the entire system. The influence of the kitchen and laundry is felt throughout the entire institution. Skillful management consists not alone in the ability to attend to the apparently important affairs with ease, but in never losing sight of the minor details. Nothing is so large as to be of paramount importance, nothing so small as to be considered immaterial, where human lives are concerned.

The Housekeeper’s Province

To define the exact limits of the housekeeper’s province is impossible, as institutions vary so greatly in size and in the number of officers. Local conditions always influence the situation. One lone woman may have to manage the domestic affairs of an institution, superintend its entire business, including its nursing, manage its bookkeeping, do the work of an interne in emergencies, and act in various other capacities, that readily suggest themselves to those who are acquainted with life in a small hospital. In another institution her province may be limited entirely to the purely domestic affairs, the purchase and preparation of food, care of linen, the cleaning, and the management of those who work in these departments. In either instance, the responsibility is great. To meet this responsibility without being oppressed by its weight, requires that the working force be completely organized, the work definitely divided and assigned. There should not be a square inch of the building for which someone is not directly responsible for its good order and cleanliness. Real success in management, however, does not alone consist in the work going on as it should while the housekeeper is there to direct and supervise. Her own health and efficiency demand that she have recreation and rest, and, as a matter of fact, depend on her not being always there. Her skill and generalship of the situation will be shown in the fact that, whether present or absent, the routine of the work is not noticeably interrupted. In every institution there should be some individual who is sufficiently acquainted with her methods to assume control and carry on the system in her absence.

Bookkeeping

In addition to the mastery of the details of the practical work, the hospital housekeeper must know how to give an account of her stewardship to those who have a right to demand it. The business side of hospital work, that which has to do with dollars and cents, is one of her many duties that has special importance. It is one of the corner-stones in the hospital foundation, and however much the housekeeper may dislike the tedious work of adding and subtracting, and reckoning, and itemizing, if she is a faithful steward of trust funds, she will give it due attention. The weak point in a great many hospitals is the looseness of methods of accounting. Frequently the board of managers are not sufficiently impressed with their responsibility to plan and demand a system of bookkeeping that will furnish plain facts in a shape that will be easily grasped; and it is not to be wondered at that the housekeeper is, if not careless, then not sufficiently careful for her books to be of any value as institutional records.

The busy housekeeper needs a simple method of accounting that is at once comprehensive and easy to handle. A simple, convenient form for a general expense book is here shown. One page can be devoted to each week’s or month’s expenditures and the use of such method makes the annual financial statement an easy matter to arrange. It is not claimed that this is the best method for a general expense account; it is one method—a simple, workable method.

In addition to this the use of a small day book will be necessary, which will show on the left-hand page the money received and on the other side the disbursements for the day. For this an ordinary blank book that has spaces ruled for dates, items, dollars and cents, will be sufficient. In this each day will be recorded the article purchased, the date and the cost. Periodically this itemized account is gone over, the articles grouped under the several heads and copied in the general expense book.

GENERAL HOSPITAL

An “order book” should contain an account of all orders given, the quantity, cost, date ordered, date received. An ordinary blank-book may be ruled with columns for each of these entries, and the month and year. This furnishes information that is valuable from several standpoints. If the housekeeper is suddenly called away, it is easy to turn to for a list of the firms patronized, or to find the usual amounts ordered, and is valuable for comparison and reference from month to month and year to year. All dealers’ checks sent with goods should be preserved, for comparison with the itemized monthly account, before indorsing it for payment.

Hospital Inventory

In the matter of the hospital inventory, various forms may be adopted, according to the purposes for which the inventory is intended. It may be a simple list of the furnishings of the hospital, made up without any special plan, and with or without the value or cost of the article attached. In case of loss by fire, this inventory might have special value as an insurance record. Such books should of course be kept in the safe, with other documents and articles of value.

As convenient as any way of keeping a hospital inventory, is to have the contents of the building arranged under the heads of the rooms for which the articles were purchased. The kitchen, storerooms, diet kitchens, offices, reception rooms, wards, private rooms, etc., all have stationary furniture especially for them, and for purposes of reference it will be most convenient to list this in connection with the room containing it. If the value of each article is attached a recapitulation will show at a glance the total value of the hospital furnishings.

Once each year, at least, the housekeeper should make a business of finding out the average cost per day of feeding her hospital family, and the average cost of feeding one patient. This knowledge is valuable not alone for statistics, but for her own satisfaction. It should give confidence in her administration, or show whether there is a weakness that might be corrected.

CHAPTER II.

The Main Entrance

“There is nothing in a hospital small enough to be careless about,” is a remark frequently heard in hospital corridors. It is important for the housekeeper to bear in mind that, although oft quoted, this statement happens to be true. Perhaps no one thing will produce a more lasting impression on a casual visitor than the manner in which he is received at the front entrance. Two trained nurses who spent a couple of days in visiting hospitals in an eastern city related the following experience: At hospital number one the door was opened by a very untidy-looking, irrepressible colored boy, who seemed to feel it his duty to do the gallant thing according to his ideas of gallantry. After an entirely unnecessary speech, his concluding remarks were that he would just love to go through the hospital with them, but he “ain’t got no time,” and he guessed he’d have to ask Dr. —— to go with them. At hospital number two, no one specially seemed to be in charge of the door, and, after repeated rings, a resident physician, who, judging from his hair and general appearance, had been napping, came rushing through the hall—the door was open—getting into his coat by the time he reached the door. The climax was reached at hospital number three, which was a maternity hospital, an adjunct of a large city hospital. Here the door was opened by a colored woman in the last stages of pregnancy. At hospital number four a pert maid, none too tidy, was on duty at the front entrance. Her distinguishing feature seemed to be that she “didn’t know.” At hospitals five and six, the persons in charge knew what was expected, and did the proper thing, but the varied experiences served to show the laxity that exists in that one particular.

The Porter

The careful hospital housekeeper will see to it that the person in charge of the main entrance knows his business and is reliable and courteous. He need not know all the business of the institution, but he should know enough to answer questions properly and when to be silent. If no special uniform is provided, he should be neatly and quietly attired. Parcels, telegrams, messages, are constantly being delivered for the inmates, and he should be responsible for them until they are delivered to the nurse in charge. Letters should be placed in a locked box, the key to be held by some reliable person who will see to their distribution. Mail for the patients should not be given to the inmates direct, but to the nurse in charge, and some nurse should always be in charge. Carelessness at this point may result in an important letter or message not being delivered, or delivered at a time when it is specially important that the patient’s mind be free from disturbance or intrusion of any kind. Complaints are frequently made, of large hospitals especially, that boxes of flowers sent to patients have been thrown carelessly into a parcel room, and not delivered at all, or delivered after their beauty and fragrance had gone. If the person at the door is careless about matters of that kind, he will be just as likely to be careless about more serious things. A temporary substitute at the door should always be arranged for when the porter is obliged to be absent, even for a few minutes.

The Private Rooms

In all apartments intended for the use of patients some degree of uniformity should be observed in the furnishings, though this may easily be carried to extremes. These rooms vary in size and price, but the essentials for all are the same. The chief thought should be to have the furnishings suitable, sensible and restful. Dainty white enameled furniture for hospital rooms is rapidly replacing that of darker hue and adds greatly to the attractiveness of the hospital. For the average room a combination dresser and washstand is preferable to cumbering the room with two separate pieces of furniture. These have the essential features of the dresser, in that they provide a mirror and drawers, and of the washstand by having a towel rack and cupboard. In any case, small dressers are preferable to large ones. Every private room should have its own wash bowl and pitcher, soap dish, mug, receptacle for toilet brush, water bottle and drinking glass. The bed should be placed so that the nurse can have access to it on three sides. The woven-wire springs should be warranted not to sag in the middle.

Combination Dresser and Washstand

Blankets, on account of the frequent washings, should not be all wool, nor too heavy. For warmth it is better to depend on light blankets than on any form of “comforter.”

Rugs may be as bright and handsome as the hospital can purchase. The cheap wool rugs that are everywhere displayed for sale are a poor investment. The most satisfactory rugs are those made to order of tapestry Brussels, or when it can be afforded, the more expensive grade of Brussels or velvet. For small rooms three widths are usually sufficient and these made without border are not an expensive rug. For larger rooms a border is preferable, but in any case such rugs are economical and serviceable.

Long lace curtains should have no place in a hospital. They are always getting in the way and being torn, always collecting dust and always an obstacle to the view and to ventilation. At best they are a nuisance, an unnecessary expense and serve no useful purpose. Soft, plain white sash curtains are the only suitable curtains for the hospital window. Provision should be made for looping them back if the patient desires it, and most patients have a longing desire to see out of doors.

A comfortable, roomy rocker, with arms and without any “squeaks,” is indispensable in the private room.

Hospital Couches

If large enough, the room should also have a couch. It makes an agreeable change from the bed during convalescence. The common couches with elevated head are most unsatisfactory. No patient can lie on an inclined plane for any length of time in comfort. When it becomes necessary for a nurse to sleep in the patient’s room when on “special duty” these couches are an abomination. No nurse could ever get up feeling really rested, after trying to sleep on such a couch. The best hospital couch is that styled sometimes “the den couch.” The bed is flat, a full six feet by two, and the headboard being at right angles, effectually prevents the pillows from slipping off. Such a couch can be made as comfortable as a bed, combining both beauty and utility. They can be made to order by any firm that manufactures couches or beds. When covered with the best grade of pantasote these couches cost usually from fifteen dollars upward and when covered with leather from thirty dollars upward. They are the only kind of hospital couches it pays to invest in.

HOSPITAL COUCH

INVALID TABLE

Other Accessories

A straight-back chair, a wardrobe for the patient’s clothing, a movable screen and a small table or two, complete the essentials in the modern sick room. The newest hospital tables are of iron and glass and may be had in different sizes. An invalid’s table that will extend over the bed is a luxury much appreciated by the patient, especially during convalescence. Plenty of pillows is another luxury that will add to the patient’s comfort. A small pillow or two to tuck around the patient, in places where a little warmth or support is desired, is a sensible addition to the ordinary furnishing of the sick room. Half a dozen will be none too many.

