,transcriber's ,notes3 ,underscores 80 before and after a word or phrase indicate italics in the original text4 ,equal signs 80 before and after a word or phrase indicate bold in the original text4 ,small capitals have been converted to ,,solid capitals4 ,illustrations have been moved so they do not break up paragraphs4 ,old spellings have been preserved4 ,typographical and punctuation errors have been silently corrected4 ,,hospital ,,housekeeping ,by ,,charlotte ,a4 ,,aikens ,late ,director ,sibley ,memorial ,hospital1 ,washington1 ,d4 ,c42 ,late ,superintendent of ,iowa ,methodist ,hospital1 ,des ,moines2 ,superintendent of ,columbia ,hospital1 ,pittsburg2 ,former ,associate ,editor ,the ,national ,hospital ,record ,,second ,,edition ,detroit1 ,mich4 ,,del ,t4 ,,sutton #aiaj ,copyright #aijf by ,,del ,t4 ,,sutton ,,preface ,in the preparation of this volume1 three classes of readers have been in mind3 the trained nurse who1 without practical experience in hospital management1 finds herself in charge of a hospital1 small or large2 the practical woman who1 having had no opportunity for special training1 has upon her the responsibility of the direction of the domestic affairs of an institution2 and the lady member of the hospital board of managers who1 in the discharge of the duties of her position1 becomes responsible to the public for the proper government of institutional affairs4 ,it was thought that the latter1 especially1 might1 through the use of this volume1 secure a better grasp of the details of hospital housekeeping as a whole than is possible without some such aid4 ,the ability to see all around a situation1 to view the institution as a whole1 is essential to good management4 ,as a rule1 such ability comes only by experience4 ,especial pains have been taken to make the volume thoroughly practical1 and to present clearly and concisely lessons learned in actual dealing with1 and close study of1 the questions discussed4 ,the greater portion of the contents of the volume have already seen the light of day in the columns of the ,national ,hospital ,record4 ,since their appearance in that journal1 the papers have been carefully revised1 and much new and important matter added4 ,for assistance in preparation1 the author has been under great obligation to a number of hospital superintendents1 who have furnished information as to methods1 and to contemporary writers1 especially on the subject of dietetics4 ,special mention should be made of the works of ,w4 ,gilman ,thompson1 ,m4 ,d41 ,mrs4 ,ellen ,h4 ,richards1 ,i4 ,burney ,yeo1 ,m4 ,d41 ,sir ,henry ,burdett1 and of the literature of the ,united ,states ,department of ,agriculture4 ,to ,miss ,emma ,lynch1 who1 as hospital matron1 has been for several years associated with the author in institutional work1 special thanks are due for valuable assistance4 ,many practical suggestions have been gleaned from the papers given at the annual conventions of the ,association of ,hospital ,superintendents4 ,to the writers of these papers the author expresses grateful appreciation4 ,many of the electrotypes used for illustration have been kindly furnished by courtesy of the business firms whose names accompany them4 ,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 appliances4 ,so far as the author is aware1 no attempt has previously been made to discuss the subject of hospital housekeeping as a whole4 ,as a pioneer in the field1 the book doubtless has many defects4 ,if it proves of practical value to even a small number of those for whose assistance it was prepared1 it will have justified its existence4 ,,charlotte ,a4 ,,aikens4 ,,table ,,of ,,contents4 ,,preface #g-h ,,chapter ,i--,the ,hospital ,housekeeper2 ,the ,housekeeper's ,province2 ,bookkeeping2 ,hospital ,inventory #ac-ai ,,chapter ,,ii--,the ,main ,entrance2 ,the ,porter2 ,the ,private ,rooms2 ,hospital ,couches2 ,fumigation2 ,the ,daily ,cleaning2 ,dusting2 ,bath ,rooms #bj-bi ,,chapter ,,iii--,the ,hospital ,ward2 ,soiled ,clothing2 ,buying ,beds2 ,bed ,making2 ,ward ,lockers2 ,care of ,patients' ,clothing2 ,ward ,medicines and ,records2 ,adjuncts to the ,hospital ,ward2 ,quiet ,room2 ,matters ,miscellaneous2 ,destruction of ,appliances2 ,screens2 ,a ,twenty-,bed ,ward ,equipment #cj-db ,,chapter ,,iv--,the ,linen ,room2 ,bed ,linen2 ,the ,room2 ,linen ,accounting2 ,discarded ,linen2 ,emergency ,supply2 ,removing ,stains2 ,new ,linen2 ,shelf ,management2 ,laundry ,bags #dc-ej ,,chapter ,v--,the ,hospital ,laundry2 ,manager's ,duties2 ,laundry ,workers2 ,starching2 ,blueing2 ,drying2 ,ironing2 ,routine of ,work2 ,the ,laundry ,plant #ea-ei ,,chapter ,,vi--,the ,hospital ,kitchen2 ,general ,construction2 ,kitchen ,cabinet2 ,plan of a ,model ,kitchen2 ,cold ,storage2 ,the ,storeroom2 ,dishwashing2 ,dishcloths and ,towels2 ,the ,chief ,kitchen ,employees2 ,training ,needed2 ,the ,diet ,kitchen #fj-gj ,,chapter ,,vii--,the ,purchase and ,care of ,food ,supplies2 ,judging ,food ,values2 ,bread2 ,milk2 ,care of ,milk2 ,cheese2 ,eggs2 ,economy and ,care2 ,meat2 ,beef2 ,veal and ,mutton2 ,chickens2 ,fish2 ,pork2 ,butter2 ,fresh ,vegetables2 ,approximate ,estimate of ,quantities of ,food for a ,twenty-five ,bed1 a ,fifty-,bed and a ,one ,hundred-,bed ,hospital #ga-hg ,,chapter ,,viii--,preparation of ,food2 ,object of ,cooking2 ,classes of ,diets2 ,broths2 ,soups2 ,cooking ,meats2 ,cooking ,vegetables2 ,time of ,meals #hh-ig ,,chapter ,,ix--,diet ,lists and ,blanks2 ,serving of ,food2 ,tray ,setting2 ,bills of ,fare2 ,dishes2 ,hints on ,serving #ih-aaj ,,chapter ,x--,hospital ,dietaries2 ,supplies for ,one ,hundred ,persons for ,thirty ,days2 ,menus for ,nitrogenous ,diet #aaj-aai ,,chapter ,,xi--,hospital ,hygiene2 ,prevention of ,disease2 ,sanitary ,kitchens2 ,pure ,food2 ,filters and ,water2 ,air2 ,cleanliness2 ,flies2 ,garbage2 ,garbage ,crematories #abj-aca ,,chapter ,,xii--,the ,help ,question2 ,number of ,servants2 ,contracts2 ,merit ,system2 ,schedule of ,work2 ,rules2 ,servants' ,dining ,rooms2 ,sleeping ,rooms2 ,attire2 ,housekeeper's ,relation to ,servants #acb-adc ,,chapter ,,xiii--,the ,problem of ,waste2 ,main ,causes2 ,first ,steps2 ,surgical ,department2 ,utilizing ,hospital ,waste2 ,soap making2 ,drugs2 ,wasteful ,physicians2 ,teach ,economy2 ,abuse of ,appliances2 ,careful ,accounting2 ,watching the ,expenditures2 ,dietetic ,department2 ,system #add-aeh ,,appendix--,disinfection2 ,fumigation ,can2 ,exterminationof ,vermin2 ,care of ,floors #aei-afb ,,hospital ,,housekeeping ,,chapter ,i4 ,sidenote3 ,the ,hospital ,housekeeper ,hospital housekeeping is intensely practical business4 ,if it is to be successfully and satisfactorily conducted1 it demands that the housekeeper be a woman of no inferior or uncertain attainments4 ,all the elements that make for success in home housekeeping1 and many more1 are needed in a hospital4 ,there must be breadth of vision1 the qualities of an organizer1 the ability to deal with large problems1 a keen sense of justice1 and the executive force needed to manage1 without fear1 fuss or favor1 the various classes of people that touch the housekeeper's realm4 ,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 store4 ,and the same may be said of the average woman in hospital housekeeping4 ,apart from the special knowledge of the business1 that comes only by diligent study1 accurate observation and experience--never by accident--the housekeeper needs special qualities of mind and heart4 ,indeed1 special qualifications are needed by every one whose life work is to be wrought out in an institution4 ,a hospital or any institution that has to deal with infirm1 aged or unfortunate members of society1 is no place for a person of strong racial antipathies4 ,it is no place for the tale-bearer or the gossip1 nor for the person who has a grudge against fate and feels she has never received justice4 ,it is no place for the person who is discouraged1 or who assumes the air of a martyr1 and leads a crushed life1 bemoaning the fact that her highest motives and best efforts are never appreciated4 ,those who would live happily in an institution must be prepared to be misunderstood1 and fortified against discouragement from that source4 ,sympathy with the aims of the institution is a primary qualification4 ,no one should enter an institution as a worker1 and especially as head of a department1 who is not prepared to have her interests centered in the people for whose benefit the institution was brought into existence4 ,ability to see things from more than one standpoint1 to work comfortably with different classes of people1 an infinite capacity for detail1 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 hospital4 ,it need hardly be mentioned that she needs a healthy body and a strong constitution4 ,the hospital housekeeper needs1 if anyone needs it1 reliability of judgment1 and poise of soul4 ,if she is to control others1 she must know how to control herself4 ,the ability to reprimand without arousing antagonism must be hers4 ,she should endeavor to cultivate the feeling of personal responsibility in all over whom she has authority1 and to make them understand that the success of an institution depends not on perfection of equipment1 nor in numbers1 but in thorough co-ordination of the work in all the departments1 and faithful service on the part of all4 ,they should know that a lack of punctuality or carelessness in one department disturbs the working of the entire system4 ,the influence of the kitchen and laundry is felt throughout the entire institution4 ,skillful management consists not alone in the ability to attend to the apparently important affairs with ease1 but in never losing sight of the minor details4 ,nothing is so large as to be of paramount importance1 nothing so small as to be considered immaterial1 where human lives are concerned4 ,sidenote3 ,the ,housekeeper's ,province ,to define the exact limits of the housekeeper's province is impossible1 as institutions vary so greatly in size and in the number of officers4 ,local conditions always influence the situation4 ,one lone woman may have to manage the domestic affairs of an institution1 superintend its entire business1 including its nursing1 manage its bookkeeping1 do the work of an interne in emergencies1 and act in various other capacities1 that readily suggest themselves to those who are acquainted with life in a small hospital4 ,in another institution her province may be limited entirely to the purely domestic affairs1 the purchase and preparation of food1 care of linen1 the cleaning1 and the management of those who work in these departments4 ,in either instance1 the responsibility is great4 ,to meet this responsibility without being oppressed by its weight1 requires that the working force be completely organized1 the work definitely divided and assigned4 ,there should not be a square inch of the building for which someone is not directly responsible for its good order and cleanliness4 ,real success in management1 however1 does not alone consist in the work going on as it should while the housekeeper is there to direct and supervise4 ,her own health and efficiency demand that she have recreation and rest1 and1 as a matter of fact1 depend on her not being always there4 ,her skill and generalship of the situation will be shown in the fact that1 whether present or absent1 the routine of the work is not noticeably interrupted4 ,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 absence4 ,sidenote3 ,bookkeeping ,in addition to the mastery of the details of the practical work1 the hospital housekeeper must know how to give an account of her stewardship to those who have a right to demand it4 ,the business side of hospital work1 that which has to do with dollars and cents1 is one of her many duties that has special importance4 ,it is one of the corner-stones in the hospital foundation1 and however much the housekeeper may dislike the tedious work of adding and subtracting1 and reckoning1 and itemizing1 if she is a faithful steward of trust funds1 she will give it due attention4 ,the weak point in a great many hospitals is the looseness of methods of accounting4 ,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 grasped2 and it is not to be wondered at that the housekeeper is1 if not careless1 then not sufficiently careful for her books to be of any value as institutional records4 ,the busy housekeeper needs a simple method of accounting that is at once comprehensive and easy to handle4 ,a simple1 convenient form for a general expense book is here shown4 ,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 arrange4 ,it is not claimed that this is the best method for a general expense account2 it is one method--a simple1 workable method4 ,in addition to this the use of a small day book will be necessary1 which will show on the left-hand page the money received and on the other side the disbursements for the day4 ,for this an ordinary blank book that has spaces ruled for dates1 items1 dollars and cents1 will be sufficient4 ,in this each day will be recorded the article purchased1 the date and the cost4 ,periodically this itemized account is gone over1 the articles grouped under the several heads and copied in the general expense book4 ,,general ,,hospital ,receipts and ,expenditures from to ---------------------------------------- ---- ,,receipts ,balance on hand 4444 #ast1 #aij444 ,received from 444444444444444444 ,received from 444444444444444444 ,received from 444444444444444444 ,received from other sources 4444 ---------------------------------------- ---- ,,expenditures ,meat ,fish ,butter ,flour1 bread and meal ,milk ,water supply ,ice ,potatoes and vegetables ,groceries and provisions not above enumerated ,soap and cleaning appliances ,fuel ,gas1 oil and light ,bedding and general house furnishings ,nurses' uniforms ,other training school expenses ,advertising1 printing1 stationery1 postage ,repairs ,stationary furnishings ,contingencies ---------------------------------------- ---- ,an 8order book0 should contain an account of all orders given1 the quantity1 cost1 date ordered1 date received4 ,an ordinary blank-book may be ruled with columns for each of these entries1 and the month and year4 ,this furnishes information that is valuable from several standpoints4 ,if the housekeeper is suddenly called away1 it is easy to turn to for a list of the firms patronized1 or to find the usual amounts ordered1 and is valuable for comparison and reference from month to month and year to year4 ,all dealers' checks sent with goods should be preserved1 for comparison with the itemized monthly account1 before indorsing it for payment4 ,sidenote3 ,hospital ,inventory ,in the matter of the hospital inventory1 various forms may be adopted1 according to the purposes for which the inventory is intended4 ,it may be a simple list of the furnishings of the hospital1 made up without any special plan1 and with or without the value or cost of the article attached4 ,in case of loss by fire1 this inventory might have special value as an insurance record4 ,such books should of course be kept in the safe1 with other documents and articles of value4 ,as convenient as any way of keeping a hospital inventory1 is to have the contents of the building arranged under the heads of the rooms for which the articles were purchased4 ,the kitchen1 storerooms1 diet kitchens1 offices1 reception rooms1 wards1 private rooms1 etc41 all have stationary furniture especially for them1 and for purposes of reference it will be most convenient to list this in connection with the room containing it4 ,if the value of each article is attached a recapitulation will show at a glance the total value of the hospital furnishings4 ,once each year1 at least1 the housekeeper should make a business of finding out the average cost per day of feeding her hospital family1 and the average cost of feeding one patient4 ,this knowledge is valuable not alone for statistics1 but for her own satisfaction4 ,it should give confidence in her administration1 or show whether there is a weakness that might be corrected4 ,,chapter ,,ii4 ,sidenote3 ,the ,main ,entrance 8,there is nothing in a hospital small enough to be careless about10 is a remark frequently heard in hospital corridors4 ,it is important for the housekeeper to bear in mind that1 although oft quoted1 this statement happens to be true4 ,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 entrance4 ,two trained nurses who spent a couple of days in visiting hospitals in an eastern city related the following experience3 ,at hospital number one the door was opened by a very untidy-looking1 irrepressible colored boy1 who seemed to feel it his duty to do the gallant thing according to his ideas of gallantry4 ,after an entirely unnecessary speech1 his concluding remarks were that he would just love to go through the hospital with them1 but he 8ain't got no time10 and he guessed he'd have to ask ,dr4 ---- to go with them4 ,at hospital number two1 no one specially seemed to be in charge of the door1 and1 after repeated rings1 a resident physician1 who1 judging from his hair and general appearance1 had been napping1 came rushing through the hall--the door was open--getting into his coat by the time he reached the door4 ,the climax was reached at hospital number three1 which was a maternity hospital1 an adjunct of a large city hospital4 ,here the door was opened by a colored woman in the last stages of pregnancy4 ,at hospital number four a pert maid1 none too tidy1 was on duty at the front entrance4 ,her distinguishing feature seemed to be that she 8didn't know40 ,at hospitals five and six1 the persons in charge knew what was expected1 and did the proper thing1 but the varied experiences served to show the laxity that exists in that one particular4 ,sidenote3 ,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 courteous4 ,he need not know all the business of the institution1 but he should know enough to answer questions properly and when to be silent4 ,if no special uniform is provided1 he should be neatly and quietly attired4 ,parcels1 telegrams1 messages1 are constantly being delivered for the inmates1 and he should be responsible for them until they are delivered to the nurse in charge4 ,letters should be placed in a locked box1 the key to be held by some reliable person who will see to their distribution4 ,mail for the patients should not be given to the inmates direct1 but to the nurse in charge1 and some nurse should always be in charge4 ,carelessness at this point may result in an important letter or message not being delivered1 or delivered at a time when it is specially important that the patient's mind be free from disturbance or intrusion of any kind4 ,complaints are frequently made1 of large hospitals especially1 that boxes of flowers sent to patients have been thrown carelessly into a parcel room1 and not delivered at all1 or delivered after their beauty and fragrance had gone4 ,if the person at the door is careless about matters of that kind1 he will be just as likely to be careless about more serious things4 ,a temporary substitute at the door should always be arranged for when the porter is obliged to be absent1 even for a few minutes4 ,sidenote3 ,the ,private ,rooms ,in all apartments intended for the use of patients some degree of uniformity should be observed in the furnishings1 though this may easily be carried to extremes4 ,these rooms vary in size and price1 but the essentials for all are the same4 ,the chief thought should be to have the furnishings suitable1 sensible and restful4 ,dainty white enameled furniture for hospital rooms is rapidly replacing that of darker hue and adds greatly to the attractiveness of the hospital4 ,for the average room a combination dresser and washstand is preferable to cumbering the room with two separate pieces of furniture4 ,these have the essential features of the dresser1 in that they provide a mirror and drawers1 and of the washstand by having a towel rack and cupboard4 ,in any case1 small dressers are preferable to large ones4 ,every private room should have its own wash bowl and pitcher1 soap dish1 mug1 receptacle for toilet brush1 water bottle and drinking glass4 ,the bed should be placed so that the nurse can have access to it on three sides4 ,the woven-wire springs should be warranted not to sag in the middle4 ,illustration3 ,combination ,dresser and ,washstand ,blankets1 on account of the frequent washings1 should not be all wool1 nor too heavy4 ,for warmth it is better to depend on light blankets than on any form of 8comforter40 ,rugs may be as bright and handsome as the hospital can purchase4 ,the cheap wool rugs that are everywhere displayed for sale are a poor investment4 ,the most satisfactory rugs are those made to order of tapestry ,brussels1 or when it can be afforded1 the more expensive grade of ,brussels or velvet4 ,for small rooms three widths are usually sufficient and these made without border are not an expensive rug4 ,for larger rooms a border is preferable1 but in any case such rugs are economical and serviceable4 ,long lace curtains should have no place in a hospital4 ,they are always getting in the way and being torn1 always collecting dust and always an obstacle to the view and to ventilation4 ,at best they are a nuisance1 an unnecessary expense and serve no useful purpose4 ,soft1 plain white sash curtains are the only suitable curtains for the hospital window4 ,provision should be made for looping them back if the patient desires it1 and most patients have a longing desire to see out of doors4 ,a comfortable1 roomy rocker1 with arms and without any 8squeaks10 is indispensable in the private room4 ,sidenote3 ,hospital ,couches ,if large enough1 the room should also have a couch4 ,it makes an agreeable change from the bed during convalescence4 ,the common couches with elevated head are most unsatisfactory4 ,no patient can lie on an inclined plane for any length of time in comfort4 ,when it becomes necessary for a nurse to sleep in the patient's room when on 8special duty0 these couches are an abomination4 ,no nurse could ever get up feeling really rested1 after trying to sleep on such a couch4 ,the best hospital couch is that styled sometimes 8the den couch40 ,the bed is flat1 a full six feet by two1 and the headboard being at right angles1 effectually prevents the pillows from slipping off4 ,such a couch can be made as comfortable as a bed1 combining both beauty and utility4 ,they can be made to order by any firm that manufactures couches or beds4 ,when covered with the best grade of pantasote these couches cost usually from fifteen dollars upward and when covered with leather from thirty dollars upward4 ,they are the only kind of hospital couches it pays to invest in4 ,illustration3 ,,hospital ,,couch ,illustration3 ,,invalid ,,table ,sidenote3 ,other ,accessories ,a straight-back chair1 a wardrobe for the patient's clothing1 a movable screen and a small table or two1 complete the essentials in the modern sick room4 ,the newest hospital tables are of iron and glass and may be had in different sizes4 ,an invalid's table that will extend over the bed is a luxury much appreciated by the patient1 especially during convalescence4 ,plenty of pillows is another luxury that will add to the patient's comfort4 ,a small pillow or two to tuck around the patient1 in places where a little warmth or support is desired1 is a sensible addition to the ordinary furnishing of the sick room4 ,half a dozen will be none too many4 ,the best finish for the walls of the private room is a coat of oil paint4 ,they can then be subjected to periodical cleaning without being defaced4 ,the shades should be soft and delicate and restful4 ,a pretty shade of greenish blue is a delight to most eyes4 ,on the wisdom of pictures in a sick room1 opinion is divided4 ,some would banish them as unnecessary1 and because they afford a lodging place for dust and disease germs4 ,others would introduce them to banish the monotony and relieve the walls of the bare effect4 ,if used at all1 pictures should be carefully selected1 and have plain wooden frames1 that will not be injured by disinfectants4 ,to many patients the illuminated scripture texts on the walls are a comfort1 and few1 even of those who in health have no use for such things1 object to them when sick4 ,the custom of making memorial rooms1 picture galleries or museums where the memory of benefactors is enshrined1 is to be condemned4 ,a simple plate on the wall or on the door is sufficient4 ,more than this is unwise and in bad taste4 ,the craze for memorials has reached a point that is embarrassing in many hospitals1 and the time must surely come when doctors and hospital officers will interfere1 and protest against having the patient forever gazing into the countenance of some member of the family of the benefactor of the institution4 ,as soon as possible after a patient has left the room1 it should undergo a thorough cleaning4 ,every article but the stationary furnishings should be removed4 ,carelessness about this matter sometimes proves very embarrassing4 ,drawers1 cupboards1 and wardrobes should be washed with a solution of bichloride of mercury4 ,the windows should be cleaned and fresh sash curtains put on4 ,the walls should be brushed1 the floor cleaned1 the mattress disinfected1 the bed clothing washed and all utensils thoroughly aired4 ,if the last occupant was afflicted with a communicable disease1 the mattress should be subjected to steam sterilization4 ,sidenote3 ,fumigation ,fumigation of the rooms periodically is necessary to ensure the safety of the coming patients4 ,formaldehyde for fumigation purposes has largely superseded sulphur4 ,when the room is ready for fumigation1 the windows should be closed1 the drawers of the furniture opened1 all chinks stopped1 the keyhole stopped with cotton1 and the room left closed for twenty-four hours4 ,it may then be opened1 and1 when thoroughly aired1 is again ready for occupancy4 ,the sheet method of fumigation1 using a pint of formaldehyde to every #a1jjj cubic feet of air-space1 has been thoroughly tested and proven reliable4 ,the drug is simply poured on the sheet1 which is hung over a line in the room to be disinfected1 which has been prepared as above directed4 ,it should be remembered that formaldehyde has little or no power of penetration1 and for this reason all possible surfaces of materials to be disinfected should be exposed4 ,sidenote3 ,the ,daily ,cleaning ,in the daily cleaning1 the work should be so divided throughout the entire hospital that the regular morning cleaning can be accomplished in a comparatively short time1 leaving special cleaning to be completed later in the day4 ,in order to accomplish this1 it may be necessary to employ special cleaners by the hour4 ,this does away with the necessity of providing meals and lodging for a large force of cleaners4 ,by nine o'clock in the morning the halls and stairs should be in order1 front steps and walks cleaned1 wards swept and dusted and the whole interior presenting a neat appearance4 8,dust in a hospital is not only dust1 but danger40 ,domestic cleanliness and hospital cleanliness are quite different terms4 ,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 health4 ,on the hardwood floors a soft hair brush will raise less dust than the ordinary broom4 ,wet tea leaves should be sprinkled whenever obtainable4 ,the dust should be taken up frequently4 ,the ward floors1 unless polished1 should be washed every day4 ,it is well to change the water often and not use it too freely4 ,special attention needs to be given to corners4 ,after each meal it will be necessary to brush up the crumbs4 ,sidenote3 ,dusting ,the dusting is even more important than the sweeping1 and must be done with great thoroughness and care4 ,each patient in the hospital is helping to make the atmosphere impure by throwing off disease germs4 ,dried particles of pus1 blood and excreta1 lint from blankets and bedding1 scales of epithelium and other matter1 more or less dangerous1 are flying about in the air and being deposited on ledges1 skirting boards1 window sills1 bedstead rails and the various parts of furniture4 ,to bring in a feather duster or a dry cloth and attempt to dust1 is simply to flap the dust from one place only to have it settle in another4 ,it results in a more equal distribution of the dust1 but it is not dusting4 ,dusting is removing dust1 and the only way that can be done effectually is by the use of a damp cloth1 to which the particles will adhere4 ,furniture that will be injured by that kind of dusting is out of place in a hospital4 ,special attention needs to be given to dusting under radiators and in obscure nooks where dust will accumulate if not looked into daily4 ,sidenote3 ,bath ,rooms ,the bath rooms1 toilet rooms and lavatories also need constant supervision1 and ought to be as carefully cleaned and ventilated as any part of the hospital4 ,indeed1 special pains are needed if they are to be free from bad odors4 ,disinfectants should be used freely in these places at least once a week1 and any evidence of imperfect drainage promptly reported and attended to4 ,a good disinfectant for this purpose is the one known as the 8,american ,standard10 made by dissolving six ounces of chloride of lime in a gallon of water4 ,for cleaning bath tubs kerosene is recommended4 ,it is a wise precaution to constantly keep posted over closets and sinks a notice prohibiting the throwing of matches1 hair and insoluble material into them4 ,more than one plumber's bill has been caused by a careless maid emptying her bar of soap from her scrubbing pail into the closet4 ,in fact1 so common is that occurrence that a careful housekeeper has invented a device for holding the soap1 thus preventing such accidents1 and also the waste caused by leaving the soap in the water4 ,this device is a tin box about eight inches long by four inches wide and four inches deep in front and six at the back4 ,on the back are two pieces of wire bent over to fasten the box to the outside of the scrubbing pail4 ,these can be made by any tinsmith at a very small cost1 and will hold a cake of soap and a cake of sapolio4 ,they will save many times their cost in a year4 ,,chapter ,,iii4 ,sidenote3 ,the ,hospital ,ward ,it is in the hospital ward that the major portion of routine hospital work is accomplished1 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 neatness1 in proper systems of ward work and good hospital housekeeping4 ,inasmuch as the number of hospital officers varies with the size and demands of the hospital1 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 harmony4 ,in all but small hospitals1 competent assistants in both the nursing and domestic departments will be needed1 but the authority and responsibility of affairs domestic should be centered in one woman4 ,whatever may be the opinion of hospital trustees on that point1 no one who has lived for a year in a hospital where the superintendent of nurses and the matron were equal in authority1 and pulling in opposite directions1 will sigh for a repetition of the experience4 ,the architecture of the hospital ward1 and the general plans of the building1 will have not a little influence in creating difficulties for the housekeeper and in adding to1 or lessening1 the burdens of the nursing staff4 ,tiled floors and walls are ideal for wards1 but too expensive for every hospital to have4 ,even five feet of tiling on ward walls is greatly to be desired4 ,denied that luxury1 as many hospitals are1 the next best thing is to have the walls finished in cement or hard