Notes on Nursing: What It Is, and What It Is Not/Chapter VII

by Florence Nightingale

VII. WHAT FOOD?

I will mention one or two of the most common errors among women in charge of sick respecting sick diet. One is the belief that beef tea is the most nutritive of all articles. Now, just try and boil down a lb. of beef into beef tea, evaporate your beef tea, and see what is left of your beef. You will find that there is barely a teaspoonful of solid nourishment to half a pint of water in beef tea; — nevertheless there is a certain reparative quality in it, we do not know what, as there is in tea; — but it may safely be given in almost any inflammatory disease, and is as little to be depended upon with the healthy or convalescent where much nourishment is required. Again, it is an ever ready saw that an egg is equivalent to a lb. of meat, — whereas it is not at all so. Also, it is seldom noticed with how many patients, particularly of nervous or bilious temperament, eggs disagree. All puddings made with eggs, are distasteful to them in consequence. An egg whipped up with wine, is often the only form in which they can take this kind of nourishment. Again, if the patient has attained to eating meat, it is supposed that to give him meat is the only thing needful for his recovery; whereas scorbutic sores have been actually known to appear among sick persons living in the midst of plenty in England, which could be traced to no other source than this, viz.: that the nurse, depending on meat alone, had allowed the patient to be without vegetables for a considerable time, these latter being so badly cooked that he always left them untouched. Arrowroot is another grand dependence of the nurse. As a vehicle for wine, and as a restorative quickly prepared, it is all very well. But it is nothing but starch and water. Flour is both more nutritive, and less liable to ferment, and is preferable wherever it can be used.

Again, milk and the preparations from milk, are a most important article of food for the sick. Butter is the lightest kind of animal fat, and though it wants the sugar and some of the other elements which there are in milk, yet it is most valuable both in itself and in enabling the patient to eat more bread. Flour, oats, groats, barley, and their kind, are, as we have already said, preferable in all their preparations to all the preparations of arrowroot, sago, tapioca, and their kind. Cream, in many long chronic diseases, is quite irreplaceable by any other article whatever. It seems to act in the same manner as beef tea, and to most it is much easier of digestion than milk. In fact, it seldom disagrees. Cheese is not usually digestible by the sick, but it is pure nourishment for repairing waste; and I have seen sick, and not a few either, whose craving for cheese shewed how much it was needed by them.^[1]

But, if fresh milk is so valuable a food for the sick, the least change or sourness in it, makes it of all articles, perhaps, the most injurious; diarrhœa is a common result of fresh milk allowed to become at all sour. The nurse therefore ought to exercise her utmost care in this. In large institutions for the sick, even the poorest, the utmost care is exercised. Wenham Lake ice is used for this express purpose every summer, while the private patient, perhaps, never tastes a drop of milk that is not sour, all through the hot weather, so little does the private nurse understand the necessity of such care. Yet, if you consider that the only drop of real nourishment in your patient's tea is the drop of milk, and how much almost all English patients depend upon their tea, you will see the great importance of not depriving your patient of this drop of milk. Buttermilk, a totally different thing, is often very useful, especially in fevers.

In laying down rules of diet, by the amounts of "solid nutriment" in different kinds of food, it is constantly lost sight of what the patient requires to repair his waste, what he can take and what he can't. You cannot diet a patient from a book, you cannot make up the human body as you would make up a prescription, — so many parts "carboniferous," so many parts "nitrogenous" will constitute a perfect diet for the patient. The nurse's observation here will materially assist the doctor — the patient's "fancies" will materially assist the nurse. For instance, sugar is one of the most nutritive of all articles, being pure carbon, and is particularly recommended in some books. But the vast majority of all patients in England, young and old, male and female, rich and poor, hospital and private, dislike sweet things, — and while I have never known a person take to sweets when he was ill who disliked them when he was well, I have known many fond of them when in health, who in sickness would leave off any thing sweet, even to sugar in tea, — sweet puddings, sweet drinks, are their aversion; the furred tongue almost always likes what is sharp or pungent. Scorbutic patients are an exception, they often crave for sweetmeats and jams.

Jelly is another article of diet in great favor with nurses and friends of the sick; even if it could be eaten solid, it would not nourish, but it is simply the height of folly to take ¹⁄₈ oz. of gelatine and make it into a certain bulk by dissolving it in water and then to give it to the sick, as if the mere bulk represented nourishment. It is now known that jelly does not nourish, that it has a tendency to produce diarrhœa, — and to trust to it to repair the waste of a diseased constitution is simply to starve the sick under the guise of feeding them. If 100 spoonfuls of jelly were given in the course of the day, you would have given one spoonful of gelatine, which spoonful has no nutritive power whatever.