The best finish for the walls of the private room is a coat of oil paint. They can then be subjected to periodical cleaning without being defaced. The shades should be soft and delicate and restful. A pretty shade of greenish blue is a delight to most eyes. On the wisdom of pictures in a sick room, opinion is divided. Some would banish them as unnecessary, and because they afford a lodging place for dust and disease germs. Others would introduce them to banish the monotony and relieve the walls of the bare effect. If used at all, pictures should be carefully selected, and have plain wooden frames, that will not be injured by disinfectants. To many patients the illuminated scripture texts on the walls are a comfort, and few, even of those who in health have no use for such things, object to them when sick. The custom of making memorial rooms, picture galleries or museums where the memory of benefactors is enshrined, is to be condemned. A simple plate on the wall or on the door is sufficient. More than this is unwise and in bad taste. The craze for memorials has reached a point that is embarrassing in many hospitals, and the time must surely come when doctors and hospital officers will interfere, and protest against having the patient forever gazing into the countenance of some member of the family of the benefactor of the institution.

As soon as possible after a patient has left the room, it should undergo a thorough cleaning. Every article but the stationary furnishings should be removed. Carelessness about this matter sometimes proves very embarrassing. Drawers, cupboards, and wardrobes should be washed with a solution of bichloride of mercury. The windows should be cleaned and fresh sash curtains put on. The walls should be brushed, the floor cleaned, the mattress disinfected, the bed clothing washed and all utensils thoroughly aired. If the last occupant was afflicted with a communicable disease, the mattress should be subjected to steam sterilization.

Fumigation

Fumigation of the rooms periodically is necessary to ensure the safety of the coming patients. Formaldehyde for fumigation purposes has largely superseded sulphur. When the room is ready for fumigation, the windows should be closed, the drawers of the furniture opened, all chinks stopped, the keyhole stopped with cotton, and the room left closed for twenty-four hours. It may then be opened, and, when thoroughly aired, is again ready for occupancy. The sheet method of fumigation, using a pint of formaldehyde to every 1,000 cubic feet of air-space, has been thoroughly tested and proven reliable. The drug is simply poured on the sheet, which is hung over a line in the room to be disinfected, which has been prepared as above directed. It should be remembered that formaldehyde has little or no power of penetration, and for this reason all possible surfaces of materials to be disinfected should be exposed.

The Daily Cleaning

In the daily cleaning, the work should be so divided throughout the entire hospital that the regular morning cleaning can be accomplished in a comparatively short time, leaving special cleaning to be completed later in the day. In order to accomplish this, it may be necessary to employ special cleaners by the hour. This does away with the necessity of providing meals and lodging for a large force of cleaners.

By nine o’clock in the morning the halls and stairs should be in order, front steps and walks cleaned, wards swept and dusted and the whole interior presenting a neat appearance. “Dust in a hospital is not only dust, but danger.” Domestic cleanliness and hospital cleanliness are quite different terms. The hospital housekeeper owes it to the public and to the sick whom she serves to keep the wards and rooms in the best condition for the promotion of health.

On the hardwood floors a soft hair brush will raise less dust than the ordinary broom. Wet tea leaves should be sprinkled whenever obtainable. The dust should be taken up frequently. The ward floors, unless polished, should be washed every day. It is well to change the water often and not use it too freely. Special attention needs to be given to corners. After each meal it will be necessary to brush up the crumbs.

Dusting

The dusting is even more important than the sweeping, and must be done with great thoroughness and care. Each patient in the hospital is helping to make the atmosphere impure by throwing off disease germs. Dried particles of pus, blood and excreta, lint from blankets and bedding, scales of epithelium and other matter, more or less dangerous, are flying about in the air and being deposited on ledges, skirting boards, window sills, bedstead rails and the various parts of furniture. To bring in a feather duster or a dry cloth and attempt to dust, is simply to flap the dust from one place only to have it settle in another. It results in a more equal distribution of the dust, but it is not dusting. Dusting is removing dust, and the only way that can be done effectually is by the use of a damp cloth, to which the particles will adhere. Furniture that will be injured by that kind of dusting is out of place in a hospital. Special attention needs to be given to dusting under radiators and in obscure nooks where dust will accumulate if not looked into daily.

Bath Rooms

The bath rooms, toilet rooms and lavatories also need constant supervision, and ought to be as carefully cleaned and ventilated as any part of the hospital. Indeed, special pains are needed if they are to be free from bad odors. Disinfectants should be used freely in these places at least once a week, and any evidence of imperfect drainage promptly reported and attended to. A good disinfectant for this purpose is the one known as the “American Standard,” made by dissolving six ounces of chloride of lime in a gallon of water. For cleaning bath tubs kerosene is recommended. It is a wise precaution to constantly keep posted over closets and sinks a notice prohibiting the throwing of matches, hair and insoluble material into them. More than one plumber’s bill has been caused by a careless maid emptying her bar of soap from her scrubbing pail into the closet. In fact, so common is that occurrence that a careful housekeeper has invented a device for holding the soap, thus preventing such accidents, and also the waste caused by leaving the soap in the water. This device is a tin box about eight inches long by four inches wide and four inches deep in front and six at the back. On the back are two pieces of wire bent over to fasten the box to the outside of the scrubbing pail. These can be made by any tinsmith at a very small cost, and will hold a cake of soap and a cake of sapolio. They will save many times their cost in a year.

CHAPTER III.

The Hospital Ward

It is in the hospital ward that the major portion of routine hospital work is accomplished, and where the nurses who will have much of the responsibility of the hospital work of the future will be trained in habits of accuracy and neatness, in proper systems of ward work and good hospital housekeeping. Inasmuch as the number of hospital officers varies with the size and demands of the hospital, it should be understood that for the purposes of these papers the hospital housekeeper combines the position of superintendent of nurses and matron—the plan that is generally conceded to be productive of the greatest degree of harmony. In all but small hospitals, competent assistants in both the nursing and domestic departments will be needed, but the authority and responsibility of affairs domestic should be centered in one woman. Whatever may be the opinion of hospital trustees on that point, no one who has lived for a year in a hospital where the superintendent of nurses and the matron were equal in authority, and pulling in opposite directions, will sigh for a repetition of the experience.

The architecture of the hospital ward, and the general plans of the building, will have not a little influence in creating difficulties for the housekeeper and in adding to, or lessening, the burdens of the nursing staff.

Tiled floors and walls are ideal for wards, but too expensive for every hospital to have. Even five feet of tiling on ward walls is greatly to be desired. Denied that luxury, as many hospitals are, the next best thing is to have the walls finished in cement or hard plaster, which, if well coated with enamel paint, will admit of thorough cleansing and disinfection.

Heavy moulding and sharp corners which afford a lodging place for dust and germs should not be there. The ceilings should be high, and ample air-space provided for the number of patients for which the ward is designed. The ventilating shafts, windows and radiators should be arranged with reference to the proposed location of the ward beds. When the hospital housekeeper can manage it, each ward will have its own linen room, with abundance of linen. It adds no small item to the number of miles a nurse is obliged to walk each day, if every time she needs a clean sheet, towel or gown she has to walk half the length or the whole length of a long hall to get it.

A little forethought and consideration for the nurse’s part in the hospital economy, in arranging the plans of the building, would result in at least avoiding unnecessary labor for those who will have no small part in carrying out the humane designs of the hospital.

Soiled Clothing

Of equal importance is it to have a “clothes chute” on every floor, connecting with the sorting room in the basement. This will render unnecessary large receptacles for soiled linen. The storing of quantities of soiled bed and body linen in the vicinity of the hospital ward for even a few hours can never be anything else but injurious. The atmosphere cannot be pure while soiled linen is there to give off its impure odors. Very dirty linen should be rolled in a separate bundle. Pins should be removed and disinfection attended to before being sent to the laundry. Clothing belonging to patients should be plainly marked with the owner’s name. In most cases it will prove more satisfactory to all concerned for the hospital to decline to be responsible for laundering articles of personal wear for any patient. There is always danger of their being lost or torn.

Buying Beds

The ward beds should be of uniform height and style and well coated with enamel paint. In buying beds several important points are to be considered. If beds are offered which require two men, and a hammer, and a box of bolts and a wrench, to get them adjusted, they should not be considered, even if listed at a dollar each. They are dear at any price, when one considers the prices that prevail in the labor market, the strain on human patience, and the fuss that the moving of such a bed to another room or ward entails. It is a mistake, too, to buy beds without inquiring the length. Six-foot patients are not uncommon, and these find it very distressing when put in a bed that is too short. The bed should be at least six feet four inches in length.

In all hospital beds, there should be some kind of bar at the foot, that will keep the mattress from slipping down. Some hospitals have attempted to remedy this defect in beds by having boards sawed and placed as foot boards, but these are unsightly, and if the right kind of bed is bought such makeshifts will not be necessary. Before ordering a quantity of beds, it is well to get a trial bed, and thus be sure of the quality of mesh in the wire mattress, and that other details are satisfactory. No beds without back rests should be purchased, for in the majority of cases a back rest will be necessary. Separate back rests must be purchased and stored when not in use, and these are rarely as satisfactory as when attached to the bed.

It is well, also, to look closely into the plan of the back rest. Some have a round iron rod across the lower edge If such a thing is there, a sensitive, nervous patient will discover that rod, and worry till she or it is removed.

In ordering beds it is wise always to state the height from the ground that is desired, or low beds may be sent. About twenty-four or twenty-six inches is the usual height desired. It is possible to secure beds that can be adjusted to any desired height. The disadvantage of such beds is the difficulty of adjustment so that each corner will be exactly as high as the other corners. Each one must be measured, and the moving of the wire mattress up and down on the legs of the bed, makes it impossible to keep the enamel on the legs.

By all means hospital beds should have castors, and care should be exercised to see that these castors are so constructed and adjusted that they will not fall out every time the bed is moved. There is a great difference in castors and in their durability.

For the general wear and tear of a hospital, the cotton-felt mattress is giving better satisfaction than the hair mattress, and it is somewhat less expensive. It is a good plan to have a few pads made of bed ticking thickly inlaid with cotton batting. These should be made the same size as the bed, with rings at the corners to secure them. For very filthy or unconscious patients these pads are desirable, as they can be washed and boiled as often as necessary. A couple of these pads makes a bed as comfortable as a mattress.