plaster1 which1 if well coated with enamel paint1 will admit of thorough cleansing and disinfection4 ,heavy moulding and sharp corners which afford a lodging place for dust and germs should not be there4 ,the ceilings should be high1 and ample air-space provided for the number of patients for which the ward is designed4 ,the ventilating shafts1 windows and radiators should be arranged with reference to the proposed location of the ward beds4 ,when the hospital housekeeper can manage it1 each ward will have its own linen room1 with abundance of linen4 ,it adds no small item to the number of miles a nurse is obliged to walk each day1 if every time she needs a clean sheet1 towel or gown she has to walk half the length or the whole length of a long hall to get it4 ,a little forethought and consideration for the nurse's part in the hospital economy1 in arranging the plans of the building1 would result in at least avoiding unnecessary labor for those who will have no small part in carrying out the humane designs of the hospital4 ,sidenote3 ,soiled ,clothing ,of equal importance is it to have a 8clothes chute0 on every floor1 connecting with the sorting room in the basement4 ,this will render unnecessary large receptacles for soiled linen4 ,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 injurious4 ,the atmosphere cannot be pure while soiled linen is there to give off its impure odors4 ,very dirty linen should be rolled in a separate bundle4 ,pins should be removed and disinfection attended to before being sent to the laundry4 ,clothing belonging to patients should be plainly marked with the owner's name4 ,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 patient4 ,there is always danger of their being lost or torn4 ,sidenote3 ,buying ,beds ,the ward beds should be of uniform height and style and well coated with enamel paint4 ,in buying beds several important points are to be considered4 ,if beds are offered which require two men1 and a hammer1 and a box of bolts and a wrench1 to get them adjusted1 they should not be considered1 even if listed at a dollar each4 ,they are dear at any price1 when one considers the prices that prevail in the labor market1 the strain on human patience1 and the fuss that the moving of such a bed to another room or ward entails4 ,it is a mistake1 too1 to buy beds without inquiring the length4 ,six-foot patients are not uncommon1 and these find it very distressing when put in a bed that is too short4 ,the bed should be at least six feet four inches in length4 ,in all hospital beds1 there should be some kind of bar at the foot1 that will keep the mattress from slipping down4 ,some hospitals have attempted to remedy this defect in beds by having boards sawed and placed as foot boards1 but these are unsightly1 and if the right kind of bed is bought such makeshifts will not be necessary4 ,before ordering a quantity of beds1 it is well to get a trial bed1 and thus be sure of the quality of mesh in the wire mattress1 and that other details are satisfactory4 ,no beds without back rests should be purchased1 for in the majority of cases a back rest will be necessary4 ,separate back rests must be purchased and stored when not in use1 and these are rarely as satisfactory as when attached to the bed4 ,it is well1 also1 to look closely into the plan of the back rest4 ,some have a round iron rod across the lower edge ,if such a thing is there1 a sensitive1 nervous patient will discover that rod1 and worry till she or it is removed4 ,in ordering beds it is wise always to state the height from the ground that is desired1 or low beds may be sent4 ,about twenty-four or twenty-six inches is the usual height desired4 ,it is possible to secure beds that can be adjusted to any desired height4 ,the disadvantage of such beds is the difficulty of adjustment so that each corner will be exactly as high as the other corners4 ,each one must be measured1 and the moving of the wire mattress up and down on the legs of the bed1 makes it impossible to keep the enamel on the legs4 ,by all means hospital beds should have castors1 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 moved4 ,there is a great difference in castors and in their durability4 ,for the general wear and tear of a hospital1 the cotton-felt mattress is giving better satisfaction than the hair mattress1 and it is somewhat less expensive4 ,it is a good plan to have a few pads made of bed ticking thickly inlaid with cotton batting4 ,these should be made the same size as the bed1 with rings at the corners to secure them4 ,for very filthy or unconscious patients these pads are desirable1 as they can be washed and boiled as often as necessary4 ,a couple of these pads makes a bed as comfortable as a mattress4 ,sidenote3 ,bed ,making ,the mattress should be carefully protected by a rubber sheet securely fastened at the corners4 ,every nurse thinks she knows how to make a bed before she goes to a hospital for training1 but as a matter of fact very few do4 ,it is sometimes a difficult thing for the nurse to learn1 but it is one of the most important of the early lessons in ward work4 ,the appearance of the ward beds1 and the way in which they are made1 is a good index to the character of the nurse in charge4 ,if the spread is on crooked1 the open ends of the pillow covers pointing in opposite directions1 and the bed has the loose appearance of having been thrown together without method1 one may naturally expect the general work of the nurse to be slipshod and unreliable4 ,it is well to teach nurses to stand at the ward door occasionally1 and take a critical survey of the ward1 noting down the things out of order4 ,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 disease4 ,order1 which is said to be ,heaven's first law1 should be one of the first laws of ward work4 ,even the height of the curtains of the windows add to or detract from the appearance of the ward4 ,the beds should be an equal distance apart and in a straight line4 ,the head of the bed should never be used as a drying-place for wash cloths or towels1 nor as a hook on which to hang bath robes and wrappers4 ,sidenote3 ,ward ,lockers ,aseptic ward tables of iron and glass are now being used in some hospitals1 but it is doubtful if their use will ever be general4 ,they answer some of the purposes of a ward table1 but not all4 ,even very poor patients prefer to have their own combs and toilet articles1 their own handkerchiefs and stationery1 their own books and flowers4 ,if some place is not provided for these numerous small things1 which the average patients find it necessary to have close by1 they will inevitably resort to stowing their 8things0 under the mattress--a custom not to be tolerated by the neat housekeeper4 ,good housekeeping requires that in a hospital1 as elsewhere1 a place be provided for everything and everything be kept in its place4 ,until the proper aseptic ward table is invented and offered at a reasonable price1 the small wooden locker1 well coated inside and out with enamel paint1 will continue to be used4 ,these lockers can be made to order for a very moderate price1 usually from three to five dollars each4 ,they should be about #bj inches in width1 #cj inches from the floor1 #ad inches deep1 and mounted on castors4 ,the drawer should be about #d inches deep and there should be a shelf in the lower part4 ,a daily inspection of bedside lockers is necessary1 or apple cores1 fruit peelings1 remnants of food1 and refuse of various kinds will accumulate4 ,all cupboards and linen rooms should have daily attention1 and should be in such perfect order that the doors may be thrown open at any time for inspection without embarrassing the nurse in charge4 ,sidenote3 ,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 patient1 and the list recorded in a book provided for the purpose in every ward4 ,each article should be labelled1 and placed in the locker in the general clothes room1 and the number of the locker noted with the list of clothing in the record book4 ,an accurate and uniform system of clothes records throughout the hospital should be insisted on4 ,unless this is done confusion when the nurses' places are changed will be inevitable4 ,carelessness in this duty on the part of a nurse has resulted in no small discomfiture to the hospital officers4 ,clothing has been mislaid and not found for weeks after the patient has left the hospital1 and the whole institution has been branded with negligence by the patient and his friends4 ,all the kindness received1 and the most skillful professional treatment1 will often be lost sight of1 if1 through the carelessness of a nurse1 the hospital is unable to render to the patient the clothing entrusted for safe-keeping4 ,money or valuables should never be kept either in private room or hospital ward1 but sent to the office to be deposited in the safe4 ,sidenote3 ,ward ,medicine and ,records ,though many well-regulated hospitals have a medicine cabinet in every ward1 the custom does not generally prevail1 nor is it desirable that it should4 ,the less a patient knows1 sees or thinks of medicine1 except the dose intended for him at the time1 the better4 ,the custom of hanging clinical records over the foot or at the head of the bed is another custom that might better be abandoned1 even though it be very convenient for the nurse4 ,patients are only too prone to meditate upon and discuss their symptoms1 in spite of all efforts to induce them to trust themselves entirely to doctors and nurses1 and cease questioning and worry4 ,some sympathizing friend or convalescent patient may be depended upon to keep them informed when an unpleasant symptom is recorded4 ,this will occur in spite of all rules and vigilance4 ,it is not easy under any circumstances to keep ward patients from discussing their ailments and symptoms4 ,especially is this true in women's wards4 ,in men's wards the newspapers are read1 the political situation is discussed1 city improvements and occurrences are talked about1 all sorts of subjects occupy the time of those who are able to talk1 but a different state of things entirely prevails in the women's wards4 ,what they get to eat1 how they feel1 and the nurses and doctors furnish the general topics there4 ,to have a clinical record to gossip about might divert attention from the nurses and doctors1 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 symptoms4 ,sidenote3 ,adjuncts to the ,hospital ,ward ,the tendency in modern hospitals is in favor of smaller wards1 as affording better facilities for proper classification and separation of patients4 ,a nurses' utility room adjoining every large ward or located conveniently near two or three small wards1 where medicines1 clinical records1 supply charts and blanks1 order books and the memorandum books necessary for ward work are kept1 is a much appreciated convenience in some hospitals4 ,opening off this room is the ward diet kitchen1 where the refrigerator and food supplies for the ward are kept1 and the facilities for quick preparation of special diets for individual patients4 ,sidenote3 ,quiet ,room ,a much needed adjunct to a hospital ward is an isolation or 8quiet0 room1 to which a patient whose presence is offensive to the other occupants of the ward may be removed4 ,whenever possible1 a dying patient should be separated from the other patients in the ward4 ,gruesome tales that are disgraceful have been told of patients passing out of life in full view of the other occupants of the ward1 without even the measure of privacy a screen affords4 ,it is a melancholy comfort to relatives and friends to be with the patient in his last hours1 and this cannot be permitted in a ward without confusion and discomfort to other patients4 ,when planning a ward for the care of the sick or the poor1 the object1 of course1 is the saving of lives1 but people will die in hospitals in spite of the best skill and care1 and the poor man is surely entitled to a quiet place to die in4 ,there is much in hospital life to blunt the sensibilities of those who live in such institutions constantly4 ,familiarity with suffering and death robs them of mystery and awe1 but it should never be allowed to detract from the reverent care of the dying and dead4 8,put yourself in his place10 is a good rule to observe in dealing with even the most unworthy of ,adam's sons4 ,sidenote3 ,matters ,miscellaneous ,the ease with which the routine work of the ward goes on will depend largely on proper facilities and a proper system4 ,there should be a regular order for the work of the day--a time for bed making1 a time for sweeping and dusting and washing the ward floors1 a time for the daily cleaning of the bath rooms and toilet rooms and refrigerators and cupboards4 ,interruptions may be expected1 but unless a routine order of work is established the cleaning will be executed in haphazard style4 ,neither nurses nor maids can be depended on to use their judgment in such matters4 ,if left to plan their work1 they will probably be found sweeping their wards when the doctors are ready to begin their dressings1 and the time for other things will depend on their ideas of the importance of the various duties4 ,the habit of doing things quickly and thoroughly should be formed by every one who has any responsibility of the routine work of a hospital1 where everything should move with clock-work precision4 ,so much time can be wasted by lack of system1 or in talking or dawdling4 ,the untidy habit of leaving glasses or utensils dirty till a sufficient quantity has accumulated to make it a necessity to wash them1 should never be tolerated4 ,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 basins1 and syringes1 and dressing pans1 and instruments1 and drinking-cups1 and medicine glasses1 and the thousand and one little things that go to make up the complete furnishings of the hospital ward4 ,but1 as a matter of fact1 many nurses go through their course of training hampered by a lack of facilities for proper work4 ,one set of instruments for dressing is provided1 where several are needed at the same time2 insufficient linen to keep the beds and their occupants clean is the rule1 and so on indefinitely4 ,sidenote3 ,destruction of ,appliances ,on the other hand1 head nurses and hospital housekeepers lament over the carelessness of nurses and the constant destruction of hospital appliances4 ,just what course to pursue with the girl who every few days puts a rubber catheter or rectal tube or nozzle on to boil1 and lets it burn up2 who pours boiling drinks into glass tumblers1 and thereby keeps up a constant breakage2 who leaves hypodermic needles without wires1 and finds them useless when needed again2 who breaks medicine glasses and fails to report the accident1 till the head nurse finds her measuring medicine with a spoon2 who puts the thermometer into the mouths of delirious patients or children1 and goes away and forgets it2 who lets the sterilizer boil dry2 who puts glass syringes and appliances in unsafe places1 and returns to find them broken--just what course to pursue to correct these destructive tendencies is an ever-recurring problem to the hospital housekeeper4 ,nurses who are most careful and conscientious in carrying out the doctor's orders1 and in their duties to the patients1 frequently lack that fine sense of honor regarding their duty to the hospital and the care of materials4 ,a deposit for breakage is now demanded in some hospitals when a nurse enters for training4 ,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 carelessness4 ,proper economy in the use of hospital goods is an important lesson for nurses to learn early in their career1 and one which will demand frequent emphasis throughout their course4 ,gas stoves are left burning when not in use1 and help to swell the gas bill4 ,milk is left out of the ice-box1 and quickly becomes unfit for use4 ,materials of various kinds that could be utilized are thrown away4 ,the destruction or waste of one article seems a very trivial affair1 but in the aggregate such trivial affairs amount to hundreds of dollars in the course of a year4 ,the cost of rubber sheets alone is an important item in ward expenses4 ,the best will soon crack if folded when not in use4 ,if loops of tape are fastened to the corners and the sheets hung against a closet wall when not in use1 they will be found to last twice as long4 ,sidenote3 ,screens ,plenty of screens in a hospital ward is a necessity to proper nursing4 ,the poor appreciate privacy and refinement and delicacy as much as many of their wealthier neighbors1 and they have a right to such privacy as a screen affords4 ,the timid1 frightened little woman who has just been admitted1 and who shrinks from the gaze of everybody1 ought to be screened off till the first awful feeling of strangeness wears away4 ,the patient who is critically ill needs also to be screened4 ,the general work of the ward requires the constant use of screens4 ,one screen for every two beds is not too many for the necessities of the average ward4 ,one of the most practical and altogether desirable ward screens is made of a wooden frame1 white enameled1 covered on both sides with white oilcloth4 ,a set of clothes-bars1 from four and a half to five feet high1 makes a very satisfactory frame1 that is large and yet light enough for one nurse to handle4 ,a fair equipment for a ward of twenty beds would be3 ,white enameled iron bedsteads1 with adjustable back rests #bj ,mattresses 7hair or cotton-felt7 #bj ,spreads #dj ,pillows 7hair7 #bj ,pillows 7feather7 #bj ,rubber pillow covers #f ,rubber sheets #bj ,rubber sheets 7smaller1 for baths1 dressings1 etc47 #h ,sheets #abj ,draw sheets #abj ,blankets1 forty pairs #hj ,towels 7for patients7 #abj ,bath towels #fj ,surgical towels #hj ,roller towels for lavatory and pantry #bj ,bed trays 7for meals7 #bj ,extension tables for reading1 etc4 #e ,stupe towels with sticks #aj ,pillow covers #abj ,night shirts or gowns #fj ,dressing sacks or bath robes #aj ,glass towels #ab ,bedside lockers 7with drawer and cupboard7 #bj ,folding screens1 white enameled #ab ,ward tables for nurses' use1 with drawers for charts1 records1 sheets1 etc4 #b ,medicine cabinet1 iron and glass1 white enameled #a ,dressing carriage1 glass and iron1 white enameled #a ,pus basins1 different sizes #f ,pitchers1 agate ware #c ,covered cans for sterilized water 7two gallons7 #b ,jars for ointments #f ,jars for sterile dressings #c ,jars for bandages #b ,jars for absorbent cotton #b ,trays for instruments 7agate ware7 #d ,scissors for dressings #d ,leg rests1 for elevations #b ,dressing forceps #d ,probes and directors of each #d ,covers for dressings #dj ,bowls and basins1 agate ware #h ,solution bottles 7large7 #f ,receivers for soiled dressings #d ,spatulas #b ,spirit lamp #a ,graduate glasses for surgical work #c ,thermometer 7bath7 #a ,syringes 7glass7 #d ,tape measure #a ,surgical air cushions #b ,rubber finger tips #ab ,foot tubs #d ,vomiting basins #f ,graduate glasses for measuring urine #b ,scissors for general use #a ,bandage scissors #a ,soap dishes #d ,saucepans1 graduated sizes #f ,brooms 7common7 #c ,brooms1 hair #a ,brooms 7birch for sinks1 closets1 etc47 #f ,dust pans #c ,water coolers #b ,medicine trays #d ,medicine glasses 7graduated7 #aj ,drinking glasses #ab ,refrigerator #a ,thermometer #a ,corkscrews #b ,hot water bottles #bj ,bed-cradles #b ,immersion buckets for limbs #a ,wash basins #h ,nail brushes #aj ,combs #f ,looking glasses #d ,bed pans #aj ,urinals #aj ,douche pans #d ,sputum cups #aj ,catherostat #a ,bedside chairs1 iron1 white enameled1 with rubber tips #bj ,wheel chairs #c ,rockers #d ,two-bowl washstand on rubber-tired wheels for doctors' use #a ,,chapter ,,iv4 ,sidenote3 ,the ,linen ,room ,the linen room is one of the very important parts of the institution4 ,demands will be made on it almost every hour1 and1 if the hospital is to do proper work1 it must be equal to the demands4 ,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 condition4 ,lack of knowledge on the part of the managers as to the amount of supplies necessary1 rather than a lack of money1 is accountable for the shortage of linen in many hospitals4 ,an important part of the housekeeper's duties is to know what supplies are on hand1 and keep the board informed as to the needs4 ,time1 and tact1 and perseverance in educating them as to what is absolutely necessary for proper work1 will do much to correct such defects in hospital management4 ,it is difficult for the laity1 who are perhaps accustomed to having bedding changed in their homes but once a week1 and then sometimes allowing for but one clean sheet for each bed1 to appreciate that a constant changing of beds goes on in a hospital1 both day and night1 and that economy is out of the question4 ,a hospital can really afford to be extravagant in the matter of linen4 ,that is one point1 and perhaps the only one1 in which lavish expenditure will really redound to the good of the hospital4 ,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 condition4 ,cleanliness may be next to godliness in most circumstances1 but no hospital can afford to let cleanliness take second rank with any other virtue4 ,in fact1 if want of cleanliness in the care of the beds or patients be noted1 very grave doubts as to the godliness of the management will surely arise1 be the professions in that direction never so loud4 ,sidenote3 ,bed ,linen ,the amount of linen required per bed will depend somewhat on the character of the work done in the hospital4 ,where only acute cases are handled1 and emergency work is done1 the supply must needs be greater1 as the average number of patients entirely confined to bed will be greater4 ,six pairs of sheets and pillow covers for each bed is a fair amount to begin with4 ,that number of sheets is often needed for one patient in a day1 but taking the average patient in the average ward1 that amount will usually be sufficient1 even to provide for the extra demand in special cases4 ,a half-dozen draw sheets for each bed in the ward are also necessary4 ,six face towels and four bath towels per bed is a fair estimate4 ,two spreads for each bed and two pairs of blankets will be sufficient for the ordinary ward1 but a few extra blankets should be provided for each ward1 for the use of patients who require extra heat4 ,this estimate is based on the supposition that linen sent to the laundry ,monday morning will be returned at the latest by ,wednesday morning following4 ,every well equipped hospital has its supply of gowns for the use of any patient who needs them or cares to use them4 ,they are best made to order of firm bleached muslin1 without trimming of any kind4 ,for ease in management they should be open all the way and should fasten in the back4 ,tape fastenings will be found most satisfactory1 as buttons are constantly torn off in the mangle4 ,sidenote3 ,the ,room ,the linen room should be really a room--not a closet4 ,special cupboards or closets for each ward or department will be needed1 but the general linen room has special needs that do not apply to the ward closets4 ,plenty of light is a necessity4 ,a work-table1 a sewing machine1 and a gas stove on which an iron may be heated1 should be in it1 besides the shelves and cupboards needed for the hospital linen supply4 ,to this room new linen should be sent to be marked4 ,sidenote3 ,marking ,linen ,it will be found that a uniform system of marking linen will save time in sorting4 ,sheets may be marked on the wrong side at the corner of the top end1 pillow covers an inch above the hem close to the seam1 towels in the corner of one end just above the hem1 table-napkins and tray cloths diagonally across the corner4 ,blankets and spreads may be marked by a tape sewn diagonally across the corner4 ,sidenote3 ,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 hands4 ,it is very important to have a systematic method of accounting for linen that will enable the housekeeper to know the amount on hand1 and to discover if linen is lost4 ,it matters not whether the washing is done on the hospital premises or sent to a commercial laundry1 some system of accounting is necessary unless the housekeeper is willing for a constant depletion of blankets1 sheets1 towels1 etc41 to go on without her knowledge4 ,where a public laundry is patronized the importance of this matter is evident4 ,when hundreds of towels and sheets are sent in at once1 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 amounts1 from which1 if articles were missing1 it would be quickly discovered4 ,the housekeeper of a certain institution relates the following incident bearing on this point3 ,the linen of the institution was sent to a public laundry1 and for some time she had been missing towels1 though the laundry always claimed to return the proper number4 ,finally the manager of the institution happened into a barber shop and accidentally discovered there a pile of the institution towels4 ,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 them4 ,the barber cared nothing whose mark was on the towels if he got as many as he sent4 ,a laundry employee had been in the habit of substituting linen from large institutions to make up the required number from smaller lots1 and thus the problem of the missing linen for that institution was solved4 ,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 premises4 ,if all servants and everybody about the establishment were tried and true and trustworthy1 through and through1 it might be safe1 but in these days of possible degeneracy and certain uncertainty in the servant class1 it is wise to trust implicitly but few1 and to keep an eye on those4 ,sidenote3 ,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 discarded4 ,well-worn or torn linen should not be sent to the wards4 ,a special drawer1 marked 8,discarded ,linen10 should be in the general linen room1 and into this the one who sorts linen can lay aside what in her judgment is unfit for wear or beyond mending4 ,but the housekeeper should reserve for herself the privilege of deciding when an article is to be used as old linen4 ,unless this rule is rigidly enforced1 a reckless extravagance will be the result4 ,good towels will be used as dusters or as scouring cloths4 ,sheets that might have been utilized in some other way will be torn up and used as cleaning cloths1 and a constant depletion of the supply will go on without the housekeeper's knowledge4 ,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 towels1 sheets and pillow covers for cleaning purposes4 ,constant vigilance in that direction for months was needed to impress the household that the haphazard1 loose way of handling linen was a thing of the past4 ,sidenote3 ,emergency ,supply ,every careful hospital housekeeper has found the necessity of a special closet1 for the storing of extra linen of all kinds for times of special emergency4 ,it is poor management to have the full supply in circulation at one time4 ,attention to this emergency closet will save embarrassment many times4 ,what could be more embarrassing than to have a patient injured in an accident1 brought in grimy and dirty1 and not have a clean gown to put on him8 ,and yet that very thing has happened when the hospital housekeeper has failed to anticipate the emergency4 ,sheets that are worn thin in the center may be doubled and stitched together for draw sheets1 and in that way will last for months4 ,the ends of bath towels can be hemmed for wash cloths4 ,squares of linen from partly worn tray-cloths and napkins may often be fringed for doilies for ward medicine trays4 ,the training in economy in supplies1 and in methods of utilizing material that would otherwise be wasted1 is an important part of the nurse's training that will benefit her through life4 ,sidenote3 ,removing ,stains ,the nurses1 too1 in their use of hospital linen1 are responsible in no small measure for its appearance4 ,blood-stains and various other stains can be readily washed out when the stain is fresh4 ,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 laundry4 ,a little salt in the water will hasten the process4 ,if such matters were thoroughly impressed on each nurse1 as a part of her duty in her hospital training1 there would be fewer complaints of nurses in private practice needing an extra maid to wait on them4 ,stains from certain oily dressings are exceedingly difficult to remove4 ,in fact1 in the general washing it is practically impossible to thoroughly efface such stains4 ,a little care in managing1 and1 as far as possible1 keeping one set of sheets for cases requiring such dressing1 will prevent the whole ward supply from being stained4 ,the oldest linen should be specially set apart for such cases4 ,sidenote3 ,new ,linen ,where a regular maid is in charge of the linen room1 she can usually1 in addition to the general care of the linen1 make up new material4 ,the cutting of new goods is a matter for the housekeeper's personal supervision4 ,each new lot of linen that is laid on the shelves for general use should be added to her inventory4 ,under the heading of 8,discarded ,linen0 in her linen account book1 she can mark each piece she lays aside as old linen1 and by reckoning up each month the new linen that is added1 and the discarded linen1 can readily keep account of the amount in general use4 ,in buying linen for a hospital it is questionable economy ever to buy cheap material4 ,towels and spreads should always be without fringe4 ,sidenote3 ,shelf ,management ,in placing linen on the shelves of a general linen room some method will be found advantageous4 ,if the rule is to lay towels and pillow covers on the shelves in piles of twenty1 sheets and spreads and gowns in piles of a dozen1 it is but the work of a few minutes to take an inventory of the contents of the linen room4 ,if1 in buying linen1 the housekeeper has taken pains to secure glass towels with some distinctive pattern or coloring1 it will be easy to keep the kitchen1 diet kitchen and ward glass towels in separate piles4 ,red and white check toweling for the kitchen1 blue and white check for the diet kitchen1 and plain white toweling with a single stripe on the edge1 for the ward glass towels1 is a distinction easy to secure in any place4 ,face towels for patients can be secured with red border and for nurses and officers with blue4 ,sidenote3 ,laundry ,bags ,each nurse should be instructed to bring with her two laundry bags--one to be kept in her room to receive soiled linen1 the other to be sent to the sorting room1 to remain till the clean clothes are returned in it4 ,a list of the articles contained should be pinned to each bag to facilitate the sorting of the clean clothes and for reference4 ,it is needless to state that all nurse's clothing should be marked with her full name4 ,initials may be sufficient marking in a home1 but are useless in a hospital4 ,if it can be brought about 7and it can by insisting on it71 it will be found that a uniform system of marking nurses' clothing will be a great saving of time in sorting4 ,to have a pile of thirty or forty nightdresses to sort and put in bags1 and find no two marked in the same place1 making it necessary to unfold every garment and look it over on all sides to find the mark1 is an unnecessary trial and waste of time for whoever has the sorting to do4 ,if each garment were marked on the under side of the front1 which is usually folded on top1 to sort them would be an easy matter4 ,to return clothing without being washed1 when the nurse has not marked it properly1 is the only way to teach nurses1 who are habitually