PROTEIN REQUIREMENTS

Sleeping quietly60-70 calories per hourAwake, lying still70-85 calories per hourSitting at rest100 calories per hourStanding at rest115 calories per hourTailoring135 calories per hourTypewriting rapidly140 calories per hour“Light exercise” (stationary bicycle)170 calories per hourShoemaking180 calories per hourWalking slowly (about 2¼ miles an hour)200 calories per hourCarpentry or metal work240 calories per hour“Active exercise” (stationary bicycle)290 calories per hourWalking briskly (about 3¾ miles an hour)300 calories per hourStone working400 calories per hourSevere exercise, such as sawing wood450 calories per hourRunning (about 5½ miles an hour)500 calories per hourVery severe exercise (stationary bicycle)600 calories per hour

The above table, calculated for an average man weighing 154 pounds, may seem less simple to use than one based on the energy requirements per pound of body weight per hour, of an average individual. For example, a man weighing 123 pounds and performing practically the same amount and type of work as done by the man weighing 154 pounds would require practically one-fifth less calories than the latter individual. Hence, to facilitate the estimation of the food requirements for average individuals, the following table is included.[22]

Sleeping0.42 calorie per hour, per lb. of body wt.Sitting at rest0.65 calorie per hour, per lb. of body wt.Light muscular exercise1.10 calories per hour, per lb. of body wt.Active muscular exercise1.90 calories per hour, per lb. of body wt.Severe muscular exercise3.00 calories per hour, per lb. of body wt.

Possibly a few explanatory words, as to the terms used in the above tables, will assist the nurse in making the necessary calculation. “Sleeping quietly” makes allowance for no movement save that of respiration; any undue restlessness will call for an increase in the above allowance.

“Sitting at rest” includes the time spent at meals, sitting in class room, ward office, studying or reading. It does not include much walking about the room, rising frequently, or nervous restlessness.

“Light exercise” includes all light house work, running an ordinary sewing machine, walking about office or ward, (receiving ward included). It does not include washing, sweeping or scrubbing.

“Active exercise” includes washing, sweeping, scrubbing, general house work, carpentry, and such sports as tennis, basket ball, and ordinary gymnasium work.

“Severe exercise” includes road workers (working with pick and shovel) fast running, baseball, football, and swimming.

“Very severe exercise” includes the work done by miners, handling of freight, and lumbermen, especially those working in extreme cold, where the severe cold makes extra demands on the fuel supply. By making use of the averages just mentioned it should be a simple matter to calculate the food requirements of any normal individual. It is necessary to know the weight of the person in question, and the manner in which the twenty-four hours are spent, and, in the case of elderly individuals, make the reductions believed to be necessary for health.

Method of Using the Tables.—Let us take a nurse in training for this purpose. Suppose the nurse weighs 110 pounds, and spends the twenty-four hours as follows,

Sleeping8 hoursSitting at meals2 hoursStudying2 hoursIn class1 hourOn duty9 hoursOff duty (walking briskly)2 hours

Her daily food requirements would probably be approximately 2,235 calories. This estimate would be increased,if she were obliged to do much heavy lifting, scrubbing of beds, or other duties requiring the expenditure of much effort. It would be decreased if the hours spent in study and class room work were increased and the hours on the ward shortened. The estimation may be made as follows,

Sleeping 8 hrs.110 × 0.42 × 8=370.0caloriesSitting at meals 2 hrs.110 × 0.65 × 2=143.0caloriesSitting in class 1 hr.110 × 0.65 × 1=71.5 caloriesStudying, 2 hrs.110 × 0.65 × 2=143.0caloriesOn duty 9 hrs.110 × 1.10 × 9=1089.0caloriesOff duty (walking briskly) 2 hrs.110 × 1.90 × 2=418.0caloriesTotal for day2234.5 calories

This estimate may be made to suit any individual, the man in the office or the one working on the streets, the woman living at home or the one spending eight or ten hours scrubbing the floors of a great office building; it is simply a matter of adjusting the calories in the dietary to meet the requirements of body weight and muscular activity.

Energy Requirements for Children.—In estimating the energy needs of children, the above method is not satisfactory, since the storage of material for growth must be considered, as well as the activities of the body. The growth period includes the years from birth to the eighteenth year, after which time the food requirements of the body are made on a basis of weight and muscular activity, as in all adults. The table on the following page shows the food allowances made for healthy children; in the feeding of malnourished or underweight children, more food in proportion to age is given in order to overcome the handicap under which they are suffering.