Bed Making

The mattress should be carefully protected by a rubber sheet securely fastened at the corners. Every nurse thinks she knows how to make a bed before she goes to a hospital for training, but as a matter of fact very few do. It is sometimes a difficult thing for the nurse to learn, but it is one of the most important of the early lessons in ward work. The appearance of the ward beds, and the way in which they are made, is a good index to the character of the nurse in charge. If the spread is on crooked, the open ends of the pillow covers pointing in opposite directions, and the bed has the loose appearance of having been thrown together without method, one may naturally expect the general work of the nurse to be slipshod and unreliable. It is well to teach nurses to stand at the ward door occasionally, and take a critical survey of the ward, noting down the things out of order. A nurse who is watchful in observing signs of disorder in her ward may naturally be expected to be a careful observer of signs of disease.

Order, which is said to be Heaven’s first law, should be one of the first laws of ward work. Even the height of the curtains of the windows add to or detract from the appearance of the ward. The beds should be an equal distance apart and in a straight line. The head of the bed should never be used as a drying-place for wash cloths or towels, nor as a hook on which to hang bath robes and wrappers.

Ward Lockers

Aseptic ward tables of iron and glass are now being used in some hospitals, but it is doubtful if their use will ever be general. They answer some of the purposes of a ward table, but not all. Even very poor patients prefer to have their own combs and toilet articles, their own handkerchiefs and stationery, their own books and flowers. If some place is not provided for these numerous small things, which the average patients find it necessary to have close by, they will inevitably resort to stowing their “things” under the mattress—a custom not to be tolerated by the neat housekeeper. Good housekeeping requires that in a hospital, as elsewhere, a place be provided for everything and everything be kept in its place. Until the proper aseptic ward table is invented and offered at a reasonable price, the small wooden locker, well coated inside and out with enamel paint, will continue to be used. These lockers can be made to order for a very moderate price, usually from three to five dollars each. They should be about 20 inches in width, 30 inches from the floor, 14 inches deep, and mounted on castors. The drawer should be about 4 inches deep and there should be a shelf in the lower part. A daily inspection of bedside lockers is necessary, or apple cores, fruit peelings, remnants of food, and refuse of various kinds will accumulate. All cupboards and linen rooms should have daily attention, and should be in such perfect order that the doors may be thrown open at any time for inspection without embarrassing the nurse in charge.

Care of Patient’s Clothing

The outer garments of the patient and those not needed during illness should be taken charge of by the nurse on the entrance of the patient, and the list recorded in a book provided for the purpose in every ward. Each article should be labelled, and placed in the locker in the general clothes room, and the number of the locker noted with the list of clothing in the record book. An accurate and uniform system of clothes records throughout the hospital should be insisted on. Unless this is done confusion when the nurses’ places are changed will be inevitable. Carelessness in this duty on the part of a nurse has resulted in no small discomfiture to the hospital officers. Clothing has been mislaid and not found for weeks after the patient has left the hospital, and the whole institution has been branded with negligence by the patient and his friends. All the kindness received, and the most skillful professional treatment, will often be lost sight of, if, through the carelessness of a nurse, the hospital is unable to render to the patient the clothing entrusted for safe-keeping. Money or valuables should never be kept either in private room or hospital ward, but sent to the office to be deposited in the safe.

Ward Medicine and Records

Though many well-regulated hospitals have a medicine cabinet in every ward, the custom does not generally prevail, nor is it desirable that it should. The less a patient knows, sees or thinks of medicine, except the dose intended for him at the time, the better. The custom of hanging clinical records over the foot or at the head of the bed is another custom that might better be abandoned, even though it be very convenient for the nurse. Patients are only too prone to meditate upon and discuss their symptoms, in spite of all efforts to induce them to trust themselves entirely to doctors and nurses, and cease questioning and worry. Some sympathizing friend or convalescent patient may be depended upon to keep them informed when an unpleasant symptom is recorded. This will occur in spite of all rules and vigilance. It is not easy under any circumstances to keep ward patients from discussing their ailments and symptoms. Especially is this true in women’s wards. In men’s wards the newspapers are read, the political situation is discussed, city improvements and occurrences are talked about, all sorts of subjects occupy the time of those who are able to talk, but a different state of things entirely prevails in the women’s wards. What they get to eat, how they feel, and the nurses and doctors furnish the general topics there. To have a clinical record to gossip about might divert attention from the nurses and doctors, but even these long-suffering individuals would willingly sacrifice themselves as a topic of conversation rather than have the patients read the records and constantly discuss their symptoms.

Adjuncts to the Hospital Ward

The tendency in modern hospitals is in favor of smaller wards, as affording better facilities for proper classification and separation of patients. A nurses’ utility room adjoining every large ward or located conveniently near two or three small wards, where medicines, clinical records, supply charts and blanks, order books and the memorandum books necessary for ward work are kept, is a much appreciated convenience in some hospitals. Opening off this room is the ward diet kitchen, where the refrigerator and food supplies for the ward are kept, and the facilities for quick preparation of special diets for individual patients.

Quiet Room

A much needed adjunct to a hospital ward is an isolation or “quiet” room, to which a patient whose presence is offensive to the other occupants of the ward may be removed. Whenever possible, a dying patient should be separated from the other patients in the ward. Gruesome tales that are disgraceful have been told of patients passing out of life in full view of the other occupants of the ward, without even the measure of privacy a screen affords. It is a melancholy comfort to relatives and friends to be with the patient in his last hours, and this cannot be permitted in a ward without confusion and discomfort to other patients. When planning a ward for the care of the sick or the poor, the object, of course, is the saving of lives, but people will die in hospitals in spite of the best skill and care, and the poor man is surely entitled to a quiet place to die in. There is much in hospital life to blunt the sensibilities of those who live in such institutions constantly. Familiarity with suffering and death robs them of mystery and awe, but it should never be allowed to detract from the reverent care of the dying and dead. “Put yourself in his place,” is a good rule to observe in dealing with even the most unworthy of Adam’s sons.

Matters Miscellaneous

The ease with which the routine work of the ward goes on will depend largely on proper facilities and a proper system. There should be a regular order for the work of the day—a time for bed making, a time for sweeping and dusting and washing the ward floors, a time for the daily cleaning of the bath rooms and toilet rooms and refrigerators and cupboards. Interruptions may be expected, but unless a routine order of work is established the cleaning will be executed in haphazard style. Neither nurses nor maids can be depended on to use their judgment in such matters. If left to plan their work, they will probably be found sweeping their wards when the doctors are ready to begin their dressings, and the time for other things will depend on their ideas of the importance of the various duties. The habit of doing things quickly and thoroughly should be formed by every one who has any responsibility of the routine work of a hospital, where everything should move with clock-work precision. So much time can be wasted by lack of system, or in talking or dawdling. The untidy habit of leaving glasses or utensils dirty till a sufficient quantity has accumulated to make it a necessity to wash them, should never be tolerated.

It ought not to be necessary to mention the necessity of plenty of tools and the right kind of tools for ward work—plenty of basins, and syringes, and dressing pans, and instruments, and drinking-cups, and medicine glasses, and the thousand and one little things that go to make up the complete furnishings of the hospital ward. But, as a matter of fact, many nurses go through their course of training hampered by a lack of facilities for proper work. One set of instruments for dressing is provided, where several are needed at the same time; insufficient linen to keep the beds and their occupants clean is the rule, and so on indefinitely.

Destruction of Appliances

On the other hand, head nurses and hospital housekeepers lament over the carelessness of nurses and the constant destruction of hospital appliances. Just what course to pursue with the girl who every few days puts a rubber catheter or rectal tube or nozzle on to boil, and lets it burn up; who pours boiling drinks into glass tumblers, and thereby keeps up a constant breakage; who leaves hypodermic needles without wires, and finds them useless when needed again; who breaks medicine glasses and fails to report the accident, till the head nurse finds her measuring medicine with a spoon; who puts the thermometer into the mouths of delirious patients or children, and goes away and forgets it; who lets the sterilizer boil dry; who puts glass syringes and appliances in unsafe places, and returns to find them broken—just what course to pursue to correct these destructive tendencies is an ever-recurring problem to the hospital housekeeper. Nurses who are most careful and conscientious in carrying out the doctor’s orders, and in their duties to the patients, frequently lack that fine sense of honor regarding their duty to the hospital and the care of materials. A deposit for breakage is now demanded in some hospitals when a nurse enters for training. If this is not done the nurse should be made to replace articles destroyed and to pay for repairs that are rendered necessary by her carelessness.

Proper economy in the use of hospital goods is an important lesson for nurses to learn early in their career, and one which will demand frequent emphasis throughout their course. Gas stoves are left burning when not in use, and help to swell the gas bill. Milk is left out of the ice-box, and quickly becomes unfit for use. Materials of various kinds that could be utilized are thrown away. The destruction or waste of one article seems a very trivial affair, but in the aggregate such trivial affairs amount to hundreds of dollars in the course of a year. The cost of rubber sheets alone is an important item in ward expenses. The best will soon crack if folded when not in use. If loops of tape are fastened to the corners and the sheets hung against a closet wall when not in use, they will be found to last twice as long.

Screens

Plenty of screens in a hospital ward is a necessity to proper nursing. The poor appreciate privacy and refinement and delicacy as much as many of their wealthier neighbors, and they have a right to such privacy as a screen affords. The timid, frightened little woman who has just been admitted, and who shrinks from the gaze of everybody, ought to be screened off till the first awful feeling of strangeness wears away. The patient who is critically ill needs also to be screened. The general work of the ward requires the constant use of screens. One screen for every two beds is not too many for the necessities of the average ward. One of the most practical and altogether desirable ward screens is made of a wooden frame, white enameled, covered on both sides with white oilcloth. A set of clothes-bars, from four and a half to five feet high, makes a very satisfactory frame, that is large and yet light enough for one nurse to handle.

A fair equipment for a ward of twenty beds would be:

CHAPTER IV.