careless in their marking4 ,printed laundry lists should be furnished for the sorting room1 duplicate lists of each lot of clothes sent to the laundry being made4 ,one list goes to the head laundress1 the other is retained in the sorting room for reference4 ,,housekeeper',s ,,linen ,,account ,,book ---------------------------------------- ----------------------- ,date ,supplies ,purchased ,supplies ,received ,value ,remarks ---------------------------------------- ----------------------- ---------------------------------------- ----------------------- ---------------------------------------- ----------------------- ---------------------------------------- ----------------------- ---------------------------------------- ----------------------- ,,chapter ,v4 ,sidenote3 ,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 laundry4 ,though out of sight1 its results are always in evidence1 and failure in the laundry means that every part of the work of the establishment is handicapped4 ,there may be abundance of linen to meet the needs of the hospital1 and yet if constant supervision over the work of the laundry is not exercised1 three-fourths of the linen supply may at times be found piled in the laundry1 the linen room shelves empty1 and the nurses flying hither and thither on borrowing expeditions when a clean towel is called for4 ,a wise philosopher has said1 8,every man is as lazy as he dares to be10 and the average laundry employee is like the rest of the world in that respect4 ,few of them love the work for the work's sake1 and if the weekly wage is not sufficiently large to be attractive1 they will be lazy and neglect their work if they have opportunity4 ,sidenote3 ,manager's ,duties ,a competent manager for the laundry is essential for successful work1 especially in a large institution4 ,this person should know how to manage his staff of helpers so as to secure the best possible service1 and should have a knowledge of the needs of the institution where his own department is concerned1 and of the work that is important to be done without delay4 ,good common sense in arranging the time when the different parts of the work should be done1 will prevent much trouble in any laundry4 ,nurses' clothing and articles not in constant demand1 that are returned but once a week1 can be laid aside to make way for the things in constant demand4 ,when once a competent manager is secured1 the buying of supplies may be safely entrusted to him4 ,but1 unfortunately for the hospital housekeeper1 few except the larger hospitals can afford the luxury of a skilled manager for the laundry4 ,a head laundress is the nearest they can approach to such a luxury1 and even that much needed individual is often out of reach4 ,in many cases the hospital housekeeper1 in addition to her other duties1 has really to take the place of manager of the laundry4 ,where several laundresses are employed1 and none are fitted for directing the work of others1 it is a wise provision for the housekeeper to personally divide the work and assign it1 and have each laundress responsible to her4 ,the servant problem has assumed such an acute form that it requires delicate handling in any household1 and where the character of the work is as important as that of the hospital laundry1 every possible tendency to friction should be avoided4 ,sidenote3 ,laundry ,workers ,let laundry workers understand fully what their hours of work shall be1 and that they are expected to be in their places promptly at the hour4 ,explain the importance of having the supplies for the wards and operating rooms constantly kept up to the mark1 and also the linen for the trays4 ,prohibit visitors during working hours4 ,it is always better to make such prohibitions when engaging help rather than wait for some occasion to call it forth4 ,the occasion will certainly come unless it is anticipated and prevented4 ,make some provision for them to do their own personal washing1 and let it be plainly understood they are not to take in washing from other sources to increase their income4 ,that is sometimes tried and carried on very successfully1 if it is found that the laundry has not careful supervision4 ,if it is not desirable for their own washing to be done in connection with the hospital1 then a time must be arranged for it4 ,where the laundresses are mothers of families1 as is often the case1 this point is worth mentioning at the time of engagement4 ,their washing must be done--the question is1 when and where4 ,it is better to have a plain understanding about the matter than to have them attempt a course of deception4 ,feed the laundresses well and arrange for them to make a cup of tea or coffee between meals if they want it4 ,the work is hard and exhausting1 and they cannot put their best into it if they are hungry4 ,take an interest in their health and see that their minor ailments are attended to when necessary4 ,arrange for an afternoon off at least once in two weeks4 ,they have little matters of business to attend to1 and they need the recreation as much as other people4 ,arrange to visit the laundry at least every day--twice a day if possible1 and not always at the same hour4 ,commend their work and their promptness when there is room for it4 ,a word of appreciation will often do more to inspire them to better service than a severe rebuke4 ,when they have worked overtime in some unusual rush1 do not forget to mention your appreciation of it4 ,then see that they have proper things to work with4 ,it is impossible to have satisfactory service if proper facilities are not provided4 ,sidenote3 ,starching ,the housekeeper1 where no manager of the laundry is employed1 will have the purchasing and giving out of supplies and should have an idea of how much is needed for each week's work4 ,provide a good quality of soap and starch4 ,the cheaper grades are almost always more expensive owing to the additional amount necessary for the work4 ,the better grade of starch will produce better finished work4 ,see that the vessels used for starching are well cleansed after use4 ,know something about the methods used in starching4 ,if collars1 cuffs and belts are not stiff1 inquire the reason4 ,to produce a proper stiffness1 the starch should be used as hot as can be borne by the hand1 and well rubbed in4 ,clothing that is starched should be put to dry as soon as the starching is completed4 ,if left around in baskets the articles will inevitably come out discolored4 ,it is well to give a list of the articles requiring starching rather than trust to their judgment4 ,aprons and coats for the operating room that are to be put in the sterilizer need no starching1 while other aprons and coats must be starched4 ,they will not know the difference if they are not told4 ,sidenote3 ,bluing ,if the clothes are streaked with blue1 make some inquiries into the washing process4 ,it may be the clothes have not been rinsed thoroughly free from soap4 ,they should pass through at least two rinsing waters 7three is better7 to free them from soap4 ,the first rinsing water should be quite hot4 ,the bluing should be done in plenty of water1 so that every part of the garments may be under water4 ,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 blued4 ,in mixing the bluing water1 it is easy for parts of the vessel to become deeply stained with the strong bluing solution1 which will be rubbed into the clothes and leave streaks4 ,when plenty of soda is used to soften the water there will be less trouble with black specks from the soap4 ,impress on them the fact that the nurses' uniforms and colored shirt waists are not to be boiled4 ,if the uniforms are thoroughly soaked over night in a strong salt solution they will retain the color better4 ,when uniforms are dried in the open air see that they are hung wrong side out4 ,special care needs to be used in washing blankets4 ,they should be dealt with separately and gotten through with quickly4 ,the suds should be quite hot and a little ammonia added4 ,the rinsing should be in water of the same temperature and they should be dried in the open air4 ,sidenote3 ,drying ,whenever possible have all the hospital clothes dried in the open air4 ,no drying room1 however well constructed1 can compare with nature's process of drying by fresh air and sunshine4 ,the best method of bleaching is by the use of the sun rays while the clothes are wet4 ,however1 in planning for laundry work1 it is never wise to depend entirely on open air drying4 ,an artificial dryer is a necessity where promptness is required4 ,quick drying is essential to good work4 ,where bad work is done1 the trouble is oftener in the washing than in the drying4 ,sidenote3 ,ironing ,in planning for the ironing much may be done to facilitate the work4 ,little labor-saving devices can be introduced which will increase the amount of work done in a day4 ,ironing boards of special shapes1 and for special purposes1 and tables of various designs can be had for a trifle and will result in a saving of time and more finished work4 ,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 ironed4 ,see that they have proper irons for the different parts of their work and that they have wax to use as needed4 ,supply unbleached muslin for ironing sheets or the hospital sheets will be found covering the ironing boards4 ,instruct them to keep their ironing sheets clean4 ,well-finished work cannot be produced on a dirty ironing sheet4 ,sidenote3 ,routine of ,work ,let the laundresses understand that bad work will not be accepted1 and they will not send it4 ,bad work that was passed in the linen room has often caused embarrassment in the operating room4 ,as far as possible1 have a routine order for laundry work1 and expect the laundresses to comply4 ,if they understand that clothing sent from the wards on ,tuesday morning must be returned to the wards not later than ,thursday morning1 they can arrange to have it done1 while if no limit is set for the clothes to be in the laundry1 the haphazard results will be constantly felt in the wards4 ,have a method of folding linen and insist on that method being followed4 ,it is impossible to have neat-looking shelves in the linen room if no uniformity be observed about folding in the laundry4 ,then see that the work rooms are kept clean4 ,it is useless to expect clean linen unless the laundry and its furnishings are kept in proper condition4 ,the woodwork and windows and floors should be as scrupulously clean as any other part of the hospital4 ,but they will not be kept so unless a time is set for the cleaning1 and someone sees that it is done4 ,greasy towels or clothes1 from the kitchen1 pantries and bake rooms1 should either be entirely washed by those who use them1 or have a preliminary washing before being sent to the laundry4 ,such articles cannot be washed with any other clothing2 a special suds must be gotten ready and time spent that would have counted for more if spent on other work4 ,a false economy in planning a hospital often results in a space entirely inadequate being set apart for the laundry4 ,as the general work of the hospital increases it is then found impossible to meet the demands1 and recourse has to be had to the public laundry--always an expensive arrangement4 ,another common mistake1 is to place the laundry in the basement1 where lack of light and air is always a hindrance to good work4 ,whenever possible1 the laundry should be located in a separate building1 where plenty of light and air and sunshine can penetrate1 and where there is room to separate the clothing while in its different processes and proper work can be done4 ,all clothing should be well aired and thoroughly dry before it leaves the laundry1 so that it may immediately be placed on the shelves for use4 ,sidenote3 ,the ,laundry ,plant ,it is difficult to give an accurate estimate regarding the cost of installation and operation of a laundry plant1 as conditions vary greatly4 ,a list of the articles required for a plant capable of doing the work of a sixty-bed hospital is appended4 ,in preparing this list the elimination1 so far as possible1 of all expensive features1 has been attempted4 ,a laundry plant1 like nearly everything else1 can be figured on in various ways1 and at largely varying cost1 so that1 with different machines1 a plant with the same amount of machinery will cost three times as much as another of practically equal capacity and actual working value4 ,it is well1 therefore1 before purchasing a plant1 to be thoroughly informed regarding the actual needs of a hospital1 the various makes and grades of machines1 cost of operating1 etc4 ,a very serviceable laundry equipment for a hospital of fifty to sixty patients1 is made up as follows3 ,one #ab h4 p4 vertical boiler1 complete with suitable injector and regular boiler trimmings4 ,one #f h4 p4 horizontal engine1 complete with all engine trimmings1 and a sight feed lubricator4 ,one #cf #cj wood washer4 ,one #bj-;inch solid curb extractor1 countershaft attached4 ,one #dj-;gallon galvanized steel soap tank1 with circular boil pipe4 ,one sectional dry room1 arranged to handle plain or fancy clothes1 and complete with three metal trucks1 ventilating fan1 etc4 ,one #ff-;inch steam mangle4 ,one #cj-;inch reversible body ironer4 ,two ironing tables4 ,one truck tub4 ,this outfit will cost about #a1ajj to #a1bjj1 including pipes1 pipe fittings1 valves1 shafting1 etc41 and will require a floor space of about #bd #dh feet4 ,the accompanying diagram gives a good idea of an economical arrangement of such a plant4 ,in one institution having about one hundred patients1 a plant similar to this is used4 ,all the work is done with two women and one man1 the man looking after the power and the washing4 ,if the hospital employs a man who can look after the power for two or three days in a week1 the cost for help may be reduced4 ,where the laundry work of a hospital runs up to #gej or #a1jjj a year1 there are but few instances where a direct financial saving will not be effected by the hospital operating its own laundry plant4 ,illustration ,,chapter ,,vi4 ,sidenote3 ,the ,hospital ,kitchen ,with the advance in science1 and a better knowledge of things desirable and things avoidable in hospital construction1 a gradual change is taking place in institutions designed for the care of the sick4 ,perhaps in no department have greater changes taken place than in the construction of the modern hospital kitchen4 ,instead of being located in the basement1 where odors from cooking were diffused throughout the whole building1 and where absence of light invited the accumulation of dirt1 the kitchen is now located in the top story1 or1 if the hospital be built on the cottage plan1 in a separate building4 ,in deciding on the location1 one thought should be prominent--the possibility of conveying cooked food without delay to those for whom it is prepared4 ,with proper facilities for keeping food hot1 this important point is not difficult of accomplishment4 ,sidenote3 ,general ,construction ,wherever the kitchen is located1 it should be large1 light and thoroughly ventilated4 ,proper care in planning and construction will insure the installation of vent flues and ducts to carry off smoke and odors1 as soon as generated4 ,as far as possible1 the interior of the kitchen and its furnishings should be constructed of non-absorbent material4 ,those who have had experience with cement floors claim for them that they are splendidly absorbent of grease1 exceedingly difficult to cleanse1 and liable to crack1 thereby furnishing crevices for the deposit of dirt of all kinds4 ,therefore1 in a hospital designed to be thoroughly sanitary1 cement floors will have no place4 ,tile seems to be the material that gives the most general satisfaction for kitchen floors and walls4 ,a white vitrified tile1 laid on a heavy foundation1 having the joints between the tiles carefully sealed with cement1 gives perhaps the nearest to the ideal kitchen floor yet attained4 ,if the floor is constructed so as to slope gently toward a drain properly trapped and protected1 the cleaning will be facilitated4 ,the side walls and ceiling of glass tile1 with the corners well rounded1 gives a surface that is not only bright and beautiful1 but thoroughly sanitary4 ,such a finish will endure the most severe cleaning without injury4 ,wood mouldings1 that invite the deposit of dust1 will of course be avoided4 ,the sinks in the hospital should be placed at sufficient distance from the walls1 so as to be accessible on all sides4 ,sidenote3 ,kitchen ,cabinet ,a hygienic outfit for the hygienic kitchen is of course essential1 but sometimes more difficult to secure than is the sanitary room4 ,dressers and drawers for the accommodation of the kitchen utensils must be provided1 and in these things crevices and angles and dark corners and all sorts of complications of this character seem unavoidable4 ,if these cabinets could be of metal1 all angles and corners done away with by the finishing with curves1 the shelves loose fitting and easily removable1 it would be a decided advance in kitchen arrangements4 ,the drawers could be made in the same way1 the emphasis being on the point 8easily removable40 ,thus constructed1 the person in charge would find it easier to remove them than to undertake to clean them while in position4 ,architects say1 that in hospitals where steam boilers and engines for supplying power for elevators1 electric lights1 laundries1 etc41 are in use1 arrangements should be made to utilize for cooking the large amount of exhaust steam1 that ordinarily goes to waste4 ,when this is done1 ashes1 smoke and their attendant ills can be avoided4 ,the hospital may then be not only 8a thing of beauty10 but 8a joy forever10 and the drudgery of that department greatly reduced4 ,through the courtesy of ,mr4 ,w4 ,j4 ,palmer1 architect1 of ,washington1 ,d4 ,c41 we are able to present drawings for a hospital kitchen embodying most of the features above mentioned4 ,the drawings were designed for a kitchen located on the ground floor in a separate building1 but with a few changes could be easily adapted to a kitchen located on the top floor4 ,the range is located in the center of the room1 with steam tables on each side to keep the cooked food hot4 ,a gas range is provided and a chopping block1 tables and dressers are arranged conveniently for work4 ,on one side is a small pantry1 which leads to the vegetable cellar beneath1 and adjoining it is the main diet kitchen4 ,at one end is the serving room1 where the food is divided and dispatched to the wards4 ,leading from the serving room is a hall1 off which on one side are the cooling rooms1 and on the other side storerooms for staple supplies4 ,if the kitchen be on the top floor1 a cooling room on that floor1 sufficient at least to care for one day's provisions1 will be necessary1 having the main cooling rooms located on the main floor or in the basement4 ,sidenote3 ,cold ,storage ,a good cooling room1 in which can be stored large quantities of the perishable supplies1 has now come to be regarded as essential to economical housekeeping4 ,the size of the cooling room will depend on the size of the hospital1 but there are special features which should always be kept in view1 and which can be had in cooling rooms of any size4 ,one important point is to have it so constructed that the ice can be put in from the outside1 if it is not manufactured on the premises4 ,every cooling room needs to have three departments--one large section1 well arranged with meat hooks and shelving for meats1 one with plenty of shelf space for vegetables and fresh fruits1 and one for milk1 butter and eggs4 ,the separation of these articles is highly important4 ,vegetables and fruit will taint milk and also meat1 and meat alone will injure milk4 ,the best goods that can be purchased will quickly deteriorate unless properly cared for1 and in a hospital1 where the most capricious appetites have to be catered to1 the keeping of the edibles sweet and fresh is of the utmost importance4 ,illustration ,sidenote3 ,the ,storeroom ,the storerooms should be light1 well ventilated1 cool and dry4 ,the shelving1 if arranged in sections in the central part of the room1 similar to the arrangement in libraries1 will be much easier of access and more easily kept clean4 ,labeled receptacles1 with covers for all the varied commodities used in the domestic department1 should be provided1 thus rendering it unnecessary to store supplies of any kind in paper sacks4 ,a special closet for canned fruit will also be needed4 ,provision should be in the kitchen for the care of such supplies as are needed for each day4 ,sidenote3 ,dishwashing ,dishwashing1 that bugbear of every household1 is not less a task in a hospital than elsewhere4 ,in fact1 it forms a very large part of the work of the institutional kitchens4 ,the use of mechanical dishwashers has not yet become general1 and it is doubtful if any but the largest institutions will deem it necessary to adopt them4 ,those who have had experience with them as a rule find them satisfactory1 and comment especially on the saving in breakage and time4 ,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 task4 ,if each floor has its own kitchen and diet kitchen where the ward dishes can be washed and kept1 the labor in the kitchen will be greatly reduced and fewer servants in that department will be necessary2 and this is perhaps the better way4 ,the frequent handling of dishes that is necessary1 when the supply for the whole household has to be sent to and from the main kitchen three times a day1 adds greatly to the breakage1 and results in increased labor and loss of time4 ,but in this matter1 as in many other lines of hospital work1 the housekeeper's methods are modified by the construction of the hospital4 ,if no facilities are provided on each floor for washing the dishes1 there is no alternative but to send them to the main kitchen to be handled there4 ,the real work there may be greatly facilitated if in cleaning and packing the trays1 care has been exercised in separating the different articles4 ,the silver should be collected on one tray1 the fragments placed by themselves on another1 the dishes carefully scraped and packed1 the tray-cloths shaken and folded together4 ,the maid in the kitchen receives them from the dumb waiter as they are sent from the different wards4 ,the silver and glass and delicate china should be placed together to be washed first1 the heavier china and greasy dishes on a separate table1 and when all are collected the washing begins4 ,the water for the glass and fine china should not be too hot1 and these should be finished and put away before the washing of the silver is begun4 ,but few servants can be trusted to properly handle delicate china and glassware without supervision1 and the all too prevalent custom of piling a large draining dish full of delicate articles is the cause of constant breakage4 ,a draining rack1 constructed with grooves1 and fitting on one edge of the sink1 is a much appreciated convenience in many hospital kitchens4 ,every housekeeper has her own theories of proper dishwashing1 and all are good if the result is clean dishes4 ,the main point is to have a system of preparing the dishes for washing and adhering to it2 without system the disorder and confusion in the kitchen when all the trays are sent in will disturb the most saintly individual4 ,a limit to the time when dishes may be sent from the wards is also essential to methodical work4 ,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 before4 ,the carelessness of those in charge of the ward dishes results in upsetting the arrangements of the other work of the kitchen1 the maids who had finished their task having to gather together their dishwashing utensils and begin over again4 ,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 occurrence4 ,sidenote3 ,dishcloths and ,towels ,much care needs to be used in the handling of dishcloths and towels4 ,plenty of towels should be provided1 and dishcloths should be washed and scalded after each meal4 ,it is impossible to have clean1 shining dishes if these are not kept thoroughly clean4 ,the tendency for kitchen towels to disappear may be overcome by the housekeeper requiring each maid to state the number necessary for her work1 supplying them1 insisting that each put her special mark on her own towels1 and requiring that the old towels be produced before new ones will be given out4 ,sidenote3 ,the ,chief ,kitchen employee ,in selecting a chief employee who will be responsible for the direction of the details of the work1 and for the care of the kitchen and the other rooms in her department1 several points need to be considered4 ,she should not only be familiar with methods of preparation and cooking1 proper carving and serving of food1 but she should know how to keep herself neat during the process4 ,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 utensils4 ,in fact1 one who is not neat in person cannot be trusted to observe the rules of cleanliness anywhere4 8,doing0 is dependent on 8being10 here as elsewhere4 ,sidenote3 ,training ,needed ,the secret of success in the kitchen is the same as in other departments of the institution1 and1 indeed1 of life in general4 ,it can be spelled in one word--s-y-s-t-e-m2 and be it understood here and now1 that system and red tape are not synonymous terms4 ,just as in a large department store1 every yard of ribbon sold has its relation to the whole establishment1 or in a great railway system every train dispatched influences the running of every other train1 and system is necessary to insure the success of the business or the safety of human lives1 so in a hospital every part is vitally related to the great whole4 ,some mind must plan the details1 first of the whole and then the minut of the different parts as they contribute to its harmony and success4 ,and yet1 while this truth is generally admitted1 and its importance is evident1 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 depends4 ,most graduate nurses can nurse1 they can care for a patient afflicted with an ordinary disease in a satisfactory manner1 but how much have they learned regarding the management of the household8 ,how much have they been taught regarding the purchase of supplies1 the care of food1 the management of the linen room1 the laundry and kitchen1 the supervision of servants1 and other matters of vital importance to every hospital8 ,is there not much still lacking in our present system of training8 ,if a railway company sent an engineer to conduct a train to its destination as ignorant of1 and inexperienced in1 the working of the whole train system as some graduate nurses are1 who have the responsibility of a hospital1 small or large1 placed upon them1 the public would raise its hands in horror1 and brand the railway officials with criminal carelessness4 ,while present methods continue1 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 mother1 her own native ability1 and her intuitions as to how things should be done--not on the training received in the average hospital4 ,when the nurses' course includes practical instruction in the management of every department of the hospital1 the purchase of supplies of all kinds and simple accounting1 the public1 with the nurses1 will reap the benefit4 ,in large institutions stewards may be employed1 or it may be possible to secure a trained housekeeper from some institute of domestic science4 ,but in the small hospital the superintendent must be her own housekeeper2 such superintendents must almost of necessity be nurses1 and there ought to be time in a three years' course to give them some insight into1 and experience in1 the details of hospital housekeeping4 ,sidenote3 ,the ,diet ,kitchen ,an advance step has been taken1 however1 in the introduction of cooking into the nurse's course of study4 ,the nurse's work in the diet kitchen ought to mean a lightening of some of the burden in the main kitchen4 ,the custom of management of this department varies and each institution must work out its own problems4 ,where there is a regular dietitian in charge1 with the diet kitchen work as her exclusive business1 the matter is easier of adjustment4 ,where this is not possible two nurses may be assigned for this special duty1 making the term of service two months4 ,the junior nurse may thus be initiated by the senior diet nurse1 the housekeeper having general supervision of the entire work4 ,the value of this practical experience in cooking can scarcely be overestimated1 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 surgery4 ,in order that this course in practical work be productive of the most good to the nurses1 previous instruction in the principles of nutrition1 food values1 and in the processes of digestion1 should be given4 ,valuable1 however1 as the diet kitchen work is in the nurse's education1 unless it is arranged that that department assume a certain responsibility for preparing a part of the hospital dietary1 its introduction is hardly justifiable4 ,in most cases the diet kitchen should furnish at least the special diets and desserts1 all broths1 jellies1 etc4 ,if the diet kitchen facilities are adequate1 it may be wise to have all the cooking for private patients done in this special department4 ,in this way it is possible to devote more attention to attractive arrangement of food1 as well as more care to its preparation4 ,where the housekeeper has a real interest in the people for whom the food is prepared1 and has cultivated the fine art of cookery1 or has a degree of native ingenuity1 many delightful dishes may be constructed even of odds and ends1 and a variety secured out of very little4 ,the very first essential to proper feeding is good cooking1 and this1 like most other expert service1 is an economy rather than a waste4 ,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 reckoned4 ,this is in comparison with the old method of having the cooking done by women who had received no previous training1 and had no special desire to study the art of cooking or to become more proficient in it4 ,,chapter ,,vii4 ,sidenote3 ,purchase and ,care of ,food ,supplies ,the person to whom is entrusted the purchase of the food supplies1 and the direction of the general dietary for the hospital household1 occupies a place of no small responsibility4 ,if she is to discharge this duty to the satisfaction of those who have the interests of the institution at heart1 she should have a few marks of fitness not found in the average woman4 ,first1 she should have an active1 intelligent and sympathetic interest in the welfare of both the sick and healthy members of the household1 and be in perfect harmony with the humane designs of the institution4 ,sidenote3 ,judging ,values ,second1 the purchaser of the food supplies should have sufficient experience and knowledge to detect superior and inferior qualities of the different food stuffs4 ,so far as the food for the sick is concerned1 the physician will have the responsibility of deciding the kind of food his patient shall have1 but she will have the responsibility of deciding regarding quality and preparation4 ,it does not require an expert to discover that a beef steak is tough when it comes to the table1 but that is too late for the discovery to be of any practical value4 ,the toughness should have been detected while it hung in the market4 ,so it is with all varieties of food4 ,to know the desirable and the undesirable qualities before purchasing is to possess one of the chief secrets of successful buying4 ,clever buying does not mean close buying1 though some people think it does4 ,the cheapest article often proves the most expensive1 and quality must be paid for4 ,the point is to be able to recognize1 and not pay first-grade prices for second-grade goods4 ,third1 she should keep posted regarding the fluctuations of the markets1 and not have to depend entirely on what one dealer may say regarding prices4 ,as she is spending1 not her own money1 but funds often accumulated by self-denial on the part of givers1 she needs to study to spend them wisely4 ,fourth1 she should make a point of finding out the exact price of most articles before ordering them4 ,strawberries would be appreciated by her household at any time in the year1 but while they sell at thirty or forty cents a box1 she is hardly justified in buying them freely1 if at all4 ,and this rule holds good in regard to most of the ordinary so-called luxuries--the things that are not absolutely essential as nourishment4 ,there is a time in which she can decide to have them1 and also a time to decide to do without4 ,fifth1 she should have an intelligent conception of the relative nutritive values of different foods1 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 eat4 ,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 constantly1 and endeavor to supply as far as possible the ideal meal1 which is one in which nitrogenous1 non-nitrogenous and mineral substances are supplied in the proportion required to repair the waste1 and with the minimum tax on the digestive powers4 ,the first qualification really includes three different qualifications--common sense1 conscientiousness and justice1 for all of which she will have constant need in discharging the duties of her position4 ,probably in beginning her work she will make mistakes1 as every one who accomplishes anything does1 but as she buys she will learn to buy1 and in no other way4 ,it cannot be learned from books4 ,however1 suggestions may be given and accepted that will save the housekeeper from making all the blunders others have made1 and save the hospital from the results of total inexperience and lack of knowledge4 ,the amount of supplies of any kind to be purchased at one time will depend somewhat on the demand1 but chiefly on the facilities for storing and preserving them4 ,the perishable articles are always the most important1 and also the most expensive1 and whenever possible she will find that a substantial sum may be saved each month by making cash payments for these articles as purchased4 ,with adequate cold storage arrangements1 a month's supply can be purchased at one time4 ,hand to mouth1 or day to day buying is poor policy for any hospital1 though lack of facilities for proper preservation of food often gives the buyer no other alternative4 ,sidenote3 ,bread ,among the chief staple foods of any institution is bread4 ,while with many in the hospital it is not exactly the 8staff of life10 yet it is perhaps the one thing in demand for every meal of the major portion of the household1 and fills no small part in the hospital dietary4 ,various forms of this important article are on the market1 differing in the variety and quality of flour used and in the process of manufacture4 ,three principal varieties ate in common use in this country--the fine-wheat bread1 made from the finest or so-called straight-grade flour1 the ,graham bread1 made from flour containing the entire grain of the wheat ground together1 and the whole-wheat bread1 made from flour containing the whole substance of the grain except the outer layer of bran4 ,from a chemical analysis of the three different varieties1 to ascertain the nutritive value and digestibility1 it was found that the fine-wheat bread yielded the highest percentage of digestible nutritive food1 the whole-wheat ranking second and the ,graham bread the last4 ,in providing bread for the household it is well to supply at least two varieties1 the fine-wheat as the staple and the whole-wheat and ,graham alternating4 ,another point worth noting1 proven by the same chemical analysis1 was that the digestibility depended more on the lightness of the bread than on the quality of flour used4 ,the question as to whether home-baked or baker's bread is most expensive is often asked1 and the answer almost invariably is that bread can be baked in the institution at much less cost than to purchase the ready-made article4 ,the ,u4 ,s4 ,department of ,agriculture in #aijj published the result of investigation regarding the market value of bread4 ,their investigation showed that in some places the baker's price was set by the trade name of the bread1 and in others by the size of the loaf1 and that the prices varied greatly in different cities4#a 8,in ,new ,jersey it appeared that the larger the loaf1 the higher the cost per pound tended to rise4 ,in ,new ,brunswick1 where fifty analyses were made1 the bread containing the highest amount of nutriment1 and that containing the lowest1 were sold at exactly the same price per pound1 #d4a cents4 ,when the selling price of bread and the cost of its ingredients are compared1 the results are still more striking4 ,in two experiments made in ,new ,jersey it was found that two lots of bread made from materials costing respectively #b4bh and #b4ef1 were sold for #e4fh and #f4jh4 ,this represents a profit of #aaf4e per cent over the cost of the materials1 or to put it in dollars and cents1 the baker received #baf4ej for bread whose materials cost him #ajj4 ,in ,pittsburg1 the average increase in price over the original cost was #aaj per cent40 #a ,u4 ,s4 ,dept4 of ,agriculture1 ,office of ,experiment ,stations1 ,bulletin #aab4 ,from these experiments it will be seen that a great saving of money can be effected by home baking1 even allowing for the extra cost of labor and fuel4 ,sidenote3 ,milk ,another of the important articles of diet1 and one that has special value in a hospital1 is milk4 ,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 housekeeper4 ,in order to determine the amount required for each day's consumption it will be necessary to decide1 before ordering1 the demands of the bills of fare for the different departments for the coming day4 ,this is essential for even approximate calculation4 ,the constant changing of patients and diets that goes on in a hospital makes a close calculation scarcely possible4 ,the evening of the day before the supply is to be ordered1 the head nurse in each section should submit her diet list1 showing the number of patients on liquid1 semi-solid1 light and regular diets4 ,for a patient on an exclusive milk diet1 from two to three quarts per day will be needed1 the amount being modified by the age1 sex and general condition of the patient4 ,where the liquid diet includes broth and other fluids alternating with milk1 two to four pints will be needed4 ,each patient on a semi-solid diet usually requires nourishment between meals1 and as milk enters largely into the composition of the semi-solid diet1 about the same amount will be necessary as for liquid diets4 ,for patients on light diet who must have nourishment in some form between meals1 a quart is a fair daily allowance1 and a pint for those on regular diet and for the household staff4 ,the quality of milk is a matter of paramount importance4 ,the proportion of fat or cream in milk from the same cow will vary somewhat from day to day1 but there is no doubt that the most frequent cause of variation is found in the unscrupulous methods of some dairymen4 ,three principal methods of adulteration are used3 water is added1 cream is removed1 and certain chemicals are added as preservatives4 ,whatever form of adulteration is used1 the results are bad4 ,whether water is added or the cream removed1 the nutritive value of the milk is lessened4 ,the injurious effects of chemically preserved milk depend1 of course1 on the amount consumed by one person4 ,the drugs most frequently used as preservatives are boracic acid1 borax1 salicylic acid and formaldehyde4 ,where a life is in the balance1 and milk diet is depended on to maintain the vitality1 these adulterations are of tremendous importance4 ,no housekeeper can afford to patronize a dairyman where there is a suspicion of these methods being practiced4 ,laws regarding adulteration exist in many places1 but are not always enforced4 ,but pure milk can be produced1 and if the consumer insists on having it1 and takes pains to find out at intervals the facts regarding its purity1 the milk dealer will arrange to supply the genuine article4 ,in purchasing from any dealer it is a safeguard to have the milk examined periodically by an expert chemist4 ,then the housekeeper may know for a certainty what she is getting4 ,milk which contains sediment is always suspicious4 ,in preparing a specimen for analysis care should be taken that it is a fair sample4 ,milk from the top or bottom of a bottle should not be used4 ,if the milk to be tested is poured several times from one vessel to another until no particles of cream appear on the surface1 the sample may be considered to be a fair specimen of the composition of the whole4 ,the method of computing the value of milk used by creamery experts is on the basis of the amount of fat contained4 ,if this basis were the general standard1 not only hospitals but all consumers would be the gainers4 ,while the actual food value of milk does not entirely depend on the amount of fat1 yet the buyer would have the satisfaction of getting what he paid for1 and the dealer the increased return for supplying a better grade article4 ,the milk containing less fat could be secured for cooking and that richer in cream for special purposes1 and the whole transaction would be fairer than the present system1 where a quart of adulterated and skimmed milk sells for the same money as the genuine product4 ,skimmed milk and buttermilk both have their value as nutriment1 and experts say that even after cream has been removed the skimmed milk still contains nearly ten per cent of its nutritive properties4 ,buttermilk is often more acceptable to patients than sweet milk1 and1 if it can be obtained fresh every day1 it can be used occasionally to add variety to a strictly milk or liquid diet4 ,it is said that six ounces of buttermilk has in it the same amount of nutrition as a medium-sized potato4#b 8,actual experiment has demonstrated that a fifteen-cent lunch containing nine different food materials 7soup1 beef1 potatoes1 turnips1 bread1 butter1 coffee1 milk1 sugar71 did not have any greater nutritive value than a four-cent lunch consisting of a pint of skimmed milk and ten ounces of bread40 #b ,u4 ,s4 ,department of ,agriculture1 ,bulletin #gd4 ,in ordering milk it is better to get too much than too little4 ,the excess can always be used in food combinations1 and at the prices ordinarily paid it is not an expensive food4 ,because of the ease with which it is digested by the average person1 and its nutritive properties1 it can be served in almost a numberless variety of forms to sick people1 and often in preference to other foods4 ,sidenote3 ,care of ,milk ,assuming that it is possible for dealers to supply pure milk1 and that the housekeeper knows whether or not she is getting the genuine article for her sick family1 there is still something required1 if it is to reach the patients in good condition4 ,be the article never so pure when delivered1 it can quickly become impure by careless handling4 ,the milk delivered at a very early hour may be left at the door where it is exposed to heat1 dust and flies1 and by the time it is taken into the house impurities may have entered that will account for it becoming sour in a few hours4 ,another source of contamination can be traced to the practice of putting milk in open vessels into the same refrigerator with meats and vegetables4 ,old tin or wooden vessels should never be used1 and vessels should be thoroughly scalded and scrupulously clean before the milk is put in4 ,if the racks and shelves in the cooling room are scrubbed daily1 also the inside of the milk refrigerator1 and a temperature of #ej ,f4 or lower maintained1 there should be no difficulty in keeping milk sweet twenty-hour hours or longer4 ,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 vessel4 ,each time it is handled the contents of these cans are exposed to floating dust1 and the time the milk will remain sweet is shortened4 ,the bottles in which milk is served should be carefully cleaned as soon as emptied1 and in warm weather milk should never be left without ice4 ,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 employed1 should never be tolerated in a hospital4 ,another point in handling may be worth mentioning2 milk or cream intended for the sick may be consumed by kitchen employees1 and in spite of the housekeeper's plans the supply may become exhausted before the new supply is available4 ,this often occurs at night1 when it is impossible to replenish the quantity from any source4 ,all calculations as to the amount per capita required will be valueless if servants are allowed to consume it at will4 ,if milk is to be allowed to them as a beverage1 then a much larger amount should be ordered4 ,sidenote3 ,cheese ,cheese1 which is a concentrated form of milk1 while rich in nutrition1 is somewhat difficult of digestion1 and if bought at all for hospital patients should be purchased sparingly and served in very small portions4 ,like milk1 it needs to be kept cool and entirely separate from fruits1 vegetables and meats4 ,sidenote3 ,eggs ,eggs are another of the valuable tissue-building foods in constant demand in hospitals4 ,for fully eight months of the year they can be bought at moderate prices1 and considering their great nutritive value are not an expensive form of food4 ,because of the ease with which they are digested by most invalids1 and the great variety of ways in which they may be served1 they fill a very important place in the hospital menu4 ,it is said that there are more than five hundred different ways of preparing eggs4 ,the purchase of them is1 however1 attended with some uncertainty4 ,many tests for detecting the quality are in use by experts4 ,the 8candling0 test consists in holding the egg against a light between the eye and the sun4 ,the perfectly fresh1 good egg will appear clear and unclouded and the yolk can be perceived4 ,if decomposition has begun1 it will appear dark colored4 ,changes in the appearance of the shell as shown by comparison of fresh and stale eggs are sometimes helps in detecting the quality4 ,where a hospital has an adequate cooling space1 undoubtedly the more economical method of buying is by the crate and in sufficient quantity to last several months4 ,some institutions lay in a year's stock1 buying always in ,april1 which1 it is stated1 is the only month in which it is wise to buy eggs for storage4 ,in a cooling room in which the atmosphere is sweet and pure1 a temperature of #cd ,f4 will preserve eggs for a year with very little appreciable change in quality4 ,even when the price of eggs is from twenty-five to thirty cents a dozen1 they are not more expensive than many other forms of animal food--notably beefsteak--and when served in the form of omelettes1 scrambled or creamed eggs where other substances are added to compose the dish their cost in a meal is less than steak4 ,sidenote3 ,economy and ,care ,in arranging a hospital dietary the comparative cost of food should always be borne in mind1 and where food of cheaper material supplies the place of the more costly1 the cheaper should have the preference4 ,if1 when eggs are high-priced1 the housekeeper could arrange to economize in their use in desserts and cake rather than in their use as meat substances1 it will be in the long run the more sensible plan4 ,however1 desserts in a hospital and desserts in a home are two different things4 ,the so-called dessert in a hospital often forms the meal for the patient with weakened digestive powers1 and in such cases eggs must be used1 be the price high or low4 ,for the healthier members of the hospital family1 fruits and desserts made without eggs can be depended on to take the place of desserts requiring eggs when the latter are expensive4 ,in storing eggs1 the housekeeper should remember that the shell of an egg is not impervious1 and if placed long in contact with apples1 onions or other substances of decided flavor the odor can be detected in the egg when cooked4 ,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 temperature4 ,when dealing with impaired appetites and weakened digestive powers these so-called minor points have special importance4 ,sidenote3 ,meat ,meat is the most expensive article of food in a hospital1 and for this reason the art of buying requires real study4 ,the flesh of animals seems to be especially adapted to contribute to the building up and maintenance of the organic structure of the human system1 but owing to the absence of starch is not to be depended on to produce force or energy4 ,meats are generally believed to be easier of digestion than vegetable foods4 ,the chemical ingredients are much like the various substances of the human system1 and are therefore more quickly acted upon and made ready for absorption4 ,a certain woody fibre often surrounds the nutritive ingredient of the vegetable and renders it more resistive to the action of digestive fluids4 ,sidenote3 ,beef ,beef is believed to be the most nutritious of all animal foods1 and that which seems to be most in demand in a hospital4 ,it is a meat in which quality varies greatly1 and much care needs to be used in its selection4 ,the age of the animal1 the method used in feeding it1 the condition when slaughtered1 and the length of time since slaughtering took place1 all affect the quality and flavor4 ,the flesh of a young animal is more tender1 but lacks the flavor found in the flesh of older animals4 ,a larger relative proportion of bone is found also in younger animals4 ,the best beef is usually obtained from animals of from three to six years of age4 ,when the cooling facilities are adequate1 at least a side of beef should be purchased at one time4 ,most meats improve by being kept a reasonable length of time4 ,in a hospital the various parts1 even much of the so-called refuse of the butchers1 can be utilized where several classes of diets have to be arranged daily1 and a great saving of money effected by buying in quantity4 ,this will be clearly shown by comparison if each part has to be bargained for separately4 ,in order to guard against waste and use the meat to the best advantage1 some system and skill in cutting will be needed4 ,the accompanying diagram shows the different cuts into which the side may be divided1 providing the largest amount of good cuts and with the least refuse4 ,a good quality of beef from an animal three or four years old should show elasticity on being pressed with the finger2 it should have a fair sprinkling of creamy-looking fat1 the lean portion should be a deep red and of a rather fine fibre4 ,coarse fibre usually means poor flavor4 ,tough beef is usually darker in color1 the proportion of fat will be less1 the fat instead of being a creamy white will be a decided yellow and the fibre coarse4 ,illustration ,sidenote3 ,veal ,veal may be occasionally added to the hospital menu for variety1 but because of the excessive proportion of bone it is not considered an economical meat to be used in any quantity4 ,it is also believed to be more difficult of digestion than most other meats4 ,mutton will perhaps rank next to beef for hospital uses1 and like beef it differs greatly in quality4 ,the fibre is shorter and more tender1 and the color of both the lean and fat of mutton somewhat darker than that of beef4 ,good mutton should have a sprinkling of fat1 but excess of fat should be guarded against4 ,an entire carcass should be purchased at one time1 cutting it as required4 ,sidenote3 ,chickens ,in selecting chickens for the hospital1 both young and old fowls will be needed4 ,for broths and jelly an old fowl1 not too fat1 is preferable4 ,where the meat of the chicken is the substance wanted1 a fowl of from one to two years old should be purchased4 ,the proportion of bone to meat in chickens under that age makes them quite an expensive commodity4 ,to ascertain if the meat is tender try the skin under the wing or leg4 ,if the joint of the wing yields readily or breaks it is tender4 ,sidenote3 ,fish ,fish help to supply the demand for variety in the diet1 which is more important in dealing with the capricious appetites of invalids than with those in health4 ,the different varieties vary greatly in nutritive value1 in flavor1 and also in digestibility1 owing largely to the proportion of fat4 ,the amount of bone in proportion to the meat in most ordinary fresh fish makes them a trifle more expensive than most meats1 steak and fowl being excepted4 ,because of their strong odor1 which would require for them an entirely separate storage receptacle1 it is better to buy them each day as needed4 ,salmon is considered more rich in nutrition than most other varieties of fish1 and the oily or coarser grained species more nutritious than the white or finer grained1 although the latter have the more delicate flavor and are easier of digestion4 ,in choosing the fish1 if the gills are a bright1 clear red1 the body firm and stiff1 the odor not disagreeable1 the fish may be accepted as in good condition4 ,sidenote3 ,pork ,pork will occasionally have to be purchased1 even in a hospital4 ,in spite of the fact that it is more difficult of digestion than many other forms of animal food1 and of the adverse criticisms heaped upon it1 most people in their secret heart 7or stomach7 are fond of a bit of good ham4 ,ham and bacon are more suitable for use in a hospital than fresh pork4 ,the lean of ham should be a deep pink1 and excess of fat should be avoided4 ,bacon should be quite thoroughly mottled with both fat and lean4 ,care should be taken that the ham and bacon have been cured and prepared for market by a reliable firm1 and that they are protected from dust and kept in a cool place4 ,sidenote3 ,butter ,butter is perhaps the most digestible of all animal fats1 and the most delicately flavored4 ,so many substitutes for the genuine article are now on the market that it needs to be selected with great care4 ,fat being one of the elements of food depended on for the production of heat and energy in the body1 butter has a place of some importance in the average invalid's diet4 ,for use on the tables and trays1 a good quality should be procured and a cheaper grade secured for use in cooking4 ,potatoes1 the most important of all vegetables for table use1 should be purchased in quantity in the fall when the price is lowest and stored in a cool1 dark1 dry place4 ,sidenote3 ,fresh ,vegetables ,green vegetables will1 of course1 be secured as needed4 ,when fresh there is a crispness about them that is not found in those picked longer4 ,lack of crispness usually means lack of flavor4 ,all vegetables will be improved by soaking in cold water before being cooked4 ,cereals1 sugar1 and in fact the whole list of dry food products1 and canned goods1 are a matter of much less anxiety to the hospital housekeeper than the perishable commodities4 ,on general principles1 buying in sufficient quantity to secure wholesale rates is the only sensible method4 ,but1 as has been previously remarked1 the construction of the hospital modifies all plans for housekeeping4 ,lack of storage facilities make it impossible for many housekeepers to buy wisely or economically4 ,mistaken ideas of economy in construction often mean increased and unnecessary expense as long as the hospital exists4 ,where economical housekeeping is expected1 arrangements should be made in every hospital for sufficient cold storage facilities1 at least for the storing of meats1 which usually form the largest item in the monthly accounts4 ,,approximate ,,estimate ,,of ,,quantities ,,of ,,food ,,for ,a #be-;,,bed ,,hospital1 ,a #ej-;,,bed ,,hospital ,,and ,a ,,hospital ,,of #ajj ,,beds4 ,this is taken from a month's experience with the average number of acute cases and convalescents in a hospital with an active surgical service4 ,,breakfast4 ---------------------------------------- ------------------------ ,hospital of ,hospital of ,hospital of #be ,beds #ej ,beds #ajj ,beds ---------------------------------------- ------------------------ ,beefsteak1 ,round #e lbs4 #h lbs4 #ae lbs4 0 ,porterhouse #h lbs4 #aj lbs4 #bj lbs4 ,eggs #b doz4 #d doz4 #h doz4 ,cereal1 ,cooked fresh #e qts4 #aj qts4 #bj qts4 0 ,prepared #a pkg4 #b pkgs4 #d pkgs4 ,bread for toast1 #a lb4 l'ves #d loaves #h loaves #b doz4 l4 0 7plain7 in addition #b loaves #d loaves #a doz4 l4 ,butter #a lbs4 #b lbs4 #e lbs4 ,cream 7for priv'te pat'ts74 #a pts4 #c pts4 #b qts4 ,milk 7allowing pt4 each7 #f qts4 #ab qts4 #bd qts4 ,coffee 7dry7 #c to #d cups #e to #g cups #b lbs4 ,sugar #c lbs4 #e lbs4 #ae lbs4 ,fruit fresh 7oranges1 etc47 #a doz4 #b doz4 #e doz4 ,fruit stewed #b qts4 #d qts4 #g to #i qts4 ,cocoa 7allow one teaspoon for each patient getting it and add one cup each to quantity of milk7 ---------------------------------------- ------------------------ ,,dinner4 ---------------------------------------- ------------------------ ,soup #e qts4 #aj qts4 #bj qts4 ,croutons or ,crackers #b lbs4 #e lbs4 #aj lbs4 ,roast1 ,rib #h lbs4 #ab lbs4 #bj lbs4 ,lamb1 ,leg #aj to #ab lbs4#ae to #ah lbs4 #be to #cj lbs4 ,chops #b doz4 #d doz4 #g doz4 ,potatoes #a pk4 bush4 #a bush4 ,celery #a doz4 stalks#a large bun4 #b large bun4 ,beets pk4 #a pk4 bush4 ,bread1 bakers #a lb4 #c loaves #f loaves #a doz4 l'ves loaves ,tea lb4 lb4 #a lb4 ,sugar #b lbs4 #c lbs4 #e lbs4 ,milk #c qts4 #g qts4 #ae qts4 ,dessert1 ,rice pudding #d qts4 #f to #g qts4 #ah to #bj qts4 ,ice ,cream1 in bulk #d to #f qts4 #h to #aj qts4 #d to #e gal4 ,ice ,cream1 brick #b to #c br'ks #d to #h br'ks #aj bricks ---------------------------------------- ------------------------ ,,supper4 ---------------------------------------- ------------------------- ,scalloped ,potatoes1 7potatoes1 milk1 butter7#c qts4 sliced #f qts4 #aj to #ab qts4 ,bread #f loaves #ab loaves #b doz4 ,butter #a lbs4 #c lbs4 #f lbs4 ,fruit1 stewed #b qts4 #e qts4 #aj to #ab qts4 ,tea lb4 lb4 #a lb4 ,milk #d qts4 #f to #g qts4 #aj to #ab qts4 ,eggs1 special diets #a doz4 #b doz4 #d doz4 ,cream #a pt4 #a qt4 #a gal4 ,oysters1 raw #b to #c qts4 #c to #e qts4 #f to #h qts4 ---------------------------------------- ------------------------- ,,chapter ,,viii4 ,sidenote3 ,preparation of ,food ,if the purchase of a good quality of food for the patients in a hospital is important1 the preparation and serving of it is of still greater importance4 ,the most expensive food may be spoiled in cooking1 or be served in such a manner that the patient has no desire for it4 ,on the other hand1 the cheaper article may be so tastily prepared that it will be readily partaken of4 ,in dealing with the sick1 the method of preparation and the manner of serving food assume an importance that is not sufficiently appreciated by the untrained4 ,it is hardly possible for every hospital to have a trained chef or a diet cook4 ,much of the cooking must needs be done by the ordinary servants1 but the hospital housekeeper should have an intelligent appreciation of the needs of her family1 her influence should pervade the domestic region constantly1 and her standards and methods be understood by every one who handles food for the patients4 ,the difference between the kind of cooking needed for the sick and the well needs also to be thoroughly understood1 and while in reality the housekeeper must cater to both classes1 yet the sick are her especial care4 ,the fact must be borne in mind1 too1 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 weakened4 ,these changes are accompanied by a loss of appetite and often a disgust for food4 ,yet the waste of the body1 because of the sickness1 is increased1 and special effort is needed to supply the most nutritious food with the minimum tax on digestive powers4 ,sidenote3 ,objects of ,cooking ,the method of cooking1 which is in reality preparing the food for digestion1 thus becomes a powerful factor in dealing with diseased conditions4 ,in most foods1 and in animal foods especially1 cooking develops the agreeable flavors and makes them more palatable4 ,it also enables them to become more readily masticated and therefore more easily digested4 ,the nutritive elements of food are extracted for assimilation by the action of the various digestive fluids of the body4 ,in many diseases the glands that secrete these digestive fluids are weak or inert1 and need stimulating1 and here attractive cookery and artistic serving play an important part4 ,when food is pleasing to the eye the nerves of sight and taste are excited4 ,these nerves act reflexly on the nerves of the stomach1 stimulating the gastric glands4 ,eating is1 therefore1 made more enjoyable1 a greater flow of digestive juices is produced1 and the result is better digestion1 better assimilation and increased strength4 ,sidenote3 ,classes of ,diets ,four grades of diet for patients are ordinarily recognized in a hospital4 ,besides these we have the different grades of food1 served to the different classes of employes on the working staff1 making as a rule seven different classes of dietaries for the hospital housekeeper to provide each day4 ,usually there are dishes on the regular diet that may be used for the semi-solid or the light diets1 and also for the officers' and employees' tables4 ,and as a general rule there are special forms of liquid diet prepared each day1 that may be added to the other dietaries1 thus making it possible to cook many of the dishes in bulk1 which is always the more economical way4 ,for patients on fluid or liquid diet1 such articles must be provided as beef tea1 beef juice1 chicken broth1 mutton broth1 gelatine1 barley water1 cocoa1 certain forms of strained gruel1 albumen water1 koumyss1 buttermilk1 whey and sweet milk served in its natural state or in its almost numberless combinations that vary the flavor4 ,for those on semi-solid diet such foods as oatmeal gruel1 custard1 ice cream1 rice1 tapioca1 sago1 and sometimes milk toast are used in addition to the foods included in fluid diet4 ,for patients on light diet such additions are made as bread1 toast1 some fruits1 certain kinds of fish1 such as oysters1 clams and the white-fleshed fishes1 poultry and game4 ,regular diet in a hospital may include all the above articles with beef1 mutton and other meats added1 certain vegetables and all fruits4 ,for patients in the transition stage with weakened digestive functions1 the shorter fibred meats are usually served in small quantities1 before beef1 mutton and other meats more difficult of digestion4 ,but even in the regular diets1 much discretion needs to be used4 ,many articles that are permitted in health have no place on the hospital dietary4 ,boiled cabbage1 or cucumber pickles1 or boiled dumplings1 might be relished by the heartier of the patients on regular diet1 but would be entirely unsuitable for the majority1 and therefore not an economical food to serve4 ,even though digestion is not seriously impaired1 the functions because of lack of exercise are sluggish1 and it is unwise to put unnecessary tax on the excretory organs4 ,so that though doctors may give full permission for the patient to 8eat anything10 the housekeeper's common sense will prevent her from incorporating in the hospital dietary many articles of