AgeCalories per DayYearsBoysGirlsUnder 2900-1200900-12002-31000-1300980-12803-41100-14001060-13604-51200-15001140-14405-61300-16001220-15206-71400-17001300-16007-81500-18001380-16808-91600-19001460-17609-101700-20001550-185010-111900-22001650-195011-122100-24001750-205012-132300-27001850-215013-142500-29001950-225014-152600-31002050-235015-162700-33002150-245016-172700-34002250-2500

YearsCalories per pound, per dayUnder 1 year451-240-433-437-404-537-405-635-376-734-357-832-348-930-359-1030-3510-1128-3211-1228-3212-1328-3213-1425-3014-1520-2515-1620-2516-1720-25

After which time the food requirements are based on degree of muscular activity, boys and girls of seventeen years and over requiring as much food as men and women.

Children, like adults, differ in degrees of activity; that is, one child may be very active, running and playing more strenuously than another. Hence a margin of safety mustbe allowed to cover the energy expenditures of the more active child, to safeguard it against becoming malnourished.

To facilitate the computation of the food requirements of children a schedule showing the number of calories per pound of body per day is included on opposite page.

The food requirements are such as to allow of a steady increase in the weight and stature of the child; the rate of gain for normal children should be as follows:

Age BoysAverage gain, OuncesAge GirlsAverage gain, OuncesFirst year3½-4½First year3½-4½Second year2½-3Second year2½-3Third year1¾-2Third year1¾-2Fourth to eighth year (inclusive)1¼-1½Fourth to eighth year (inclusive)1¼-1½Ninth to eleventh year (inclusive)1¾-2Ninth to twelfth year (inclusive)1¾-2¼Twelfth to thirteenth year (inclusive)2¾-3Thirteenth to fifteenth year (inclusive)2¾-3¼Fourteenth to sixteenth year (inclusive)3-4Sixteenth and seventeenth year (inclusive)1-2

The averages just given are for healthy children; those who are underweight for their age and height should show a more rapid increase in weight with an increased food allowance. It must also be remembered that a simple gain in weight is not sufficient evidence of a child’s normality; a freedom from gastro-intestinal disturbances, and a resistance to disease, are equally essential.

There have been tables arranged to show the proper weight for height for boys and girls of different ages (seeappendix). These are valuable since, by their use, attention is called to the child who is not up to the average. Medical examination of such children frequently shows reasonfor their underweight, and measures may be instituted which may save the child from a lifetime of poor health.

Dr. Pirquet has arranged a scale (Pelidisi Chart) showing the state of nutrition in children, based upon the sitting height (in centimeters), to weight (in kilograms). Seeappendix.

There is never a period in life in which protein is not needed. During the early years it is essential that the proteins, or at least a goodly portion of them, be obtained from animal sources, milk and eggs in particular; when cereals and legumes (beans and peas) are used to provide for the protein requirements, they must be supplemented by milk or eggs (or both), in order that the growth and development of the child may proceed at a normal rate.

Adults require protein for the repair of old tissues and to furnish material for the building of new cells, and again it is believed advisable to have at least a portion of this protein from animal sources, milk, meat or eggs.

Just as energy foods and proteins must be adjusted in the dietary to safeguard the health of the body, so the mineral salts must be adjusted for a like purpose. Studies made of the dietaries of a number of families brought to light the fact that the children more often suffered from a deficiency of calcium, phosphorus and iron in their diets than they did from too little protein,[25]proving that it is quite as essential to adjust the mineral salts in the diet as it is that of the organic constituents.

According to Sherman the diet of an adult should contain each day per pound of body weight:

Protein0.5000gram or morePhosphorus0.0100gram or moreCalcium0.0050gram or moreIron0.0001 gram or more

These averages, while covering the needs of the mature body, do not furnish the necessary amount of protein, or mineral salts to support the growth and development of the child. Hence, it has been deemed advisable to reckon the requirements of the latter per thousand calories, instead of per pound of body weight, in this way obviating some of the danger of protein and mineral deficiencies.

McCollum, Simmonds and Pitz have shown that a deficiency in the inorganic content of a diet may result in a retarding or suspension of growth. This result has been overcome on the introduction of the proper mineral salts into the diet. This salt mixture is such as to make the total ash, approximate that found in the composition of milk ash.

The following diagram illustrates this point.

Showing normal increasing weight gain, compared to, in period I, a deficiency leading to no weight gain, and in period II, salt mixture leading to an increasing weight gain

Effect upon growth of adding to a diet otherwise adequate a salt mixture of such composition as to make the composition of the total ash similar to that of milk ash; immediate resumption after entire suspension of growth. Courtesy of Dr. E. V. McCollum.