And, nevertheless, gelatine contains a large quantity of nitrogen, which is one of the most powerful elements in nutrition; on the other hand, beef tea may be chosen as an illustration of great nutrient power in sickness, coexisting with a very small amount of solid nitrogenous matter.

Dr. Christison says that "every one will be struck with the readiness with which" certain classes of "patients will often take diluted meat juice or beef tea repeatedly, when they refuse all other kinds of food." This is particularly remarkable in "cases of gastric fever, in which," he says, "little or nothing else besides beef tea or diluted meat juice" has been taken for weeks or even months, "and yet a pint of beef tea contains scarcely ¹⁄₄ oz. of anything but water," — the result is so striking that he asks what is its mode of action? "Not simply nutrient — ¹⁄₄ oz. of the most nutritive material cannot nearly replace the daily wear and tear of the tissues in any circumstances. Possibly," he says, "it belongs to a new denomination of remedies."

It has been observed that a small quantity of beef tea added to other articles of nutrition augments their power out of all proportion to the additional amount of solid matter.

The reason why jelly should be innutritious and beef tea nutritious to the sick, is a secret yet undiscovered, but it clearly shows that careful observation of the sick is the only clue to the best dietary.

Chemistry has as yet afforded little insight into the dieting of sick. All that chemistry can tell us is the amount of "carboniferous" or "nitrogenous" elements discoverable in different dietetic articles. It has given us lists of dietetic substances, arranged in the order of their richness in one or other of these principles; but that is all. In the great majority of cases, the stomach of the patient is guided by other principles of selection than merely the amount of carbon or nitrogen in the diet. No doubt, in this as in other things, nature has very definite rules for her guidance, but these rules can only be ascertained by the most careful observation at the bed-side. She there teaches us that living chemistry, the chemistry of reparation, is something different from the chemistry of the laboratory. Organic chemistry is useful, as all knowledge is, when we come face to face with nature; but it by no means follows that we should learn in the laboratory any one of the reparative processes going on in disease.

Again, the nutritive power of milk and of the preparations from milk, is very much undervalued; there is nearly as much nourishment in half a pint of milk as there is in a quarter of a lb. of meat. But this is not the whole question or nearly the whole. The main question is what the patient's stomach can assimilate or derive nourishment from, and of this the patient's stomach is the sole judge. Chemistry cannot tell this. The patient's stomach must be its own chemist. The diet which will keep the healthy man healthy, will kill the sick one. The same beef which is the most nutritive of all meat which nourishes the healthy man, is the least nourishing of all food to the sick man, whose half-dead stomach can assimilate no part of it, that is, make no food out of it. On a diet of beef tea healthy men on the other hand speedily lose their strength.

I have known patients live for many months without touching bread, because they could not eat baker's bread. These were mostly country patients, but not all. Homemade bread or brown bread is a most important article of diet for many patients. The use of aperients may be entirely superseded by it. Oat cake is another.

To watch for the opinions, then, which the patient's stomach gives, rather than to read "analyses of foods," is the business of all those who have to settle what the patient is to eat — perhaps the most important thing to be provided for him after the air he is to breathe.

Now the medical man who sees the patient only once a day or even only once or twice a week, cannot possibly tell this without the assistance of the patient himself, or of those who are in constant observation on the patient. The utmost the medical man can tell is whether the patient is weaker or stronger at this visit than he was at the last visit. I should therefore say, that incomparably the most important office of the nurse, after she has taken care of the patient's air, is to take care to observe the effect of his food, and report it to the medical attendant.

It is quite incalculable the good that would certainly come from such sound and close observation in this almost neglected branch of nursing, or the help it would give to the medical man.

A great deal too much against tea^[2] is said by wise people, and a great deal too much of tea is given to the sick by foolish people. When you see the natural and almost universal craving in English sick for their "tea," you cannot but feel that nature knows what she is about. But a little tea or coffee restores them quite as much as a great deal, and a great deal of tea and especially of coffee impairs the little power of digestion they have. Yet a nurse, because she sees how one or two cups of tea or coffee restores her patient, thinks that three or four cups will do twice as much. This is not the case at all; it is however certain that there is nothing yet discovered which is a substitute to the English patient for his cup of tea; he can take it when he can take nothing else, and he often can't take anything else if he has it not. I should be very glad if any of the abusers of tea would point out what to give to an English patient after a sleepless night, instead of tea. If you give it at five or six o'clock in the morning, he may even sometimes fall asleep after it, and get perhaps his only two or three hours' sleep during the twenty-four. At the same time you never should give tea or coffee to the sick, as a rule, after five o'clock in the afternoon. Sleeplessness in the early night is from excitement generally and is increased by tea or coffee; sleeplessness which continues to the early morning is from exhaustion often, and is relieved by tea. The only English patients I have ever known refuse tea, have been typhus cases, and the first sign of their getting better was their craving again for tea. In general, the dry and dirty tongue always prefers tea to coffee, and will quite decline milk, unless with tea. Coffee is a better restorative than tea, but a greater impairer of the digestion. Let the patient's taste decide. You will say that, in cases of great thirst, the patient's craving decides that it will drink a great deal of tea, and that you cannot help it. But in these cases be sure that the patient requires diluents for quite other purposes than quenching the thirst; he wants a great deal of some drink, not only of tea, and the doctor will order what he is to have, barley water or lemonade, or soda water and milk, as the case may be.