food allowed in health4 ,the foods included in each class of diets and the limitations should be thoroughly understood by the whole working staff of the hospital4 ,it is well to have printed lists conspicuously posted in different parts of the hospital4 ,on no account should milk be allowed to be given to hearty patients on full diet1 or to any patient on that class of diet unless specially ordered by the physician in charge4 ,this rule needs special emphasis or milk bills may be greatly increased with no special benefit to any one4 ,as a rule the patient who is on an exclusive liquid diet must be dealt with individually and with great discrimination4 ,the amount and kind of diet will be prescribed by the physician4 ,but in these cases special preparation becomes very important4 ,milk frequently forms a large part of the fluid diet1 as it is one of the very few complete foods4 ,various forms of pre-digested and concentrated foods are in use that are of great value in such cases1 but they belong to the drug room1 rather than the kitchen1 and need not be mentioned here4 ,sidenote3 ,broths ,next in value to milk and its preparations1 on the liquid diet sheet1 come broths4 ,when broths are required for patients suffering from acute or febrile diseases1 the housekeeper should see that a rich and nutritious article is provided--not water flavored4 ,in the preparation of these broths1 the object should be to extract as much as possible of the soluble elements of the meat into the water4 ,the meat should be cut in small pieces and put in cold water1 the temperature being gradually raised to about #afj ,f4 ,the remainder of the cooking should be a gentle simmering process4 ,for these broths the cheaper part of meat may be utilized1 and it is hardly necessary to add that when a cheaper grade article can be used with equal satisfaction it should always be done4 ,in the preparation of soups1 care must be exercised regarding the flavor4 ,all strong and decided odors1 such as onion1 should be avoided4 ,in fact it is usually better to have a carefully combined flavor than one special flavor that may be disagreeable to some tastes4 ,sidenote3 ,soups ,as a general rule it is well to have soup of some kind on all the dietaries of the hospital once a day1 except in the very hot weather4 ,the body1 even in health1 requires a large proportion of water1 and in most diseases water has a real therapeutic value4 ,it is needed as a solvent agent during digestion and assists in the various processes of absorption1 secretion and excretion4 ,when1 therefore1 it can be combined with certain food substances to form an acceptable article of diet1 it should be done4 ,the value of broths and soups is not sufficiently appreciated by the poorer classes1 and the hospital dietary should form a practical lesson on sensible diet4 ,the bones of meat can be utilized in the making of soups1 a nutritious extract consisting chiefly of gelatin being obtained by boiling them4 ,it is said that three pounds of bone contains as much carbon as one pound of meat1 and as much nitrogen as seven pounds of meat4 ,in serving broths to patients care must be taken to remove all floating grease4 ,when there is time1 it is always better to allow the soup or broth to become thoroughly cold1 and then have it carefully skimmed4 ,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 period4 ,sidenote3 ,cooking ,meats ,when the object of boiling meat is simply to cook it1 retaining as much as possible of its soluble constituents1 the meat should be in one large piece and plunged into water already boiling4 ,brisk boiling should be continued for ten minutes till the albuminous matter on the exterior is coagulated4 ,this forms a protective layer which helps in preventing the escape of the nutritious juices into the water4 ,the cooking should be completed more slowly4 ,too great heat causes the meat to be hard and shrunken4 ,roasting meat retains the nutritious juices better than boiling4 ,but1 as in the boiling1 the meat should be first exposed to a strong heat1 the cooking being completed more slowly4 ,sidenote3 ,cooking ,vegetables ,green vegetables are valuable as food1 not so much because of their nutritious elements1 but because of the salts they supply which are demanded by the system4 ,their digestibility depends greatly on their being well and carefully cooked4 ,in most of them there is a large proportion of indigestible residue1 which acts as a stimulant to peristalsis4 ,it must not be forgotten that a relish for certain vegetables is an acquired taste1 and unless an article has real nutritive value it is unwise to try to cultivate the taste while in the hospital1 even for variety4 ,celery1 for instance1 is rarely relished by poor people1 and for this reason it is a needless expense to serve it in the free wards4 ,other exceptions will readily suggest themselves4 ,potatoes are rich in starch and when cooked in quantity are best served mashed4 ,this method of serving prevents them reaching the stomach in hard1 indigestible masses1 as is often the case when served whole4 ,the profusion of books1 giving definite culinary rules for the preparation of all the various articles of diet1 both for the sick and healthy family1 makes unnecessary more than a passing mention of these few general principles to be observed in preparing a hospital dietary4 ,one general aim should be kept in view in preparing food in general2 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 possible4 ,sidenote3 ,time of ,meals ,as a general rule the heaviest meal of the day--the dinner--should be served in a hospital at mid-day4 ,this plan will be more satisfactory to those on whom the preparation of the meal devolves1 and it is distinctly better for the patients4 ,the time needed for the digestion of meats and vegetables is estimated at from three to five hours4 ,if the heavy meal is served late in the day the work of the stomach cannot be completed in time for the patient to get to sleep early1 and if the stomach is actively engaged in digestion the rest is likely to be retarded or disturbed4 ,this rule of course does not apply to patients in a weak condition who must be fed at frequent intervals and in smaller quantities4 ,and it needs also to be remembered that a perfectly empty stomach does not contribute to repose1 and indeed is a frequent cause of wakefulness4 ,a plain1 wholesome early breakfast for the 8help0 and for the nurses is a necessity in a hospital where the heaviest work comes in the morning hours4 ,this should be as substantial as the appetite and digestion are equal to4 ,with nurses who are constantly exposed to morbid and depressing influences1 the breakfast is of special importance1 and a nurse who does not partake of a hearty breakfast is always more susceptible to deleterious influences4 ,the rush of work1 long hours1 mental anxiety1 and almost constant walking or standing1 which are incident to hospital life1 make it very necessary for a good quality and quantity of food to be prepared for those who have the direct responsibility of the care of the sick4 ,and while extravagance ought to be guarded against1 yet no mistaken idea of economy should prevent the housekeeper from serving a well-balanced1 nutritious and attractive dietary to these important members of her household4 ,the housekeeper should not fail to remind herself constantly that 8variety is the spice of life10 and should see that 8wholesome variety0 characterizes her meals1 for the nurses as well as patients1 from week to week4 ,the element of surprise or unexpectedness figures largely in the pleasures of every-day life4 ,anything that leaves out the possibility of the 8unexpected10 especially on a nurses' table1 has much in it to condemn and little to commend4 ,on the nurses' table clean table linen at frequent intervals ought not to be regarded as a luxury1 and certainly it adds greatly to the enjoyment of a meal4 ,a few of the flowers that are often distributed lavishly in a ward would as fully fulfil their mission there4 ,a pretty growing plant purchased occasionally for the same purpose is an extravagance that could be forgiven4 ,then1 besides refined surroundings and neat1 attractive table service1 the character of the food1 the quality1 could be greatly improved by a little careful planning without any great1 if indeed any1 increase of expense4 ,dr4 ,peters1 of the ,rhode ,island ,hospital1 in an admirable paper on hospital dietaries1 asked the following pertinent questions3 8,do we realize the satisfaction that a variety of soups1 so easily and cheaply prepared1 give to our inmates8 ,do we remember the many ways of preparing meats to be served with a great variety of gravies and sauces8 ,do we realize that mincing meat is an important method of preparation8 ,do we appreciate how much more satisfactory fresh vegetables are than canned8 ,don't we forget the natural craving for fruit8 ,couldn't we1 with a little forethought1 give our nurses and employes salads1 ices1 etc41 at practically no greater cost than the routine dishes8 ,did you ever realize the variety of ways such common articles as potatoes1 rice1 apples1 etc41 can be cooked and served8 ,do we serve fish in as great a variety and often enough8 ,do we give attention enough to the possible varieties of dessert8 ,are all these questions trite8 ,yes2 but possibly worth repeating to act as reminders40 ,it is time that the system of arranging a nurses' bill of fare for months ahead were forever abandoned in every institution4 ,the very monotony of it makes one weary at the thought4 ,to know that on a certain day of the week one is doomed to a dinner of corned beef and cabbage is certainly not likely to create enthusiasm for the morning's work4 ,to contemplate while dressing that 8this is the day for fried liver for breakfast10 is sufficient to nauseate some of the less hearty members of the family4 ,to know that of all the list of fruits in the market only about three or four are likely to appear on the nurses' table till the authorities see fit to change the bill of fare is1 to say the least1 depressing4 ,monday1 apple sauce2 ,tuesday1 stewed prunes2 ,wednesday1 dried peaches or apricots1 etc4 ,and the desserts are often equally monotonous3 ,bread pudding1 rice pudding1 apple pie and again bread pudding1 rice or tapioca pudding2 apple pie1 with a dish of cornstarch--sometimes pink1 sometimes white--on ,sunday4 ,it is little wonder that after two or three years of this monotony in diet1 many nurses regard these articles of food as things to be avoided for the remainder of their lives4 ,as a general rule it is best to avoid1 as far as possible1 serving food that has been warmed over1 or twice cooked1 to sick people1 though perfectly proper for those in health4 ,it is better1 however1 to calculate as carefully as possible the amounts required for each meal1 and cook no more than will be used4 ,meat1 fish and vegetables1 especially1 are better for the sick when cooked fresh4 ,while many of the salads--lobster salad for instance--are not suitable for a hospital dietary1 when viewed either from the standpoint of economy or digestibility1 yet delicious salads may be made of very common articles without any extra expense4 ,a salad composed of apples1 celery1 a few nuts and a little ,french dressing could scarcely be considered an expensive dish at any season1 and yet such a simple combination would add a relish to an otherwise commonplace meal4 ,a bean salad is both dainty and nutritious4 ,many such delightful combinations will suggest themselves to the housekeeper whose heart is in her work1 and who is really mistress of her art1 and these all go to make up the difference between variety and monotony4 ,,chapter ,,ix4 ,sidenote3 ,diet ,lists and ,blanks ,for the housekeepers' guidance in preparing meals for the patients1 a diet list showing the number of patients to be provided for and the classes of diets required1 needs to be prepared4 ,the duty of preparing this list usually devolves upon the head nurses in charge of the wards and the lists should be sent in either at night or early in the morning of each day4 ,special articles for individual patients will usually be prepared in the diet kitchen1 and may or may not be placed on the diet sheet sent to the general kitchen4 ,in large institutions where there is a pantry on each floor in which special diets are prepared1 special requisition blanks are used in many hospitals in procuring the supplies4 ,the amount of eggs1 milk and beef juice and the various articles that are expensive and perishable1 are estimated by the person in charge1 and the requisition is signed by the superintending nurse before it is sent to the kitchen or store room4 ,such a requisition blank is usually about the size of a doctor's prescription blank1 and they are most convenient when prepared in blocks similar to letter pads4 ,the housekeeper will1 of course1 superintend the carving of meats and the dispensing of food from the main kitchen4 ,this is one of the most important of her duties and many a dollar can be saved or lost by neglect or attention at this point4 ,proper carving of meats results in a substantial saving in the course of a year4 ,dr4 ,w4 ,gilman ,thompson says that an 8undesirable tendency among ,american hospital dietaries is to include too much meat4 ,not over four ounces of cooked meat 7without bone7 should be allowed in the meal for men40 ,unless specially ordered meat should never be served more than twice a day in a hospital and once for the average patient is sufficient4 ,sidenote3 ,serving of ,food ,in the serving of food to the patients1 provision must be made for serving cooked food that is intended to be hot1 really hot4 ,if this is to be accomplished successfully1 it must have special attention and special facilities4 ,if there is no diet kitchen or nurses' pantry on each floor1 and the trays are prepared in the main diet kitchen adjoining the general kitchen and sent on the dumb waiter1 it means that plates must be heated thoroughly and every article of hot food covered with a hot plate or saucer4 ,the food must be really hot when served on the plates1 and delay at the other end of the line guarded against4 ,this method is the only one that can be pursued in small hospitals1 or where mistakes in construction have resulted in there being no facilities for serving food convenient to the wards4 ,it is hardly necessary to say that each tray should have on it a ticket bearing the name of the patient for whom it is intended4 ,neglect of this precaution might cost a life1 as for instance if a convalescent typhoid patient 7famished with hunger as they usually are in that stage7 who was allowed only custard or broth1 had served to him a tray laden with fruits1 meats and vegetables4 ,such accidents are not unknown1 and may happen in any hospital where laxity about the serving of food exists4 ,where there is provision on each floor for setting trays and serving food the same care needs to be exercised about heating the dishes4 ,the food will be served in bulk from the main kitchen1 usually in large covered vessels1 which should be hot before the food is put in4 ,a steam table in the diet kitchen will suffice to keep them hot till the serving is completed4 ,in winter it may even be necessary to heat the cups1 for what is more insipid than a cup of lukewarm tea or coffee8 ,equal care needs to be observed to serve cold things really cold4 ,ice may be a luxury to some people1 but the free use of ice in a hospital is an urgent necessity4 ,not only is it needed to preserve the food1 but it has its place in adding relish to a meal especially in hot weather4 ,when a patient is hot and restless and uncomfortable even the clink of a piece of ice in a glass is refreshing and will help to create a desire for the milk itself4 ,it ought not to be necessary to add that cold food should be kept as far as possible from the hot food on a tray1 and yet having more than once found a nurse carrying a tray with a dish of ice cream covering a bowl of steaming hot soup1 or the butter crowded as close to the teapot as it could be1 it may be that such reminders are not out of place4 ,if only everybody lived up to the best they knew2 if only one could be sure that what was taught would always be acted out1 the housekeeper's anxiety about the serving of food would be greatly lessened4 ,as it is1 8line upon line and precept upon precept0 is needed1 and in addition that 8eternal vigilance0 that is said to be 8the only price of safety40 ,sidenote3 ,tray ,setting ,in the setting of a tray there is a right and wrong method1 as in everything else4 ,it is not sufficient to have the dishes and the tray cloth spotlessly clean1 but the method of arranging the various dishes should have in view the patient getting the food with the greatest ease4 ,a moderate size tray is preferable4 ,the very large trays are cumbersome and awkward and it is difficult to arrange the small trays to advantage4 ,in the center of the side of the tray that will be placed nearest to the patient should be the plate1 with the knife1 fork and spoons1 arranged in their proper places on either side4 ,at the right hand should be placed the teacup and saucer1 and on the left the bread and butter plate1 or the individual butter dish4 ,back of the teacup is placed the small tea or coffee pot4 ,thoughtless nurses often reverse the position of the teapot and teacup1 making it necessary for the patient to reach over the teapot to the back of the tray every time he wants a drink4 ,in the center of the back part of the tray1 or the part farthest from the patient1 the little sugar and cream vessels should be arranged1 and in the left-hand corner of the same side the dessert4 ,the pepper and salt bottles and other small articles may be arranged as space will permit4 ,it is well to have a regular custom established of emptying the sugar vessels and washing them after each meal4 ,crumbs are dropped in or they become smeared with a wet spoon1 and unless the regular emptying and washing after each meal is insisted on1 the housekeeper can never be sure they are properly clean4 ,salt and pepper bottles should be examined daily1 and the outside washed after each meal also4 ,it is so easy to overlook this small matter and send empty salt bottles on the tray4 ,the food may be served hot and really be appetizing1 save that it needs more salt to suit the patient's taste4 ,if a bell has to be rung1 and a nurse summoned to get the salt1 the meal may have cooled and the appetite for it have waned1 before it arrives4 ,these may seem small things to dilate upon1 but in reality they are the real test of the quality of management4 ,a chain is no stronger than its weakest link1 and real success in a hospital demands attention to these apparently trivial details4 ,these trivial details are large to the patient and have much to do with keeping him happy and comfortable4 ,it is not sufficient to provide good food and prepare it carefully4 ,it is only what the patient really eats and assimilates that is a factor in his recovery1 and the best meal may be spoiled by lack of attention to the details of serving4 ,the idiosyncracies of patients are nowhere more in evidence than where their food is concerned1 and while they are sick1 these idiosyncracies and tastes should be considered as far as possible with their highest interest in view4 ,another very important point to observe in serving food is not to serve too much at one time4 ,in dealing with a capricious appetite1 the sight of a quantity of food often repels when a small portion of the same food daintily prepared and attractively served would be eaten with a relish and an appetite for more created4 ,at the same time no cause should be given for the criticism that a patient did not get sufficient to satisfy him1 when his doctor allowed him to have plenty4 ,in planning for regular diets1 the fact needs to be kept in mind that a larger quantity of food1 proportionately1 will be consumed in the men's ward than in the women's wards1 and sufficient to replenish the supply should be sent from the kitchen4 ,sidenote3 ,bills of ,fare ,a settled bill of fare for the different days of the week is never a good plan in a hospital4 ,the patients will soon learn the rotation of the different dishes4 ,old patients will tell new ones1 and the matter will come up for discussion4 ,frequently before the food is served1 some patient who has heard objections to some food stated has decided she does not want it1 when if it had been taken unexpectedly to her it would have been eaten without question4 ,sidenote3 ,dishes ,the prettiest1 daintiest dishes the house can afford should be provided for the private rooms4 ,the constant breakage of dishes and especially of dainty china1 which goes on in a hospital makes it out of the question to provide this kind of ware for the wards1 and here beauty must give place to durability4 ,but a few dainty cups1 especially for the women's wards1 will be greatly appreciated1 for there are refined1 sensitive people in the free wards1 as elsewhere4 ,these special cups can be used in serving hot effects4 ,indeed it is astonishing how few nurses know attractiveness to the food which is in itself an aid to digestion4 ,care must be observed to avoid partiality in this matter1 for patients1 like children1 are quick to discern symptoms of favoritism4 ,glasses are now so inexpensive that every hospital can afford to supply a sufficient quantity for all the patients4 ,a writer in ,table ,talk thus describes from a patient's point of view the invalid's tray in a certain hospital and shows not only what delightfully dainty effects may be secured in serving the commonest articles of food1 but how the memory of those effects remained long after the hospital experience was ended3 8,a couple of weeks spent in an up-to-date1 twentieth century hospital1 has opened my eyes on many points connected with nursing1 and especially in regard to the setting forth in an appetizing way of the tray for an invalid4 8,at breakfast1 dinner and supper these trays were artistic creations of the highest order4 ,one dinner tray was a study in golden greens and white as to china and food1 with the needed touch of color given by wreathing the salver with racines of flowers in soft old pink1 a flower whose old-fashioned name ,i could not remember1 but whose color and fragrance took me back through more years than ,i care to count to a sweet1 old ,new ,jersey garden4 8,there was a golden brown chop in a circle of riced potato2 crisp1 yellow-green lettuce leaves1 ivory white at the base2 strips of white and gluten bread spread with golden butter and piled log-cabin fashion on a pretty fluted dish of green and white china2 pale green squash2 a quivering mold of yellow custard and a pretty teapot in green and gold1 with fragrant amber tea and a tiny pitcher of yellow1 thick cream4 8,a supper tray which stands out pre-eminently in my memory1 by reason of its exquisite tones of color1 contained a plate with four luscious oysters on cracked ice1 the bivalves laid in the form of a star1 and between the rays yellow wafers and discs of lemon4 ,there was a plate of lettuce sandwiches in strips an inch wide by three long2 a mould of farina1 with its attendant pitcher of cream1 a glass dish of apple sauce whipped to a foam with white of an egg2 triangles of white and gluten bread buttered and cut in the thinnest of slices2 a pitcher of cocoa and three ,reve ,d'or roses4 8,sometimes dainty sprays of ,cecil ,bruner roses lay among the tempting viands1 and fell in delicate profusion over the edge of the tray4 ,again1 little clusters of violets peeped over its rim and perfumed the whole atmosphere1 or the ruddy glow of crimson strawberries would be accentuated by the deep red of roses of ,sharon nestling in their glossy1 dark green leaves40 ,sidenote3 ,hints on ,serving ,an ordinary fruit1 vegetable1 or meat may be quite transformed by the manner in which it is being served4 ,an orange may be cut through crosswise and served with a very small dish of powdered sugar and an orange spoon1 or it may have the whole fruit cut in carpels or sections from pole to pole and the skin drawn back from each enough to loosen it1 and then again drawn into shape4 ,if a baked potato form a part of the meal1 cut a slice from the upper side1 take out the potato with a small spoon1 mash with butter1 cream1 and salt1 whipping light with a fork2 fill the skin again1 and stand in the oven long enough for the little cone of potato exuding from the top to take a golden brown tinge4 ,fruit foams are digestible and dainty for invalids4 ,any sort of stewed fruit--apricots1 apples1 peaches1 or prunes--should be whipped smooth while warm1 and when thoroughly smooth beat in the white of an egg whipped to a stiff froth2 serve in thin glass1 a pretty cup1 or low ,japanese bowl4 ,a patient may be beguiled into eating nutritious food simply through the manner of its preparation4 ,to speak of raw beef sandwiches would doubtless destroy the appetite of a delicate person1 but if you will prepare them as follows he will eat them without knowing1 probably1 what he is eating3 ,lay a thin slice of round steak on a clean board1 and with a rather dull knife scrape off the meat1 leaving the tough fibers remaining2 do the same on the other side1 laying the scraped beef on a dish4 ,spread two slices of very thin bread with the beef1 seasoning plentifully with salt2 lay on these two slices of plain bread1 and cut into very small triangles1 squares1 or strips4 ,arrange these prettily on a fringed napkin laid on a pretty dish1 and garnish with very small inner leaves of lettuce or with watercress4 ,another way of serving beef which is digestible1 palatable1 and nutritious1 is to mould the beef1 scraped as above1 into small olives2 heat a small frying pan very hot1 sprinkle with salt2 lay in these olives and shake over a hot fire for a minute or two until the outer surfaces are heated2 turn onto a hot dish and garnish with strips of buttered toast4 ,now in a general hospital where a hundred or more or less trays have to be prepared for each meal1 it is out of the question to devote as much time to artistic serving as could be wished1 but one thing is certain1 if nurses are not impressed with the importance of taking pains to serve food attractively1 and taught how to do it while in the hospital1 they cannot be expected to secure the best results in serving food in private practice4 ,even a thing as simple of preparation as a slice of toast gives room for the production of dainty and artistic and wholesome meal more attractive4 ,butter should be rolled in little balls between wooden spatters and can be prepared hours missing text how to prepare a slice of buttered toast so that it will be just right4 ,a good deal of the time the toast served in hospitals is either burnt1 half done or soggy1 buttered over much or in patches and served in slices so that the patient cannot possibly manage to eat it without getting his hands well greased4 ,it would cost no more either of time or money to toast it a golden brown1 put the right amount of butter on it1 and serve it cut in small squares between hot plates4 ,the time element is a very important point to be considered in serving food and requires careful calculation4 ,custards as a rule are better served quite cold1 and should be cooked a sufficient length of time before the meal to allow for cooling4 ,baked potatoes are delicious and easily digested when cooked just right and promptly served1 but what is more unappetizing than a baked potato that has remained after cooking in a slow oven till it was soggy and half cold8 ,tea is another article that is spoiled if prepared too long before it is served1 and this list might be multiplied indefinitely4 ,there is no question but that this lack of forethought in calculating the time that should elapse between cooking and serving of food is responsible for many insipid1 unattractive1 indigestible meals in hospitals4 ,when so much of the food has to be prepared in bulk1 the problem is much more difficult than in dealing with an individual patient1 and only goes to show the necessity of having not only first class facilities for prompt serving1 but first class trained brains to calculate and first class hands to handle it if the best results are desired4 ,if the one in charge has had personal experience in dealing with invalids1 many little touches will suggest themselves to her that will tend to make the invalid's missing text in advance of the meal and allowed to stand in water4 ,even a dish of bread and milk may be made a dainty meal if the bread is cut in half-inch dice and piled lightly on a plate4 ,milk toast may be accepted as a delightful treat if a little thought is given to its preparation and serving4 ,as for all toast the bread should be thoroughly and evenly browned before a moderate coal fire4 ,the toast1 cut in neat squares1 with the crust removed1 may then be placed in a deep saucer 7the daintiest and prettiest the establishment affords7 and covered with a small plate which with the saucer should first be heated4 ,when the tray cover is spread1 set on it a small knife and fork and teaspoon1 a little silver teapot of hot milk1 a ball of butter and a salt shaker4 ,if the patient is able to butter his own toast and pour over it the hot milk he will enjoy doing it4 ,when a single dish is to be served use a small round tray or a large plate covered with a doily rather than the regular tray used for meals4 ,avoid putting so many dishes on a tray that it will seem crowded4 ,it is better to use a second tray for serving dessert or fruit than to pile too much on one tray and have it lack in order and neatness4 ,cracked cups or china and broken-nosed teapots are distinctly out of place on any invalid's tray and in these days of inexpensive dishes are inexcusable in any hospital4 ,special care should be used to avoid filling cups and glasses to the brim4 ,when this is done1 it is impossible to avoid an overflow if it has to be carried any distance1 the neat appearance is spoiled1 a portion of the contents is lost and it is difficult for the patient to handle without spilling4 ,a nurse who has an eye for harmonious effects in colors will not be guilty of setting a tray with a green cup and saucer and an old fashioned blue plate4 ,a sense of the fitness of things will also keep her from placing together a cup and saucer that were never intended for each other4 ,such blunders in setting a tray are indicative either of ignorance or carelessness4 ,it is always a mistake to leave food beside a patient any length of time after the patient has had time to eat it4 ,if he has no desire for it when it is first presented1 the chances are small that the desire will come if the food is allowed to stay in sight4 ,besides the exposure to the floating dust made up of the undesirable elements of a sick room will render the food unfit for use at another time4 ,food substances are the soil in which bacteria flourish4 ,a spray of maiden hair fern or any of the dainty green effects is always suitable for decoration1 as are many flowers4 ,the use of flowers on a tray should be restricted to a single blossom with a touch of green1 or a full bloom flower of the dainty varieties4 ,large bouquets on an invalid's tray are in bad taste1 as are many flowers that elsewhere would be appreciated4 ,every hospital experience ought to be a practical lesson to the patient in how to serve food4 ,a taste for the dainty and beautiful1 for wholesome and simple things1 may be created