The following outline will serve as a guide in making the estimates for the food requirements of children:

Protein25.000grams or morePhosphorus00.480gram or moreCalcium00.250gram or moreIron00.005 gram or more

Vitamine Needs.—We have seen the manner in which the energy and protein foods have been adjusted in the diet, but these can not alone assure the body, and especially the growing body of a normal maintenance and repair of its tissue, or support the growth which is essential at this time. This function is believed to belong to the vitamines, since feeding experiments have demonstrated the fact that animals soon cease to grow, develop deficiency diseases, and finally die, when deprived of the essential constituents. Gillett advises, as a safe rule, the use of one, and preferably two foods known to be rich in the fat soluble vitamine, in each day’s food allowance, milk and leafy vegetables, for example. If the foods containing phosphorus, calcium, and iron are taken in sufficient quantity, the second, or “B” vitamine needs, will probably be adequately covered, but the presence of the “C” vitamine must be carefully attended to; some fresh fruit or vegetables (see table) is obligatory each day to insure the individual against the development of scurvy.

Factors Affecting the Food Selection.—The estimation of the energy needs of the body, and the selection of the foods to furnish the fuel for this purpose, depend largely upon the individual. The digestion of the fats, as well as the way in which the body utilizes them, makes the use of this foodstuff more or less limited according to the ability of the individual to take care of them, the minimumallowance for children being between 2 and 3 ounces per day. According to Gillett, “If boys and girls get at least this amount from butter and its substitutes, cream, bacon, fat meat and oils, additional amounts from their food will provide a margin of safety, without overtaxing the digestive system.”

After determining the amount of fat required in each day’s food allowance, it is a simple matter to adjust the carbohydrates. It is safer from a health standpoint, to obtain the greater portion of this foodstuff from starchy foods rather than from the sugars, many foods rich in starch, likewise contain appreciable amounts of protein and fat, whereas sugar is practically one hundred per cent. carbohydrate. The ease, too, with which this substance ferments in the stomach, and the manner in which it destroys the appetite for other foods, makes the use of much of it in concentrated form unadvisable, especially in the diet of children.

The amount of sugar allowed each day, should be limited to an ounce or ounce and a half (2 to 3 tablespoonfuls), and a less quantity is desirable. In order to obtain the best results, with the least deleterious effect on the body, it is advisable to give sugar in dilute form. A piece of pure candy after a meal may not harm the child; but just before, or between meals, as well as the habit of making the breakfast cocoa and cereal of syrup-like sweetness is deplorable, and should in all instances be discouraged.

The American Red Cross recommends the following method for estimating the amount of sugar in the dietary: “Add one-half the weight of such foods as jellies, jams and preserves, and three-quarters the weight of such foods as candy, honey and syrup, to the weight of sugar used.” The amount of sugar consumed, as such, by the adult each day, is not of such paramount importance as it is in thecase of children, but even for adults an excessive amount of carbohydrate in this form is not considered advisable from a health standpoint.

In order to assure each member of the family of getting all of the materials needed for the growth, repair and regulation of their bodies, as well as the necessary fuel material with which to run the engine and to maintain the proper body temperature, the following practical method is suggested for the planning of the daily dietary.

1. Milk:

One quart for each child under two years of age. From 1 pint to 1 quart for each child from two to five years of age. (M. S. Rose of Teachers’ College advises at least a quart for every child of six years and under, at least 1 pint for children from six to sixteen, and one half of a pint thereafter.)

2. Cereals and Breadstuffs:

(Activity of person determining the amount.)For children under two years of age1-3 oz. a dayFor children from two to five years2-5 oz. a dayFor children from five to twelve years5-9 oz. a dayFor all over twelve years of age9-16 oz. a day

(Activity of person determining the amount.)

3. Meat or its Substitute:

For children under five years no meat is needed.(a) Meat:For children from five to ten years1-2 oz. (no more) a dayFor children from ten to fourteen years2-4 oz. (no more) a day of meat or fish.For individuals over fourteen years2-6 oz. should be the maximum for the day.(b) Eggs:For children under two yearsno eggs are given.[26]For children from two to five years3-5 eggs may be given each week, being substituted for part or all of the meat.(c) Beans, Peas, Cheese:For children it is necessary to use milk abundantly when beans or peas are substituted for the meat or egg proteins.

For children under five years no meat is needed.

(a) Meat:

(b) Eggs:

For children it is necessary to use milk abundantly when beans or peas are substituted for the meat or egg proteins.

4. Vegetables:

For children under six months[27]no vegetables need be given.For children from six to nine months1 oz. gradually increased to 6 oz. of strained vegetable soup (see formula, page223).For children from twelve to fifteen months1 small baked potato may be added, and such vegetables as peas, string beans, carrots, spinach, squash, lima beans (strained).Two vegetables, one of which should be potatoes (white), should be given each day. A leafy vegetable (spinach greens, string beans, kale, lettuce) should be given from three to four times each week and oftener if possible.