The Linen Room

The linen room is one of the very important parts of the institution. Demands will be made on it almost every hour, and, if the hospital is to do proper work, it must be equal to the demands. As well expect a carpenter to construct a building without tools as expect nurses to do conscientious work without a sufficient supply of bed and body linen to keep their patients in proper condition. Lack of knowledge on the part of the managers as to the amount of supplies necessary, rather than a lack of money, is accountable for the shortage of linen in many hospitals. An important part of the housekeeper’s duties is to know what supplies are on hand, and keep the board informed as to the needs. Time, and tact, and perseverance in educating them as to what is absolutely necessary for proper work, will do much to correct such defects in hospital management. It is difficult for the laity, who are perhaps accustomed to having bedding changed in their homes but once a week, and then sometimes allowing for but one clean sheet for each bed, to appreciate that a constant changing of beds goes on in a hospital, both day and night, and that economy is out of the question. A hospital can really afford to be extravagant in the matter of linen. That is one point, and perhaps the only one, in which lavish expenditure will really redound to the good of the hospital. Better cut down expense in a dozen other ways than to give rise to the criticism that the hospital has not sufficient linen to keep its patients and its beds in proper condition. Cleanliness may be next to godliness in most circumstances, but no hospital can afford to let cleanliness take second rank with any other virtue. In fact, if want of cleanliness in the care of the beds or patients be noted, very grave doubts as to the godliness of the management will surely arise, be the professions in that direction never so loud.

Bed Linen

The amount of linen required per bed will depend somewhat on the character of the work done in the hospital. Where only acute cases are handled, and emergency work is done, the supply must needs be greater, as the average number of patients entirely confined to bed will be greater. Six pairs of sheets and pillow covers for each bed is a fair amount to begin with. That number of sheets is often needed for one patient in a day, but taking the average patient in the average ward, that amount will usually be sufficient, even to provide for the extra demand in special cases. A half-dozen draw sheets for each bed in the ward are also necessary. Six face towels and four bath towels per bed is a fair estimate. Two spreads for each bed and two pairs of blankets will be sufficient for the ordinary ward, but a few extra blankets should be provided for each ward, for the use of patients who require extra heat. This estimate is based on the supposition that linen sent to the laundry Monday morning will be returned at the latest by Wednesday morning following. Every well equipped hospital has its supply of gowns for the use of any patient who needs them or cares to use them. They are best made to order of firm bleached muslin, without trimming of any kind. For ease in management they should be open all the way and should fasten in the back. Tape fastenings will be found most satisfactory, as buttons are constantly torn off in the mangle.

The Room

The linen room should be really a room—not a closet. Special cupboards or closets for each ward or department will be needed, but the general linen room has special needs that do not apply to the ward closets. Plenty of light is a necessity. A work-table, a sewing machine, and a gas stove on which an iron may be heated, should be in it, besides the shelves and cupboards needed for the hospital linen supply. To this room new linen should be sent to be marked.

Marking Linen

It will be found that a uniform system of marking linen will save time in sorting. Sheets may be marked on the wrong side at the corner of the top end, pillow covers an inch above the hem close to the seam, towels in the corner of one end just above the hem, table-napkins and tray cloths diagonally across the corner. Blankets and spreads may be marked by a tape sewn diagonally across the corner.

Linen Accounting

The person in charge of the linen room will be expected to keep the linen in repair and to account for every piece that passes through her hands. It is very important to have a systematic method of accounting for linen that will enable the housekeeper to know the amount on hand, and to discover if linen is lost. It matters not whether the washing is done on the hospital premises or sent to a commercial laundry, some system of accounting is necessary unless the housekeeper is willing for a constant depletion of blankets, sheets, towels, etc., to go on without her knowledge. Where a public laundry is patronized the importance of this matter is evident. When hundreds of towels and sheets are sent in at once, it is not unusual for linen to be taken from the large quantity to supply missing articles in the list of other customers who had sent smaller amounts, from which, if articles were missing, it would be quickly discovered. The housekeeper of a certain institution relates the following incident bearing on this point: The linen of the institution was sent to a public laundry, and for some time she had been missing towels, though the laundry always claimed to return the proper number. Finally the manager of the institution happened into a barber shop and accidentally discovered there a pile of the institution towels. Inquiry revealed the fact that the barber kept strict account of his towels and the laundry had to return the number sent or pay for them. The barber cared nothing whose mark was on the towels if he got as many as he sent. A laundry employee had been in the habit of substituting linen from large institutions to make up the required number from smaller lots, and thus the problem of the missing linen for that institution was solved. The inexperienced housekeeper may perhaps settle down into the belief that of course the linen sent to the hospital laundry is safe since it does not leave the premises. If all servants and everybody about the establishment were tried and true and trustworthy, through and through, it might be safe, but in these days of possible degeneracy and certain uncertainty in the servant class, it is wise to trust implicitly but few, and to keep an eye on those.

Discarded Linen

Another point that needs some emphasis is that the housekeeper or her assistant—not the nurses or the servants—must decide when linen is to be discarded. Well-worn or torn linen should not be sent to the wards. A special drawer, marked “Discarded Linen,” should be in the general linen room, and into this the one who sorts linen can lay aside what in her judgment is unfit for wear or beyond mending. But the housekeeper should reserve for herself the privilege of deciding when an article is to be used as old linen. Unless this rule is rigidly enforced, a reckless extravagance will be the result. Good towels will be used as dusters or as scouring cloths. Sheets that might have been utilized in some other way will be torn up and used as cleaning cloths, and a constant depletion of the supply will go on without the housekeeper’s knowledge. Many a housekeeper who has assumed charge of a hospital that had been previously managed without a system of linen accounting has found it one of the most difficult of her tasks to check the tendency to appropriate the hospital towels, sheets and pillow covers for cleaning purposes. Constant vigilance in that direction for months was needed to impress the household that the haphazard, loose way of handling linen was a thing of the past.

Emergency Supply

Every careful hospital housekeeper has found the necessity of a special closet, for the storing of extra linen of all kinds for times of special emergency. It is poor management to have the full supply in circulation at one time. Attention to this emergency closet will save embarrassment many times. What could be more embarrassing than to have a patient injured in an accident, brought in grimy and dirty, and not have a clean gown to put on him? And yet that very thing has happened when the hospital housekeeper has failed to anticipate the emergency.

Sheets that are worn thin in the center may be doubled and stitched together for draw sheets, and in that way will last for months. The ends of bath towels can be hemmed for wash cloths. Squares of linen from partly worn tray-cloths and napkins may often be fringed for doilies for ward medicine trays. The training in economy in supplies, and in methods of utilizing material that would otherwise be wasted, is an important part of the nurse’s training that will benefit her through life.

Removing Stains

The nurses, too, in their use of hospital linen, are responsible in no small measure for its appearance. Blood-stains and various other stains can be readily washed out when the stain is fresh. Every nurse should be taught that it is her duty to remove such stains as far as possible by a preliminary soaking and washing before being sent to mingle with other clothing in the laundry. A little salt in the water will hasten the process. If such matters were thoroughly impressed on each nurse, as a part of her duty in her hospital training, there would be fewer complaints of nurses in private practice needing an extra maid to wait on them. Stains from certain oily dressings are exceedingly difficult to remove. In fact, in the general washing it is practically impossible to thoroughly efface such stains. A little care in managing, and, as far as possible, keeping one set of sheets for cases requiring such dressing, will prevent the whole ward supply from being stained. The oldest linen should be specially set apart for such cases.

New Linen

Where a regular maid is in charge of the linen room, she can usually, in addition to the general care of the linen, make up new material. The cutting of new goods is a matter for the housekeeper’s personal supervision. Each new lot of linen that is laid on the shelves for general use should be added to her inventory. Under the heading of “Discarded Linen” in her linen account book, she can mark each piece she lays aside as old linen, and by reckoning up each month the new linen that is added, and the discarded linen, can readily keep account of the amount in general use. In buying linen for a hospital it is questionable economy ever to buy cheap material. Towels and spreads should always be without fringe.

Shelf Management

In placing linen on the shelves of a general linen room some method will be found advantageous. If the rule is to lay towels and pillow covers on the shelves in piles of twenty, sheets and spreads and gowns in piles of a dozen, it is but the work of a few minutes to take an inventory of the contents of the linen room. If, in buying linen, the housekeeper has taken pains to secure glass towels with some distinctive pattern or coloring, it will be easy to keep the kitchen, diet kitchen and ward glass towels in separate piles. Red and white check toweling for the kitchen, blue and white check for the diet kitchen, and plain white toweling with a single stripe on the edge, for the ward glass towels, is a distinction easy to secure in any place. Face towels for patients can be secured with red border and for nurses and officers with blue.

Laundry Bags

Each nurse should be instructed to bring with her two laundry bags—one to be kept in her room to receive soiled linen, the other to be sent to the sorting room, to remain till the clean clothes are returned in it. A list of the articles contained should be pinned to each bag to facilitate the sorting of the clean clothes and for reference. It is needless to state that all nurse’s clothing should be marked with her full name. Initials may be sufficient marking in a home, but are useless in a hospital. If it can be brought about (and it can by insisting on it), it will be found that a uniform system of marking nurses’ clothing will be a great saving of time in sorting. To have a pile of thirty or forty nightdresses to sort and put in bags, and find no two marked in the same place, making it necessary to unfold every garment and look it over on all sides to find the mark, is an unnecessary trial and waste of time for whoever has the sorting to do. If each garment were marked on the under side of the front, which is usually folded on top, to sort them would be an easy matter. To return clothing without being washed, when the nurse has not marked it properly, is the only way to teach nurses, who are habitually careless in their marking.

Printed laundry lists should be furnished for the sorting room, duplicate lists of each lot of clothes sent to the laundry being made. One list goes to the head laundress, the other is retained in the sorting room for reference.

HOUSEKEEPER’S LINEN ACCOUNT BOOK

CHAPTER V.

The Hospital Laundry

Perhaps no part of the hospital housekeeper’s domain will call for a greater expenditure of her energy and patience than the laundry. Though out of sight, its results are always in evidence, and failure in the laundry means that every part of the work of the establishment is handicapped. There may be abundance of linen to meet the needs of the hospital, and yet if constant supervision over the work of the laundry is not exercised, three-fourths of the linen supply may at times be found piled in the laundry, the linen room shelves empty, and the nurses flying hither and thither on borrowing expeditions when a clean towel is called for.

A wise philosopher has said, “Every man is as lazy as he dares to be,” and the average laundry employee is like the rest of the world in that respect. Few of them love the work for the work’s sake, and if the weekly wage is not sufficiently large to be attractive, they will be lazy and neglect their work if they have opportunity.