there that will permanently influence the sick one to higher ideals of living4 ,and certainly the manner of serving food is a pretty fair indication of the tone of the institution4 ,refinement or absence of refinement will be detected at a glance by one who has a keen appreciation of the aesthetic4 ,the best results in food service will never be secured in any hospital until some one person is appointed whose chief business is the preparation of special diets and the oversight of serving4 ,in many large or well-regulated hospitals this matter is in the hands of women specially trained in dietetics1 and there one has a right to expect better service than in institutions where one overworked woman must attend to that and a dozen other things1 or where the responsibility of serving food is divided among many4 ,if the person in charge has had in addition to the training in dietetics practical experience as a hospital nurse1 still better service may be expected4 ,a genuine sympathetic interest1 or as some one else has termed it1 8an affectionate interest10 in the people for whom the food is prepared1 a keeping in mind the ,golden ,rule in serving and preparing food1 as in other departments of the hospital1 is fully as important as a knowledge of the science of nutrition4 ,the soul life of the individual can find abundant opportunities for its expression in the diet kitchen as in the ward4 ,there is a field here for specializing which is fully as worthy of a nurse's attention as some of the other lines of nursing4 ,,chapter ,x4 ,sidenote3 ,hospital ,dietaries ,the following dietary regulations have been adopted in the ,new ,york ,hospital3 8,all patients shall be furnished the regular house diet1 unless otherwise specially directed by the attending physician or surgeon4 ,as a substitute for the house diet there may be furnished1 on the order of the attending physician or surgeon only1 either of the following3 8#a4 ,restricted diet4 8#b4 ,milk diet4 8,the attending physician or surgeon shall specify on the occasion of his first visit to a patient which diet shall be furnished4 ,this duty may not be delegated to the house physician1 except that on the admission of a patient to a ward it shall be his duty to give instruction on the subject to the nurse in charge1 and such instruction shall be followed until the first visit of the attending physician or surgeon4 8,the wards shall be supplied with blanks called diet lists4 ,the head nurse shall carry one of these with her regularly when accompanying the attending physician or surgeon on his visits1 and shall note down carefully all his instructions as to diet2 he shall sign these lists before leaving the ward4 8,milk diet or restricted diet may not be ordered in addition to the regular house diet1 but only as a substitute therefor1 but the attending physician or surgeon may order items of special diet in particular cases4 8,lists defining the different classes of diet shall be furnished each attending physician and surgeon4 8,cards appropriately inscribed shall be placed at the head of each bed1 which shall designate the class of diet and also the amount of stimulant which is furnished each patient4 8,a diet kitchen is established under the direction and control of the directress of nurses1 wherein articles of special diet shall be prepared and served as ordered4 ,,daily ,,house ,,diet4 8,breakfast4--,oatmeal or hominy2 tea or coffee1 with milk and sugar2 bread and butter4 8,dinner4--,potatoes2 bread and butter2 one or more of the following vegetables3 ,turnips1 sweet potatoes1 beets1 spinach1 squash4 8,supper4--,tea with milk and sugar2 bread and butter2 stewed or fresh fruit4 8,in addition on ,sunday3 ,breakfast--,eggs4 ,dinner--,roast beef and cornstarch pudding4 ,monday3 ,breakfast--,baked potatoes4 ,dinner--,stock soup1 stewed beef or mutton1 rice pudding4 ,tuesday3 ,breakfast--,mutton chops4 ,dinner--,pea soup1 roast mutton1 bread pudding4 ,wednesday3 ,breakfast--,fried or stewed potatoes4 ,dinner--,roast beef1 cornstarch pudding4 ,thursday3 ,breakfast--,eggs4 ,dinner--,stock soup1 stewed beef or mutton1 tapioca pudding4 ,friday3 ,breakfast--,salt mackerel or codfish4 ,dinner--,bean soup1 baked fish1 beans1 rice pudding4 ,saturday3 ,breakfast--,beefsteak4 ,dinner--,corned beef1 cabbage1 bread pudding4 ,,restricted ,,diet4 8,breakfast4--,tea or coffee 7with milk and sugar71 farinaceous food 7with milk71 eggs4 8,dinner4--,soup2 either of the following3 ,raw oysters1 roast beef1 steak1 chicken with vegetables1 pudding 7bread1 rice1 tapioca or cornstarch74 8,supper4--,tea 7with milk and sugar71 bread 7with butter71 fruit1 fresh or dried4 ,,milk ,,diet4 8,six pints of milk daily4 ,,articles ,,of ,,special ,,diet4 8,milk1 eggs1 beef tea1 oysters1 cornstarch1 chops1 steak1 chicken1 chicken soup1 rice1 broth1 farina1 ice creams1 as ordered by the attending physician or surgeon4 8,salt fish1 jellies1 custards1 gruels40 ,dietary of the ,roosevelt ,hospital1 ,new ,york4 8,the ward diet of the ,roosevelt ,hospital1 ,new ,york1 is classified as follows3 ,,full ,,diet4 8,daily4--,meat dressed1 eight ounces2 potatoes1 eight ounces2 bread1 twelve ounces2 butter1 one ounce2 sugar1 two ounces and a half2 milk1 half-pint2 coffee1 half an ounce2 tea1 an eighth of an ounce4 8,on ,sundays1 ,tuesdays and ,thursdays other vegetables in addition to potatoes1 two ounces2 bread1 rice or tapioca pudding4 8,on ,mondays and ,wednesdays1 soup1 one pint4 8,on ,fridays1 fish4 8,breakfast4--,coffee with sugar and milk1 bread and butter1 porridge of oatmeal1 wheaten grits or samp4 8,dinner4--,sunday3 ,roast beef1 tomatoes1 potatoes or other vegetables1 bread and bread pudding4 ,monday3 ,soup1 boiled mutton1 potatoes and bread4 ,tuesday3 ,corned beef1 twelve ounces2 cabbage or turnips1 potatoes and bread4 ,wednesday3 ,soup1 roast beef1 potatoes and bread4 ,thursday3 ,soup1 boiled beef1 potatoes1 onions1 tapioca1 sago1 or farina pudding and bread4 ,friday3 ,fish1 boiled or roast beef1 potatoes1 bread1 boiled rice sweetened with sugar and milk and raisins4 ,saturday3 ,stew of mutton1 potatoes and bread4 8,supper4--,tea with sugar and milk1 bread and butter1 baked apples or stewed pears or prunes or green or dried apple sauce1 and on ,sundays gingerbread varied alternate weeks with currant buns4 ,,half ,,diet4 8,daily4--,meat dressed1 four ounces2 potatoes1 four ounces2 bread1 six ounces2 of other articles the same as in full diet4 ,,milk ,,diet4 8,daily4--,milk1 two pints2 bread1 twelve ounces2 rice or samp1 two ounces2 butter1 one ounce4 ,,extras4 8,in addition to the above1 the following extras may be ordered by the visiting physicians and surgeons3 ,beefsteak1 chicken soup1 gruel1 beef tea1 oysters or clams1 cornstarch1 mutton chops1 milk1 rice1 chicken1 eggs4 8,ward ,dietary of the ,new ,york ,infirmary for ,women and ,children1 #aija4 8,the following is a sample mid-summer diet from a smaller hospital having about seventy beds1 in which attention is economically given to variety in food cookery1 which would be impossible in a larger institution without incurring needless expense--,thompson4 ,,sunday4 8,breakfast4--,full ,diets3 ,hominy with milk1 fish balls or creamed fish1 brown bread or biscuit1 coffee with milk and sugar1 fresh fruit4 ,half ,diets3 ,hominy with milk1 toast1 coffee1 fresh fruit4 8,dinner4--,full ,diets3 ,soup1 bread1 roast beef1 sweet or white potatoes1 spinach or egg plant1 pudding4 ,half ,diets3 ,clam broth1 toast1 chicken or beef jelly1 rice or ice cream4 8,supper4--,full ,diets3 ,pressed beef or cream salmon1 bread and butter1 cocoa4 ,half ,diets3 ,indian meal porridge and milk1 toast1 cocoa1 fruit4 ,,monday4 8,breakfast4--,full ,diets3 ,oatmeal and milk1 bread and butter1 poached eggs on toast1 coffee with milk and sugar4 ,half ,diets3 ,oatmeal1 eggs on toast1 coffee1 fresh fruit4 8,dinner4--,full ,diets3 ,soup1 bread1 roast lamb1 spaghetti1 tomatoes or lima beans1 rice1 prune or cottage pudding4 ,half ,diets3 ,chicken broth1 toast1 spaghetti1 rice pudding or cottage pudding4 8,supper4--,full ,diets3 ,baked potatoes and bacon or creamed beef on toast1 bread and butter1 tea1 fruits4 ,half ,diets3 ,hominy and milk1 bread and butter or toast1 tea1 fruit4 ,,tuesday4 8,breakfast4--,full ,diets3 ,wheat flakes and milk2 beef mince or hash1 bread and butter1 coffee4 ,half ,diets3 ,wheat flakes1 buttered toast1 coffee1 fresh fish4 8,dinner4--,full ,diets3 ,soup1 bread1 steak1 cresses1 potatoes1 beans or carrots or beets1 boiled or baked custards or ice cream4 ,half ,diets3 ,mutton broth1 rice1 toast1 custard or ice cream4 8,supper4--,full ,diets3 ,brown bread and butter1 cream cheese or boiled eggs1 or sliced beef1 fruit1 cocoa4 ,half ,diets3 ,oatmeal jelly and milk1 toast1 fruit1 cocoa4 ,,wednesday4 8,breakfast4--,full ,diets3 ,hominy with milk1 lamb mince or lamb with cream sauce1 bread1 butter1 coffee4 ,half ,diets3 ,hominy with milk1 buttered toast1 boiled eggs1 coffee1 fresh fruit4 8,dinner4--,full ,diets3 ,soup1 bread1 chicken1 potatoes or rice1 peas1 tapioca or fruit pudding or custard4 ,half ,diets3 ,broth1 rice1 toast1 tapioca4 8,supper4--,full ,diets3 ,spaghetti and tomato or sliced tomatoes or baked corn1 bread and butter1 tea1 fruit4 ,half ,diets3 ,wheat flakes and milk1 toast1 tea1 fruit4 ,,thursday4 8,breakfast4--,full ,diets3 ,oatmeal and milk1 fresh fish1 bread and butter1 coffee4 ,half ,diets3 ,oatmeal and milk1 toast1 coffee1 fresh fruit4 8,dinner4--,full ,diets3 ,soup1 bread1 braised beef1 macaroni1 spinach or string beans1 wine jelly or fruit jelly4 ,half ,diets3 ,chicken broth1 macaroni1 toast1 wine jelly4 8,supper4--,full ,diets3 ,beef stew or cream toast or pea soup1 bread and butter1 cake1 fruit1 cocoa4 ,half ,diets3 ,cream toast1 cocoa1 fruit4 ,,friday4 8,breakfast4--,full ,diets3 ,wheat flakes and milk1 scrambled eggs on toast1 bread and butter4 ,half ,diets3 ,wheat flakes and milk1 eggs1 toast1 coffee1 fresh fruit4 8,dinner4--,full ,diets3 ,soup1 bread1 fish1 potatoes1 peas or tomatoes1 bread pudding or ,indian pudding or ice cream4 ,half ,diets3 ,lamb broth1 rice1 bread pudding or ice cream4 8,supper4--,full ,diets3 ,chowder or boiled eggs1 bread and butter1 tea1 fruit4 ,half ,diets3 ,oatmeal jelly1 toast1 tea1 fruit4 ,,saturday4 8,breakfast4--,full ,diets3 ,indian meal porridge and maple syrup or milk1 beef ragout1 bread and butter1 coffee4 ,half ,diets3 ,indian porridge1 toast1 coffee4 8,dinner4--,full ,diets3 ,soup1 bread1 steak1 potatoes1 cauliflower or squash4 ,half ,diets3 ,chicken broth1 toast1 rice1 rennet custard1 blanc mange4 8,supper4--,full ,diets3 ,lamb stew or baked beans1 bread and butter1 tea1 fruit4 ,half ,diets3 ,wheat flakes and milk1 toast1 tea1 fruit4 8,food which may be ordered by resident or attending physician when daily diet is not adequate or suitable3 ,beef steak1 chops1 chicken1 beef jelly1 chicken jelly1 scraped beef balls1 raw beef sandwiches1 clam broth1 crackers1 extra eggs and milk1 gruels1 oatmeal jelly1 wine or fruit jelly1 cold beef extract1 made with hydrochloric acid40--,practical ,dietetics4--,thompson4 ,,menus ,,for ,,nitrogenous ,,diet4 ,a nitrogenous diet is one in which the use of starchy foods is greatly restricted1 if not entirely forbidden4 ,sugars and acids are also prohibited in many cases4 ,this diet is used chiefly in certain forms of digestive disorder and occasionally in some general diseases4 ,bread is usually allowed in the form of zwieback1 crisp toast1 ,graham bread or shredded wheat biscuits4 ,where sugar is prohibited1 saccharine or sweetina may be used for sweetening4 ,the latter can be secured either through grocers who handle special food products1 or through druggists4 ,where the ordinary bread is forbidden1 the use of gum gluten or gluten flour--a wheaten flour from which the starch has been wholly or partially washed--may be necessary4 ,many gross adulterations of gluten products are on the market and care should be exercised to see that the product furnished is up to a certain standard and certified4 ,the ,state ,board of ,health of ,new ,hampshire has announced that 8standard gluten flour must contain at least #cj per cent of proteid and not over #dh per cent of starch40 ,recipes for using the gluten flour are easily obtained and a variety of biscuits1 wafers and bread may be secured4 ,breakfast4--,omelette1 crisp buttered toast1 coffee1 cream4 ,dinner4--,strained vegetable soup1 gluten wafers1 lamb chop1 lettuce salad1 snow pudding with soft egg custard1 tea4 ,supper4--,oyster broth1 gluten biscuits1 celery1 cottage cheese1 cream1 tea4 ,breakfast4--,broiled beefsteak1 crisp toast1 coffee1 cream4 ,dinner4--,pea puree1 gluten wafers1 whitefish1 celery1 egg and lettuce salad1 ,graham bread1 coffee jelly with whipped cream4 ,supper4--,cold roast beef2 cress2 gluten biscuit1 baked custard4 ,breakfast4--,broiled fish2 zwieback2 soft boiled egg2 coffee1 cream4 ,dinner4--,chicken broth2 gluten wafers2 beef 7steak or roast71 string beans1 ,graham bread1 junket4 ,supper4--,bean soup strained2 chicken salad1 ,graham bread1 sherbet1 milk4 ,breakfast4--,scrambled eggs with shredded wheat biscuits1 cresses1 coffee4 ,dinner4--,bouillon1 mutton chop1 spinach1 ,graham bread2 junket-ice cream2 tea4 ,supper4--,pea puree1 fish salad1 cottage cheese on lettuce2 gluten biscuits1 tea4 ,breakfast4--,omelette with chopped parsley1 cold tongue1 crisp toast1 coffee4 ,dinner4--,celery broth1 gluten wafers1 minced chicken1 string beans1 ice cream4 ,supper4--,raw oysters1 gluten wafers1 lettuce and egg salad1 bran biscuit1 ,spanish cream4 ,,menus ,,for ,a ,,farinaceous ,,diet4 ,a farinaceous dietary is not infrequently called for in hospitals4 ,in certain forms of kidney disease it is an important part of the treatment4 ,in this diet all flesh foods are forbidden4 ,milk and butter are allowed and certain fruits4 ,eggs1 if used at all1 must be used very sparingly4 ,breakfast4--,orange1 wheat breakfast food1 baked potato1 rolls1 coffee4 ,dinner4--,asparagus soup1 riced potato1 tomato salad1 tapioca cream4 ,supper4--,creamed macaroni1 corn muffins1 white bread1 prune whip4 ,breakfast4--,apple sauce1 oatmeal porridge1 buttered toast1 coffee4 ,dinner4--,barley soup1 crackers1 baked potato1 scalloped corn1 blanc mange with apple jelly4 ,supper4--,potato puree1 crackers1 macaroni with tomatoes1 white and brown bread1 pears4 ,breakfast4--,baked apple1 hominy1 corn bread1 toast1 coffee4 ,dinner4--,tomato soup1 crackers1 scalloped potatoes1 white and brown bread1 apple whip4 ,supper4--,potato puree1 baked rice1 bran biscuits1 stewed prunes1 cocoa4 ,,menu ,,for ,a ,,typhoid ,,fever ,,dietary4 #f a4 m4--,cup of hot milk1 coffee4 #h a4 m4--,glass of orange jelly4 #aj a4 m4--,chicken broth with equal portions of milk4 ,noon4--,junket1 cup of tea4 #b p4 m4-- ,milk with vichy1 barley or oatmeal water4 #d p4 m4--,chicken or beef broth4 #f p4 m4--,glass of buttermilk4 #h p4 m4--,cup of cocoa4 #aj p4 m4--,cup of hot malted milk4 ,,convalescent ,,dietary4 ,beginning three or four days after temperature remains normal3 ,,first ,,day4 #f a4 m4--,equal parts of milk and strained oatmeal gruel4 #h a4 m4--,egg-nog4 #aj a4 m4--,junket4 ,noon4--,milk toast1 cup of tea4 #b p4 m4--,cup of cocoa prepared with milk4 #d p4 m4--,ice cream4 #f p4 m4--,beef broth with well cooked rice4 ,,second ,,day4 #f a4 m4--,milk toast1 cup of coffee4 #h a4 m4--,malted milk4 #aj a4 m4--,buttermilk4 ,noon4--,chicken broth1 crackers1 orange sherbet4 #b p4 m4--,cup of tea or cocoa4 #d p4 m4--,lemon jelly4 #f p4 m4--,steak1 chewed but not swallowed1 junket4 ,,third ,,day4 #f a4 m4--,farina with cream1 coffee4 #i a4 m4--,soft boiled egg1 cracker4 ,noon4--,potato puree strained1 scraped beef sandwich1 tea4 #c p4 m4--,ice cream4 #f p4 m4--,milk toast1 cocoa1 orange jelly4 ,,supplies ,,for ,,one ,,hundred ,,persons ,,for ,,thirty ,,days4 ,austin ,flint gives the following estimate of food supplies for the ,new ,york ,state ,hospital3 ,meat1 with bone1 including fresh and salted fish and poultry4 ,total #b1bej lbs4 ,flour 7may be partly substituted for by corn meal and macaroni7 #b1bej lbs4 ,potatoes #b1bej lbs4 ,milk #a1ejj qts4 ,eggs #bej doz4 ,sugar #dij lbs4 ,butter #dcj lbs4 ,cheese #bae lbs4 ,rice #ajh lbs4 ,hominy #ajh lbs4 ,oatmeal #ajh lbs4 ,coffee #ahj lbs4 ,tea #bf lbs4 ,,chapter ,,xi4 ,sidenote3 ,hospital ,hygiene ,some sage has remarked that men and women are doomed1 from birth to the grave1 to combat three things--disease1 dirt and the devil4 ,with a great many of the human race1 the effort put forth to oppose either one of the ,d's is so weak that it could scarcely be called a combat4 ,the ,d's are on hand1 when the first breath is drawn1 and the unfortunate individual weakly yields to force of circumstances4 ,if he does not succumb to their influence early in life1 he drags through an existence somehow and calls it living4 ,but in a hospital1 if the health of the workers is to be preserved1 if the hopes of those who come as seekers of health are not to be defeated1 if life for any of its inmates is to be considered safe1 then nothing less than an unceasing war1 a hand-to-hand combat with the three ,d's must be maintained4 ,sidenote3 ,prevention of ,disease ,preventive medicine and preventive nursing are each year assuming a larger place in the study not only of those who deal with disease1 but of the public in general1 and in no place is such knowledge of greater importance than in a hospital4 ,to ,florence ,nightingale we are under a debt of gratitude for giving to the world some of its first and best lessons on hospital sanitation4 ,when she1 with her corps of ,english nurses1 entered the huge hospital in ,scutari in #ahef and began her work among the six thousand wounded soldiers1 the disorder and filth and consequent suffering was appalling4 ,she shocked the propriety of some of the army officials beyond measure1 but she saved lives4 ,she transformed the hospital1 and the haughty officials who on her arrival in astonishment had remarked3 8,fancy6 ,some women have come to the hospital6 ,a ,miss ,nightingale1 with a force of assistants4 ,was anything ever more improper than women in such a place80 learned in less than a week some lessons they were sadly in need of from that self-same woman4 ,much of her teaching on hospital sanitation we have not yet outgrown1 in spite of all the progress we have made4 ,in the average home1 under the best conditions1 the skill of the intelligent housewife is taxed to the utmost to prevent disease from invading its precincts4 ,how much the more vigilance is required in a hospital with all its adverse influences to contend with8 ,many years ago a medical officer of a health department in ,england1 in speaking on this subject1 said3 8,that which makes the healthiest house makes likewise the healthiest hospital2 the same fastidious and universal cleanliness1 the same never-ceasing vigilance against the thousand forms in which dirt may disguise itself1 in air1 in soil and water1 in walls and floors and ceilings1 in dress and bedding and furniture1 in pots and pans and pails1 in sinks and drains and dust-bins2 it is but the same principle of management1 but with immeasureably greater vigilance and skill2 for the establishment which has to be kept in such exquisite perfection of cleanliness is an establishment which never rests from fouling itself2 nor are there any products of its foulness1 not even the least odorous of such products1 which ought not to be regarded as poisons4 ,above all this applies to the fouling of the air within hospital wards by exhalations from the persons of the sick4 ,in such exhalations are embodied the most terrible powers of disease1 the spreading flames1 as it were1 of some infections and the explosive fuel of others2 and any air in which they are allowed to accumulate soon becomes a very atmosphere of death40 ,the subject of hospital sanitation is so large1 so many-sided1 that to do it justice in the space allotted is impossible4 ,it involves a consideration of the site of the hospital and the plans1 the separation of the departments1 the materials used in its construction1 its ventilating system1 its plumbing and sewerage connection1 its food and water supplies1 its facilities for isolation of infectious diseases1 for disinfection1 for disposal of the waste and refuse from the various departments1 and its arrangement for living conditions for those on whom the responsibility of carrying on the work of the hospital involves4 ,sidenote3 ,sanitary ,kitchens ,sidenote3 ,pure ,food ,the days of hospital gangrene1 of outbreaks of erysipelas1 pyaemia and puerperal fever in hospitals have passed1 but we have still too many cases of typhoid fever1 diphtheria and other diseases developing in hospitals and institutions of various kinds in this twentieth century4 ,the teachings of ,pasteur and ,lister that bacteria are the cause of a large number of the ills that flesh is heir to1 and that these micro-organisms may be destroyed by the use of proper means--these teachings have revolutionized some departments of hospital work4 ,one very important department that has not been entirely revolutionized is the hospital kitchen4 ,the number of sanitary kitchens is increasing1 it is true1 but in many hospitals the kitchen is out of harmony with the other departments4 ,it is not unusual to find a beautiful and imposing front entrance1 to find marble and tile entering largely into the construction of many parts of the building1 to find a costly modern equipment in many departments1 and to find the kitchen of that same institution1 dark1 too small1 poorly equipped1 poorly ventilated1 cheaply constructed throughout1 and thoroughly unsanitary1 a splendid place for the development of germs--a place that is1 if not a disgrace to the institution1 at least far from creditable4 ,who is to blame8 ,somebody surely is4 ,certainly when so much value is being placed on the food supplies sent from the kitchen as weapons in the fight with disease no hospital built in the twentieth century should have in it a kitchen that is not in keeping with the rest of the building1 that will not bear critical inspection1 that cannot be shown with as much confidence and satisfaction as the operating room or the wards4 ,and not only in the situation1 construction and equipment of the hospital kitchen is this lack of progress evident1 but in no part of the hospital is the germ theory so little regarded in practical work4 ,pure blood is regarded as one of the great essentials of health1 and much study has been devoted to that important part of the human system4 ,the most perfect apparatus for examining the blood is considered none too good1 but how often in the average hospital are tests applied to the materials from which blood is made8 ,are all butchers and bakers and grocers and dairymen so honorable that occasional analysis of the products supplied is quite unnecessary8 ,an examination of the ice supply in a certain hospital1 not many months ago1 led to the discovery of the ice as the cause of an epidemic of typhoid fever1 that seriously embarrassed the institution4 ,a careful inquiry into such matters might have prevented serious embarrassments in a number of other institutions within recent years4 ,prevention is better than cure1 and far cheaper4 ,it is always better to be sure than sorry1 and now that scientific research is popular1 it ought to be possible for every hospital to arrange for periodical examination of its food and water supplies4 ,sidenote3 ,filters and ,water ,filters are now regarded as essential in every hospital1 but it is quite possible for too much confidence to be placed in filters4 ,the filter that will run fast is likely to be the favorite1 whether it really filters or not4 ,elmer ,g4 ,horton1 ,b4 ,s41 bacteriologist to the ,ohio ,state ,board of ,health1 in speaking of the weaknesses of domestic filters1 says3 8,if the rate of filtration is not moderately fast1 the consumer will not buy4 ,the maker realizes this1 and slights efficiency in order to gain a more rapid flow4 ,the filtering material is made coarser or more porous1 and1 with the resistance decreased1 the water passes through more readily1 and so do the bacteria4 8,no filter will continuously yield a perfect effluent without being often cleaned4 ,whatever a filter takes out of the water remains in the filter until removed by cleansing2 and if that cleansing be delayed the filter will dispose of the accumulated filth by way of the passing water4 ,we must expect an unclean or foul filter to yield an effluent of like character1 although that effluent may appear clear4 8,after all1 the more harmful things in a water are not so much the easily discernible ones--mud1 floating vegetation1 iron1 odors1 etc41 but the invisible living micro-organisms1 and especially those forms capable of producing disease in man4 ,it is true1 and greatly to be regretted1 that clearness is the criterion by which the average citizen measures the efficiency of his filter1 but let it never be forgotten that the clearness of a water is no guarantee of its purity4 ,this bottle of water which ,i pass around is clear enough1 and no doubt looks good enough to drink1 but it actually contains not thousands but millions of typhoid fever bacilli4 8,a sample of filtered water from the filter in the dining room of a large boarding-house was examined and found to contain five times as many bacteria as the unfiltered water4 8,recently samples of filtered and unfiltered water were taken from a filter in one of the offices of the ,state ,house4 ,the #b1bjj bacteria per cc4 of the untreated water had increased to #ad1jjj in passing through their 8germ-proof0 filter4 ,organic matter collects in the filter and serves as food1 and there is developed a breeding nest for the bacteria40 ,parkes in his manual of hygiene suggests this plan for the examination of water3 ,first1 a physical examination of water2 second1 a microscopical examination of suspended matters and sediment2 third1 a quantitative examination of dissolved solids2 fourth1 a biological examination4 ,sidenote3 ,air ,while it is important for every hospital to know something of the quality of the food and water supplied to its inmates1 it is of still greater importance to know that in every department of the hospital there is provision for the entrance of pure air and the exit of impure air4 ,we may live without food for days or weeks1 but the breath of life is the first great essential of existence4 ,deprived of it and death results4 ,poison it and deterioration in health results4 8,bountiful nature has supplied an inexhaustible supply of this essential1 and the means for its purification4 ,only when man's ingenuity or stupidity thwarts her efforts1 confines the air1 prevents its free circulation1 does it retain the poison he has contributed to it40 ,a large part of the science of sanitation can be summed up in one word3 cleanliness2 clean air1 clean food1 clean water1 clean rooms1 clean beds and bed linen1 clean occupants of the beds1 and clean appliances4 ,sidenote3 ,dirt ,dirt has been defined as 8matter out of place40 ,to have the ability to recognize when matter becomes dirt1 and get it into its proper place and proper form1 is to have the key to hospital sanitation4 ,it means a strict attention to what elsewhere might be considered small details4 ,it is said that under the microscope the dust of an ordinary house resolves itself into soot1 minute particles of cotton and wool fibres1 spores of bacteria1 starch grains1 pulverized straw1 epithelial and epidermic debris1 and fragments of food4 ,it consists to a great extent of organic substance1 capable of decomposition4 ,when added to this we have some of the constituents of dust common to a hospital1 such as shreds of linen or wool from soiled bedding1 pieces of hair1 dried particles of pus1 blood1 and human tissue1 crystals of urine1 etc41 the consideration of how to get dust into its proper place and form1 how to deal with it1 so that it is not a menace to both the healthy and sick inmates1 is no small or unimportant part of hospital management4 ,sidenote3 ,flies ,flies--the common1 innocent-looking house flies1 that formerly were regarded simply as annoyances to be endured1 have been found to be among the most active agents in the spread of disease4 ,now that the germ theory is so well understood1 it is not difficult to see how this takes place4 ,victor ,vaughan1 a member of the ,army ,medical ,commission during the ,spanish-,american war1 states as follows his observations regarding the fly as an agent in spreading typhoid fever in the camps3 8,they swarmed over fecal matter in the latrines4 ,they visited and fed on food prepared for soldiers in the mess tents4 ,in some instances when lime had been spread over the contents of latrines1 flies1 with their feet white with lime1 were seen walking over the food4 ,officers whose mess tents were protected by means of screens suffered less proportionately than those whose tents were not so protected40 ,dr4 ,m4 ,j4 ,rosenau1 in his valuable book on 8,disinfection and ,disinfectants10 expresses his opinion with no uncertain sound on the fly question when he says3 8,in fact1 as our knowledge of the subject increases we find that domestic animals and vermin are playing a very conspicuous role in the transmission of disease4 ,so dangerous do we now know that the fly and mosquito may be1 that when the matter is more generally understood1 it should be a greater reproach to the housewife to have these dangerous vermin in the household than to have bedbugs40 ,where dressings soiled with pus and excreta have constantly to be handled1 as in a hospital1 the presence of flies is a real source of danger that no careful housekeeper will ignore4 ,to keep them out of the building1 and manage so that no substance about the exterior may be left to attract them1 means that a systematic inspection of the premises must be made1 to see that fruit peelings or scraps of food are not thrown from the windows1 that careful and prompt disposal of all refuse is accomplished1 that scrupulous cleanliness in and about the institution is practiced1 and that properly fitting screen windows and doors are in place early in the season1 and left till cold weather has caused the fly to leave for parts unknown4 ,sidenote3 ,garbage ,the disposal of garbage and the waste accumulation from the wards forms one of the most serious problems that confronts the hospital housekeeper4 ,there is but one safe method of disposal and that is by cremation1 prompt and swift and sure4 ,the too common method of storing garbage in large cans1 and allowing it to vitiate the air with its obnoxious odors1 and attract to itself flies an other vermin1 till the city garbage collector gets around to remove it1 is a practice that ought to be abandoned as speedily as possible by every institution4 ,much responsibility rests upon the superintendent in such matters4 ,she alone cannot effect desired improvements1 but she realizes the need as no member of the board can1 and she ought to tactfully educate the board and urge the necessity of proper appliances for this purpose4 ,recently twenty letters were sent out to twenty various sized hospitals inquiring as to the methods used in disposing of soiled dressings and refuse from the wards4 ,answers were received from almost if not all1 and there was a general agreement that cremation was the only proper method of disposal4 ,however1 in only three or four of the twenty had any provision been made in the plans of the hospital for this very important work4 ,some hospitals burnt them in the furnace1 some in the laundry stove in the basement1 