Two vegetables, one of which should be potatoes (white), should be given each day. A leafy vegetable (spinach greens, string beans, kale, lettuce) should be given from three to four times each week and oftener if possible.

5. Fruit:

For children from six months on (earlier if physician approves)1-2 tablespoons orange or prune juice a day.For children from first to second year1-3 tablespoons twice daily.For children from two to five years3-4 tbsp. or more, twice daily (amount governed by health of child).All children should be given fresh fruit three or four times a week; some fruit given every day. Adults may be served dried fruit most days, but some fresh fruit should be given each week.

All children should be given fresh fruit three or four times a week; some fruit given every day. Adults may be served dried fruit most days, but some fresh fruit should be given each week.

6. Desserts:

One sweet dish (custards, cereal puddings, junkets) once or twice a day, but little if any clear sugar should be given (cereals should be served with very little if any sugar).

7. Fats:

For each person over five2-3 oz. of fat (purchased as such) a day, depending upon the age and ability of the individual to digest fats.

Suggestions for Serving Meals.—After reckoning the number of calories needed for the day, it is well to remember that the protein must be adequate in type and amount; that there should be an abundant supply of vitamines and iron in each day’s ration; that milk should always be included in order to make sure of having a sufficient amount of calcium in the diet; that there should be only one heavy protein dish at any one meal, and that it is unwise to serve a meal in which the fluids predominate on account of their deficiency in energy and proteins.

If a meal is made up of the right kind of foods, in the proper proportion, and each individual eats sufficient to assure the maintenance of the normal weight, is free from gastro-intestinal disturbances, and shows a normal resistance to disease, it is more than probable that a sufficient quantity is being consumed each day.

All foods should be carefully selected, and properly prepared in order to derive the maximum benefit therefrom, and the regularity and attractiveness with which the meals are served have almost as much to do with the health and happiness of the individual, as the character of the foods included in the day’s dietary.

(a) Calculate the dietary requirements of a nurse weighing 125 pounds, who spends 8 hours sleeping, 8 hours on duty, 2 hours at meals, 2 hours brisk walking, 2 hours in the class room, and 2 hours reading or studying.(b) Calculate the diet for a child of ten years of age, weighing 65 pounds, showing the number of calories, the amount of protein, calcium, phosphorus and iron necessary to make this diet cover the requirements of the child.

(b) Calculate the diet for a child of ten years of age, weighing 65 pounds, showing the number of calories, the amount of protein, calcium, phosphorus and iron necessary to make this diet cover the requirements of the child.

FOOTNOTES:[20]“Archives of Internal Medicine,” Vol. XXVII (1916), p. 916.[21]“Chemistry of Food and Nutrition,” (revised), p. 186, by Henry Sherman.[22]The Same.[23]Gillett, A. I. C. P. of N. Y.[24]Table compiled from material in “Feeding the Family,” by Rose.[25]“The Adequacy and Economy of Some City Dietaries,” by Sherman and Gillett.[26]Part of soft-cooked egg may be given at the beginning of eleventh month; this must be given at the noon meal, and should not be included in each day’s meal (two or three times a week is sufficient).[27]Dr. Hess advises the use of canned tomato juice as a substitute for orange juice when the latter is unobtainable.

[20]“Archives of Internal Medicine,” Vol. XXVII (1916), p. 916.

[21]“Chemistry of Food and Nutrition,” (revised), p. 186, by Henry Sherman.

[22]The Same.

[23]Gillett, A. I. C. P. of N. Y.

[24]Table compiled from material in “Feeding the Family,” by Rose.

[25]“The Adequacy and Economy of Some City Dietaries,” by Sherman and Gillett.

[26]Part of soft-cooked egg may be given at the beginning of eleventh month; this must be given at the noon meal, and should not be included in each day’s meal (two or three times a week is sufficient).

[27]Dr. Hess advises the use of canned tomato juice as a substitute for orange juice when the latter is unobtainable.

There are several methods of feeding which have been adopted to meet the needs of the individual under various conditions: Feeding by mouth, gavage or forced feeding, rectal feeding (nutrient enemata), and inunction.

Feeding by Mouth.—The first method is the one used in health and in the majority of abnormal conditions. In cases where there is a certain abnormal development of the mouth or throat, and in some cases of insanity or unconsciousness, where for some reason it is impossible for the individual to swallow, this method cannot be used.

Forced Feeding.—With very young children and babies gavage or forced feeding is found at times to be necessary. In these cases a small rubber catheter is introduced into the stomach through the nostrils and the milk or other fluid poured through the tube. In unconscious or insane patients it is often found necessary to insert a gag (a cork will serve the purpose) between the teeth to prevent the biting of the tube when it is inserted through the mouth into the stomach.