Manager’s Duties

A competent manager for the laundry is essential for successful work, especially in a large institution. This person should know how to manage his staff of helpers so as to secure the best possible service, and should have a knowledge of the needs of the institution where his own department is concerned, and of the work that is important to be done without delay. Good common sense in arranging the time when the different parts of the work should be done, will prevent much trouble in any laundry. Nurses’ clothing and articles not in constant demand, that are returned but once a week, can be laid aside to make way for the things in constant demand. When once a competent manager is secured, the buying of supplies may be safely entrusted to him.

But, unfortunately for the hospital housekeeper, few except the larger hospitals can afford the luxury of a skilled manager for the laundry. A head laundress is the nearest they can approach to such a luxury, and even that much needed individual is often out of reach. In many cases the hospital housekeeper, in addition to her other duties, has really to take the place of manager of the laundry.

Where several laundresses are employed, and none are fitted for directing the work of others, it is a wise provision for the housekeeper to personally divide the work and assign it, and have each laundress responsible to her. The servant problem has assumed such an acute form that it requires delicate handling in any household, and where the character of the work is as important as that of the hospital laundry, every possible tendency to friction should be avoided.

Laundry Workers

Let laundry workers understand fully what their hours of work shall be, and that they are expected to be in their places promptly at the hour. Explain the importance of having the supplies for the wards and operating rooms constantly kept up to the mark, and also the linen for the trays. Prohibit visitors during working hours. It is always better to make such prohibitions when engaging help rather than wait for some occasion to call it forth. The occasion will certainly come unless it is anticipated and prevented. Make some provision for them to do their own personal washing, and let it be plainly understood they are not to take in washing from other sources to increase their income. That is sometimes tried and carried on very successfully, if it is found that the laundry has not careful supervision. If it is not desirable for their own washing to be done in connection with the hospital, then a time must be arranged for it.

Where the laundresses are mothers of families, as is often the case, this point is worth mentioning at the time of engagement. Their washing must be done—the question is, when and where. It is better to have a plain understanding about the matter than to have them attempt a course of deception. Feed the laundresses well and arrange for them to make a cup of tea or coffee between meals if they want it. The work is hard and exhausting, and they cannot put their best into it if they are hungry. Take an interest in their health and see that their minor ailments are attended to when necessary. Arrange for an afternoon off at least once in two weeks. They have little matters of business to attend to, and they need the recreation as much as other people. Arrange to visit the laundry at least every day—twice a day if possible, and not always at the same hour. Commend their work and their promptness when there is room for it. A word of appreciation will often do more to inspire them to better service than a severe rebuke. When they have worked overtime in some unusual rush, do not forget to mention your appreciation of it. Then see that they have proper things to work with. It is impossible to have satisfactory service if proper facilities are not provided.

Starching

The housekeeper, where no manager of the laundry is employed, will have the purchasing and giving out of supplies and should have an idea of how much is needed for each week’s work. Provide a good quality of soap and starch. The cheaper grades are almost always more expensive owing to the additional amount necessary for the work. The better grade of starch will produce better finished work. See that the vessels used for starching are well cleansed after use. Know something about the methods used in starching. If collars, cuffs and belts are not stiff, inquire the reason. To produce a proper stiffness, the starch should be used as hot as can be borne by the hand, and well rubbed in. Clothing that is starched should be put to dry as soon as the starching is completed. If left around in baskets the articles will inevitably come out discolored. It is well to give a list of the articles requiring starching rather than trust to their judgment. Aprons and coats for the operating room that are to be put in the sterilizer need no starching, while other aprons and coats must be starched. They will not know the difference if they are not told.

Bluing

If the clothes are streaked with blue, make some inquiries into the washing process. It may be the clothes have not been rinsed thoroughly free from soap. They should pass through at least two rinsing waters (three is better) to free them from soap. The first rinsing water should be quite hot. The bluing should be done in plenty of water, so that every part of the garments may be under water. In preparing the bluing water see that the blue is dissolved in a separate pail before being put into the vessel in which the articles are to be blued. In mixing the bluing water, it is easy for parts of the vessel to become deeply stained with the strong bluing solution, which will be rubbed into the clothes and leave streaks. When plenty of soda is used to soften the water there will be less trouble with black specks from the soap. Impress on them the fact that the nurses’ uniforms and colored shirt waists are not to be boiled. If the uniforms are thoroughly soaked over night in a strong salt solution they will retain the color better. When uniforms are dried in the open air see that they are hung wrong side out.

Special care needs to be used in washing blankets. They should be dealt with separately and gotten through with quickly. The suds should be quite hot and a little ammonia added. The rinsing should be in water of the same temperature and they should be dried in the open air.

Drying

Whenever possible have all the hospital clothes dried in the open air. No drying room, however well constructed, can compare with nature’s process of drying by fresh air and sunshine. The best method of bleaching is by the use of the sun rays while the clothes are wet. However, in planning for laundry work, it is never wise to depend entirely on open air drying. An artificial dryer is a necessity where promptness is required. Quick drying is essential to good work. Where bad work is done, the trouble is oftener in the washing than in the drying.

Ironing

In planning for the ironing much may be done to facilitate the work. Little labor-saving devices can be introduced which will increase the amount of work done in a day. Ironing boards of special shapes, and for special purposes, and tables of various designs can be had for a trifle and will result in a saving of time and more finished work. A box of thin pine boards with a hinge cover and with perforations in the sides is a convenient receptacle for storing dampened clothing waiting to be ironed. See that they have proper irons for the different parts of their work and that they have wax to use as needed. Supply unbleached muslin for ironing sheets or the hospital sheets will be found covering the ironing boards. Instruct them to keep their ironing sheets clean. Well-finished work cannot be produced on a dirty ironing sheet.

Routine of Work

Let the laundresses understand that bad work will not be accepted, and they will not send it. Bad work that was passed in the linen room has often caused embarrassment in the operating room. As far as possible, have a routine order for laundry work, and expect the laundresses to comply. If they understand that clothing sent from the wards on Tuesday morning must be returned to the wards not later than Thursday morning, they can arrange to have it done, while if no limit is set for the clothes to be in the laundry, the haphazard results will be constantly felt in the wards.

Have a method of folding linen and insist on that method being followed. It is impossible to have neat-looking shelves in the linen room if no uniformity be observed about folding in the laundry.

Then see that the work rooms are kept clean. It is useless to expect clean linen unless the laundry and its furnishings are kept in proper condition. The woodwork and windows and floors should be as scrupulously clean as any other part of the hospital. But they will not be kept so unless a time is set for the cleaning, and someone sees that it is done.

Greasy towels or clothes, from the kitchen, pantries and bake rooms, should either be entirely washed by those who use them, or have a preliminary washing before being sent to the laundry. Such articles cannot be washed with any other clothing; a special suds must be gotten ready and time spent that would have counted for more if spent on other work.

A false economy in planning a hospital often results in a space entirely inadequate being set apart for the laundry. As the general work of the hospital increases it is then found impossible to meet the demands, and recourse has to be had to the public laundry—always an expensive arrangement. Another common mistake, is to place the laundry in the basement, where lack of light and air is always a hindrance to good work. Whenever possible, the laundry should be located in a separate building, where plenty of light and air and sunshine can penetrate, and where there is room to separate the clothing while in its different processes and proper work can be done. All clothing should be well aired and thoroughly dry before it leaves the laundry, so that it may immediately be placed on the shelves for use.

The Laundry Plant

It is difficult to give an accurate estimate regarding the cost of installation and operation of a laundry plant, as conditions vary greatly. A list of the articles required for a plant capable of doing the work of a sixty-bed hospital is appended. In preparing this list the elimination, so far as possible, of all expensive features, has been attempted. A laundry plant, like nearly everything else, can be figured on in various ways, and at largely varying cost, so that, with different machines, a plant with the same amount of machinery will cost three times as much as another of practically equal capacity and actual working value. It is well, therefore, before purchasing a plant, to be thoroughly informed regarding the actual needs of a hospital, the various makes and grades of machines, cost of operating, etc.

A very serviceable laundry equipment for a hospital of fifty to sixty patients, is made up as follows:

One 12 h. p. vertical boiler, complete with suitable injector and regular boiler trimmings.

One 6 h. p. horizontal engine, complete with all engine trimmings, and a sight feed lubricator.

One 36 × 30 wood washer.

One 20-inch solid curb extractor, countershaft attached.

One 40-gallon galvanized steel soap tank, with circular boil pipe.

One sectional dry room, arranged to handle plain or fancy clothes, and complete with three metal trucks, ventilating fan, etc.

One 66-inch steam mangle.

One 30-inch reversible body ironer.

Two ironing tables.

One truck tub.

This outfit will cost about $1,100 to $1,200, including pipes, pipe fittings, valves, shafting, etc., and will require a floor space of about 24 × 48 feet. The accompanying diagram gives a good idea of an economical arrangement of such a plant.

In one institution having about one hundred patients, a plant similar to this is used. All the work is done with two women and one man, the man looking after the power and the washing. If the hospital employs a man who can look after the power for two or three days in a week, the cost for help may be reduced.

Where the laundry work of a hospital runs up to $750 or $1,000 a year, there are but few instances where a direct financial saving will not be effected by the hospital operating its own laundry plant.

CHAPTER VI.

The Hospital Kitchen

With the advance in science, and a better knowledge of things desirable and things avoidable in hospital construction, a gradual change is taking place in institutions designed for the care of the sick. Perhaps in no department have greater changes taken place than in the construction of the modern hospital kitchen. Instead of being located in the basement, where odors from cooking were diffused throughout the whole building, and where absence of light invited the accumulation of dirt, the kitchen is now located in the top story, or, if the hospital be built on the cottage plan, in a separate building. In deciding on the location, one thought should be prominent—the possibility of conveying cooked food without delay to those for whom it is prepared. With proper facilities for keeping food hot, this important point is not difficult of accomplishment.

General Construction

Wherever the kitchen is located, it should be large, light and thoroughly ventilated. Proper care in planning and construction will insure the installation of vent flues and ducts to carry off smoke and odors, as soon as generated. As far as possible, the interior of the kitchen and its furnishings should be constructed of non-absorbent material. Those who have had experience with cement floors claim for them that they are splendidly absorbent of grease, exceedingly difficult to cleanse, and liable to crack, thereby furnishing crevices for the deposit of dirt of all kinds. Therefore, in a hospital designed to be thoroughly sanitary, cement floors will have no place. Tile seems to be the material that gives the most general satisfaction for kitchen floors and walls. A white vitrified tile, laid on a heavy foundation, having the joints between the tiles carefully sealed with cement, gives perhaps the nearest to the ideal kitchen floor yet attained. If the floor is constructed so as to slope gently toward a drain properly trapped and protected, the cleaning will be facilitated. The side walls and ceiling of glass tile, with the corners well rounded, gives a surface that is not only bright and beautiful, but thoroughly sanitary. Such a finish will endure the most severe cleaning without injury. Wood mouldings, that invite the deposit of dust, will of course be avoided.