some covered them up and carried them to the laundry stove in an outbuilding1 some had them carted away to the city dumping ground4 ,from one ,chicago hospital of whom inquiry was made we had the following report3 ,we have a water heater and garbage burner which runs day and night1 and into this burner we put all of our soiled dressings and garbage of every description at any hour1 day or night4 ,they are consumed without causing us any trouble whatever4 ,we certainly find it a great comfort not to have any garbage1 not even a garbage box or barrel on the premises4 ,our pails and baskets are brought down to the boiler room twice daily1 and there immediately emptied into the burner4 ,the pails are scalded and cleansed1 so that we keep everything sweet and clean40 ,from a ,new ,england hospital we had the following report3 8,for four years we have used a crematory for disposing of soiled dressings1 and have found it most satisfactory4 ,it has gas burners and could be placed in a bath room if it is large4 ,with such a crematory on each floor dressings can be burned immediately1 and thus the objectionable dressing or refuse pail be dispensed with4 ,a careful nurse will turn out the gas after the dressings are dry and ignited1 and the expense of the apparatus will thus be very slight40 ,through the courtesy of the ,morse-,boulger ,co41 who have installed crematories in a considerable number of large hospitals in the east and in some smaller institutions as well1 we are able to present a cut of a crematory for a small hospital4 ,illustration3 ,,garbage ,,crematory ,sidenote3 ,garbage ,crematories ,the crematories are built in many sizes to conform to the location4 ,they provide a medium for the disposal on the premises with the utmost rapidity and economy of every class of waste produced in a hospital4 ,they can be operated with any available fuel and all are provided with perfectly efficient means of consuming the smoke and inflammable gases thrown off by the burning material4 ,these crematories can be placed in the basement or cellar if necessary and connected directly with the chimney or smoke pipes1 from the heaters or steam boilers of a building1 or can be placed outside when deemed desirable4 ,in order to ascertain some facts concerning the working of these crematories1 letters of inquiry were also sent to a number of hospitals in which the ,morse-,boulger crematories are in use1 and without exception the reports were most favorable4 ,the following from one of the largest ,philadelphia hospitals is characteristic of all the reports received and goes to show that there is no risk of unsatisfactory working in such an apparatus3 8,it is true that we have a ,morse-,boulger garbage destructor1 and it has been in service about four years4 ,the capacity of the chamber is about twenty barrels4 ,in selecting the size we had in view the quantity of garbage that we have to burn each twenty-four hours1 so that the chamber would hold all the garbage produced in twenty-four hours at one charging1 thus relieving the necessity of keeping the fire going all the time4 ,as it is now1 the fire is started in our crematory about #d o'clock in the afternoon1 and by #aj o'clock at night the charge is all burned out4 ,this gives the apparatus time to cool off1 so that the night fireman can clean it out before he goes off duty and leave it ready for re-charging in the morning4 8,the destructor has worked very satisfactorily for us1 and burns the whole of our garbage with about #ejj pounds of buckwheat coal per day1 which means an expense of from forty to seventy cents a day1 owing to the price one has to pay for the coal4 8,i do not believe you can recommend too strongly the use of such an apparatus for hospital purposes40 ,other and cheaper crematories for the use of the smaller hospitals are in the market1 they being efficient1 so far as the capacity goes1 and the price being within the reach of practically every small hospital4 ,an illustration of one of the best of these cheaper crematories1 made by the ,bramhall-,deane ,co41 is here shown4 ,certainly every institution with new buildings or additions in course of erection that has not yet made provision for the sanitary disposal of garbage and refuse1 should keep this matter in view as one of the improvements to be arranged for as speedily as possible4 ,there is no royal road to safety in a hospital4 ,there are hidden dangers on every side4 8,eternal vigilance is the price of safety40 ,the most expensive and wisely constructed building and the best modern equipment will not long remain in a sanitary condition unless watchful care is exercised1 and intelligence and energy applied to the eradication of dirt1 and conditions that favor the multiplication of the enemies to life and health that are ever present4 ,in the regular daily cleaning of a hospital no 8royal road0 has been discovered4 ,there are on the market a great variety of washing powders1 scouring soaps and such things1 but nothing has been discovered that quite takes the place of human labor4 ,,chapter ,,xii4 ,sidenote3 ,the ,help ,question ,when one considers the numbers of boxes of good brass pens1 the quarts of ink1 and the reams of paper 7to say nothing of such cheap things as brains and time and vitality7 that have been consumed within the last score of years1 in bringing forward 8solutions of the servant problem20 when one sees that self-same problem1 still to the front1 dangling in the air as it were1 refusing to settle itself or be settled1 it surely ought to be sufficient to deter all but the most audacious from touching it4 ,instead of being solved1 it is growing larger and more difficult to deal with4 ,it is not much wonder that men suggest that women demonstrate their ability to manage their own domestic domain1 and get the servant question settled1 before seeking to get into politics and take a hand in the government of the state and nation4 ,however1 a prominent member of the board of a certain hospital remarked optimistically not long ago1 that 8since the ,irish land question seemed to be getting worked out10 she had some hope that somewhere1 around some unexpected corner1 some bright man or woman would discover a means of really solving 8the servant problem40 ,but up to the present moment that discovery has not been made1 and let it be understood here and now1 that a solution of that problem is not attempted here4 ,neither is any special claim made for originality1 for the subject has been so thoroughly gone over that it seems there is nothing new to be said4 ,but difficult as the subject may be to deal with1 either theoretically or practically1 it cannot well be ignored in dealing with hospital housekeeping1 since it consumes no small portion of the time and energy of the housekeeper1 and is of vital importance to the institution4 ,sidenote3 ,numbers of ,servants ,perhaps the best place to attack the subject would be to calculate how many servants are necessary to do the work in a certain hospital of a certain capacity4 ,but at the outset one is baffled at that point because institutions differ so very greatly4 ,some buildings are much more difficult to keep clean1 more difficult to get work done in because of mistakes in construction that entail more labor4 ,servants also differ in their ability1 standards of work vary1 and the organization of the working force varies4 ,some institutions require nurses to do all the sweeping of wards and private rooms1 others have it all done by maids4 ,some hospitals require nurses to wash ward dishes4 ,in others nurses do none of that work4 ,in a place where soft coal is used more help will be required to maintain the same standard of cleanliness throughout the building1 than if that difficulty had not to be contended with4 ,some institutions have no laundry work done on the premises1 others have it all done at home4 ,some hospitals bake all their own bread1 others bake none4 ,all these and many other things have to be considered in reckoning the number of servants required4 ,each institution must be largely a law unto itself in this matter4 ,in a paper read at the ,philadelphia meeting of hospital superintendents1 ,mr4 ,lathrop threw out a suggestion about engaging servants that might well be adopted by hospitals in general4 ,in referring to the system of hospital records and reports used in ,roosevelt ,hospital1 he said3 8,a book1 entitled #8,a ,list of ,officers and ,employees1' alphabetically arranged1 contains the signature of each to a contract at the head of the page4 ,the contract reads as follows3 ,sidenote3 ,contract 8,i1 the undersigned1 accept the terms herein mentioned1 agree to do faithfully the work assigned to me and to conform to all rules of the hospital while in its employment2 and it is distinctly understood and agreed that whether ,i am paid by the day1 week1 month or year1 my engagement is to terminate upon notice by the superintendent that my services are no longer required2 and upon payment being made to me for the actual time of service rendered1 ,i agree to accept and receipt for the same in full consideration for all demands against the institution4 ,the hospital reserves the right to deduct for absence from whatever cause40 ,this contract reduces to a minimum the difficulty in getting rid of undesirable help without unpleasantness4 ,the last clause is especially important4 ,the only possible way of making an impression on some servants1 and keeping them up to the mark in punctuality1 is by touching their pocket4 ,when the absence or tardiness occurs from a legitimate cause1 as in illness1 it may not be best1 if the time lost is trifling1 to make any deduction1 but at any rate the servant should understand that part of the agreement1 and when it is not enforced he will be likely to have a due appreciation of the fact4 ,merit ,system ,when a hospital pays a fair rate of wages to its employees it is in a position to insist on certain conditions1 and to maintain certain standards regarding work in all departments4 ,if it pays the lowest market price for such labor it must expect its servants to remain only till something better is found4 ,the merit system has been successfully used in other lines of work1 and ought to yield equally good results in a hospital4 ,if after giving a servant a fair trial1 he is found faithful and anxious to please and capable1 he ought to be shown that these qualities are appreciated4 ,if he was engaged for fifteen dollars a month1 a raise of wages of one dollar every three or four months until it has reached a certain point1 would give him some inducement to stay4 ,the habit of expressing satisfaction with work well done is a powerful incentive to continuance in well doing and better service in the future4 ,servants are all human4 ,they need reproof and correction1 but need quite as much the kind word of appreciation of their efforts4 ,there are but few people who will long continue to do their best if they think nobody cares or notices it4 ,sidenote3 ,schedule of ,work ,when servants enter the employ of the hospital1 it is a good plan to have some kind of schedule of the routine work ready to give them4 ,certain duties will have to be performed every day1 others on stated days of the week4 ,usually the housekeeper is subject to demands of all kinds4 ,it is necessary for her to study how to get routine work done well1 with the least tax on her memory or vitality1 and the schedule will help in that direction4 ,proper instruction at the beginning is always important4 ,many a servant has become discouraged in a few days and left his place vacant1 when a patient explanation of what to do1 and how to do what seemed to be expected of him1 would have developed a capable worker4 ,it is never a good plan to have such fixed ideas as to how a desired end should be reached that no other method will be accepted4 ,if servants have been accustomed to one certain way of doing things1 and their way yields as good results as some others1 it is well for the housekeeper to let them follow their own plans unless it is found to entail a waste of time and material4 ,in a hospital where there is such a multiplicity of details to be attended to1 no housekeeper can afford to waste much time over non-essentials4 ,the point is to be able to recognize non-essentials and not to ignore things of importance4 ,if she sees that time and material can be saved by doing things according to her methods1 a suggestion and a little teaching ought to effect the desired change4 ,if it does not1 if they do not try to improve1 and refuse to apply the instruction received1 then it is better to let them go and try to secure more tractable material4 ,there is seldom a time when all help is just what the housekeeper wants1 and it is safe to predict there never will be4 ,some will need more supervision than others4 ,some will remember a thing if told once1 others will need to have it repeated again and again4 ,one would naturally expect that a thing that had to be done every day would soon be done as a matter of habit1 but this is by no means the case1 as every housekeeper knows4 ,it is not enough to say3 8,this thing must be done every day40 ,somebody must be on the watch to see that it is done4 ,some servants when they find a neglect passes unnoticed will be very likely to repeat it1 and the lack of proper supervision accounts for the general slipshod condition of the domestic department of many institutions4 ,usually there are enough hands to do the work if they were kept up to the mark and properly supervised4 ,in the matter of cleanliness and neatness a great difference in standards is observed in visiting institutions4 ,suffice it to say that in a hospital1 above all other places1 there should not be a spot from attic to basement that the superintendent would not wish to throw open for inspection4 ,ice-boxes1 kitchens1 pantries1 storerooms1 basement1 laundry1 all should be models in respect to cleanliness and good order4 ,military rule1 or organization based on it1 is supposed to prevail to a large extent in the training school1 and it is equally important for it to prevail throughout the other departments of the hospital4 ,while with nations1 civil laws undergo changes as the spirit of the times change1 yet the fundamental principles of military organization remain unchanged4 ,there is a distinct gradation of officers1 and every man is recognized only in his station4 ,if a private soldier has a grievance or a report1 he is expected to state it to the officer immediately above him4 ,the captain cannot officially approach a general and ignore the intermediate officers4 ,the general gives his orders to the officer next to him in rank1 and they pass down the line from rank to rank4 ,only thus can a general hope to command the army of a nation successfully4 ,each man is expected to be in his place and attend to the duties of his position and not meddle with the affairs of others4 ,practically the same system prevails in large business corporations1 and no better basis for organizing a working force of an institution has been discovered4 ,sidenote3 ,rules ,much as the average ,american dislikes rules1 the fact remains that some are necessary4 ,the business is greatly overdone in some hospitals1 in others too much laxity exists1 and this inevitably tends to lower the tone of the institution4 ,for the domestic department it is wise to have cards with a set of general rules printed and framed and posted in conspicuous places to serve as reminders4 ,each hospital superintendent will have his own ideas of what general rules should be made for the government of his hospital employees1 but a specimen set of rules may not be out of order4 #a4 ,all services are at certain rates per month or week for time actually served4 ,employees desiring to leave shall give one week's notice to the superintendent4 ,the superintendent reserves the right to summarily discharge any employee for any cause when his presence is detrimental to the interests of the institution4 #b4 ,no reading or smoking in bed at night is allowed and smoking or chewing of tobacco is forbidden during working hours4 #c4 ,no duplicate keys for any part of the hospital shall be made except for and by the hospital4 ,all persons having hospital keys shall deliver them to the superintendent if absence over night is anticipated4 #d4 ,no employee shall enter the room of another at the hospital without knocking and waiting for reply4 ,female employees shall on no account visit men's rooms nor male employees women's rooms4 #e4 ,no employee1 unless duty requires it1 shall enter the wards without permission of the superintendent1 nor shall they enter departments where they have no duty except on business4 #f4 ,employees shall be prompt at meals4 ,those coming late will be expected to explain the reason4 ,no cooking1 heating or keeping of tea1 coffee1 or food shall be allowed on the premises other than in places provided for them and by persons employed for such duties4 #g4 ,all employees will1 when practicable1 be allowed two half days off duty each month and when convenient a part of each ,sunday1 subject to the needs of the institution and the discretion of the superintendent4 #h4 ,discharged employees are not entitled to the freedom of the premises and must stop in the waiting-room1 like other visitors1 while those discharged for cause are not admitted except as patients or on business to the superintendent4 #i4 ,employees shall attend to matters out of repair in their departments1 and report all articles broken or injured to the head of their department4 ,nails shall not be driven into the building or furniture without permission4 ,scratching of matches on walls is forbidden4 #aj4 ,the house will be closed at #aj3cj p4 m4 ,employees desiring late leave must get permission from the matron or superintendent4 ,no employee shall go in or out any window1 except those used as doors1 unless engaged in working about the same4 #aa4 ,employees shall not keep in their possession nor have on the premises1 spirituous liquors1 and the intoxication of any employee shall be the cause of instant dismissal4 #ab4 ,loitering around the kitchen during working hours1 or at any time1 by those not employed there is prohibited4 ,kitchen employees are not allowed to linger around the kitchen when off duty4 #ac4 ,all persons connected with the hospital are expected to be civil and polite at all times4 ,sleeping rooms1 wardrobes1 dressers1 closets1 cupboards1 etc41 shall be subject to inspection at any time4 ,rooms shall be in order and beds made by #aj a4 m4 and shall at all times be kept clean1 orderly and free from vermin4 #ad4 ,no one connected with the hospital shall remove the property1 however small1 from one room or ward to another without the permission of the superintendent4 #ae4 ,employees are expected by precept and example to assist in keeping the hospital quiet and orderly and free from dust1 dirt and foul air4 ,boisterous or profane language and whistling or singing cannot be permitted4 #af4 ,cleanliness and neatness in appearance1 habits and work are imperative4 ,all employees are expected to be punctual in reporting for duty4 ,visitors to employees are not allowed during working hours4 ,in exceptional cases permission may be obtained from the superintendent4 #ag4 ,all articles broken or destroyed will be charged to the person breaking them1 at cost price4 ,having made rules1 it becomes necessary to see to their enforcement4 ,exceptions should be few and far between4 ,a rule that is not enforced weakens the institutional government1 and had better never have been made4 ,if it is good and necessary let it be enforced1 if it is neither good nor necessary let it be abolished4 ,the question of incompatibility of temper among servants is a common perplexity4 ,when it occurs it is just as well to plan for a separation1 letting the one who seems to be the strongest element of discord go4 ,in feeding help there should be always plenty provided--the quality being about what is provided for ward patients4 ,a separate bill of fare for them would entail extra cost1 both for material and labor1 and they would be none the better for it4 ,sidenote3 ,servants' ,dining ,rooms ,is it too much to hope1 that1 sometime1 all hospitals will have a servants' dining room1 where1 apart from the heat and odor of the kitchen1 they can take their meals in comfort like respectable people8 ,many of those who have labored on the servant problem seem to have begun at the top for a solution1 instead of getting down to the foundations to build up a system4 ,they have sought to establish training schools and give diplomas1 believing that was the one thing needful to dignify the position of servants and make them happy and contented in that kind of work4 ,there is certainly no objection to plans for training1 providing they are not allowed to obscure other features bearing on the problem4 ,but one does not need to live more than a day in some homes or institutions to find one reason for the prevailing discontent among servants as a class4 ,a hospital that provides an attractive dining room for its help 7which could also be used as a reception room for their friends71 that sees that they have good bath rooms1 lavatories1 toilet rooms and sleeping rooms1 may expect to attract a superior class of servants1 who will have some inducement to remain where provision has been made for their comfort4 ,they will have more respect for themselves and for the institution and better service can be expected4 ,sidenote3 ,sleeping ,rooms ,there is a possibility of people becoming so charitable that they forget to be just4 ,some are so intent on providing the most modern equipment for the care of the unknown indigent patient that they entirely overlook the necessity of proper living conditions for those who must help in caring for the unknown indigent4 ,how many hospital managers would throw open with pride1 for the inspection of a party of visitors1 the doors of their servants' sleeping quarters1 as they do the doors to the free wards8 ,while text-books and teachers are emphasizing the necessity of pure air1 the need of a certain number of cubic feet of air-space for each occupant of every sleeping room1 hospital authorities are defying these self-same rules of hygiene1 by compelling their servants 7and often nurses1 too7 to sleep in crowded quarters without proper means of ventilation1 and which sometimes the direct rays of the sun can never penetrate4 ,it is nothing uncommon to find six or eight people crowded into one dormitory not larger than #ajx#ae1 and that not only in a ,new ,york tenement but in a modern hospital4 ,every intelligent person professes to believe that 8,pure air is as important as pure food in the production of vital energy of the body and mind1 but it is another case of not living according to one's belief4 ,what we greatly need is a realization of the fact that hygiene is not alone a science to be studied1 but an art to be practiced1 in the hospital1 in all its departments and elsewhere40 ,sidenote3 ,attire ,the working attire of the servants may seem a trifling thing to mention1 but it too is an indication of the standards of the management in that respect4 ,a hospital is no place for a slovenly1 untidy man or woman4 ,if they have not sufficient self respect to keep themselves clean and neatly clad they certainly cannot be expected to cook and serve food in a respectable1 appetizing1 healthful way or do their work in a cleanly manner4 8,the apparel oft proclaims the man40 ,it oft proclaims the institution1 too4 ,if the hospital is to make a desirable reputation and maintain it1 heads of departments must be on the alert in minor as well as major matters4 ,a chain is no stronger than its weakest link1 and each individual in the long human chain of hospital employees is either helping to make or mar the good reputation of the institution4 ,sidenote3 ,housekeeper's ,relation to ,servants ,the housekeeper's relation to the servants is too large a subject to more than touch1 but it is altogether too important to be left out entirely4 ,it is well to bear in mind the fact that laxity does not mean kindness1 nor does it always mean 8good nature10 as some people appear to believe4 ,neither does severity mean dignity4 ,it is quite possible to be dignified and approachable at the same time4 ,it is quite possible to be systematic about methods and work1 and strict in the observance of the rules of the institution1 and at the same time thoroughly kind and tender hearted and womanly4 ,the housekeeper who lets her servants know that she sympathizes with them in the trials and difficulties incident to their life will have much less trouble in governing them than the one who maintains a frigid air1 shuts her eyes and ears to things that are large to them1 and treats them like machines4 ,there are a hundred ways in which she can touch their lives helpfully1 and influence them to higher ideals if she chooses4 ,questions of dress1 health1 morals all suggest themselves at this point4 ,the all too prevalent tendency with the servant class to spend their hard-earned dollars in silks1 cheap feathers and tawdry finery1 to follow the fashions1 even if they have to go in debt1 is something that can be observed in the hospital as elsewhere4 ,this often has a bearing on health4 ,many who have spent their all in jewelry or finery which they did not need1 are obliged to go without proper shoes1 stockings1 under-clothing and things that are really essential for health and comfort4 ,if the housekeeper has won the respect and confidence of her help1 she ought to have a decided influence in checking this tendency among her maids and promoting habits of thrift and wise expenditure4 ,proper hours for retiring is another matter that will come in the housekeeping province as it relates to servants1 and one that no institution can afford to neglect4 ,late hours are neither conducive to good health nor good morals1 and certainly do not help in getting good work done4 ,for all these reasons the housekeeper1 where the help are housed on the premises1 should insist that the same hours that nurses are obliged to observe in getting home1 and getting lights turned out should be observed in the servants' quarters4 ,whether she wants the responsibility or not1 whether she thinks it or not1 the influence of the head of the domestic department is felt in the lives of her servants4 ,characters are being molded and built up that will leave their impress on future generations4 ,the world of the average servant is as a rule very small4 ,they live on the surface of things4 ,trifles seem large sometimes4 ,at other times very serious and far-reaching questions seem to them quite unimportant4 ,education of the conscience and of the hand can go on1 ought to go on1 together4 ,,chapter ,,xiii4 ,sidenote3 ,the ,problem of ,waste ,next in importance to the three vital questions which daily confront the hospital housekeeper1 in common with other mortals--8,what shall we eat1 what shall we drink and wherewithal shall we be clothed80 comes the question of how to prevent waste of the money and materials supplied for carrying on the work of the hospital4 ,few institutions afford such abundant opportunities for waste1 along so many different lines4 ,the sources of leaks seem to be endless4 ,the individuals who are responsible for waste may be found in all departments1 and represent all degrees of intelligence4 ,the varied composition of the hospital household1 the emergencies of the life and the fact that of necessity in a hospital of even moderate size the work is divided into departments with separate heads1 renders the problem of the prevention of waste exceedingly complicated4 ,then the lack of any thorough system of inspection1 the loose method of keeping accounts1 and rendering reports of expenditure and income1 the absence of uniformity of methods1 makes intelligent comparison with other institutions difficult1 if not impossible4 ,because of these conditions1 waste may constantly go on in an institution where apparently everyone is trying to be economical4 ,sidenote3 ,main ,causes ,there are usually three or four main causes existing where habitual waste goes on3 ,lack of an accurate system of accounting for supplies4 ,lack of careful supervision in the use of supplies4 ,lack of a general knowledge as to the average amounts of supplies necessary for each department for a given time4 ,unwise purchasing and ignorant or careless handling4 7,employing people who 8do not know how0 is also a frequent source of waste47 ,sidenote3 ,first ,steps ,it has been well said that the first step toward thrift is taking account of the items4 ,a proper system of accounting for the daily supplies sent to each department will go a long way toward checking extravagance4 ,this system of accounting secures facts about the consumption of supplies1 that are absolutely necessary for the detection of extravagance or waste1 and it should be adhered to as an important part of the work of every department4 ,the surgical department is one which needs special supervision4 ,while perhaps it would not technically come under the head of housekeeping1 it often is in charge of the hospital housekeeper1 and in considering the sources of waste it cannot be well omitted4 ,in measures for the prevention of waste1 the departments of a hospital should be a unit4 ,only thus can the problem be handled successfully4 ,referring to the excessive use of surgical supplies1 ,dr4 ,john ,w4 ,brannan1 president of the board of trustees of ,bellevue and allied hospitals1 ,new ,york1 in an open letter to ,charities has said3 ,sidenote3 ,surgical ,department 8,i wish to lay especial stress upon the possibility of effecting a very material saving in the use of surgical appliances and expensive drugs in all the hospitals4 ,in order to accomplish this it is necessary to have the goodwill and co-operation and constant thought1 not only of the superintendent and his staff1 but also of the surgeons and physicians1 both attending and house4 ,if the visiting physicians and surgeons were to exercise the same consideration in the use of surgical dressings and expensive drugs as they do in their private practice among people of moderate means1 and exact the same of the house staff2 there would be1 in my opinion1 a marked reduction in the amount of the supply account4 8,the following is an example of what can be done in the way of saving in surgical supplies3 ,the attention of the visiting surgeon of one of the divisions of ,bellevue ,hospital was called about a month ago to the large consumption of gauze in his wards1 some #b1ajj yards having been used in the previous week4 ,he at once made an investigation1 with the result that the next week the amount of gauze consumed was only #a1ajj yards1 and during the week following that only #faj yards1 although the service continued just as active and the patients were cared for fully as well as before40 ,the author of 8,the ,commissariat0 stated that in the hospitals of ,london1 where the surgical department is diligently supervised1 it has been found possible to effect an annual saving amounting to five pounds for each bed1 and that without in any way lowering the standard of nursing or treatment4 ,sidenote3 ,utilizing ,hospital ,waste ,at the ,boston meeting of the ,association of ,hospital ,superintendents1 ,dr4 ,f4 ,a4 ,washburn1 ,jr41 of the ,massachusetts ,general ,hospital1 in a paper on 8,methods of ,utilizing ,hospital ,waste0 described the methods used in that hospital to reduce the consumption of gauze