Food Used for Forced Feeding.—The food in these cases consists of reënforced soups, milk gruels, or nutrient beverages, not more than six or eight ounces given at one time. Finely chopped meat and vegetable purées have been given in this way when the digestion of the patient was not impaired, but when conditions rendered it necessary to resort to this method of feeding.

Technique of Gavage.—The apparatus used in gavage consists of a moderate sized soft rubber tube to which is attached a rubber or glass funnel and a “pinch cock.” The tube should be filled with water to prevent air entering the stomach and causing pain or discomfort. In certain cases the patient refuses to swallow the tube and it will be found necessary to use some means to force the passage if the throat is shut off. By closing the nostrils the patient will be obliged to breathe through the mouth, thus opening the passage into the throat through which the tube may be quickly slipped. In certain abnormal conditions the gastric organ is so badly impaired as to render it impossible for the patient to retain food taken in by way of the mouth. It is often found that food introduced into the stomach by means of the “stomach tube” will be retained and utilized which otherwise would be rejected. It is disagreeable, however, and should only be used when it is impossible to feed otherwise.

Rectal feedingis used when the other organs of digestion are impaired to such an extent as to render the need of more food obligatory. Many investigators believe that rectal feeding is absolutely useless, while others have firm faith in its efficacy.

Technique of Rectal Feeding.—The rectum should be cleansed by flushing with a soapsuds enema one hour before the nutrient enema is given. This should be done once a day, in the morning. The cleansing enema may be either soapsuds, a solution of bicarbonate of soda, or boric acid (1 teaspoonful to the pint), or a saline solution. When there is much mucus, or if the rectum is inflamed, the soda or boric acid solution may be more soothing than the saline or soapsuds enema. After one hour’s rest the patient should be given a nutrient enema.

The method of administering nourishment through the rectum is important. A nutrient enema injected only intothe lower bowel not only does no good, but may actually cause a good deal of unnecessary discomfort to the patient.

Temperature of Enema.—Care must be taken not to have the temperature of the nutrient enema too hot or too cold or it will be promptly rejected. The patient is placed on the side with one knee flexed; the solution is poured into a fountain syringe bag or an enamel container (heat the container before pouring the solution into it or the latter will be chilled). The bag or container has attached to it a rubber tube with a cock adjusted so that only a small stream will flow in at a time. To the end of this tube a rubber rectal tube or catheter—1 cm. (about ½ inch)—is attached. This should be well greased (do not use glycerin as this substance is irritating to the mucous lining of the rectum). The liquid should be allowed to fill the tube before it is inserted into the rectum, to prevent any air passing in with it. The tube should be inserted with a gentle twisting movement, using very little force or the tender mucous membranes will be injured. Insert the tube twelve or more inches, since the solution is more completely absorbed if given high up in the bowel. The bag containing the solution should be held only a few inches higher than the rectum, thus allowing only a small stream to pass in and allowing an air space above the stream for the passage of gas which may be accumulated in the upper part of the rectum. The tube should be allowed to remain in the rectum for fifteen or twenty minutes, then very gently withdrawn to prevent the liquid from being rejected. A pad of gauze may be pressed against the anus to assist the patient in retaining the enema. It is well to divert the attention of the patient also, to further assist her in retaining the liquid.

Duration of Rectal Feeding.—Rectal feeding cannot be substituted for a great length of time, first, because the patient cannot absorb sufficient nourishment in this way tofully cover the body requirements, and, second, because the rectum becomes more or less sensitive and will reject the liquid before it has an opportunity to be absorbed. From three to four nutrient enemas a day is about the limit for the average patient. Between the nutrient enemas it is advisable to give one of saline solution.

The following régime is practiced during the “Total Abstinence Period” in the treatment of gastric ulcer: 7A.M., cleansing enema; 8A.M., nutrient enema; 1P.M., nutrient enema; 3P.M., saline enema; 6P.M., nutrient enema. One saline and one nutrient enema may be given during the night if the patient is very weak. She should not be wakened, however, to be given the enema.

Feeding by Inunction.—This method consists in the rubbing into the body of certain nutrient oils, such as olive oil, cocoanut oil, cocoa butter, etc. It is of little value, but is occasionally resorted to with very much emaciated and underfed infants, when digestional disorders make it impossible to introduce enough food by mouth to cover the needs of the body.

There are a number of diets formulated to meet the various normal and abnormal conditions. In hospitals these are classified as follows, for the convenience of both nurse and doctor:

House Diet.—That which is served to the hospital staff, the nurses, and those patients not requiring special diets.