Lehman, quoted by Dr. Christison, says that, among the well and active "the infusion of 1 oz. of roasted coffee daily will diminish the waste" going on in the body "by one-fourth," and Dr. Christison adds that tea has the same property. Now this is actual experiment. Lehman weighs the man and finds the fact from his weight. It is not deduced from any "analysis" of food. All experience among the sick shows the same thing.^[3]

Cocoa is often recommended to the sick in lieu of tea or coffee. But independently of the fact that English sick very generally dislike cocoa, it has quite a different effect from tea or coffee. It is an oily starchy nut having no restorative power at all, but simply increasing fat. It is pure mockery of the sick, therefore, to call it a substitute for tea. For any renovating stimulus it has, you might just as well offer them chestnuts instead of tea.

An almost universal error among nurses is in the bulk of the food and especially the drinks they offer to their patients. Suppose a patient ordered 4 oz. brandy during the day, how is he to take this if you make it into four pints with diluting it? The same with tea and beef tea, with arrowroot, milk, &c. You have not increased the nourishment, you have not increased the renovating power of these articles, by increasing their bulk, — you have very likely diminished both by giving the patient's digestion more to do, and most likely of all, the patient will leave half of what he has been ordered to take, because he cannot swallow the bulk with which you have been pleased to invest it. It requires very nice observation and care (and meets with hardly any) to determine what will not be too thick or strong for the patient to take, while giving him no more than the bulk which he is able to swallow.

1. In the diseases produced by bad food, such as scorbutic dysentery and diarrhœa, the patient's stomach often craves for and digests things, some of which certainly would be laid down in no dietary that ever was invented for sick, and especially not for such sick. There are fruit, pickles, jams, gingerbread, fat of ham or bacon, suet, cheese, butter, milk. These cases I have seen not by ones, nor by tens, but by hundreds. And the patient's stomach was right and the book was wrong. The articles craved for, in these cases, might have been principally arranged under the two heads of fat and vegetable acids.
   There is often a marked difference between men and women in this matter of sick feeding. Women's digestion is generally slower.
2. It is made a frequent recommendation to persons about to incur great exhaustion, either from the nature of the service, or from their being not in a state fit for it, to eat a piece of bread before they go. I wish the recommenders would themselves try the experiment of substituting a piece of bread for a cup of tea or coffee, or beef tea, as a refresher. They would find it a very poor comfort. When soldiers have to set out fasting on fatiguing duty, when nurses have to go fasting in to their patients, it is a hot restorative they want, and ought to have, before they go, not a cold bit of bread. And dreadful have been the consequences of neglecting this. If they can take a bit of bread with the hot cup of tea, so much the better, but not instead of it. The fact that there is more nourishment in bread than in almost anything else, has probably induced the mistake. That it is a fatal mistake, there is no doubt. It seems, though very little is known on the subject, that what "assimilates" itself directly, and with the least trouble of digestion with the human body, is the best for the above circumstances. Bread requires two or three processes of assimilation, before it becomes like the human body.
   The almost universal testimony of English men and women who have undergone great fatigue, such as riding long journeys without stopping, or sitting up for several nights in succession, is that they could do it best upon an occasional cup of tea—and nothing else.
   Let experience, not theory, decide upon this as upon all other things.
3. In making coffee, it is absolutely necessary to buy it in the berry and grind it at home. Otherwise you may reckon upon its containing a certain amount of chiccory, at least. This is not a question of the taste or the wholesomeness of chiccory. It is that chiccory has nothing at all of the properties for which you give coffee. And therefore you may as well not give it.
   Again, all laundresses, mistresses of dairy-farms, head nurses, (I speak of the good old sort only — women who mite a good deal of hard manual labor with the head-work necessary for arranging the day's business, so that none of it shall tread upon the heels of something else,) set great value, I have observed, upon having a high-priced tea. This is called extravagant. But these women are "extravagant" in nothing else. And they are right in this. Real tea-leaf tea alone contains the restorative they want; which is not to be found in sloe-leaf tea.
   The mistresses of houses, who cannot even go over their own house once a day, are incapable of judging for these women. For they are incapable themselves, to all appearance, of the spirit of arrangement (no small task) necessary for managing a large ward or dairy.