The sinks in the hospital should be placed at sufficient distance from the walls, so as to be accessible on all sides.

Kitchen Cabinet

A hygienic outfit for the hygienic kitchen is of course essential, but sometimes more difficult to secure than is the sanitary room. Dressers and drawers for the accommodation of the kitchen utensils must be provided, and in these things crevices and angles and dark corners and all sorts of complications of this character seem unavoidable. If these cabinets could be of metal, all angles and corners done away with by the finishing with curves, the shelves loose fitting and easily removable, it would be a decided advance in kitchen arrangements. The drawers could be made in the same way, the emphasis being on the point “easily removable.” Thus constructed, the person in charge would find it easier to remove them than to undertake to clean them while in position.

Architects say, that in hospitals where steam boilers and engines for supplying power for elevators, electric lights, laundries, etc., are in use, arrangements should be made to utilize for cooking the large amount of exhaust steam, that ordinarily goes to waste. When this is done, ashes, smoke and their attendant ills can be avoided. The hospital may then be not only “a thing of beauty,” but “a joy forever,” and the drudgery of that department greatly reduced.

Through the courtesy of Mr. W. J. Palmer, architect, of Washington, D. C., we are able to present drawings for a hospital kitchen embodying most of the features above mentioned. The drawings were designed for a kitchen located on the ground floor in a separate building, but with a few changes could be easily adapted to a kitchen located on the top floor. The range is located in the center of the room, with steam tables on each side to keep the cooked food hot. A gas range is provided and a chopping block, tables and dressers are arranged conveniently for work. On one side is a small pantry, which leads to the vegetable cellar beneath, and adjoining it is the main diet kitchen. At one end is the serving room, where the food is divided and dispatched to the wards. Leading from the serving room is a hall, off which on one side are the cooling rooms, and on the other side storerooms for staple supplies. If the kitchen be on the top floor, a cooling room on that floor, sufficient at least to care for one day’s provisions, will be necessary, having the main cooling rooms located on the main floor or in the basement.

Cold Storage

A good cooling room, in which can be stored large quantities of the perishable supplies, has now come to be regarded as essential to economical housekeeping. The size of the cooling room will depend on the size of the hospital, but there are special features which should always be kept in view, and which can be had in cooling rooms of any size. One important point is to have it so constructed that the ice can be put in from the outside, if it is not manufactured on the premises. Every cooling room needs to have three departments—one large section, well arranged with meat hooks and shelving for meats, one with plenty of shelf space for vegetables and fresh fruits, and one for milk, butter and eggs. The separation of these articles is highly important. Vegetables and fruit will taint milk and also meat, and meat alone will injure milk. The best goods that can be purchased will quickly deteriorate unless properly cared for, and in a hospital, where the most capricious appetites have to be catered to, the keeping of the edibles sweet and fresh is of the utmost importance.

The Storeroom

The storerooms should be light, well ventilated, cool and dry. The shelving, if arranged in sections in the central part of the room, similar to the arrangement in libraries, will be much easier of access and more easily kept clean. Labeled receptacles, with covers for all the varied commodities used in the domestic department, should be provided, thus rendering it unnecessary to store supplies of any kind in paper sacks. A special closet for canned fruit will also be needed. Provision should be in the kitchen for the care of such supplies as are needed for each day.

Dishwashing

Dishwashing, that bugbear of every household, is not less a task in a hospital than elsewhere. In fact, it forms a very large part of the work of the institutional kitchens. The use of mechanical dishwashers has not yet become general, and it is doubtful if any but the largest institutions will deem it necessary to adopt them. Those who have had experience with them as a rule find them satisfactory, and comment especially on the saving in breakage and time. Provision ought to be in every hospital kitchen for handling dishes in large quantities and the adoption of a routine method of dishwashing will do much to prevent confusion and simplify the task. If each floor has its own kitchen and diet kitchen where the ward dishes can be washed and kept, the labor in the kitchen will be greatly reduced and fewer servants in that department will be necessary; and this is perhaps the better way. The frequent handling of dishes that is necessary, when the supply for the whole household has to be sent to and from the main kitchen three times a day, adds greatly to the breakage, and results in increased labor and loss of time. But in this matter, as in many other lines of hospital work, the housekeeper’s methods are modified by the construction of the hospital. If no facilities are provided on each floor for washing the dishes, there is no alternative but to send them to the main kitchen to be handled there. The real work there may be greatly facilitated if in cleaning and packing the trays, care has been exercised in separating the different articles. The silver should be collected on one tray, the fragments placed by themselves on another, the dishes carefully scraped and packed, the tray-cloths shaken and folded together. The maid in the kitchen receives them from the dumb waiter as they are sent from the different wards. The silver and glass and delicate china should be placed together to be washed first, the heavier china and greasy dishes on a separate table, and when all are collected the washing begins. The water for the glass and fine china should not be too hot, and these should be finished and put away before the washing of the silver is begun. But few servants can be trusted to properly handle delicate china and glassware without supervision, and the all too prevalent custom of piling a large draining dish full of delicate articles is the cause of constant breakage. A draining rack, constructed with grooves, and fitting on one edge of the sink, is a much appreciated convenience in many hospital kitchens. Every housekeeper has her own theories of proper dishwashing, and all are good if the result is clean dishes. The main point is to have a system of preparing the dishes for washing and adhering to it; without system the disorder and confusion in the kitchen when all the trays are sent in will disturb the most saintly individual. A limit to the time when dishes may be sent from the wards is also essential to methodical work. Much unnecessary delay and unpleasant feeling is often caused by the late arrival of a consignment of dirty dishes which should have reached the kitchen an hour or two before. The carelessness of those in charge of the ward dishes results in upsetting the arrangements of the other work of the kitchen, the maids who had finished their task having to gather together their dishwashing utensils and begin over again. To require that the delinquents assume the responsibility of washing all dishes not sent to the kitchen at the proper time will do much to prevent the repetition of this unpleasant occurrence.

Dishcloths and Towels

Much care needs to be used in the handling of dishcloths and towels. Plenty of towels should be provided, and dishcloths should be washed and scalded after each meal. It is impossible to have clean, shining dishes if these are not kept thoroughly clean. The tendency for kitchen towels to disappear may be overcome by the housekeeper requiring each maid to state the number necessary for her work, supplying them, insisting that each put her special mark on her own towels, and requiring that the old towels be produced before new ones will be given out.

The Chief Kitchen employee

In selecting a chief employee who will be responsible for the direction of the details of the work, and for the care of the kitchen and the other rooms in her department, several points need to be considered. She should not only be familiar with methods of preparation and cooking, proper carving and serving of food, but she should know how to keep herself neat during the process. Neatness and cleanliness about the person of the workers in the kitchen is fully as essential as neatness in the care of the room and utensils. In fact, one who is not neat in person cannot be trusted to observe the rules of cleanliness anywhere. “Doing” is dependent on “being,” here as elsewhere.

Training Needed

The secret of success in the kitchen is the same as in other departments of the institution, and, indeed, of life in general. It can be spelled in one word—s-y-s-t-e-m; and be it understood here and now, that system and red tape are not synonymous terms. Just as in a large department store, every yard of ribbon sold has its relation to the whole establishment, or in a great railway system every train dispatched influences the running of every other train, and system is necessary to insure the success of the business or the safety of human lives, so in a hospital every part is vitally related to the great whole. Some mind must plan the details, first of the whole and then the minutæ of the different parts as they contribute to its harmony and success. And yet, while this truth is generally admitted, and its importance is evident, how little training does the average nurse of the present day receive to fit her for the responsibilities of hospital housekeeping—that on which much of the comfort and well-being of the whole institution depends. Most graduate nurses can nurse, they can care for a patient afflicted with an ordinary disease in a satisfactory manner, but how much have they learned regarding the management of the household? How much have they been taught regarding the purchase of supplies, the care of food, the management of the linen room, the laundry and kitchen, the supervision of servants, and other matters of vital importance to every hospital? Is there not much still lacking in our present system of training? If a railway company sent an engineer to conduct a train to its destination as ignorant of, and inexperienced in, the working of the whole train system as some graduate nurses are, who have the responsibility of a hospital, small or large, placed upon them, the public would raise its hands in horror, and brand the railway officials with criminal carelessness. While present methods continue, the success or failure of the nurse as an executive officer and housekeeper depends largely on the thoroughness of the domestic training she received from her mother, her own native ability, and her intuitions as to how things should be done—not on the training received in the average hospital. When the nurses’ course includes practical instruction in the management of every department of the hospital, the purchase of supplies of all kinds and simple accounting, the public, with the nurses, will reap the benefit. In large institutions stewards may be employed, or it may be possible to secure a trained housekeeper from some institute of domestic science. But in the small hospital the superintendent must be her own housekeeper; such superintendents must almost of necessity be nurses, and there ought to be time in a three years’ course to give them some insight into, and experience in, the details of hospital housekeeping.

The Diet Kitchen

An advance step has been taken, however, in the introduction of cooking into the nurse’s course of study. The nurse’s work in the diet kitchen ought to mean a lightening of some of the burden in the main kitchen. The custom of management of this department varies and each institution must work out its own problems. Where there is a regular dietitian in charge, with the diet kitchen work as her exclusive business, the matter is easier of adjustment. Where this is not possible two nurses may be assigned for this special duty, making the term of service two months. The junior nurse may thus be initiated by the senior diet nurse, the housekeeper having general supervision of the entire work. The value of this practical experience in cooking can scarcely be overestimated, for unfortunately a great many young women enter a hospital with no more definite idea of how to prepare food for invalids than they have of medicine or surgery. In order that this course in practical work be productive of the most good to the nurses, previous instruction in the principles of nutrition, food values, and in the processes of digestion, should be given. Valuable, however, as the diet kitchen work is in the nurse’s education, unless it is arranged that that department assume a certain responsibility for preparing a part of the hospital dietary, its introduction is hardly justifiable. In most cases the diet kitchen should furnish at least the special diets and desserts, all broths, jellies, etc. If the diet kitchen facilities are adequate, it may be wise to have all the cooking for private patients done in this special department. In this way it is possible to devote more attention to attractive arrangement of food, as well as more care to its preparation. Where the housekeeper has a real interest in the people for whom the food is prepared, and has cultivated the fine art of cookery, or has a degree of native ingenuity, many delightful dishes may be constructed even of odds and ends, and a variety secured out of very little. The very first essential to proper feeding is good cooking, and this, like most other expert service, is an economy rather than a waste. For this reason many institutions that have tried both methods claim that the employment of a trained chef at a good salary was really a saving to the institution when the total cost of the culinary department was reckoned. This is in comparison with the old method of having the cooking done by women who had received no previous training, and had no special desire to study the art of cooking or to become more proficient in it.