Liquid or Fluid Diet.—Consisting of milk, nutrient and other palatable beverages, broths, and thin gruels.

Light, Semi-solid or Convalescent Diet.—Composed of thick or cream soups, eggs, toast, cereals, custards, jellies and ice cream, and later vegetable purées, broiled birds, chicken, lamb chops, and rare beefsteak.

Mixed Diet.—The diet used in normal conditions and for those not affected by any special food.

Special Diets.—Those designed to be used for certain pathological conditions, such as scarlet fever, nephritis, etc. These diets are classified as follows:

Milk Diet.—A diet in which milk is the sole article of food.

Carbohydrate-free Diet.—One in which the sugars and starches are eliminated.

Purin-free Diet.—One in which the foods rich in purin bases are eliminated. This is used in gout, arteriosclerosis, etc.

Salt-free Diet.—Diet in which sodium chloride (salt) is as far as possible excluded. It is used in certain cases of nephritis when edema is present.

Nephritic Diet.—A diet used in nephritis and diseases complicated by nephritis (scarlet fever). In this diet the protein foods, meat in particular, are restricted, milk being the exception.

Diabetic Diet.—A diet in which the carbohydrates are restricted or eliminated.

“Allen Treatment of Diabetes”consists chiefly of “starvation” for a given period and a reëducation of the organs to a toleration for carbohydrates.

Emaciation Diets.—Those containing a high percentage of fat-forming foods, such as milk, cream, eggs, cereals, potatoes, etc., olive oil.

Obesity Diets.—Those containing as few of the fat-forming foods as possible, such as cream, olive oil, potatoes, white bread, etc., pastry and desserts, candy and soda water, and containing lean meats, fish or shellfish cooked and served without butter or other fats, fresh or stewed fruit without sugar, green vegetables and salads served without oil or other fats; one egg a day two or three times a week, coffeeand tea without sugar or cream, toasted gluten bread (1 slice) without butter, saccharine substituted for sugar.

There are a number of other diets, but they come more or less under the above heads.

As the patient’s tray assumes an important part of the daily régime, it is necessary to give close attention to the arrangement and serving of it. There are certain definite rules to observe: (1) The linen, silver, glassware, china, and food must be absolutely clean. (2) The tray must be sufficiently large not to appear crowded. (3) The arrangement of the obligatory articles, such as salt and pepper, silver, water glass, napkin, etc., must be alike at every meal; this not only facilitates the service by making it easy for the nurse to see whether any of these necessary articles are left off, but it also enables the patient to find them without trouble.

The Linen.—The linen cover of the tray must be clean and uncreased. The napkin likewise must be clean and unwrinkled. The china must be free from chips and cracks. Care must be taken not to put a collection of odd pieces on the tray as it gives an untidy appearance.

The Silver.—The silver must be bright and in cold weather made slightly warm, as must also the china. The chill of cold silver may readily obliterate a fragile appetite, and to place hot food in cold dishes will deprive it of much of its palatability. The foods intended to be hot must be really hot, not warm, and those which are intended to be cold should be thoroughly chilled before being served to a patient. The placing of flowers on a tray is a questionable addition to it; a single flower laid across the folded napkin may add daintiness and attractiveness, but it is poor judgment to over-decorate, either with flowers or by garnishing the dishes.

Arranging the Tray.—If the nurse will place the necessary articles upon the tray and memorize their position so that she will be able to duplicate the same at each meal, she will be able to tell at a glance if everything needed is in its proper place, thereby saving herself unnecessary steps and the patient the worry of having to wait until they can be brought. Food should not be allowed to stand in the sickroom, and glasses or plates in which food has been served should be removed from sight as soon as the patient finishes with them. Care must be taken, however, not to create the impression of hurry or the patient will be made nervous and either will lose her appetite or have indigestion.

The nurse should be careful of her topics of conversation during the meal hour. Especially must disagreeable subjects and business matters be rigidly excluded if the invalid is to obtain the full benefit of the food served her.

1.Setting the Tray.—Tray should be sufficiently large not to give the appearance of being crowded, but not too large.

2. Tray cover must be spotless, and of a size to just cover the edges of tray; if too large, make a pleat down the center.

3. Place service plate directly in front of patient.

4. Knife, cutting edge in, to the right of plate; fork, tines up, to the left of plate.

5. Spoons, bowls up, next to the knife.

6. Napkin on the lower left side of tray, open edges to the lower right side.

7. Bread and butter plate on top of napkin.

8. Soup tureen in lower right corner, with cup and saucer above it.

9. Tea or coffee pot and hot water pot in upper right-hand corner of tray, with sugar bowl next to hot pot and cream pitcher next to sugar bowl.