and soap4 ,the paper contains so much that is valuable by way of illustrating what might be accomplished and how1 that we have requested permission to insert it in this connection4 8,two main principles are involved in reducing hospital expenditures3 8#ast4 ,using less new material4 8#bnd4 ,utilizing waste material4 8,in this paper ,i will dwell principally upon some of the methods which may be employed in carrying out the second of these two principles1 namely1 utilizing material which has formerly gone to waste4 8,the item of absorbent gauze is a large one in every general hospital4 ,at the ,massachusetts ,general ,hospital1 in #aijb1 it amounted to #f1jgi4ha1 in #aijc1 to #e1iei4cg4 8,up to one year ago1 at this hospital1 it had been customary to destroy all gauze which had been soiled by blood or pus1 and ,i believe that this was the rule at all hospitals1 although some had made an attempt to recover the gauze from their clean cases4 ,in ,october1 #aijd1 with the consent of the visiting staff1 a process of washing and sterilizing all gauze was adopted1 and its success has exceeded our expectations4 8,in the first eight months of #aijd we used over one hundred and forty miles of new gauze three feet wide4 ,in the first eight months of #aije1 we used fifty-one miles4 ,the new gauze used in the first eight months of #aijd would have stretched from ,boston nearly to ,new ,haven1 ,conn41 while in a corresponding period of #aije it would have reached only five miles beyond ,providence1 ,r4 ,i4 ,money actually expended for gauze during the first eight months of #aijj was3 #aijj1 #c1ggd4ja2 #aija1 #d1bge4ia2 #aijb1 #c1hgb4fa2 #aijc1 #d1jbi4bb2 #aijd1 #d1cff4eb2 #aije1 #a1bec4dj4 8,that shows a saving of about #c1jjj in eight months over the cost in #aijc and #aijd4 8,the method employed is as follows3 8,all gauze and bandages from ward dressings1 amphitheater and out-patient department and operating rooms is collected in paper bags and taken to the laundry4 ,it is transferred from these paper bags to open work bags made of cord1 these bags being only half filled4 ,the gauze is kept in these bags throughout the rest of the process of washing and the laundry sterilization4 8,it is put in soak over night in cold water which is changed several times4 ,the following morning it is put in an iron washer capable of resisting steam pressure up to ten pounds4 ,it is then washed in cold water until the water runs perfectly clear4 ,the gauze is then washed with warm water1 soap1 and sal soda4 ,after this washing it is rinsed in hot water4 ,after the rinsing1 enough hot water is turned into the washer to cover the bags of gauze as they lie on the bottom of the washer4 ,steam is then turned on to a pressure of ten pounds4 ,a self-registering thermometer placed in the gauze twice showed a temperature of #bci and #bdj4 ,the thermometer1 which registers on the outside of the washer1 showed a temperature of #bcf at pressure of ten pounds4 ,this temperature is maintained for one-half hour4 ,during all this process1 the washer is moving with a to-and-fro motion1 which continually agitates the gauze and presents all parts of it to the action of the water and steam4 8,the gauze is then put in the extractor and when dry is sent to the out-patient department1 where it is overhauled under the direction of an intelligent maid4 ,it is untangled and straightened1 and the maid is instructed to throw out any piece of gauze which is stained or has anything adherent to it4 ,the gauze is again handled by nurses or maids when it is cut and placed in packages for the last sterilization4 ,these women1 also1 have instruction to look the gauze over carefully for any stained piece or any piece with foreign matter adherent4 ,the final sterilization is then done at a temperature of #bej ,f41 with a pressure of fifteen pounds in the sterilizing room4 8,it is found that the washed gauze is softer and more absorbent than the new gauze4 ,repeated tests conducted in the pathological laboratory have shown the safety of the process4 ,the overhauling and straightening of the washed gauze involves a very considerable amount of labor1 and if it were necessary to hire additional people to do the work the saving would be much less4 ,at the ,massachusetts ,general ,hospital we utilize labor that would otherwise go to waste4 ,in our large out-patient department we must have a certain force of messenger boys and maids when the clinic is at its largest and at the busiest hours of the day4 ,much of the time all this force is not required for running the clinics or cleaning the buildings1 and their time is utilized on the gauze4 8,so much for the gauze which is recovered and utilized again as gauze4 ,there is a part which is in too small pieces or is too badly tangled to be worth straightening4 ,this material is run through a rag picker and becomes a very light and absorbent lint1 which is sterilized and used in dressings where absorbent cotton or oakum is ordinarily used4 ,it is also used in the boiler house in the place of waste for wiping around the engines4 ,another part of the gauze is thrown out because it is stained with chemicals4 ,these pieces are utilized by the housecleaning force4 ,this process1 therefore1 means not only less gauze bought1 but less absorbent cotton1 less oakum1 less waste for the engine room4 ,all pieces of compress cloth1 many of which have been thrown away in the past1 are washed and sterilized by this same process1 used over again if large enough1 run through the picker if small4 8,packages which are sent to the boiler house to be burned are overhauled and inspected at frequent and irregular intervals1 and if it is found that material which should be saved is being wasted1 the responsible head nurse is called to account4 ,safety pins1 rubber dam1 knives1 forks and spoons are recovered from this inspection4 ,i believe that it will pay to have a systematic inspection by a careful employee of everything brought from any part of the hospital to be destroyed or thrown away4 ,such a man cannot fail to more than earn his pay and board1 nor would his inspection work take the whole of his time4 ,sidenote3 ,soap ,making 8,about one year ago the ,massachusetts ,general ,hospital started to make its own soap4 ,i have endeavored to make a comparison of the cost to the hospital of buying soap for the seven months1 ,february to ,august1 #aijd1 and making it for the seven months1 ,february to ,august1 #aije4 8,we formerly used in the laundry a soap chip for which we paid about #d cents a pound4 ,we used a common yellow bar soap for which we paid #e to #e cents per pound4 ,savogran for the floors1 etc41 at #f cents a pound1 and soft soap for ward use at #c cents4 ,all these have been nearly or quite replaced by our homemade soft soap1 which we find answers all these purposes in a satisfactory manner4 ,we still use a small amount of ,savogran on the white tile floors of our surgical building1 and a little bar of yellow soap here and there4 ,this latter we shall make ourselves as soon as our stock on hand is used up4 ,but soft soap practically replaces everything except sand soap1 toilet soap1 soap polish1 etc41 which we buy as before4 8,in the seven months of #aijd under consideration1 we paid #ece4bf more for ,savogran than in the seven months of #aije2 #ajh4dh more for yellow bar soap2 #bd4ii more for soft soap1 and #cjj4fe more for soap chips1 a total of #ifi4ch more paid for soap effected by our home soap making in seven months of #aijd than in the seven months of #aije4 8,to counterbalance this we received in the seven months of #aije1 #bee4ae less for grease4 ,soap making takes about a third of the time of one man1 estimated at #agg4be for seven months4 ,potash cost #bic4ia4 ,steam used in cooking soap estimated at #e per month1 #ce4 ,a total saving of #bfh4jg in seven months4 8,we have less trouble with our washers in the laundry because of the larger amount of free alkali in the soap made by our recipe1 which is practically the same as that used at the ,mc,lean ,hospital and the ,state ,hospital4 ,it is as follows3 8,dissolve twenty-two pounds of potash in six nine-quart pails of water1 add thirty-four pounds of grease and boil very slowly six hours4 ,then fill a #ajj-;gallon tank half full of water and let it come to a boil again4 ,when it becomes stringy turn off the steam and fill the tank with water4 8,the soap has been tested by the hospital apothecary and is found to correspond to the maximum of free alkali allowed by the #aijj ,united ,states ,pharmacopia4 ,various fabrics have been allowed to soak in this soap for several days and have shown no detriment4 ,the practical test of a year's use shows no injury to clothing40 ,sidenote3 ,drugs ,dr4 ,w4 ,e4 ,dreyfus1 chemist of ,bellevue and ,allied ,hospitals1 calls attention to another leak that formerly existed in those establishments and the same kind of leak may be found in the majority of hospitals of the country4 ,in commenting on the hospital deficit question ,dr4 ,dreyfus says3 8,you know that all chartered charitable institutions are entitled to tax-free alcohol1 but very few take advantage of it4 ,the saving for our city institutions on tax-free alcohol during #aijc amounted to about #ba1jjj1 the indirect benefit therefrom being about #i1jjj more4 ,to give a specific instance3 ,before the ,king's ,county ,hospitals were supplied from this department1 they spent the sum of #ag1gga4ab for drugs1 liquors1 etc4 ,after they were consolidated with this department we furnished them the same amount at a saving of nearly #d1jjj per annum40 ,these figures are large1 because the institutions concerned are large1 but when smaller institutions buy and continue to buy alcohol and pay the tax1 which amounts to #b4jg a gallon1 it is easy to see that a proportionate sum is being wasted in the majority of the hospitals of this country through this one channel4 ,there is no question that hundreds of thousands of dollars in the aggregate every year are taken from the hospital treasuries of the country and poured into local liquor dealers' pockets and various other pockets that ought to be expended in supplying legitimate needs4 ,sidenote3 ,wasteful ,physicians ,just what to do with physicians who are habitually wasteful is a question4 ,it has been a noticeable fact in some hospitals that physicians who owned hospitals of their own were always more economical in the use of surgical supplies than others1 whose only hospital experience was gained in institutions supported by the public4 ,they knew the cost of supplies4 ,they were footing the bills and wasted material meant money taken directly out of their pockets4 ,therefore they had formed habits of economy and were quick to check nurses who showed a tendency to wastefulness4 ,if the spirit of economy1 the spirit of personal ownership could take possession of the doctors connected with hospitals it would mean an enormous saving in the course of a year4 ,sidenote3 ,teach ,economy ,sidenote3 ,abuse of ,appliances ,the lack of careful instruction in the use and abuse of hospital supplies and the absence of conscientious1 competent supervision may always be expected to result in general waste4 ,if in the very beginning of an interne's or nurse's course in a hospital1 some pointed1 practical and definite instruction could be given as to the cost of supplies1 and the avoidance of common methods of waste1 much might be accomplished4 ,if a sense of individual responsibility can be cultivated at all1 efforts in that direction cannot be begun too soon4 ,it is lamentably true that there is perhaps no class of employees who carelessly destroy so much that is useful as those whose names appear as students and employees of our institutions4 ,usually what is common property is no concern of theirs4 ,a loss to the institution is no loss to them4 ,whether or not a feeling of responsibility can be aroused in all hospital workers is an open question1 but it is worthy of diligent and constant effort4 ,one thing specially needs frequent emphasis1 and that is regarding the misappropriation of appliances4 8,use an article for the purpose for which it is intended and for no other40 ,this cannot be too thoroughly drilled into them4 ,how many valuable hospital instruments are broken annually because nurses persist in using them to take corks out of bottles because no corkscrew is in sight4 ,this is only one common illustration out of hundreds that might be cited on this point4 ,a rigid rule requiring a money return or a replacing of the article and a careful account of the articles in each department is the only way to force a study of economy4 ,the abuse of appliances which renders them unfit for use1 in an unreasonably short time1 can be met in the same way1 requiring also that every article reported unfit for use be submitted for the inspection of the head of the department1 before being condemned or thrown away as worthless4 ,sidenote3 ,careful ,accounting ,sidenote3 ,watching the ,expenditures ,by careful accounting 7and only in that way7 can be ascertained the average amount of supplies that should be required in caring for a given number of patients4 ,if this average amount is generally known or understood by heads of departments1 internes1 and nurses1 it will be found that more care will be exercised to keep at least within ordinary limits4 ,very frequently the necessity for economy is never brought to the attention of the workers4 ,heads of departments too often seem in no way to be concerned with the cost or consumption of supplies4 ,when this condition exists somebody is to blame4 ,the superintendent1 if he is the head of the hospital1 as his official title would indicate1 holds more of the power of checking waste in his hands than any other one or two persons4 ,if he does not keep his financial eye on the expenditures of different departments1 if he does not give time and study to the question of how to keep current expenses down to the minimum and at the same time do good work1 if he does not1 up to a certain point1 regulate the purchase and distribution of the enormous quantities of supplies needed in the hospital1 and insist on his colleagues in charge of departments doing the same thing1 then waste is inevitable4 ,if the father of a family simply pays bills for supplies without having a voice in controlling the consumption or use of those supplies he need not wonder if he finds the figures on accounts creeping higher and higher each month1 and that is probably what is occurring in some hospitals1 where the expense is excessive as compared with other institutions doing the same amount and same class of work4 ,that economy and efficiency are quite compatible can be easily shown by actual results in hospitals that have never adopted the plan of running the institution on a deficit1 that either have to pay their bills promptly or close their doors4 ,sidenote3 ,dietetic ,department ,no doubt the dietetic department of the hospital can furnish more concrete illustrations of waste than any other4 ,some of this so-called waste is legitimate and inevitable2 much of it represents material that should not be saved1 that has been rendered unfit for use by handling1 but there is no question that a large proportion of this waste of food comes from a failure to fit the amount and character of the food served to the needs and tastes of the individual patient4 ,a wise discrimination on the part of the one who serves the food would prevent much of it4 ,another important cause of waste comes from imperfect preparation of the food4 ,food cooked in bulk1 and with no bond of connection between the one who cooks and those who consume the cooked product1 is almost sure to be handled carelessly1 overdone or under-done or unpalatable4 ,food that is properly cooked and tastefully served1 so that it will appeal to the eye and to the palate as well1 is much less likely to be wasted or rendered unfit for use by handling4 ,pecuniary economy1 a large part of it at least1 and also hygienic economy of food and nutrition1 depend greatly on the manner of handling of food in the kitchen1 in transit1 and in the wards4 ,success in fitting the food to the consumer1 then1 demands skill and care in cooking and serving4 ,it demands discrimination1 a proper sense not only of the physiological demands of the consumer1 but of his tastes1 and it demands1 besides1 proper facilities for getting the food to the patient in its most palatable and attractive form4 ,without these three factors being recognized1 waste is inevitable4 ,then1 too1 the buyer of food must carry a good deal of responsibility4 ,the quality of food purchased1 the place in which it was stored1 and various other features enter into the question of waste4 ,without proper storage facilities 8intelligent economy0 in purchasing and caring for food is impossible4 ,buying over the telephone is one of the methods to be discouraged4 ,careful selection of perishable goods in open market is the only sensible way4 ,some hospitals have succeeded in reducing the expense from food waste by disposing of the garbage to contractors for a stipulated sum4 ,in the heating of a hospital there is room for a great waste of money4 ,one small hospital1 this last winter1 one of the most severe seasons in years1 saved two hundred dollars on the cost of fuel as compared with last year1 as the result of 8the intelligent economy0 practiced by the engineer4 ,a very considerable reduction in the expense of machinery1 light and repairs is attributed by the board to the same source4 ,intelligent economy6 ,the term deserves to be popularized1 for of all things in hospitals it needs to be studied and cultivated4 ,this system of daily accounting for supplies is one that can be managed in even the smallest hospital4 ,an inventory book in which is listed all the articles found in a department at a given time1 such as hypodermic syringes1 feeding cups1 drinking glasses1 medicine glasses1 rectal tubes1 catheters1 etc41 can also be used for requisitions or for noting1 as furnished1 additional articles of that class4 ,sidenote3 ,system ,another book for food supplies should be brought to the kitchen or storeroom each time supplies are replenished4 ,another book for keeping track of surgical supplies should be brought with each requisition4 ,some hospitals have also a 8linen book10 which tells the amount of each kind of linen sent to the laundry from each department4 ,clean linen is noted in the book also when given out4 ,these books should be sent to the office each week 7,monday morning is usually a good time7 and the amounts supplied to each department reckoned up4 ,when this amount in any department is excessive an investigation can be made with facts as a basis4 ,regarding this system1 ,sir ,henry ,burdette in 8,the ,commissariat0 says3 8,no true economy can ever be expected under a system by which the persons who order and use supplies1 and the person who is responsible for the bills1 both work independently and pull different ways4 ,it is absolutely essential to a well-balanced administration that a spirit of responsibility should permeate the whole establishment1 from the manager1 on whom the multifarious charges accumulate for payment1 down to the youngest probationer charged with serving out the rice pudding in her ward4 ,and this spirit of responsibility must in all cases recognize a double duty4 ,there is the duty towards those for whom each person invested with authority of any kind is called on to provide1 and there is the duty toward the institution1 represented by the person next in authority4 ,where this dual sense of responsibility is nicely balanced in every member of the institution1 the management may be considered perfect4 ,to that end1 it is1 above all things1 necessary that there should be one person invested with general control and endowed with a grasp of the whole situation4 ,it cannot be too often repeated that in these matters to know is to control4 ,there is no other road to economy4 ,it cannot be compassed by appeals to conscience1 not by nagging1 not by a grudging1 stingy giving out of necessary articles as though the consumer were guilty in requiring them4 ,let each housemaid know how many yards of cloth she is expected to use in her cleaning in a given time1 let each pound of lint be registered against someone's name1 who shall be accountable2 let each article be given out at the right time1 on the right day1 to the right person1 and with the understanding that the transaction1 slight though it may be1 has been noted down and will duly find its place in the weekly average and in the record of the whole expenditure4 ,let such a system once take root and then1 be the institution large or small1 rich or poor1 hampered with old traditions or brimming over with untried theories1 a spirit of true economy will reign throughout every department1 worth far more1 indeed1 than the trifling secretarial labor expended in its production40 ,,appendix4 ,disinfection--,infected clothing from wards should be immediately placed in a vessel containing sufficient disinfecting fluid to cover it1 and should be kept in it till disinfection is accomplished4 ,the length of time varies with different disinfectants4 ,by actual experiment1 the length of time to destroy bacteria should be learned4 ,too much so-called disinfection is on the shot-gun plan1 and no attempt is made to find out whether it produces the desired results4 ,most disinfectants are more powerful if used hot4 ,other conditions that modify the power of disinfectants are the kind and number of bacteria to be destroyed1 the quality of associated material1 as well as the strength and temperature of the solution4 ,bichloride of mercury destroys all forms of pathogenic micro-organisms and spores4 ,for the latter a solution of #a in #ejj is needed1 the exposure to be not less than one hour4 ,it should not be used for the disinfection of excreta1 because of its property of precipitating albuminous matter4 ,this forms a coating around the bacteria1 which prevents the penetration of the solution4 ,this solution may be used in disinfecting clothing or rooms1 but should never be used on metal substances4 ,a solution that is highly recommended for clothing contains the following3 ,carbolic acid #c parts ,common soft soap #a parts ,water #ajj parts ,common laundry soap is first dissolved in water1 the carbolic acid is added and the mixture is vigorously stirred4 ,experiments with this solution show that non-spore forming bacteria are destroyed in an exposure of one-half hour4 ,commercial carbolic acid may be used1 which is somewhat less expensive than the purified product4 ,for the disinfection of excreta1 a solution known as the ,american ,standard is officially prescribed in the ,united ,states ,army1 it being specially stated that the chloride of lime should be of good quality1 and not have undergone decomposition4 ,it is made by dissolving six ounces of chloride of lime in a gallon of water4 ,for the disinfection of mattresses1 live steam should be used whenever possible4 ,when no facilities exist for steam disinfection of mattresses and pillows1 a fumigation can will be found very valuable4 ,fumigation ,can--,this can is made of galvanized iron1 with a tight-fitting cover4 ,it needs to be about four and a half feet high1 and at least two feet and a half in diameter4 ,a slat shelf1 with iron or wire hooks that fasten over the top of the can1 will be useful in sterilizing small articles4 ,this contrivance is superior to any closet1 as it confines the formaldehyde in small space1 and can be made almost entirely air tight4 ,it should always be remembered that formaldehyde has almost no power of penetration1 and therefore special care is needed to expose all possible surfaces to the fumes4 ,extermination of ,vermin--,to prevent bedbugs in hospital is no easy matter where patients and visitors are coming from all kinds of homes4 ,a leading hospital superintendent recommends sulphur fumigation4 ,it is said to be the only thing that will effectually destroy them4 8,in order to secure the desired results the fumes must be very dense4 ,in preparing for fumigation large pans are used made to hold from twenty-five to thirty pounds of sulphur1 and other pans are filled with water4 ,the heat from the burning sulphur will cause steam1 which makes the sulphur fumigation more effective4 ,in order to accomplish the entire destruction of the bedbug1 it is necessary to fumigate three or four times in a month4 ,it takes three weeks for the bugs to be hatched and eleven weeks to mature4 ,by successive fumigations in this way a room or ward may be considered safe1 but this treatment should be repeated twice a year4 ,for keeping beds free from bugs1 the following prescription is recommended3 ,corrosive sublimate #a ounce ,spirits of turpentine #a pint ,coal oil #a pint ,the corrosive sublimate should first be dissolved in alcohol and the mixture used through an atomizer or oil can4 ,to exterminate pediculi of the head1 saturate the hair thoroughly with kerosene for three successive days and wash with warm water and green soap4 ,for pediculi on other parts of the body the following is recommended3 ,salicylic acid1 #b parts2 toilet vinegar1 #be parts2 alcohol1 #ge parts4 ,apply with a flannel or piece of absorbent cotton4 ,one application is usually sufficient4 ,,care ,,of ,,floors4 ,the best finish1 the ideal finish1 for wood floors in hospitals1 has yet to be invented4 ,at the ,cincinnati convention of hospital superintendents the subject of floor finishes was discussed1 and the following recommendations made1 which were based on experience3 ,on new maple floors two coats of ,berry ,brothers liquid granite varnish is applied1 then a finish composed of the following ingredients3 ,one pound of paraffine dissolved in #a pints of linseed oil and #b gallons of turpentine4 ,this preparation is applied once a week with a mop by the ward maids1 and is afterwards rubbed down with hair brushes covered with flannel4 ,water or alcohol dropped on these floors softens the wax1 but spots can be touched up with the brush when necessary4 ,on old floors two coats of oil is used and then the above mixture4 ,where local conditions render frequent washing of floors necessary the following preparation has been used with satisfaction3 ,grain alcohol #e gallons ,orange shellac #b pounds ,canada balsam #b ounces ,castor oil #b ounces ,this is a government formula1 and desirable for use where soft coal is burned for fuel4 ,it should be mixed thoroughly in a suitable vessel1 and allowed to stand for a day1 before using4 ,add alcohol if it is too thick4 ,apply with a brush after the floors have been cleaned1 and keep room vacant eighteen hours to allow time for drying4 ,another formula that is used in some hospitals is3 ,paraffine melted1 #f ounces2 turpentine1 #a gallon1 thoroughly mix and add soft soap1 #d ounces4 ,mix well and let it stand #bd hours4 ,apply with a woolen cloth and rub in4 ,,the ,,presbyterian ,,hospital ,,diet ,,sheet 444444444 ,division ,new ,york 444444444444 #aij4444 ,ward ,no4 444444444 ---------------------------------------- --------- ,,names ,,of ,,patients ---------------------------------------- --------- ,house diet 44444444444444444444444444444444 ,convalescent diet44444444444444444444444444444444 ,nitrogenous diet 44444444444444444444444444444444 ,farinaceous diet 44444444444444444444444444444444 ,milk diet 44444444444444444444444444444444 ,extra diet 44444444444444444444444444444444 ---------------------------------------- --------- ,no4 of patients on house diet 4444444444 ,no4 of patients on convalescent diet 444 ,no4 of patients on nitrogenous diet 4444 ,no4 of patients on farinaceous diet 4444 ,no4 of patients on milk diet 44444444444 ,no4 of patients on extra diet 4444444444 ,total ,no4 of patients in ward 444444 4444444444444444444444444444 ,attending ,physician--,surgeon 4444444444444444444444444444 ,house ,physician--,surgeon ,,sample ,,diet ,,sheet ,sample ,page of ,hospital ,linen ,book ,,month ,,of 44444444444444 #aij444 ---------------------------------------- ------------------------------ ,day of ,in ,in ,new ,req'r'd ,month ,in,laun-,resv4 ,article ,dis- ,linen ,total ,miss-,remarks ,use dry carded,addedon hand ing ---------------------------------------- ------------------------------ 4444444444444444444,bed ,spreads 444444444444444444444444444444 4444444444444444444,sheets 444444444444444444444444444444 4444444444444444444,draw ,sheets 444444444444444444444444444444 4444444444444444444,children's ,sheets 444444444444444444444444444444 4444444444444444444,operating room sheets444444444444444444444444444444 4444444444444444444,bath ,towels 444444444444444444444444444444 4444444444444444444,face ,towels 444444444444444444444444444444 4444444444444444444,glass ,towels 444444444444444444444444444444 4444444444444444444,roller ,towels 444444444444444444444444444444 4444444444444444444,surgical ,towels 4444444444444444444 7for wards7 444444444444444444444444444444 4444444444444444444,operating ,room ,towels444444444444444444444444444444 4444444444444444444,dresser ,covers 444444444444444444444444444444 4444444444444444444,sash ,curtain 444444444444444444444444444444 4444444444444444444,blankets 444444444444444444444444444444 4444444444444444444,men's ,gowns 444444444444444444444444444444 4444444444444444444,women's ,gowns 444444444444444444444444444444 4444444444444444444,children's ,gowns 444444444444444444444444444444 4444444444444444444,covers for ,dressings 444444444444444444444444444444 4444444444444444444,plain ,bandages 444444444444444444444444444444 4444444444444444444,breast ,bandages 444444444444444444444444444444 4444444444444444444,many-tailed ,bandages 444444444444444444444444444444 4444444444444444444,t4 ,bandages 444444444444444444444444444444 4444444444444444444,special ,bandages 444444444444444444444444444444 4444444444444444444 ,etc41 ,etc41 ,etc4 444444444444444444444444444444 ---------------------------------------- ------------------------------ ,sample ,page of ,hospital ,cash ,book4 ,receipts for ,month of 444444444444 ---------------------------------------- ---- 4444,bal4 on hand from previous month 4444444 4444,from ,in-,patients 4444444 4444 0 ,out-,patients 4444444 4444 0 ,private ,nursing 4444444 4444 0 ,special ,nursing 4444444 4444 0 ,sale of ,medicine ,supplies 4444444 4444 0 ,entertainments 4444444 4444 0 ,interest on ,invested ,funds 4444444 4444 0 ,annual ,contributions 4444444 4444 0 ,other ,sources 4444444 ,total 44444444444444444 ,balance 44444444444444444 ---------------------------------------- ---- ,disbursements for ,mo4 of 44444444 #ai444 ---------------------------------------- ---- 4444,balance for previous month 4444444 4444,for ,meat 4444444 4444 0 ,fish 4444444 4444 0 ,butter 4444444 4444 0 ,flour1 ,bread and ,meal 4444444 4444 0 ,milk 4444444 4444 0 ,water 4444444 4444 0 ,ice 4444444 4444 0 ,potatoes and ,vegetables 4444444 4444 0 ,groceries and ,provisions not above enumerated 4444444 4444 0 ,soap and ,cleaning ,appliances 4444444 4444 0 ,fuel 4444444 4444 0 ,gas1 ,oil and ,light 4444444 4444 0 ,bedding and ,gen4 ,house ,fur4 4444444 4444 0 ,nurses' ,uniforms 4444444 4444 0 ,other ,training ,school ,ex4 4444444 4444 0 ,wines and ,spirits 4444444 4444 0 ,drugs and ,surgical ,appliances4444444 4444 0 ,surgical ,dressings 4444444 4444 0 ,advertising1 ,print4 ,postage4444444 4444 0 ,repairs 4444444 4444 0 ,taxes and ,insurance 4444444 4444 0 ,contingencies 4444444 ,total 44444444444444444 ,balance 44444444444444444 ---------------------------------------- ----