CHAPTER VII.

Purchase and Care of Food Supplies

The person to whom is entrusted the purchase of the food supplies, and the direction of the general dietary for the hospital household, occupies a place of no small responsibility. If she is to discharge this duty to the satisfaction of those who have the interests of the institution at heart, she should have a few marks of fitness not found in the average woman.

First, she should have an active, intelligent and sympathetic interest in the welfare of both the sick and healthy members of the household, and be in perfect harmony with the humane designs of the institution.

Judging Values

Second, the purchaser of the food supplies should have sufficient experience and knowledge to detect superior and inferior qualities of the different food stuffs. So far as the food for the sick is concerned, the physician will have the responsibility of deciding the kind of food his patient shall have, but she will have the responsibility of deciding regarding quality and preparation. It does not require an expert to discover that a beef steak is tough when it comes to the table, but that is too late for the discovery to be of any practical value. The toughness should have been detected while it hung in the market. So it is with all varieties of food. To know the desirable and the undesirable qualities before purchasing is to possess one of the chief secrets of successful buying. Clever buying does not mean close buying, though some people think it does. The cheapest article often proves the most expensive, and quality must be paid for. The point is to be able to recognize, and not pay first-grade prices for second-grade goods.

Third, she should keep posted regarding the fluctuations of the markets, and not have to depend entirely on what one dealer may say regarding prices. As she is spending, not her own money, but funds often accumulated by self-denial on the part of givers, she needs to study to spend them wisely.

Fourth, she should make a point of finding out the exact price of most articles before ordering them. Strawberries would be appreciated by her household at any time in the year, but while they sell at thirty or forty cents a box, she is hardly justified in buying them freely, if at all. And this rule holds good in regard to most of the ordinary so-called luxuries—the things that are not absolutely essential as nourishment. There is a time in which she can decide to have them, and also a time to decide to do without.

Fifth, she should have an intelligent conception of the relative nutritive values of different foods, so as to be able to supply a well balanced dietary for the different classes of people who are dependent on her very largely to direct what they shall eat. She ought to bear in mind the fact that the chief value of any food lies in its adaptability to repair the waste of tissue that goes on constantly, and endeavor to supply as far as possible the ideal meal, which is one in which nitrogenous, non-nitrogenous and mineral substances are supplied in the proportion required to repair the waste, and with the minimum tax on the digestive powers.

The first qualification really includes three different qualifications—common sense, conscientiousness and justice, for all of which she will have constant need in discharging the duties of her position. Probably in beginning her work she will make mistakes, as every one who accomplishes anything does, but as she buys she will learn to buy, and in no other way. It cannot be learned from books. However, suggestions may be given and accepted that will save the housekeeper from making all the blunders others have made, and save the hospital from the results of total inexperience and lack of knowledge.

The amount of supplies of any kind to be purchased at one time will depend somewhat on the demand, but chiefly on the facilities for storing and preserving them. The perishable articles are always the most important, and also the most expensive, and whenever possible she will find that a substantial sum may be saved each month by making cash payments for these articles as purchased. With adequate cold storage arrangements, a month’s supply can be purchased at one time. Hand to mouth, or day to day buying is poor policy for any hospital, though lack of facilities for proper preservation of food often gives the buyer no other alternative.

Bread

Among the chief staple foods of any institution is bread. While with many in the hospital it is not exactly the “staff of life,” yet it is perhaps the one thing in demand for every meal of the major portion of the household, and fills no small part in the hospital dietary. Various forms of this important article are on the market, differing in the variety and quality of flour used and in the process of manufacture. Three principal varieties ate in common use in this country—the fine-wheat bread, made from the finest or so-called straight-grade flour, the Graham bread, made from flour containing the entire grain of the wheat ground together, and the whole-wheat bread, made from flour containing the whole substance of the grain except the outer layer of bran. From a chemical analysis of the three different varieties, to ascertain the nutritive value and digestibility, it was found that the fine-wheat bread yielded the highest percentage of digestible nutritive food, the whole-wheat ranking second and the Graham bread the last. In providing bread for the household it is well to supply at least two varieties, the fine-wheat as the staple and the whole-wheat and Graham alternating. Another point worth noting, proven by the same chemical analysis, was that the digestibility depended more on the lightness of the bread than on the quality of flour used.

The question as to whether home-baked or baker’s bread is most expensive is often asked, and the answer almost invariably is that bread can be baked in the institution at much less cost than to purchase the ready-made article. The U. S. Department of Agriculture in 1900 published the result of investigation regarding the market value of bread. Their investigation showed that in some places the baker’s price was set by the trade name of the bread, and in others by the size of the loaf, and that the prices varied greatly in different cities.[1] “In New Jersey it appeared that the larger the loaf, the higher the cost per pound tended to rise. In New Brunswick, where fifty analyses were made, the bread containing the highest amount of nutriment, and that containing the lowest, were sold at exactly the same price per pound, 4.1 cents. When the selling price of bread and the cost of its ingredients are compared, the results are still more striking. In two experiments made in New Jersey it was found that two lots of bread made from materials costing respectively $2.28 and $2.56, were sold for $5.68 and $6.08. This represents a profit of 116.5 per cent over the cost of the materials, or to put it in dollars and cents, the baker received $216.50 for bread whose materials cost him $100. In Pittsburg, the average increase in price over the original cost was 110 per cent.”

[1] U. S. Dept. of Agriculture, Office of Experiment Stations, Bulletin 112.

From these experiments it will be seen that a great saving of money can be effected by home baking, even allowing for the extra cost of labor and fuel.

Milk

Another of the important articles of diet, and one that has special value in a hospital, is milk. It is the one article of diet that contains all the essentials for nourishment and because of its perishable character it is the food that usually causes the greatest anxiety to the housekeeper. In order to determine the amount required for each day’s consumption it will be necessary to decide, before ordering, the demands of the bills of fare for the different departments for the coming day. This is essential for even approximate calculation. The constant changing of patients and diets that goes on in a hospital makes a close calculation scarcely possible. The evening of the day before the supply is to be ordered, the head nurse in each section should submit her diet list, showing the number of patients on liquid, semi-solid, light and regular diets. For a patient on an exclusive milk diet, from two to three quarts per day will be needed, the amount being modified by the age, sex and general condition of the patient. Where the liquid diet includes broth and other fluids alternating with milk, two to four pints will be needed. Each patient on a semi-solid diet usually requires nourishment between meals, and as milk enters largely into the composition of the semi-solid diet, about the same amount will be necessary as for liquid diets. For patients on light diet who must have nourishment in some form between meals, a quart is a fair daily allowance, and a pint for those on regular diet and for the household staff.

The quality of milk is a matter of paramount importance. The proportion of fat or cream in milk from the same cow will vary somewhat from day to day, but there is no doubt that the most frequent cause of variation is found in the unscrupulous methods of some dairymen. Three principal methods of adulteration are used: water is added, cream is removed, and certain chemicals are added as preservatives. Whatever form of adulteration is used, the results are bad. Whether water is added or the cream removed, the nutritive value of the milk is lessened. The injurious effects of chemically preserved milk depend, of course, on the amount consumed by one person. The drugs most frequently used as preservatives are boracic acid, borax, salicylic acid and formaldehyde. Where a life is in the balance, and milk diet is depended on to maintain the vitality, these adulterations are of tremendous importance. No housekeeper can afford to patronize a dairyman where there is a suspicion of these methods being practiced. Laws regarding adulteration exist in many places, but are not always enforced. But pure milk can be produced, and if the consumer insists on having it, and takes pains to find out at intervals the facts regarding its purity, the milk dealer will arrange to supply the genuine article. In purchasing from any dealer it is a safeguard to have the milk examined periodically by an expert chemist. Then the housekeeper may know for a certainty what she is getting. Milk which contains sediment is always suspicious. In preparing a specimen for analysis care should be taken that it is a fair sample. Milk from the top or bottom of a bottle should not be used. If the milk to be tested is poured several times from one vessel to another until no particles of cream appear on the surface, the sample may be considered to be a fair specimen of the composition of the whole.

The method of computing the value of milk used by creamery experts is on the basis of the amount of fat contained. If this basis were the general standard, not only hospitals but all consumers would be the gainers. While the actual food value of milk does not entirely depend on the amount of fat, yet the buyer would have the satisfaction of getting what he paid for, and the dealer the increased return for supplying a better grade article. The milk containing less fat could be secured for cooking and that richer in cream for special purposes, and the whole transaction would be fairer than the present system, where a quart of adulterated and skimmed milk sells for the same money as the genuine product.

Skimmed milk and buttermilk both have their value as nutriment, and experts say that even after cream has been removed the skimmed milk still contains nearly ten per cent of its nutritive properties. Buttermilk is often more acceptable to patients than sweet milk, and, if it can be obtained fresh every day, it can be used occasionally to add variety to a strictly milk or liquid diet. It is said that six ounces of buttermilk has in it the same amount of nutrition as a medium-sized potato.[2] “Actual experiment has demonstrated that a fifteen-cent lunch containing nine different food materials (soup, beef, potatoes, turnips, bread, butter, coffee, milk, sugar), did not have any greater nutritive value than a four-cent lunch consisting of a pint of skimmed milk and ten ounces of bread.”

[2] U. S. Department of Agriculture, Bulletin 74.