10. Place salt and pepper next to cream pitcher (to the left).

11. Water glass in upper right corner of tray.

12. Second vegetable dish placed on the upper right side of dinner plate.

13. Place dessert to the upper left of dinner plate.

Suggestions for Serving.—Make tray as attractive as possible.

In the cases requiring special diets, the nurse should make out the “diet sheet” for the day. In hospitals this is passed to the dietitian, who carries out the directions laid down by the physician. The nurse, however, should carefully check the tray before serving it, since mistakes sometimes occur, and to give the wrong food to a patient suffering from certain disorders may give rise to serious trouble, causing pain and discomfort and at times death.

Contamination of Food.—Food should always be protected from dirt and dust and from contamination and pollution from flies and other insects. Typhoid fever and certain intestinal disturbances have been known to result from flies coming in contact with raw food—milk, for example. Poisoning due to polluted water used to freshen vegetables has already been spoken of. All of these types of poisoning may be avoided by using care in the handling of the fresh foods.Ptomaines, however, are not easy to prevent. Their source cannot always be traced to one particular article of diet. They may be present in cooked, raw, frozen, or canned foods. At times the evidence of extreme decomposition will be found in the foods themselves, while at other times there will be no such evidence in the food, but the result of the ptomaine will be perfectly evident whenever certain individuals partake of that food. This is a personal idiosyncrasy which it is impossible to account for.

Food Poisoning.—Poison caused by decomposed eggs has manifested itself in individuals who have partaken ofcake in which such eggs were used. Canned meat and fish have produced the most violent types of ptomaine poisoning. As a rule in these cases the canned article has begun to decompose and while the decomposition may not have advanced sufficiently far to be discernible from the flavor or odor, it is there, and if the resistance of the individual eating this food is not great, serious danger may result. Poisoning develops in some individuals upon the eating of shellfish, strawberries, oranges, pimentos, and various other foods,—another evidence of personal idiosyncrasy against certain articles of diet. There is no way to overcome these idiosyncrasies; the only thing to do is to warn the individuals so affected to let the offending foods alone.

The adulteration of food, which formerly was practised by unscrupulous dealers to cover up inferior articles, or by manufacturers to prevent or arrest decomposition in canned goods, is regulated by law. The passage of the National Pure Food and Drug Act gave the Government authority to regulate the preservatives and coloring matter used in canned and bottled goods, forcing the manufacturers to state on the label the exact contents of each bottle or can. There are likewise stringent laws governing the adulteration of milk, butter, and other articles of food.

Tests for Adulterants.—Boric acid, borax, and formaldehyde are the preservatives more often found in milk. These chemicals are introduced to arrest the natural souring and decomposition which takes place after milk reaches a certain age. Occasionally salicylic acid and sodium carbonate are used. Formaldehyde may be detected by placing about 20 c.c. of milk in a small glass vessel or tube. Dilute with an equal amount of pure water, add commercial sulphuric acid, allowing it to flow gently down the inside of the tube. A purple ring will appear at the zone of contactif formaldehyde is present. “Boric acid and borax may be detected by adding a drop or two of hydrochloric acid to a few drops of milk in a white dish and then several drops of a saturated alcoholic solution ofturmeric. The dish is then heated gently for a few minutes, and, if boric acid or borax is present, a pink or dark red color will appear. A dark blue-green should appear when the dish is cooled and a drop of ammonia added.”[28]

Canned goodsmust be carefully examined before being used. The domestic canned goods are rarely adulterated, but imperfect sterilization and defective cans may bring about a condition of fermentation and gas formation due to bacterial action. Cans should have a concave appearance on the top. If there is a bulging of the can it may be due to gas formation, and a small hole should be made in the can to note any escape of this gas. Should there be any indication of fermentation, the contents should be discarded. It is advisable to look with suspicion on cans that appear old, rusty, and soiled; they are probably left-over stock and liable to be bad. Peas which have been imperfectly sterilized produce a type of gas which is soluble in the liquid. After decomposition has occurred there will be no apparent evidence by the escape of gas, but the liquid will be found to be excessively acid, and will present a muddy appearance. Certain foreign importations of canned goods are preserved in color by the introduction of certain color preservatives. Peas—petits pois, for example—and the very small string beans which are imported are intensely green from the copper sulphate used. Its presence may be detected by adding a few drops of hydrochloric acid to some of the colored material, then dropping in a bright steel nail, knitting needle, or knife blade. There will be a deposit of copper salts (like copper plating) upon the steel if the preservative is present in the can. Canned corn is oftenartificially sweetened with saccharine, which may be detected by shaking several tablespoonfuls of the liquid in an equal amount of chloroform. Saccharine is soluble in chloroform, while sugar is not. Allow the mixture to stand a few minutes and remove some of the chloroform which has settled at the bottom. Place in a small dish, evaporate the chloroform by gently heating the dish; taste the residue; if sweet, saccharine is present.

Coffeeis adulterated more often when it is put up in ground or powdered form than when sold in the bean. Real coffee contains a small percentage of oil, and will float when thrown into a glass of water. Substitutes generally sink to the bottom. Coffee substitutes are often made up of starch-containing materials, such as cereals, beans and peas. This starch may be detected by mixing one tablespoonful of the suspected coffee in a little cold water, adding one cup of boiling water; allow it to boil two minutes, filter through cotton, and pass the liquid through charcoal to remove the color. When it is cold, add a few drops of dilute iodine solution. If starch is present, a blue color will appear.

Food is prepared for consumption by a number of methods and the method by which the food is prepared either increases or decreases its digestibility, palatability, and general usefulness.

Certain foods, as has already been stated, require a high degree of temperature to make them wholesome, but if this temperature is applied by means of heated fat, as in frying, the food is changed from a wholesome to a more or less indigestible article. In health the organs of digestion are capable of overcoming much of the harm wrought by wrong preparation, but even in the healthy, normal individual a steady diet of fried food will eventually undermine what isknown as good digestion. In abnormal conditions (illness) frying is a method seldom, if ever, used.

Preparation of Food.—The various methods to which food is subjected in preparation for human consumption may be summed up as follows: boiling, simmering, steaming, baking, roasting, broiling, frying, sautéing.

Boilingis cooking in water raised to the boiling point, 212° F. (sterilizing). This method is commonly used in the cooking of starchy vegetables and cereals, and in the cooking of green vegetables, such as spinach, carrots, beets, corn, asparagus, etc. Stewing is a form of boiling. As a rule water is used, and the vessel is left uncovered, so that as the food is cooked the surplus moisture evaporates, leaving the food tender. Dried fruits, such as prunes and apricots, are prepared by this method.

Simmeringis cooking in water, the temperature of which is not raised to the boiling point, but kept between 200° F. and 210° F. This method is used in the preparation of eggs and dishes in which eggs predominate, since proteins are made tough if subjected to a high degree of temperature. Coddled eggs, for example, are prepared by placing the egg in a clean vessel and pouring over it the boiling water, then covering the vessel and allowing it to stand for ten or fifteen minutes. The vessel and the cold egg reduce the temperature of the water to about 185° or 190° F. and in this way prevent a toughening of the albumen of which eggs are chiefly composed. Soups, broths, ragouts, etc., are prepared by this method.

Steamingis cooking over hot water or by steam. This method may be accomplished on the top of the stove in a “double boiler” or in the oven in a deep covered pan fitted with a “rack” to hold the article to be cooked. Either method allows the vessel in which the food is placed to be surrounded by boiling water, but does not insure sufficient heat to raise the food within to the boiling point.

Bakingandroastingare both brought about in the oven. Bread, biscuits, pies and other pastry, potatoes, cakes, etc., are baked, while meats, roast of beef, lamb, veal, mutton, as well as chicken, turkey, duck, and large fish are roasted. The heat in the oven may be intense. The outside or cut surface of the meat is seared, the soluble albumens are coagulated, thus sealing the juices within. If the meat is placed in a pan surrounded by cold water and then placed in the oven, the juices are “drawn out” in the water. These juices contain the flavoring matter or extractives. Meat so treated is not so palatable or highly flavored as that which has first been subjected to intense heat, the water for the gravy added later.

Fryingandsautéingis cooking in hot fat. Food may be fried in deep fat, as is demonstrated in the cooking of croquettes, doughnuts, etc., or it may be sautéd in butter or oil in a shallow frying pan or griddle. The latter method is used in making hashed brown potatoes, for example; also in the cooking of griddle cakes, etc.

Broiling.—In broiling or grilling the article to be cooked is exposed to direct heat, either to the blaze or to a very hot surface. The result is the same as in roasting. The outer surface is seared, sealing the juices within. Meat to be broiled is generally cut thinner than that to be roasted. The article, whether it is meat (steak), chops, birds, or chicken, is placed about three inches away from the flames and turned frequently until the surfaces are seared, after which the article is placed in a cooler part of the stove to allow the interior to be cooked. Pan broiling is done on top of the stove. The article to be broiled is placed directly upon a very hot surface, there is no grease used and the meat must be turned frequently to prevent burning.

Poaching.—This term is applied chiefly to the cooking of eggs in a shallow pan of water heated just below the boiling point. To be properly poached an egg must beperfectly fresh, or the white and yolks will run together and present an unappetizing, unpalatable appearance.

The following time-table should be used in the preparation of food to insure correct cooking:

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