In ordering milk it is better to get too much than too little. The excess can always be used in food combinations, and at the prices ordinarily paid it is not an expensive food. Because of the ease with which it is digested by the average person, and its nutritive properties, it can be served in almost a numberless variety of forms to sick people, and often in preference to other foods.

Care of Milk

Assuming that it is possible for dealers to supply pure milk, and that the housekeeper knows whether or not she is getting the genuine article for her sick family, there is still something required, if it is to reach the patients in good condition. Be the article never so pure when delivered, it can quickly become impure by careless handling. The milk delivered at a very early hour may be left at the door where it is exposed to heat, dust and flies, and by the time it is taken into the house impurities may have entered that will account for it becoming sour in a few hours. Another source of contamination can be traced to the practice of putting milk in open vessels into the same refrigerator with meats and vegetables. Old tin or wooden vessels should never be used, and vessels should be thoroughly scalded and scrupulously clean before the milk is put in. If the racks and shelves in the cooling room are scrubbed daily, also the inside of the milk refrigerator, and a temperature of 50 F. or lower maintained, there should be no difficulty in keeping milk sweet twenty-hour hours or longer.

Milk delivered in bottles which have been previously sterilized will be found more satisfactory than that which has been carried in large cans and dipped from vessel to vessel. Each time it is handled the contents of these cans are exposed to floating dust, and the time the milk will remain sweet is shortened. The bottles in which milk is served should be carefully cleaned as soon as emptied, and in warm weather milk should never be left without ice. The careless habit that exists in some kitchens of allowing the milk to stand in a heated room for an hour or more because every one is otherwise employed, should never be tolerated in a hospital.

Another point in handling may be worth mentioning; milk or cream intended for the sick may be consumed by kitchen employees, and in spite of the housekeeper’s plans the supply may become exhausted before the new supply is available. This often occurs at night, when it is impossible to replenish the quantity from any source. All calculations as to the amount per capita required will be valueless if servants are allowed to consume it at will. If milk is to be allowed to them as a beverage, then a much larger amount should be ordered.

Cheese

Cheese, which is a concentrated form of milk, while rich in nutrition, is somewhat difficult of digestion, and if bought at all for hospital patients should be purchased sparingly and served in very small portions. Like milk, it needs to be kept cool and entirely separate from fruits, vegetables and meats.

Eggs

Eggs are another of the valuable tissue-building foods in constant demand in hospitals. For fully eight months of the year they can be bought at moderate prices, and considering their great nutritive value are not an expensive form of food. Because of the ease with which they are digested by most invalids, and the great variety of ways in which they may be served, they fill a very important place in the hospital menu. It is said that there are more than five hundred different ways of preparing eggs. The purchase of them is, however, attended with some uncertainty. Many tests for detecting the quality are in use by experts. The “candling” test consists in holding the egg against a light between the eye and the sun. The perfectly fresh, good egg will appear clear and unclouded and the yolk can be perceived. If decomposition has begun, it will appear dark colored. Changes in the appearance of the shell as shown by comparison of fresh and stale eggs are sometimes helps in detecting the quality.

Where a hospital has an adequate cooling space, undoubtedly the more economical method of buying is by the crate and in sufficient quantity to last several months. Some institutions lay in a year’s stock, buying always in April, which, it is stated, is the only month in which it is wise to buy eggs for storage. In a cooling room in which the atmosphere is sweet and pure, a temperature of 34 F. will preserve eggs for a year with very little appreciable change in quality.

Even when the price of eggs is from twenty-five to thirty cents a dozen, they are not more expensive than many other forms of animal food—notably beefsteak—and when served in the form of omelettes, scrambled or creamed eggs where other substances are added to compose the dish their cost in a meal is less than steak.

Economy and Care

In arranging a hospital dietary the comparative cost of food should always be borne in mind, and where food of cheaper material supplies the place of the more costly, the cheaper should have the preference. If, when eggs are high-priced, the housekeeper could arrange to economize in their use in desserts and cake rather than in their use as meat substances, it will be in the long run the more sensible plan. However, desserts in a hospital and desserts in a home are two different things. The so-called dessert in a hospital often forms the meal for the patient with weakened digestive powers, and in such cases eggs must be used, be the price high or low. For the healthier members of the hospital family, fruits and desserts made without eggs can be depended on to take the place of desserts requiring eggs when the latter are expensive. In storing eggs, the housekeeper should remember that the shell of an egg is not impervious, and if placed long in contact with apples, onions or other substances of decided flavor the odor can be detected in the egg when cooked. Another point to be remembered is that an egg kept in a refrigerator will take longer to boil than if kept in a room at the ordinary temperature. When dealing with impaired appetites and weakened digestive powers these so-called minor points have special importance.

Meat

Meat is the most expensive article of food in a hospital, and for this reason the art of buying requires real study. The flesh of animals seems to be especially adapted to contribute to the building up and maintenance of the organic structure of the human system, but owing to the absence of starch is not to be depended on to produce force or energy. Meats are generally believed to be easier of digestion than vegetable foods. The chemical ingredients are much like the various substances of the human system, and are therefore more quickly acted upon and made ready for absorption. A certain woody fibre often surrounds the nutritive ingredient of the vegetable and renders it more resistive to the action of digestive fluids.

Beef

Beef is believed to be the most nutritious of all animal foods, and that which seems to be most in demand in a hospital. It is a meat in which quality varies greatly, and much care needs to be used in its selection. The age of the animal, the method used in feeding it, the condition when slaughtered, and the length of time since slaughtering took place, all affect the quality and flavor. The flesh of a young animal is more tender, but lacks the flavor found in the flesh of older animals. A larger relative proportion of bone is found also in younger animals. The best beef is usually obtained from animals of from three to six years of age. When the cooling facilities are adequate, at least a side of beef should be purchased at one time. Most meats improve by being kept a reasonable length of time. In a hospital the various parts, even much of the so-called refuse of the butchers, can be utilized where several classes of diets have to be arranged daily, and a great saving of money effected by buying in quantity. This will be clearly shown by comparison if each part has to be bargained for separately. In order to guard against waste and use the meat to the best advantage, some system and skill in cutting will be needed. The accompanying diagram shows the different cuts into which the side may be divided, providing the largest amount of good cuts and with the least refuse. A good quality of beef from an animal three or four years old should show elasticity on being pressed with the finger; it should have a fair sprinkling of creamy-looking fat, the lean portion should be a deep red and of a rather fine fibre. Coarse fibre usually means poor flavor. Tough beef is usually darker in color, the proportion of fat will be less, the fat instead of being a creamy white will be a decided yellow and the fibre coarse.

Veal

Veal may be occasionally added to the hospital menu for variety, but because of the excessive proportion of bone it is not considered an economical meat to be used in any quantity. It is also believed to be more difficult of digestion than most other meats.

Mutton will perhaps rank next to beef for hospital uses, and like beef it differs greatly in quality. The fibre is shorter and more tender, and the color of both the lean and fat of mutton somewhat darker than that of beef. Good mutton should have a sprinkling of fat, but excess of fat should be guarded against. An entire carcass should be purchased at one time, cutting it as required.

Chickens

In selecting chickens for the hospital, both young and old fowls will be needed. For broths and jelly an old fowl, not too fat, is preferable. Where the meat of the chicken is the substance wanted, a fowl of from one to two years old should be purchased. The proportion of bone to meat in chickens under that age makes them quite an expensive commodity. To ascertain if the meat is tender try the skin under the wing or leg. If the joint of the wing yields readily or breaks it is tender.

Fish

Fish help to supply the demand for variety in the diet, which is more important in dealing with the capricious appetites of invalids than with those in health. The different varieties vary greatly in nutritive value, in flavor, and also in digestibility, owing largely to the proportion of fat. The amount of bone in proportion to the meat in most ordinary fresh fish makes them a trifle more expensive than most meats, steak and fowl being excepted. Because of their strong odor, which would require for them an entirely separate storage receptacle, it is better to buy them each day as needed. Salmon is considered more rich in nutrition than most other varieties of fish, and the oily or coarser grained species more nutritious than the white or finer grained, although the latter have the more delicate flavor and are easier of digestion. In choosing the fish, if the gills are a bright, clear red, the body firm and stiff, the odor not disagreeable, the fish may be accepted as in good condition.

Pork

Pork will occasionally have to be purchased, even in a hospital. In spite of the fact that it is more difficult of digestion than many other forms of animal food, and of the adverse criticisms heaped upon it, most people in their secret heart (or stomach) are fond of a bit of good ham. Ham and bacon are more suitable for use in a hospital than fresh pork. The lean of ham should be a deep pink, and excess of fat should be avoided. Bacon should be quite thoroughly mottled with both fat and lean. Care should be taken that the ham and bacon have been cured and prepared for market by a reliable firm, and that they are protected from dust and kept in a cool place.

Butter

Butter is perhaps the most digestible of all animal fats, and the most delicately flavored. So many substitutes for the genuine article are now on the market that it needs to be selected with great care. Fat being one of the elements of food depended on for the production of heat and energy in the body, butter has a place of some importance in the average invalid’s diet. For use on the tables and trays, a good quality should be procured and a cheaper grade secured for use in cooking.

Potatoes, the most important of all vegetables for table use, should be purchased in quantity in the fall when the price is lowest and stored in a cool, dark, dry place.

Fresh Vegetables

Green vegetables will, of course, be secured as needed. When fresh there is a crispness about them that is not found in those picked longer. Lack of crispness usually means lack of flavor. All vegetables will be improved by soaking in cold water before being cooked.

Cereals, sugar, and in fact the whole list of dry food products, and canned goods, are a matter of much less anxiety to the hospital housekeeper than the perishable commodities. On general principles, buying in sufficient quantity to secure wholesale rates is the only sensible method. But, as has been previously remarked, the construction of the hospital modifies all plans for housekeeping. Lack of storage facilities make it impossible for many housekeepers to buy wisely or economically. Mistaken ideas of economy in construction often mean increased and unnecessary expense as long as the hospital exists. Where economical housekeeping is expected, arrangements should be made in every hospital for sufficient cold storage facilities, at least for the storing of meats, which usually form the largest item in the monthly accounts.

Approximate Estimate of Quantities of Food for a
25-bed Hospital, a 50-bed Hospital and a
Hospital of 100 Beds.

This is taken from a month’s experience with the average
number of acute cases and convalescents in a hospital
with an active surgical service.

BREAKFAST.

DINNER.

SUPPER.

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.